Ultrasound experts – Ask a POCUS pioneer: Interview with Marco Daoura

In our series of interviews with experts to understand the Covid-19 crisis and the context of point of care ultrasound’s role better, we speak with Marco Daoura, a Washington-based entrepreneur innovative-strategist and expert in ultrasound hardware and software innovation.

Marco provides his perspective about healthtech innovation, and how ultrasound and other technologies can help in the Covid-19 crisis.

Marco Daoura graduated from the University of Washington with both a Bachelor of Science in Electrical Engineering and a Master of Science in BioEngineering with focus on Control Theory and Molecular Biotechnology. He is currently an Innovation Lead Consultant at Premera Blue Cross and remains heavily involved in helping Health-Tech start-ups with how to best take their innovations from ideation to commercialization (I2C), in such a heavily regulated industry. Marco has over 20 years in the healthcare industry from Philips Healthcare to Fujifilm Medical Systems, UltraLinq Healthcare, Novuson Surgical, and consulting with Healthcare companies.

Our team sat down with him for an interview to ask him, as an ultrasound technology expert, what he wants the public to know about POCUS (point of care ultrasound) Covid-19 crisis from an ultrasound, POCUS and health innovation perspective.

MD:  Thank you, Courtney for the opportunity to share my thoughts with you, and however my experiences and knowledge may help you or others continue to innovate in this space.

Yeah – so let me preface this by saying, while I have dedicated the largest portion of my career in medical devices and namely in the Ultrasound technology, I am not a clinician. Not even close. I’m an engineer who spent a good deal of years working in R&D, and was intrigued enough by the many facets of Healthtech that I challenged myself into Product Services, Sales and Marketing, and Product Management. And through my journeys I got to spent a lot of time with the customer who often is the Provider (the physician using the ultrasound tech) and sometimes is the Patient as this technology gets closer and closer to the consumer space. And so, a lot of my opinions, ideas, and strategies in this space while grounded by technology, are heavily influenced by having worked much of my time with clinicians. To understand their needs, their workflows, and the gaps they experience, and have had to shadow them countless of times to understand what a day in the office means to them – You know what they say – fall in love with the problem first and then connect it back to the technology and the solution.

CW:  How have you seen handheld ultrasound evolve?

MD:  Through my journeys, and this is going to date me now, I’ve worked on ultrasound systems that were as big as a washing machine all the way to tablet and phone sized solutions. Ultrasound is so unique because it is still the only tech, to date, that allows you to visualize through the body, and it fits in your pocket. And I’ve had the opportunities to experience how it evolved from traditional clinical spaces all the way to completely remote locations without a physician in site! And when we talk specifically about handheld, technology has never been the barrier to adoption. Other barriers may have been cost or training needed to read the Ultrasound image. So yes, it has evolved quite a bit, and I think its biggest evolution is yet to be observed, when is demystified as training becomes mainstream in med school curriculum, with telemedicine … and telesonography, with augmented intelligence, (I am not going to say the buzz word AI here) ……

CW:  With your experience in ultrasound, what is your opinion about POCUS as a triage tool for Covid-19 and other urgent situations?

MD:  It amazes me how when certain resources or tools get meager we resort to new ways or tools. So you know we all herd the story, in one of the hospitals dealing with COVID in Italy, Dr. Volpicelli started triaging with ultrasound, a technique not yet peer reviewed for diagnosing COVID19, but he and his colleagues became convinced that lung ultrasounds should be done at the bedside for all patients suspected of infection, even people with mild symptoms…

Now early on this was just a new technique, but while misunderstood as a Diagnosing solution at first, it became clearer afterwards that Ultrasound is not the tool to diagnose rather it is the tool to confirm the disease severity in the Lung or the Heart, and I emphasize both here Lung and heart,  which is even as import if not more important than the lab diagnosis,  to help the physician make more informed decisions about the next best care path options for the patient. So again, and as I learned from experts whom I connected with and read their articles, the approach with ultrasound for COVID19 triaging, is that Ultrasound itself DOES NOT DIAGNOSE COVID19, but it’s a great tool to evaluate known or suspected patients, it helps define the extent of the disease, should the patient be admitted and get a respirator? Or ultrasound may suggest alternate processes

Also, these patients are usually really sick: Ultrasound comes in real handy there to visually guide venous access for managing fluids and medications, or if they are in shock and need a shock assessment. And last but not least Ultrasound is the only tech that can do the job at the bedside by the physician and reducing virus contact and exposure to other clinicians – without involving a tech, without having to take the patient to an imaging lab etc…so it does reduce exposure to personnel, and other patients in the hospital.

CW:  What’s the next frontier for POCUS and what technologies or integrations do you see that are promising?

MD:  I truly feel Ultrasound is evolving as it should – taking full advantage of tech miniaturization and consumerization. I mentioned Augmented Intelligence earlier, computing on Ultrasound is so powerful that image processing, analysis and intelligence can certainly help us make faster decisions. And just as we’re learning more and more today with COVID19, the importance of telepresence and telemedicine – and telesonography follows that as well. Why? Well let me step back first. So I always talk about the three levels of proficiencies in Ultrasound 1) knowing how to use the tech ( use to call it knobology now it’s just knowing how to use a common sense intuitive interface) 2) knowing the anatomy and knowing where to position the probe complemented with my knowledge on how to use the tech (this takes some training for sure and many clinicians are empowered to do this NPs, PAs, etc.., 3) the third level is really left for the experienced user who can read the image – the physician specialist who understands the pathology and is able to make diagnosis. Now we’ve practiced for a while that we can train one person to take the image and rely on another to diagnose, the question is can we do it instantaneous as if the expert was in the room, when it is normally so difficult to do that. I think the other concept for evolution in Ultrasound is not o much at the POC (POCUS), but at the POL because the patient may not be in a care location, but in a living location going about their life. So how can I in the future as a family man buy an ultrasound for use at home with my family, and use it as instructed by my remote clinical assistant, and remoting into my mobile device? That is really the future and going beyond the Star Trek Tricorder!

CW:  What advice do you have for POCUS users right now?

MD:  Today Train early, Practice a lot – and not just physicians, but paramedics, Emergency medical Response personnel….Midwives, Nurses, Physician Assistants…

Tomorrow, be very open to doing things that don’t have a protocol set yet – Basically be ready to use ultrasound in ways never thought of before, create new workflows, and set the path for new protocols and clinical needs. Challenge the status quo, and it’s intriguing how much attentive policy makers are now, and receptive to new ways of thinking and caring, so we do have their listening ears to create a more impressive future for Ultrasound. The ultrasound technology has so much more to offer! And we’ve just scratched the surface on what it will be able to do in the future.

CW:  Marco, thank you very much for sitting down and discussing POCUS with me today.

MD:  I hope my Insights were thought provoking!

Ultrasound experts – Ask a family medicine doctor: Interview with Dr. Daphne Rosales Barragan

In our series of interviews with experts to understand the Covid-19 crisis and the context of women’s health better, we speak with family medicine provider, Dr. Daphne Rosales Barragan, family medicine at El Rio Health in Tucson, Arizona.

Dr. Daphne Rosales Barragan, Family Medicine Physician at El Rio Community Healthcare in Tucson, Arizona provides her perspective about women’s health and how to have a safe, healthy, happy pregnancy during the Covid-19 crisis.

Dr. Rosales Barragan is a graduate of the University of Arizona College of Medicine. Her clinical areas of interest include Women’s Health, Geriatrics, Education, Research, and Border/Refugee Care.     

Our team sat down with her for an interview to ask her, as a health expert, what she wants the public to know about the Covid-19 crisis from a family medicine and women’s health perspective.  As both a physician and at the same time a person in the third trimester of pregnancy, she is able to provide a unique perspective about how women’s health has been affected by the crisis and how patients, pregnant or otherwise, can take care of themselves during this pandemic.

CW:  I just want to start by saying thanks so much Dr. Rosales for spending some time with me.  I really appreciate it.

Dr. R:  You’re welcome.

CW:  For the benefit of others, this is Dr. Daphne Rosales Barragan.  She is a family medicine doctor at El Rio Health here in Tucson.  I’m really excited to connect to learn about family medicine care and also pregnancy care during the time of Covid.  So to start off, how are you doing and how are you feeling?

Dr. R:  I am doing great, actually.  I am currently working from home because of the Covid pandemic.  But I was enjoying working at the clinic, with the proper protection of course, to stay with that human contact at least. 

CW:  So for the benefit of other people, can you tell us a little about your daily work, both before and now?

Dr. R:  Before the pandemic I was working both in the outpatient and inpatient setting.  That means we do some clinic work, but the majority of my work is in the clinic.  I have my patient panel and we follow up longitudinally and we form really nice relationships with the patients. I work in the south part of Tucson and we serve the underserved as I work for the community health center. Then besides that, I rotate through the St. Mary’s Hospital in the inpatient adult medicine service, and that also would be serving our El Rio patients.  As a family doctor, I’m able to see, at least in the clinic, the full spectrum of family medicine, which as it says, is babies, newborns, pediatric patients, women’s health, adult health, and geriatrics.  In my case, I do have a wide range of them.  But I would say about 50% are geriatrics, and there are also a lot of newborns. 

CW: How have things changed?  Are you able to do telemedicine at all?

Dr. R:  Yes, so now since the pandemic, we are still in clinic as family medicine doctors.  The patients that are high risk for complications if they were to get an infection, those are the ones we are trying to target through the phone visits, video and audio visits, to keep them at home and help keep them out of unnecessary exposure.  Those patients would be pregnant patients, or those who are elderly or have diabetes that is uncontrolled or heart failure that is not well controlled.  That way, the patients are in the comfort of their home and then we can continue to follow them longitudinally.  So at the end of this pandemic, we don’t end up with all these other clinical conditions that are out of control – or while the hospitals are busy taking care of all these respiratory issues related to the virus they also have to take care of these patients that maybe have complications from their chronic heart conditions or their diabetes.  I think at least at El Rio, we have been very fortunate that our clinical leadership has definitely taken a step ahead and we have been able to prevent and target that early on. 

For me because I’m pregnant (I’m 32 weeks pregnant), I was advised to stay home and do all of my visits now from home.  I have been home for almost two weeks now.  I do miss going into the clinic and interacting with my medical assistants and other physicians, but I do understand that it’s safer for me and my baby to be home. We can still serve the patients via video or audio. It’s both my panel as well as other providers’ panels.  The doctors that are at the center, they do serve, like I said, we do limit the exposure in the clinic, but we do have a specific space in the clinic for “sick patients.”  That means patients that are showing some signs or symptoms of the respiratory infection related to the Covid virus.  Of course, those visits are with protection.  I am forever in debt to those doctors doing those sick visit service to the patients. I am very grateful to them that they are serving the community still.

CW:  You are as well, so thank you for continuing to do the work you do.   So how do you then take care of yourself?  Being pregnant and being a provider right now, and what advice do you have for your pregnant patients and anyone else who is pregnant during this health crisis?

Dr. R:  Well, being pregnant in the third trimester it’s a little hard to stay sitting for long periods of time, which is required during virtual visits.   I make sure I have a water break every other patient and walk, go to the bathroom and at the ends of my sessions I definitely stretch. I do yoga and is a big part of my life and I do incorporate it in my patients’ visits and my patients’ treatment plans.  Yoga has been very helpful not only for the muscle and ligaments stretch necessary after 8-9 hours of work at the desk but also mindfully, putting your mid at ese, not getting your mind lost in the details.  As a pregnant woman you’re planning for your baby to come and of course it’s very, very exciting. But with the current Covid status, you can get lost in the details of “how is it going to look when my parents come in, when my in-laws come?  Am I going to let them see the baby?”  All the things that are very uncertain right now that just create more stress and then of course your baby is going to feel the stress. Even if maybe you are not conscious of it, it does generate a reaction in your body that of course is transmitted to the baby. 

I try to stay on a day-by-day vision.  For instance, daily goals like going out for a walk.  Our neighborhood is pretty far away for other homes, but even if it wasn’t, wearing appropriate protection, going for walks around sunset.  When my husband comes in, staying supportive with him.  Even the daily meals.  It’s the little accomplishments.  Otherwise, life currently would be very monotonous and it would just feel dull.  Sleep of course is very important.  In the third trimester it’s very difficult to sleep throughout the night, at least for most of us. But I try to make sure to get at least 7-8 hours of sleep per night. Staying hydrated is very important too throughout pregnancy to prevent those contractions that might be the false contractions, Braxton Hicks as they’re called, or to prevent cramps, low blood pressure, headaches, all of those things that come from dehydration that can be very, very well prevented.  In this case I would tell my pregnant patients, do as I do, instead as do as I say.  I am trying to practice what I preach also.  Stay focused on right now, the day that’s coming ahead of you.  Don’t get lost in the details.  Maybe things might get better if they’re due in August or September, and hopefully things will get back to normal by then and all of this uncertainties and stress wasn’t necessary. 

But currently, staying in the now and stay home as much as possible.  Whenever you go out, because the CDC and WHO do recommend for us to be protected and our mouth and nose to be covered with a face mask, and make sure that people are staying at least 6 feet away from you, especially strangers.  Like when you’re grocery shopping, which you can, and I actually find that very therapeutic for me, try to go with someone else that’s going to help you because you do need some help lifting some things.  Keeping your nose and mouth covered and washing your hands as soon as you get home. The mask I have found is helpful for protecting yourself from yourself.  Sometimes we tend to touch our noses and mouths.  Use a mask, a bandana or a scarf.  If it’s cloth I do recommend that as soon as you come home from visiting or very close family members in close quarantine or coming back from grocery shopping you wash the mask so you can use it again.  It does need to be washed after being exposed or technically being exposed to the outside. 

CW:  Awesome advice.  Need to be taking some of that advice actually….  Are there any changes to the types of screenings you’d recommend for patients right now?  Or keep everything as normal?  What are your thoughts?

Dr. D:  Screening for the virus and particularly to pregnant patients?  So, we are considered high risk patients because we’re pregnant. The reason is that our immune system is considered to be a little less active.  Your immune system is going to identify something that doesn’t belong and try to attack it. In pregnancy, you’re growing another human and technically it doesn’t belong to you so your immune system sort of needs to tune and calm down so the baby continues to grow.  Because of that we have that relative immunodeficiency or weakened immune system, so that’s why we’re considered high risk patients.  AS with any other high risk patient if you start feeling like you get the flu, you’re having a very bad cold, you have a cough, you have a runny nose, it’s hard to breathe – and I know that’s that hard to gauge in pregnancy because when you get to the third trimester, it’s hard to breathe because your belly is getting bigger – but if it’s not just sporadically, if it’s all coming together, hard to breathe, developing a cough headache body aches, and you have a low grade temperature, and you feel hot and having a fever, that sounds lie the flu for most people.  Maybe a sore throat too, because the flu comes with a sore throat.  If you’re feeling not yourself, under the weather, and it’s not just for a few hours or for one day, the definitely there’s a recommendation to call your OB or your family medicine doctor or primary care provider. 

At least at El Rio, what we’re trying to do is catch those patients over the phone so that we can say, “Ok, no it doesn’t sound like it, it sounds more like a cold or a sinusitis or something else.  Stay home and we’re going to follow up with you over the phone in a couple of days.”  Or, “Yes, you definitely need to come and get tested.”  We’re trying to reach our patients first via a way that is not going to expose them to even more sickness in the real world, but that we’re still going to provide them with care and very close follow up.

Of course, if it’s the middle of the night, and there’s a high-grade fever and you have chest pain, you of course need to call the paramedics, which is the first thing I’d recommend, or go to the ER.  Also, it’s important to say hydrated as I said before, because you could be having body aches because you’re dehydrated, that will of course cause more contractions.  Those would be initially false contractions, but that could predispose you to a preterm labor. 

Tylenol is your best friend if you have back pain.  Tylenol is the best thing to take.  If you’re taking it to consistently feel better because you’re getting a fever or pain everywhere in your body, or getting a headache consistently, that’s when I would say reach out to the primary care provider, ideally first through phone or video and audio services to prevent exposure.  Just imagine, in the ER everyone there really, or even by statistics, at least one person there is going to have some sort of virus. Not necessarily the Covid virus, but some sort of disease or infection that gets transmitted via droplets or being in close proximity.  Of course we don’t want a pregnant patient to be sick.  Every physician or practitioner should have the current guidance and criteria to check pregnant patients.  Also if you don’t have symptoms but you know that you have been in very close contact with someone who has a positive Covid test, and close contact means within 6 feet from you (maybe you were just talking or it’s your partner), that’s another reason to call your provider.  Under some circumstances it would be recommended for you to be tested.  On the bright side, some of the patients that unfortunately have acquired the virus that have been pregnant have delivered in the majority healthy babies and they have had good outcomes in the third trimester.  That’s good news too.

CW:  It’s amazing to actually have good news in span of all this.  I have two more questions for you.  One, do you have any visibility into how the delivery process is changing or what people have to be aware if they have to deliver in the near future or even in the next several months?

Dr. R:  I know that in Tucson they’re only allowing one guest or one companion with the patient.  Normally, we’d allow two or three or as many as the patient would feel comfortable with but right now it’s only one.  I know that could change if our numbers rise or if we see a ramp up of the rate of cases.  At least right now for Arizona we’re getting more cases.  But that’s because we’re testing more and we weren’t testing a lot before.  If we see an increased rate of cases or locally at the hospital there are more cases, then they may actually not even let the companion go into labor with the patient. That’s nerve-wracking in a way for us as pregnant patients.  It’s also a bit discouraging for the partner, that other companion that was going to be there.  I would assume they would allow an iPad or some sort of technology so that the partner could at least be there for part of the laboring process. 

Also I see some of the patients and the community are thinking about laboring more at home I that early stage of labor when you’re just getting comfortable and your contractions are coming, but not too often.  Normally as a physician that’s what we tell our patients.  The reason to come to the hospital is when your contractions are happening every four minutes for a minute, for an hour, (4-1-1 rule).  You need to have a timer with you. It sounds over the top but it helps you gauge things better.  That’s when generally that’s the start of active labor, when your body starts making those changes more rapidly to help baby come down the birth canal and eventually for you to deliver.  So before that, we just say, ok, stay at home, keep track of things, drink water (maybe they’re not real contractions), relax, practice ways of coping with pain, anxiety or stress.  A lot of pregnant women in community, that’s what they’re trying to practice more now.  Of course that should not be a decision you make before touching base with your OBGYN or family medicine doc, or your midwife. You should reach out to them and tell them, hey, I’m thinking about doing this, are you ok with that as my provider?  Of course your situation may be different.  Not everyone’s situation is the same.  I personally think that’s what we would do. We’d practice our pain management and breathing techniques at home before the doctor tells us to go to the hospital. 

That’s another thing.  The positive of this time is that it expands your spectrum of resources and as a woman, a pregnant woman, it really makes you dig into that powerful and positive side of yourself.  Yes, I can do this.  At least that is what I envision and what I hope a lot of women have.  Yes, it’s scary, intimidating to be delivering in this time.  It’s almost a challenge to reach out to that strong, powerful raw woman that has that power within us. Our body knows how to grow babies.  We don’t tell it how to grow babies.  It challenges you to reach out to the things and people you have around you and the techniques you have developed within yourself like breathing techniques or positions or yoga or the birthing ball or warm water.  All those methods that are not invasive are very powerful and accessible to a lot if people.  These times make you reach out to those techniques more.  And of course, communication with your provider. I think it’s a beautiful thing. 

CW:  Wow, that’s amazing.  You kind of touched on it already, but I wanted to end on an additional positive note.  What gives you hope right now?  There are many people that are so stressed out, pregnant or not, with medical conditions or not, and it can be really overwhelming to be in a pandemic, or isolating.  What personally gives you hope?  What can you share with your patients or the general public that might give them hope too?

Dr. R:  I think we’re very fortunate because we have this life coming developing inside of us.  Us as pregnant women, we bring joy in this area of crisis.  When I go out (with my mask of course), everyone smiles at me.  Before the pandemic, I would be like, “Oh that’s nice.  How cool.  Okay.”  But now, it still feels good, but taking it from their perspective, we bring joy and bring up a smile to strangers.  Really, people need, in this time, even more of a reminder of the kindness of the world.  How amazing that you as a pregnant person, a pregnant woman, can inspire that in a stranger. That’s just amazing.   So that keeps me in a positive light. Also, focusing on my baby, the near future.  How I am going to name my baby, what outfit or what clothes.  Washing and organizing the clothes.  Seeing more kids around you, envisioning your child.  Just focusing on the baby keeps me really positive.  I think that hopefully will bring that positive note on the pregnant patients. 

Also, I generally thrive on negative things but when there is a lot of uncertainty, the thing that keeps me going is that every day that passes by, we are a day closer to the end of this pandemic.  It’s a very general statement, but if I remind myself of that and that also helps me stay positive. 

For patients that aren’t pregnant or don’t have a pregnant family member around them, things I tell my patients to keep them positive, to be present in the moment, to realize all the things they already have is actually what they need.  With that, it’s helping them healthy, it’s keeping them alive, and grateful to be alive.  I invite them to be mindful and grateful of what they have already.  Maybe before they had plans to get a new car or something else – that’s actually not what they needed.  What they have around them is enough. 

I do recommend that when we watch the news or read the news that we are selective of what we read, and like everything, that it’s the right amount.  Don’t watch the morning, afternoon, and evening news, because they’re all saturated with Covid.  Just pick your source and do that once a day because it’s important to stay informed.  Other than that, find a new hobby. 

It could be writing, journaling, drawing (doesn’t have to be good), gardening, or something new that is going to help cope with the dullness and anxiety provoking time.

A lot of my patients they’re knitting, watching cooking videos, in the garden, some of them are fortunate enough to have a stationary bike at home so they’re doing that.  I have one patient who recorded herself to show me she was doing that.  If they have access to social media to use it on a positive note.  You can work out with your friends, you watch a video together everyone with their phones or on TV and you can debrief at the end and hang out.  If you keep that consistently, it won’t feel like such lonely times. 

CW:  Great suggestions.  Seriously thank you so much for sharing them.  It is true.  Every one day, we are getting closer to the end and that is super powerful to keep in mind.  Thank you.  Thank you for spending time with me today and sharing medical expertise and life expertise with us. Really appreciate it. 

Dr. R:  It’s nice.  It’s enjoyable.  I’m very happy you asked me to talk. 

Ultrasound experts – Ask a radiologist: Interview with Dr. Berndt Schmit

In our series of interviews with experts to understand the Covid-19 crisis and the context of ultrasound imaging and healthcare better, we start by speaking with medical expert, Dr. Berndt Schmit, Section Chief of Emergency Radiology and President of Humanitarian Radiology Development Corps. In this interview, Dr. Schmit gives his perspective about radiology’s role in addressing the Covid-19 crisis, how low resource settings are particularly affected, and what we each can do to help.

Dr. Schmit and his 501c3 focus on providing education, training and capacity development with radiology programs in limited resource locations including Nicaragua, Bolivia, Haiti, and Ghana. Humanitarian Radiology Development Corps donate ultrasound equipment and provide training on how to install and use the it. Our team sat down with him for an interview to ask him, as a health expert, what he wants the public to know about the Covid-19 crisis from a radiology perspective.

CW: Thanks you so much for joining me today. I’m really looking forward to hearing your perspective about what is going on with this global pandemic.

Dr. S: Hi Courtney. Glad to be with you on this beautiful morning. It’s hard to tell there’s actually a crisis going on.

CW: For folks, can you give us a brief snapshot of your background and the different areas in which you’ve worked?

Dr. S: My name is Berndt Schmit. I’m a board-certified radiologist and a full-time faculty at University of Arizona. I’m trained in Musculoskeletal radiology but now work full time as an emergency radiologist and actually started our program there last year.

CW: I’m also really interested in hearing more about your work with Humanitarian Radiology Development Corps, so if you could give a bit of background about that as well, that would be great.

Dr. S: I started working in third world countries four or five years ago and rapidly got experience with it. If you’re doing radiology work, it’s very equipment intensive and infrastructure intensive. I migrated from going to these countries to do work or educate people there, to realizing we had to help build their capacity to do radiology work. People essentially didn’t have fishing poles so we had to transition into the idea of we have to help them build fishing poles, maintain their fishing poles, so to speak.  So we started Humanitarian Radiology Development Corps about two years ago and we work now mostly in Haiti but we also have completed projects in Bolivia.  We are ramping up projects in Nicaragua and Ghana now.

We have a pretty large focus on donating ultrasound equipment and then doing the associated training to help the client become functional with ultrasound service.  We’re tip-toeing into much bigger projects.  One sound bite is we’re basically building imaging centers and radiology departments in the developing world.  Very challenging work.  Very fulfilling work.  What we’re trying to do is grow a Rolodex of contacts for people who can donate their time and for institutions who can donate equipment so we can do this heavy scale work that we’re doing.  

CW:  Thank you thank you so much for the background and the work you’re doing.  We really identify with it and think it’s really important.

Dr. S: There is a lot of debate in the field of radiology about what the radiologist’s role is as imaging specialists. Some organizations and people maintain that there is nothing particularly specific about Covid-19 that appears on chest films or CT scans, even ultrasound, so the role of a radiologist should be somewhat limited. Then, there is a lot of information from places that are doing a lot of work with Covid, such as Italians, Spaniards, Chinese, who are using a lot of CT imaging and bedside ultrasound.

There is some confusion or clarity that can still be developed around the concepts of triage – the idea is that you may not have a diagnostic imaging modality, yet you can use the imaging tool for management purposes or true triage. The concept of triage is a sort of grim concept, but triage really becomes relevant when you don’t have enough resources. Essentially, then physicians in charge have to make really difficult choices about who gets resources or not, which is a really uncomfortable way of saying some may have to die.

So, a lot of our country fortunately is not at that level, but I think we’re starting to see that in New York, and I’m pretty sure other countries have seen that when their system gets overwhelmed. I think that’s where putting the radiology hat back on, if you have a CT scan, it may not be specific, with Covid, if you have a tremendous amount of disease, that’s probably a sicker patient. It’s reasonable to make the assumption that that person has a poorer prognosis.

If you’re faced with two 30-year-olds who have disease and one looks really bad and you only have one ventilator left, this may help inform how you direct resources.  You may decide to use the resources for the sicker patient or you can imagine it’s if it’s bad enough maybe that’s a reason not to give that person that resource. I think imaging is such a powerful set of tools to get information and it doesn’t always have to be diagnostic, it may just be added information about severity or whether there are complications. 

When the dust settles in say in 6 months from now, we as radiologists will say, wow, imaging plays this huge role.  Maybe it’s not diagnostic, but boy can it be helpful in who gets admitted, who goes to an ICU, who gets a ventilator, what do we tell family members until lab tests come back. 

A problem we’ve had in the United States is that our lab testing takes so long. It’s slowly getting better it seems, but the market seems to be different in their experience.  If you’re facing five days of waiting for a lab test and a CT scan might be able to tell you that this looks pretty classic for Covid, it’s not specific, but you can go back home and if you have grandparents or family member with a renal transplant, they’d be very high risk for a fatal outcome.  

So again, imaging is such a set of powerful tools and we’re going to learn better how to manage it from a triage concept and from a management concept.

CW:  Just wondering, with all the different imaging modalities you have available, if you had just one at your disposal, which would you pick to combat the Covid fight, and why? 

Dr. S: Well, I’m talking to one of the best ultrasound entrepreneurs in the world, probably, so I should say ultrasound –

CW: Haha, no, you shouldn’t!

Dr. S: As radiologists, oddly, we don’t use much ultrasound for lung and pleura imaging but as I am working more and more with emergency doctors, they do. So getting on a learning curve about that. It sounds like ultrasound has been very helpful at the bedside for the actual ICU physicians in Italy. Being able to do a quick imaging test to tell are things better or worse without having to bring in a machine, expose the CT technologist to that patient… you have someone already in a sealed suit in the room pull out a handheld ultrasound device and just answer the question “Is there more or less lung disease?” It gives a clinical picture and helps them make decisions.

I think in the context of “Are you in an ICU, do you have a really sick patient?” ultrasound may actually be a really helpful tool. It’s so portable now the logistics around it are much simpler. That said, CT probably gives the most information. We can see the lung really well, we can see the pleura really well. It’s still not specific, as we discussed, but boy, your ability to see things. In the early phase of the Covid infection is when you might see characteristic features that might be Covid-suggestive, shall we say. Later on the lung just gets so horrible we talk about end stage lung, or ARDS appearance and that’s not specific really at all.

CW: Got it. And I’m curious, with all your international experience and the global mindset that you bring to your practice, what are you hearing about the places you work with for example in Nicaragua and Haiti? How are they handling the crisis. We hear a lot about Italy, we hear a lot about Europe, maybe a little about Asia as well. But we haven’t heard as much about the emerging economies of the world that are having to tackle this challenge as well.

Dr. S: Great question! I wish I could travel cause I’d love to go see firsthand but I read a newspaper article about Nicaragua, and it just sounds like they are promoting social activities in a denial phase of things. That’s really scary because that’s not a good approach to a respiratory infectious agent. I have a couple contacts in Haiti I’ve talked to and it sounds like they are just starting to see the disease there. I don’t know what their testing capability is. I don’t know if they’re sending lab tests out to say to the United
States somehow. Or if they’re doing local tests. But it sounds like they have proven Covid cases.

The problem in a resource poor environment is that there aren’t enough ventilators, there are not a lot of physicians who are good at handling severe ICU cases. The terrifying part is that the population density in slums is so high the idea of social distancing is somewhat fantastical.

I have been listening to some news reporters from India and other places and the idea of being able to wash your hands multiple times a day is a real luxury. You have to have clean water, you have to have soap. For the poorest of the world, that is fantastical. They won’t be able to do that.

I think the terrifying part for a country like Haiti is that once Covid gets going, it could be a massive, overwhelming pandemic. There are no places for these patients to go. They can’t spread out, there’s no high quality healthcare facilities. These are places that were overwhelmed before health crises like Covid. I think about the poorest parts of the world and I think Covid could just be an incredible horror show.

CW: This is devastating to hear. In closing, what do you recommend? As a lay person what can I do, both here in my home country and what can I do for those abroad?

Dr. S: Wow, so what I think we’re doing right now with social distancing seems to be working, and working well. So, in a wealthy country where we live in individual homes and we can move around in cars that are kind of hermetically sealed, we have some fantastic options. If we were just disciplined as a society, we may flatten the curve, to the point that only a modest number of people have the disease at any point and our healthcare system should be able to handle that fairly well. It’s going to be expensive, it is going to be disruptive. But we have options. If we’re careful about what we do, if we don’t just ramp up the economy quickly and tidal wave back into crowded environments like restaurants or stores, I could see the United States doing ok.

I think six or 12 months from now when we look back, we’ll say well New York is a really unique environment. The subways – I’ve been to New York a bunch of times – the restaurants there, the stores there, everything is so much more crowded. When you’re talking about a respiratory droplet spread infectious agent, that the kind of way you can spread it effectively. A slum environment, high density environment, a mass transit environment, it is going to be a good mechanism for spread.

If the rest of the country can somehow make do with current social distancing, maybe we’ll have to explore with how you have limited return to work and limited return to school, we may do okay. I think that’s the personal, what we as individuals can do. What we’re doing now seems to be helping, helping a lot maybe.

On a bigger picture, we’ll look back and wonder why did the richest country, most technology-advanced, highly informed society not prepare well? A lot of people will do the political spin, maybe we did or didn’t, but frankly no. We didn’t prepare well and there should be some lessons learned. Hopefully we don’t spend too much time pointing fingers, but rather we have to think about how we can organize our actual healthcare system into something that is integrated and can respond as a whole.

It’s an interesting thing to think about. If we have a million ventilators in the country we don’t need a lot of them in Kansas right now, but we sure need a lot of them in New York. If we were an integrated healthcare system with say a Ministry of Health that could be done. We could move all the ventilators to New York, and as they finished their curve, we could move them to Kansas or LA or wherever the next surge of disease is.

But we’re not an integrated system, we don’t have leadership, and into that vacuum has stepped a very politicized government and we have a mess of slow response and it’s unfortunate. Hopefully on the other side of this, we’ll as a nation we’ll think about can we better leave healthcare, and provide physicians and experts with clinical knowledge.

CW: I for one think Dr. Schmit for the first Minister of Health in the US would be awesome. Truly, thank you so much for sharing your expertise with me and helping us understand the context of the crisis not just here but globally. It’s really important. Thanks for letting us for rely on your expertise. We’re grateful for the expertise you bring to us and the rest of the world, so thank you.

If you’re interested in learning more about Humanitarian Radiology Development Corps and how you can help with education and capacity building in their projects in Haiti, Nicaragua, Ghana, and Bolivia, contact bpschmit12@gmail.com or visit: hrdcorps.org.

A Beginner’s Guide to Ultrasound Technology

The Importance of Ultrasound

Diagnostic ultrasound, or sonography, is a common, noninvasive method for taking real time images from inside your body. The first thing that may come to mind when you think about ultrasound is probably pregnancy. This makes sense, as ultrasound is a bit of a gold standard for obstetrics and gynecology. Safe and gentle, routine scanning for pregnant women can aid in preventing perinatal and maternal mortality due to complications such as prematurity, birth asphyxia and congenital malformations1. Sonography was introduced to OB/GYN beginning in 19582, with early abdominal ultrasound images. These paved the way for the eventual development of equipment and scanners that could be used to locate the placenta and later conduct fetal biometry2. The technology took off through the rest of the 20th century as scientists improved upon scanning systems and probes that displayed its robust range of capabilities such as detecting placenta location, observing the heartbeat, identifying the presence of twins and monitoring high risk pregnancies. By the year 2000, medical professionals offered real-time scanning and 3D images with high resolution abdominal and endovaginal transducers2. With all of its modern capabilities, sonography is on the rise in other areas of medicine such as cardiology, emergency point of care, sports medicine and even ophthalmology.

How it Works

Ultrasound probes generally utilize piezoelectric crystalsto transmit high frequency soundwaves into the body through a transducer. Ultrasonic frequencies differ from others in that they cannot be heard by the human ear (above 20,000 Hz), with typical scanners operating in a range of 2 to 18 megahertz3. Rapidly applying and removing voltage to said crystals causes them to expand and contract, producing the ultrasonic waves. As the waves travel some are absorbed, and others are reflected back.  Modern methods use a sonar-like principle to register the pulse reflected off of the boundary between two tissues with differing acoustic resistance3. The acoustic resistance is simply the resistance to the flow of sound through a given surface. These echoes travel back to the crystal and generate a different voltage depending on the wave intensity. The transducer sends these signals to the ultrasound machine to be converted to an image.

There are four primary modes3 for scanning tissue:

  • A-mode or amplitude mode, which uses a single transducer to scan a line through the body and plot the echoes as a function of depth.
  • B-mode or 2D mode, uses a linear array of transducers (phased array) to scan a plane through the body and generate a 2D image.
  • M-mode or motion, employs a rapid sequence of B-mode scans in sequence to view range of motion.
  • Doppler mode, chiefly used to measure and visualize blood flow using the doppler effect.

Common Probe Types

Different devices tune the sound waves to focus on particular depths, either through controlled pulses from the machine or by utilizing differently shaped probes. Some common probe types include linear, curvilinear, phase array and endocavity4,5. Numerous probe types allow for diverse imaging applications:

  • Linear probes are used for imaging structures near the surface as well as vascular imaging and guided procedures. High frequency waves offer better resolution, but cannot penetrate as deep.
  • Curvilinear or convex probes use lower frequency waves in order to gain deeper penetration and have a wider field depth. They can be general purpose and are commonly used for abdominal imaging.
  • Phased Array probes have a smaller contact area and are primarily used for intercostal imaging of the liver between the ribs and for cardiac scans.
  • Endocavity or Intracavity probes are designed to image inside the body cavity and have a longer, slim design.

Challenges

Despite numerous benefits, traditional cart-based ultrasound equipment is expensive and difficult to maneuver. Ultrasound units can cost anywhere between $10,000 and $200,0006 depending on the machine, and may require more budget for additional probes and maintenance. Components such as piezoceramics tend to be expensive, though recent progress in fabrication of capacitive micromachined transducers could eventually reduce the cost as well as advance current technology 7. Another pitfall is the need for a trained operator as experience is generally necessary to obtain quality images and for making a correct diagnosis. Detailed user training courses can cost providers an additional $1000-$6000 6, consuming valuable time and resources. Portable scanners are an emerging technology targeted at addressing some of these issues. Conventional ultrasound machines require higher voltages to drive their transducers7, and early scaled-down applications struggled to compete at first. However, recent advances in computing and batteries have allowed for the development of new, smaller equipment that can image on a similar level to cart based systems.

The Benefits of Portable Ultrasound

Easy-to-use handheld ultrasound systems present a cost effective solution for diagnostic imaging on the go as well as reducing the learning curve for operators. The VistaScan software shrinks your typical carted ultrasound machine into a conveniently sized cell phone or tablet, in addition to being 20 times less expensive. This mobile health innovation makes it possible for clinicians to capture and save images and video loops at the touch of a button with choice of four different types of probes. USB probes can conveniently be swapped out to adapt to a doctor’s needs even out of the hospital or in rural areas. Those seeking a second opinion or assistance in diagnosing a patient are able to send an image through the platform and receive a diagnosis report back within minutes. By reducing the time and cost to diagnose patients, VistaScan helps people receive treatment faster and feel better sooner.

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References

[1] Amo Y, T. A, T. E. The Role of Obstetric Ultrasound in Reducing Maternal and Perinatal Mortality. Ultrasound Imaging – Medical Applications. August 2011. doi:10.5772/22847.

[2] Campbell S. A short history of sonography in obstetrics and gynaecology. Facts Views Vis Obgyn. 2013;5(3):213-29.

[3] Carovac A, Smajlovic F, Junuzovic D. Application of ultrasound in medicine. Acta Inform Med. 2011;19(3):168-71.

[4] Szabo, T. L. and Lewin, P. A. (2013), Ultrasound Transducer Selection in Clinical Imaging Practice. Journal of Ultrasound in Medicine, 32: 573-582. doi:10.7863/jum.2013.32.4.573

[5] Stanford Medicine 25. (2019). Bedside Ultrasound. [online] Available at: https://stanfordmedicine25.stanford.edu/the25/ultrasound.html [Accessed 1 Feb. 2019].

[6]Costowl.com. (2019). 2019 Average Ultrasound Machine Prices: How Much Does an Ultrasound Machine Cost?. [online] Available at: https://www.costowl.com/healthcare/healthcare-ultrasound-machine-costs.html [Accessed 1 Feb. 2019].

[7]J. M. Baran and J. G. Webster, “Design of low-cost portable ultrasound systems: Review,” 2009 Annual International Conference of the IEEE Engineering in Medicine and Biology Society, Minneapolis, MN, 2009, pp. 792-795. doi: 10.1109/IEMBS.2009.5332754

More than Obstetrics: 5 Unlikely Uses for Ultrasound

Today’s medical professionals have access to a variety of imaging procedures. Ultrasound is one of the more convenient methods as it doesn’t require exposing patients to radiation and provides relative freedom in movement. Because of this added safety, sonography is a preferred method for monitoring pregnancy and majorly contributed to recent developments in obstetrics. Nonetheless, obstetricians don’t have a monopoly on this expanding technology. Here are 5 other areas where its adoption proved useful:

1: Cardiology and Acute Care

Cardiovascular ultrasound provides physicians with a valuable look inside of the chest cavity as well as a look at vasculature throughout the body. Cardiac ultrasounds, or echocardiograms, produce images of heart anatomy such as valves, chambers and shed light on any abnormalities that may be present when investigating heart function. Vascular ultrasound is used to evaluate blood flow and detect blockages as well as blood clots. This is especially helpful for following up and monitoring recent recipients of stents or grafts. Echocardiograms are traditionally interpreted by a cardiologist. Recently however, the use of limited echocardiography by providers such as anesthesiologists and emergency medicine physicians is becoming more common 1 . These point of care echocardiograms are utilized by non-cardiologists along with thoracic ultrasonography to evaluate for cardiac trauma, hypotension, pneumothorax and alveolar/interstitial diseases that can lead to respiratory failure 2 . Though it cannot replace a comprehensive exam, ultrasound delivers vital supplementary information for monitoring patients and establishing diagnosis in an acute setting.

2: Radiology

In situations where a standalone PET, MRI or CT scan doesn’t afford enough scope, radiologists take advantage of an innovative technique that incorporates ultrasound to gather more data. Fusion imaging is the process in which images from the above scans are overlaid or used side by side with ultrasound images. Newer high-end software is even capable of fusing scans with live ultrasound 3 . This is advantageous for both physicians and patients because tissues can be viewed in real time and compared to findings from multiple modalities. Sonography is also a more convenient option for real time scanning compared to MRI as there’s no need to factor in things like contrast injections or worry about metal implants. With applications ranging from brain surgery and liver procedures to ultrasound guided tumor removal 3 , fusion imaging is gaining momentum in the diagnostic world.

3: Musculoskeletal Imaging

Another useful trait of sonography is that it’s the most sensitive imaging technique for assessing the extent of tendon tears 4 . This is particularly helpful in sports medicine as well as podiatry, where clinicians frequently need to evaluate injury sites and differentiate between inflammation and actual tears. Other key applications include evaluating conditions such as plantar fasciitis and determining whether an athlete has merely suffered from a muscle strain or a full on avulsion fracture 4 . In addition to visualizing muscle tissue, joints, fascia and tendons, musculoskeletal sonography assists in outlining bones. Although ultrasonic waves do not penetrate bones, they can still image features on the surface. Research even suggests that ultrasound is a feasible method for diagnosing stress fractures, particularly in the lower extremities 5 . An added trait of newer ultrasound is that more portable technologies allow evaluations to take place out of the clinic as well as assessing the function of moving parts while in use as opposed to being limited to static images.

4: Dermatology

Ultrasound is employed by dermatologists to evaluate skin conditions and adjust treatment plans. Cost is factor that inhibits dermatologists from adopting new imaging methodologies because advanced techniques such as reflectance confocal microscopy and optical coherence tomography require expensive computing systems as well as training 7 . When extreme detail isn’t necessary, skin ultrasonography serves as an economic, reliable solution for rapid examination and measurements. High frequency scanners are able to monitor detectable, irregular properties in the dermis while lower frequencies detect deeper structures such as lymph nodes and subcutaneous tumors 6 . Given these capabilities, sonography is a cost-saver for identifying inflammatory conditions such as psoriasis or looking at skin lesions and tumor thickness.

5: Handheld, Bedside Ultrasound

This final application utilizes multiple modalities. The adoption of diagnostic ultrasound is growing in the rural and developing world, and in particular, handheld, bedside ultrasound performed by clinicians 8 . This is a simple and elegant solution in regions where more expensive systems and infrastructure are difficult to access. Portable devices with abdominal, cardiac and musculoskeletal capabilities among others are making a difference where medical imaging may not have been an option previously. Sonography provides a basic diagnostic tool for a number of ailments in low and middle income countries such as tuberculosis, malaria, and ectopic pregnancy 8 . Medical professionals worldwide have taken advantage of the technology and are making a statistical impact by administering obstetrical, abdominal, cardiac, renal, pulmonary, soft tissue and vascular exams in rural areas of Africa, Asia and North America 8 . Diagnostic ultrasound is a powerful mechanism with functionality in all areas of medicine. With varying frequencies and modes, physicians from different backgrounds utilize sonography to image conditions spanning from the most superficial of ailments all the way to organ trauma and tumor identification. Its diverse capabilities and relative cost make it a tool worth having available.

References

  1. Klugman D, Berger JT. Echocardiography and Focused Cardiac Ultrasound. Pediatr Crit Care
    Med. 2016;17(8 Suppl 1):S222-4.
  2. Whitson MR, Mayo PH. Ultrasonography in the emergency department. Crit Care.
    2016;20(1):227. Published 2016 Aug 15. doi:10.1186/s13054-016-1399-x
  3. Ewertsen C, Săftoiu A, Gruionu LG, Karstrup S, Nielsen MB. Real-Time Image Fusion
    Involving Diagnostic Ultrasound. American Journal of Roentgenology. 2013;200(3).
    doi:10.2214/ajr.12.8904
  4. Hashefi M. Ultrasound in the Diagnosis of Noninflammatory Musculoskeletal Conditions.
    Annals of the New York Academy of Sciences. 2009;1154(1):171-203. doi:10.1111/j.1749-
    6632.2009.04391.x.
  5. Amoako A, Abid A, Shadiack A, Monaco R. Ultrasound-Diagnosed Tibia Stress Fracture: A
    Case Report. Clin Med Insights Arthritis Musculoskelet Disord. 2017;10:1179544117702866.
    Published 2017 Apr 10. doi:10.1177/1179544117702866
    6.Schmid-Wendtner M, Burgdorf W. Ultrasound Scanning in Dermatology. Arch Dermatol.
    2005;141(2):217–224. doi:10.1001/archderm.141.2.217
    7.Hibler B, Qi Q, Rossi A. Current state of imaging in dermatology. Seminars in Cutaneous
    Medicine and Surgery. 2016;35(1):2-8. doi:10.12788/j.sder.2016.001.
  6. Sippel S, Muruganandan K, Levine A, Shah S. Review article: Use of ultrasound in the
    developing world. Int J Emerg Med. 2011;4:72. Published 2011 Dec 7. doi:10.1186/1865-1380-
    4-72