Download Ultrasound – The new Stethoscope?

Avant-garde?
Is ultrasound forwardthinking?
Cindy Allen
MSHS, RT-R, RDMS, RVT
Objectives
Recognize traditional and new users of
ultrasound.
Recall high-tech uses of ultrasound with EUS,
combination imaging, elastography, 4D.
Realize ultrasound growth potential.
Recall screening potential of u/s for disease.
Know where to research information regarding
the profession.
“Traditional”
Radiology
OB/GYN – MFM
Cardiology
Vascular Surgery
“Newbies”
Orthopedics – 1970’s
Rheumatology – 1980’s
Sports Medicine - 1970s
Anesthesiology – 1980s
Internal Medicine – 1990
Family Medicine – 2000s
Surgeons -1990s
Emergency Medicine 1980s
Endocrinology
Nephrology
IV Therapy nurses
Respiratory therapy
Musculoskeletal Imaging
“Newbies”
Orthopedics
Rheumatology
Sports Medicine
Podiatrist
Musculo-Skeletal Ultrasound
200% ↑ MSK 1996-2006 based on CPT codes
Radiologist-based MSK exams only grew 42% (19962006)
– Operator-dependent, equipment- dependent
– Concern about learning curve
– Sonographers – learning anatomy and pathology
– Musculoskeletal radiologists comfort with ultrasound
– If…ultrasound paid better than MRI?
–
Erik L. Ridley
AuntMinnie January 20, 2009
Away from Radiology?
“If radiologists don't perform
musculoskeletal ultrasound, others will”
Diagnostic referrals and therapeutic
procedures are at risk
Most MSK radiologists are not ultrasound
modality aware
Lack of ACR support
Erik L. Ridley
AuntMinnie January 20, 2009
US Directly Benefits the Clinician
Clinical evaluation and imaging in one visit
Extension of the physical exam
Reduce costly MRI studies
Provide guidance for interventions
Clinical physicians have an appreciation of
disease states and functional anatomy
Clinicians know the clinical history and
differential diagnosis
Increase patient convenience
– Erik L. Ridley
AuntMinnie January 20, 2009
Central/Peripheral Venous
Catheterization
Implementation:
Anywhere an IV is inserted
centrally or peripherally
Addressing a HealthCare Problem
Central Line Infections
According to the Centers for Disease Control
(CDC), there are > 80,000 infections/year.
IV tube, containing bacteria is inserted into a
large vein and infects the patient’s bloodstream.
Cost the nation ≤ $2.3 billion.
Result in 20,000 deaths/year in intensive care
units in the U.S. (2002)
http://www.nchc.org/facts/quality.shtml
CVC
Parenteral Nutrition
Intravascular depletion
Access for medications
Hemodynamic monitoring
IV access
Explosion – CVC
Preventable injuries related to CVC
(Central Vascular Catheters)
– Wire or Catheter Embolus
– Cardiac Tamponade
– Carotid Artery Cannulation or Puncture
– Hemothorax
– Pneumothorax
Source: Domino, K. et. Al. Injuries and Liability
Related to Central Vascular Catheters.
Anesthesiology. June 2004.
Central Venous Catheterization
SOAP-3 trial
– Dynamic ultrasound had odds 53.5% higher
than landmark technique for access. (Milling,
Critical Care Medicine, 2005)
Critical Care Ultrasound
Intensivist, Pulmonologist,
Internal Medicine, Family
Medicine, Nephrologist,
Anesthesiologist, Primary Care
Importance
Extension of bedside examination
– Focused, targeted exam
Increased safety of procedures
Not feasible for 24/7 coverage by
sonographer/cardiologist/radiologist.
Proficiency in use of ultrasound to guide
central line placement and thoracentesis is
strongly recommended by American Board
of Internal Medicine. www.abim.org
American Society of
Echocardiography
Level 1 training
– 150/75 exams (Imaging/Doppler)
– Introductory Level
Level 2 training
– 150/150 exams (Imaging/Doppler)
– Ability to take call, Interpret
Level 3 training
– Sufficient expertise to direct an echocardiography
laboratory
- 450 examinations (using both imaging and Doppler)
Explosion – Critical Care
Hemodynamic instability
–
–
–
–
Ventricular failure
-Hypovolemia
PE
- Cardiac Tamponade
Acute valvular dysfunction
Complications post-op
Infective endocarditis
Aortic dissection, rupture
Unexplained hypoxia
Source of emboli
Explosion – Critical Care
Pericardiocentesis, Thoracentesis, etc.
Urinary Bladder scan
Focused Assessment of the Trauma
patient
Intra-aortic balloon counter-pulsation
Pleural effusion evaluation
Pneumothorax
Impact
Targeted exam, not a replacement for
complete exam
Immediate diagnosis for the patient
Treatment, quicker
Emergency Medicine
Trauma Surgeon, Emergency
Physician
Explosion – Emergency Medicine
eFAST – extended Focused Assessment for
Sonography in Trauma.
–
–
–
–
–
Pleura slide
Subcostal 4 chamber
Hepatorenal space (AKA Morrison’s pouch)
Splenorenal space
Bladder
Ectopic pregnancy
Abdomen
Cardiac Emergencies
Importance
Point of care ultrasound in the Emergency
Department “improved patient care by
decreasing cost, length of stay and
lowering mortality.” Melniker, L. 2006
Average fast exam time is 2.5 minutes,
varying from 2-10 minutes.
Implications
Established ultrasound training programs
Residency programs for Emergency
Medicine incorporate ultrasound training in
the US.
Implementing ultrasound in care for > 20
years.
American College of Emergency
Physicians (ACEP)
Need for emergency ultrasound imaging on a
24-hour basis and that emergency room
physicians should perform such
examinations.(2001)
16-hour initial comprehensive course with
foundation in emergency ultrasound
≥ 25 -50 documented, reviewed cases in each
primary application: Trauma, IUP, Emergency
Cardiac, AAA, Biliary, Renal, DVT, Vascular
Access, etc.
Implications
Documented 15% decrease in length-ofstay of patients with gallbladder
examinations for experienced physicians
(>100 gallbladder scans) compared with
on-call sonographer. (Blaivas, Academic
Emergency Medicine, 1999)
Implications
Residents Learn to Use Hand-Held
Echocardiography at Bedside (Helman,
The American Journal of Medicine, 2005)
– 30 residents studied
– One-on-one supervision given
Findings of needs:
– Minimum of 20 training studies
– 3-5 directly supervised
– 20 hours didatic
Implications
DVT study: of 156, 34 diagnosed with DVT
with 99% agreement. ED time: 95
minutes, triage to disposition: 220
minutes. (Theodoro, The American
Journal of Emergency Medicine, 2004)
Radiology Studies Affected
Impact of Emergency Medicine Resident
Training in Ultrasonography on Ultrasound
Utilization. Michael Heller. 1999.
– A significant increase (from 5.8% to 9.8%)
Global trend
Awareness of indications and reason for
abdominal ultrasounds
Validity of emergency medicine findings
Confirm positive or negative findings
Anesthesiology
Peripheral Nerve Blocks and
Cardiothoracic Monitoring
Explosion – Anesthesiology
Cardiothoracic (TEE)
– ASD/VSD repairs
– Valve replacement
– CABG
Nerve blocks
– Peripheral (Orthopedic surgery)
– Abdominal (Hernia repairs, etc)
Importance
TEE: Monitoring patient during surgery to
improve outcome
Ultrasound-guided nerve blocks:
– Increase safety
– Increased success of block
Without ultrasound, 60-95% (Neal, 2002)
With ultrasound, 80-100% (Schwemmer, 2006)
– Knowledge of anesthetic spread
– Decrease pain and discomfort
– Shorter ambulation time
Healthcare Impact
Peripheral Nerve Blocks: Nerve
Stimulator versus Ultrasound
Sandhu, et. al calculated a minute of
surgical time cost $8.00 (2004)
Based on quicker, more accurate onset, a
successful ultrasound-guided nerve block
saves $160.00 per patient.
Importance
Organized training for physicians by
physicians
Guidelines for TEE training through
residency
Guidelines for nerve block training through
residency
Ultrasound Is…
Ultrasound is…
Pattern recognition
Today’s Imaging
We see a mass and we look for size,
shape, location. We can get growth data.
What if:
– We could establish whether or not the mass is
malignant?
– What if the ultrasound were capable of
distinguishing a pattern of a disease process
from a normal person?
Futuristic Use of Ultrasound
Delivery of therapeutic drugs directly into
the body where they need to be
– Selective introduction of drugs into diseased
tissue
– Activated by sound
– Sonoluminescene (light from sound) dates to
1930, but technology is coming to age
– May be ten years away
– Don Baker, December 31, 2008 SDMS News Wave
4D
Ultrasound Contrast
 Detection of liver mets
 Improved imaging with cirrhosis
 Potential for assessment of buried grafts
following oropharynx surgery
 Screen for calf peripheral artery disease
 Malignant vs. benign renal tumors
Imagify
Declined by FDA November 2008
The product was administered to 1,194 subjects,
including 911 patients with known or suspected
coronary artery disease
– 1% (11/911) reported serious adverse events
3 patients experienced vasovagal syncope.
– 4% (38/911) experienced hypotension or decreased
blood pressure
– 2% (16/911) had exam permanently discontinued
because of adverse events.
Support Ultrasound Contrast
Join International Contrast Ultrasound
Society
Objective: The promotion of safe and
efficacious use of contrast-enhanced
ultrasound (CEUS) in patients with diverse
medical profiles and disease states.
Free membership
http://www.sonoworld.com/sonoworld/icus/
Forms/ICUS_Letter-Form.PDF
Fusion Imaging
Researchers are working to perfect a fusion of
technologies to provide imaging:
Non-ionizing
Higher doses to the tumor and periphery
Accurate daily patient positioning
Dose escalation in a given session
Real-time targeting of tumors and tumor beds
Image-fusion between various visualization
modes (MRI, Ultrasound)
On-line treatment planning
procedures/protocols
High Intensity Focused Ultrasound
to fight Cancer
The new findings from animal experiments suggest that
once activated by the ultrasound, the immune system
might even seek and destroy cancer cells , including
those that have spread through the bloodstream to lurk
in other parts of the body.
This high-intensity focused ultrasound, or HIFU, is in use
or testing in China, Europe and the United States to kill
tumors by heating them. But Duke researchers now find
that HIFU might work even better if it is first delivered in
a manner that just shakes the cells. That shaking
ruptures tumor cell membranes, causing them to spill
their contents. The toxic spill then alerts the immune
system to the cancer threat, leading to the production of
tumor-fighting white blood cells.
http://www.physorg.com/news105711171.html
Elastography
A non-invasive method in which stiffness
or strain images of soft tissue are used to
detect or classify tumors.
A tumor or a suspicious cancerous growth
is normally 5-28 times stiffer than the
background of normal soft tissue.
When a mechanical compression or
vibration is applied, the tumor deforms
less than the surrounding tissue.
Acoustic Radiation Force Impulse
Imaging (ARFI) – Research only
Breast mass imaging
Colorectal tumor Imaging/Staging
Liver Fibrosis quantification
Imaging RF ablation lesions
Artery characterization
Cardiac imaging
Prostate imaging
Thermal therapy
In vivo imaging of malignant tumors
Wikipedia.org
Screening Services
Impact of AAA
Positive for AAA:
– Smoking Cessation Program
– Follow-up at 6 months if 4.0-5.4 cm
Looking for variations of > 0.5 cm
– Preliminary medication studies for
Doxycycline, Macrolide antibiotics, Statins
and A-tocpherol.
– Endovascular repair > 5.5 cm
– Open repair >5.5 cm
1 in 6 AAA-related deaths from elected repair
Screening AAA
AAA – 1 in 250 people over the age of 50
will die of a ruptured AAA.
AAA affects ≤ 8% of people > 65%.
17th leading cause of death.
Asymptomatic.
Untreated, 50% die of rupture.
Men > Women 4 x more often.
www.sirweb.org
Screening IMT
Intimal Media Thickness
Screening for cardiovascular disease or
effectiveness of medications to treat CVD
(statins)
Measures the media thickness
– anterior and posterior wall
– anterior, lateral and posterior windows
– up to 1000 points along 1 inch of artery
– Plots on graph
Impact of IMT
Medicare
Private Payors
Cardiovascular Disease
– Stroke Belt
– Cardiac Deaths
– Monitor Statin use
Status of the Profession
Impact
Physicians hiring sonographers (PT/FT)
– Internal Medicine
– Cardiology
– Sports Medicine
– Vascular or General Medicine
Mobile services
Implication – Sonographers
Physicians are performing Focused
studies, not a full routine.
Documentation by sonographers, with
interpretation by a trained physician
medically necessary.
Physicians tend to see the strengths.
Ultimately gain respect for ultrasound.
Outlook – RDMS
Job growth is expected
Sonography becomes an increasingly attractive
alternative, as patients seek safer treatment
methods.
Sonographic technology is expected to evolve
rapidly.
Hospitals will remain the principal employer of
diagnostic medical sonographers.
Employment is expected to grow more rapidly in
offices of physicians and in medical and
diagnostic laboratories, including diagnostic
imaging centers.
http://www.bls.gov/oco/ocos273.htm
Outlook – CardioVascular
Growth will occur as the population ages,
because older people have a higher incidence of
heart disease and other complications of the
heart and vascular system.
Procedures such as ultrasound are being
performed more often as a replacement for more
expensive and more invasive procedures.
Employment of vascular technologists and
echocardiographers will grow as advances in
vascular technology and sonography reduce the
need for more costly and invasive procedures.
http://www.bls.gov/oco/ocos100.htm
Lab
Radiography
Respiratory
Therapist
EMT
↓
Diagnostic
Medical
Social
Workers
RN
Occupational
Therapist
Radiation
Therapist
Health
Educators
30%
Cardiovascular
Technologist
Physical
Therapist
PA
Dental
Hygenist
Comparisons
2006-2016 Outlook
35%
↓
25%
20%
15%
10%
5%
0%
The Future of Ultrasound
By all appearance, is very strong.
RDMS: Employment change. is expected to
increase by about 19 percent through 2016—
faster than the average for all occupations—as
the population ages.
RDCS/RVT: Employment is expected to
increase by 26 percent through the year 2016,
much faster than the average for all occupations.
Registry vs. License
Registry vs. License
Code of Virginia 54.1-100
Regulations of professions and occupations.
The right of every person to engage in any
lawful profession, trade or occupation of his
choice is clearly protected by both the
Constitution of the United States and the
Constitution of the Commonwealth of Virginia.
The Commonwealth cannot abridge such rights
except as a reasonable exercise of its police
powers when it is clearly found that such
abridgment is necessary for the preservation of
the health, safety and welfare of the public.
Code of Virginia, cont.
No regulation shall be imposed upon any profession or
occupation except for the exclusive purpose of protecting
the public interest when:
The unregulated practice of the profession or occupation
can harm or endanger the health, safety or welfare of the
public, and the potential for harm is recognizable and not
remote or dependent upon tenuous argument;
The practice of the profession or occupation has inherent
qualities peculiar to it that distinguish it from ordinary
work and labor;
The practice of the profession or occupation requires
specialized skill or training and the public needs, and will
benefit by, assurances of initial and continuing
professional and occupational ability; and
The public is not effectively protected by other means
Registry vs. License
“States disinterested.”
SDMS has pushed for NATIONAL credentialing
to avoid the state issues
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Licensure board representation
Additional licensure fees
50 different laws
State tests vs national tests
Problems with reciprocity – moving from one state to
another, etc.
– Denise Lewis, Society of Diagnostic Medical Sonography
– February 23, 2009
License vs. Registered
Mandatory minimum qualifications
Protects the consumer
Minimum standards for practice defined by law
Sets timetable for phasing out those who do not
meet the requirements
Identifies qualified sonographers
May enhance profession image of sonographers
Drive educational programs to seek accreditation
Allows access for statistical and records about
sonographer
May reduce costs associated with repeated
examinations from suboptimal testing
Annitta J. Morehead, BA, RDCS, FASE, Timothy P. Obarski, DO, FACC, FACP
SDMS Syllabus 2003
Licensed vs
. Registered
Government control of the profession
Licensure combined with other medical specialties
– Without diverse sonographer representation on the
board
– Without differentiation of echocardiography, vascular
area of practice
– With lower minimum standards
– With limitation to scope of practice.
Requirements of attendance of accredited education
programs could limit entry into the program on the board
Annitta J. Morehead, BA, RDCS, FASE, Timothy P. Obarski, DO, FACC, FACP
Syllabus 2003
SDMS
Licensed vs
. Registered, cont
Benefits to the public of licensure is
not evident
Additional monetary cost to the
sonographer, consumer, and state or
province
License in one state may not be
accepted in another state (reciprocity)
Enforcement and monitoring
problems
Annitta J. Morehead, BA, RDCS, FASE, Timothy P. Obarski,
DO, FACC, FACP SDMS Syllabus 2003
Additional Resources for You
www.imagegently.org
www.auntminnie.com
www.sonoworld.com
http://www.bls.gov
www.ultrasoundcases.info
Thank you!
[email protected]
[email protected]