Using AI and Ultrasound to Diagnose COVID-19 Faster

Coronavirus disease 2019 (COVID-19) is a newly identified virus that has caused a recent outbreak of respiratory illnesses starting from an isolated event to a global pandemic. As of July 2020, there are over 2.8 million confirmed COVID-19 cases in the U.S. and over 11.4 million worldwide. In the United States alone, over 130,000 Americans have died from COVID-19, with no end in sight. A major cause of this rapid and seemingly endless expansion can be traced back to the inefficiency and shortage of testing kits that offer accurate results in a timely manner. The lack of optimized tools necessary for rapid mass testing produces a ripple effect that includes the health of your loved ones, jobs, education, and on the national level, a country’s Gross Domestic Product (GDP), but artificial intelligence and ultrasound may help.

STATE OF ART IN DIAGNOSIS

Prof. Alper Yilmaz, PhDCurrently, there are two types of tests that are conducted by healthcare professionals–diagnostic tests and antibody tests. The diagnostic test, as the name implies, helps diagnose an active coronavirus infection in a patient. The ideal diagnostic test and the “gold standard” according to the United States Center for Disease Control (CDC) is the Reverse Transcription Polymerase Chain Reaction, or simply, RT-PCR. RT-PCR is a molecular test not only capable of diagnosing an active coronavirus infection, but it can also indicate whether the patient has ever had COVID-19 or were infected with the coronavirus in the past. However, the time required to conduct the test limits its effectiveness when mass deployed.

A much faster but less reliable diagnostic test alternative to RT-PCR is an antigen test. Much like the gold standard, the antigen test is capable of detecting an active coronavirus infection in a much shorter timeframe. Although antigen tests produce rapid results, usually in about an hour, the results are deemed highly unreliable, especially with patients who were tested negative according to the US FDA.

In contrast, the antibody test is designed to search for antibodies produced by the immune system of a patient in response to the virus and is limited by its ability to only detect past infections, which is less than ideal to prevent an ongoing pandemic.

THE PROBLEM 

To combat the rapid expansion of an airborne virus such as COVID-19, or future variations of a similar virus, rapid and reliable solutions must be developed that aim at improving the limitations of current methods. Although highly accurate, methods such as RT-PCR do not meet the speed requirements needed for testing on a large scale. Depending on the location, diagnosis of an active coronavirus infection with RT-PCR may take anywhere between several hours and up to a week. When the number of daily human-to-human interactions are considered, the lack of speed in diagnosing an active coronavirus patient could be the difference between a pandemic or an isolated local event.

As an alternative to molecular tests, Computed Tomography (CT) scans of a patient’s chest have shown promising results in detecting an infection. However, in addition to not being recommended by the CDC to diagnose COVID-19 patients, there are many unwanted consequences with the use of CT scans. With CT scans used to diagnose multiple illnesses, some of which relate to serious emergencies such as brain hemorrhaging, they cannot be used as the primary tool for diagnosing COVID-19. This is especially true in rural areas where the healthcare infrastructure is underfunded. Mainly due to the required deep cleaning of the machine and room after each patient, which usually requires 60 to 120 minutes, many institutions are unable to provide CT scans as a viable primary diagnostic tool. Ultimately, given the need for CT scanners for several other health complications combined with limited patient capacity at each hospital, alternative methods must be developed to diagnose an active coronavirus patient.

THE SOLUTION 

Recently Point-of-Care (POC) devices have started to be adopted by many healthcare professionals due to its reliability and portability. An emerging popular technique, which adopts improvements made in mobile ultrasound technology, allows for healthcare professionals to conduct rapid screenings on a large scale.

Working since mid-March, when early cases of physicians adopting mobile ultrasound technology emerged, the research team at The Ohio State University, Dr. Alper Yilmaz and PhD student Shehan Perera, started developing a solution that can automate an already well-established process. Dr. Yilmaz is the director of the Photogrammetric Computer Vision lab at Ohio State. Dr. Yilmaz’s expertise in machine learning, artificial intelligence, and computer vision combined with the research experience of Shehan Perera laid a strong foundation to tackle the problem at hand. As it stands, the screening of a new patient, with the use of a mobile ultrasound device takes about 13 minutes, with the caveat that it requires a highly trained professional to interpret the results generated by the device. With the combination of deep learning and computer vision, the research team was able to use data generated from the ultrasound device to accurately identify COVID-19 cases. The current network architecture, which is the product of many iterations, is capable of detecting the presence of the virus in a patient with a high level of accuracy.

Many fields have been revolutionized with modern deep learning and computer vision technologies. With the methods developed by the research team, this technology can now allow any untrained worker to use a handheld ultrasound device, and still be able to provide a service that rivals that of a highly trained doctor. In addition to being extremely accurate, the automated detection and diagnosis process takes less than 10 minutes, which includes scanning time, and sanitation is as simple as removing a plastic seal that covers the device. The benefits of this technology can not only be useful for countries such as the United States, with a well-established healthcare system, but, more importantly, can significantly help countries and areas where medical expertise is rare.

CONCLUSION 

The United States healthcare system is among the best in the world, yet we are failing to provide the necessary treatment patients clearly need. The developments made in artificial intelligence, deep learning, and computer vision offer proven benefits, which can not only be leveraged to improve the current state of the global pandemic but can lay the foundation to prevent the next. Alternative testing methods such as mobile ultrasound devices combined with novel artificial intelligence algorithms that allow for mass production, distribution, and testing could be the innovation that could help decelerate the spread of the virus, reducing the strain on the global healthcare infrastructure.

Feel Free to Reach the Authors at: 

Photogrammetric Computer Vision Lab – https://pcvlab.engineering.osu.edu/
Dr. Alper Yilmaz, PhD
Email: Yilmaz.15@osu.du
LinkedIn: https://www.linkedin.com/in/alper-yilmaz

Shehan Perera
Email: Perera.27@osu.edu
LinkedIn: https://www.linkedin.com/in/shehanp/

References 

https://www.fda.gov/consumers/consumer-updates/coronavirus-testing-basics

https://www.whitehouse.gov/articles/depth-look-COVID-19s-early-effects-consumer-spending-gdp/#:~:text=BEA%20estimates%20that%20real%20GDP,first%20decline%20in%20six%20years.&text=This%20drop%20in%20GDP%20serves,in%20response%20to%20COVID%2D19.

 

Interested in learning more about COVID-19 or AI? Check out the following posts from the Scan:

https://connect.aium.org/home

The Invisible Front Line

2020’s trials seem to have come on like a freight train; full steam ahead with no signs of stopping. Australia was still burning when we first heard stories of a novel virus with pandemic potential in Wuhan, China. Numbers and other details seemed to change daily. Weeks went by as we watched world news intently, taking note of the infection rate and death toll, all the while steeling ourselves for a possible outbreak at home. As much as we tried to go about our daily lives, Wuhan and the virus was never too far from our minds. Was this virus airborne? There were still so many unanswered questions, but one thing was certain; COVID-19 was spreading like wildfire and it was only a matter of time now before we would be on our own front line.Huang

Sonographers and other medical professionals soon began deployment into COVID wards in our own hospitals: areas that had been sealed off and outfitted as negative pressure cohort units to treat the infected patients. Then the deluge of daily updates and dizzying policy changes began as we tried to keep up with CDC guidelines. Rumors surfaced of limited PPE (personal protective equipment) supplies. Only doctors and nurses needed n95s? Regular procedure masks were fine for everyone else? Surely that was incorrect. Surely they knew what kind of prolonged contact sonographers have with our patients? X-ray was making contact with every patient under investigation (PUI). CT was scanning countless chests. Worries intensified as we all tried to navigate this new reality.

I’ll never forget my first assignment in the cohort. Only one other sonographer in my department had gone into the cohort at that time. He relayed seeing 3 morgue carts lining a hallway on his first trip inside. I thought about that often in the days that followed and I knew my turn was coming. How would I handle that? Some of our respiratory therapy (RT) and interventional radiology (IR) colleagues had tested positive by this time. I thought about my little boy. I saw news coverage of doctors and nurses who were self-quarantining after their shifts to decrease the potential spread to their families. I didn’t have that option as a single mother.

Finally, it came: my first COVID+ request. I told myself it would be fine. I just needed to be brave, be safe, and stay alert. I’ve never been to battle but having the media images in my mind and knowing the death toll numbers, I imagined this is what it might feel like on some small level. I thought about the PPE shortage and the rumors that we wouldn’t have access to n95s. I steeled my nerves and walked one foot in front of the other with Apollo (my LOGIQ E10). I arrived outside the cohort and was immediately greeted by the plastic sheeting that sealed off the unit. I found an anteroom with shelves overflowing with supplies. A lovely volunteer helped outfit me with everything I needed: a fresh n95, a surgical mask to go on top, a contact gown, shoe covers, eye protection, and a scrub hat. We exchanged nervous chatter for a moment as she gave me a once over to make sure I was ready. She opened the door and I exhaled as I walked inside.

As I made my way to my first patient, I noticed things were definitely different. Physicians and nurses donned full respirator masks, patient information was written on the room windows so staff could see information such as code status from the hallway, and iv poles with extra tubing sat outside of patient rooms so nurses could adjust pumps without going inside. I also learned that doctors were either doing virtual or modified rounds with one MD per team going into the patient’s room while the rest stayed outside. One came in during my 30-minute exam. As I stood hip-to-hip with my patient, he stood at the foot of the bed, asked the patient a few questions, and was gone in about 2 minutes. It struck me how much extra caution was being taken for doctors and nurses to limit their exposure times.

Some other things in the cohort looked like business as usual. I saw radiographers and cardiac sonographers going about their usual work. I saw food service delivering meals. I saw housekeeping working to stay on top of the mountains of doffed contact gowns and other garbage. Everyone was working individually on this front line for a common goal: our patients. Yet, as I arrived home that day and turned on the news, I was once again told by the media that nurses and doctors are the essential workers in this pandemic. While I absolutely believe nurses and doctors deserve every ounce of recognition they receive, I sometimes think people forget that it takes a team to deliver excellent patient care. I was fortunate enough to be able to share my experiences with Alison Bowen of the Chicago Tribune recently in the hopes of illuminating just some of what we do in a day as Diagnostic Medical Sonographers.

My first patient had a seizure during my exam that day. As I approached my second patient’s room to perform a liver Doppler, a doctor sitting outside of the room informed me the patient had just passed away. My third patient was about to receive a Foley catheter and was extremely nervous. Her nurse asked me to help assist before I started my ultrasound. The patient was still very nervous so I went to the hallway to find extra help. I asked an employee there if she wouldn’t mind coming in and holding the patient’s hand. She looked behind herself and then back at me before stating, “I’m just EVS [environmental services] but I’m happy to help if it’s OK.” She donned a gown and jumped right in.

 

Angela Huang, BS, RDMS (AB,OB/GYN,PS), RVT, is a Diagnostic Medical Sonographer for a large research hospital in Chicago. She attended DePaul University for undergraduate studies where she majored in Biology. Huang went on to Sonography school at El Centro College in Dallas, Texas. Now, she has a 10-year-old son who keeps her laughing and they love to travel and explore.

Interested in learning more about COVID-19? Check out the following posts from the Scan:

 

https://connect.aium.org/home

No Words Are Strong Enough

Low- and middle-income countries have always faced major health difficulties related to lack of human resources, facilities, and access to drinking water and electricity. Added to these factors are the lack of a suitable road, geographical remoteness, and poverty. Hence, the management of patients is compromised both diagnostically and therapeutically.

IMG_20200513_125259_B

Point-of-care ultrasound (POCUS) offers wide possibilities to health professionals who work in areas with limited resources by means of the portable machine with a good battery. Therefore it is possible for the clinician to go to low- and middle-income countries to dispense quality care services on the spot while giving access to diagnostics and guiding the management and emergency invasive procedures. IMG_20200513_100229

As a primary care physician, I was trained on clinical ultrasound through the Canadian platform in the emergency unit. I use it in my routine practice as part of my physical exam with my patients, which greatly increases my precision. No words are strong enough to describe how we feel when we examine a young woman who consults for severe pelvic pains associated with metrorrhagia and we suspect an ectopic pregnancy and the B-HCG urine test comes out positive, so you grab your US probe and you find an empty uterus, a hemoperitoneum. The fact that you saw the patient’s interior and were to be able to show her what exactly is wrong…. It’s a strength beyond what the words can explain, the precise diagnosis is reliable and prompt.

Once a month, I travel to Yabassi, a small village surrounded by a forest in the littoral region of Cameroon, which is difficult to access and rarely supplied with electricity, to do ultrasound for pregnant women discouraged by the bad state of the road and the distance to reach the nearest town. I help them meet their babies for the first time and I enable adequate follow up for the pregnancy and prevent certain complications that might occur during the delivery.

With a minimum of 1 doctor for 30,000 people, it is imperative for the clinician to go to the patients and not the reverse. And POCUS can help in these situations because of its ability to save the images to be shown to other experts for their expertise if needed. Ultrasound offers immense possibilities in upper-income countries, and I think it’s even more important in low- and middle-income countries to have access to that highly efficient and accessible method, to greatly improve the management of patients while offering quality healthcare at a low cost.

 

Yannick Ndefo, MD, is a general practitioner at St Thomas hospital in Douala, Cameroon.

Interested in learning more about ultrasound in low-resource settings? Check out the following posts from the Scan:

The Development of a Reporting and Data System Using Ultrasound: My ACR O-RADS Journey

Supervising the development of the American College of Radiology Ovarian-Adnexal Imaging-Reporting and Data System for Ultrasound (ACR O-RADS US)1 has been a journey that has challenged and substantially improved my leadership and management skills.Rochelle F. Andreotti, MD

O-RADS is a quality assurance tool and clinical decision support system for the standardized description of ovarian/adnexal pathology and its management consisting of a lexicon and risk stratification system. It is 1 of 10 Reporting and Data Systems (RADS) sponsored by the American College of Radiology (ACR). The committee was formed in 2015 under the direction of the ACR Ultrasound Commission and Commissioner, Beverly Coleman. I was asked to Chair the committee with Dr. Phyllis Glanc from Toronto, Canada, as Vice-chair.

“The best and the brightest”

O-RADS is an international initiative that has involved extensive collaboration with competing national and international societies. We began in the summer of 2015 developing our mission and membership. Our membership was primarily derived from several major initiatives that prompted our formation. These included the SRU Consensus Statement, a North American initiative helpful in determining management of cystic lesions, the International Consensus, the first collaboration of European and North American management approaches promoting a more conservative, standardized approach while optimizing the referral pattern to a GYN-oncologist when malignancy is suspected and terms and risk stratification models developed by the International Ovarian Tumor Analysis Group (IOTA). It was also highly recommended that the committee consist of members representing national and international related societies who could contribute to and eventually help promote our system. As a result, from the beginning, I was facing highly opinionated, accomplished colleagues so that there would need to be lots of creative thinking to navigate the pathway going forward.

Lumper, not a splitter

I can see the overall picture and am an accomplished problem solver but concentrating on the smaller details is not my forte and I often find them cumbersome. In order to achieve group consensus, the next 2 years that we spent establishing the lexicon was a thought-provoking and prolonged experience in which both of these qualities were essential.

Ergo, I needed to step up my game.

Evaluating quality of evidence using a comprehensive scoring system was an early point of contention, but fairly quickly we were able to come to agreement that scoring articles for quality would not be of much concern in the lexicon phase, although evaluating the quality of the study would be useful if the article added support to the risk management phase.  The method chosen to develop the lexicon became a tedious process of culling evidence-based and frequently used terms from the literature using a survey, then through a consensus process, narrowing down the list to a workable group. Inevitably, since the IOTA terms were the most evidence-based, this became the foundation of the lexicon.

Looking back at other approaches, perhaps there may have been an easier, less time-intensive pathway that would also have led to the same results. Nevertheless, the process taught me that no matter how well thought out a strategy, always be prepared for others who, out of their own desire to work toward the greater good, will complicate the plan.

Let’s keep this as simple as possible

On a similar note to the “lumper” versus “splitter” mindset, we vigorously debated the specific modalities to be included in this system. There was no question that ultrasound (US) as the primary modality and magnetic resonance imaging (MRI) as a problem-solving tool were key. However, would it be prudent to add CT/PET, tools not recommended for these adnexal mass diagnoses, although occasionally demonstrating incidental findings?

Limiting our bandwidth to the two tracks was my recommendation. However, this high-spirited deliberation came close to splintering our fledgling committee, be it not for the ACR staff’s suggestion of a vote that finally put to bed the possibility of a third O-RADS track. The vote left us with the two original parallel US and MRI working groups, preventing much added unnecessary work and anxiety. From this encounter, I learned the value of highly polished social skills.

The European mathematical model and the North American pattern approach- the challenge of working internationally

The relationship of the Ultrasound Working Group of the ACR O-RADS Committee with the IOTA Group has been collaborative but, at times, complicated and contentious. The reasons for this were two-fold. Foremost, the IOTA Group had already developed a set of applicable terms that were evidence-based as well as validated mathematical models to risk stratify lesions and were most interested in expanding their influence. However, these European models, while highly accurate, were less accepted in North America where a pattern-recognition approach is generally more desirable. Since IOTA provided their cohort of over 5900 surgically proven lesions, to support our pattern approach, compromise needed to be reached regarding further incorporation into the O-RADS Ultrasound System.

In the early development of the risk stratification system at our 2017 meeting at ACR headquarters in Reston Virginia, Dr. Dirk Timmerman from Leuven, Belgium, our IOTA representative, first presented to the group a proposal of a dual approach with addition of the IOTA Simple Rules2. After further work using a more generalized pattern approach based upon IOTA data, this was not pursued.

However, later in 2019, we were confronted with the need to incorporate the more accurate, well-validated IOTA ADNEX mathematical model3 into the O-RADS system as an alternate approach. In this way, we were able to obtain acknowledgment from key players representing IOTA with the hope of allowing O-RADS US to be launched internationally in addition to North American acceptance.

With continued use of the system, I have found an extra advantage of incorporating the ADNEX model when evaluating higher risk lesions in that it adds additional specificity to the diagnosis, information greatly appreciated by the gynecologic oncologists.

Impact factor

Any success that I have had in the field of medicine can be attributed to a desire to influence and leave this world, in some way, a little better for it. My hope is that this data system will prove to be something that will make a meaningful contribution and be my legacy to women’s healthcare.

 

References:

  1. Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: A consensus guideline from the ACR Ovarian-Adnexal reporting and data system committee. Radiology 2020;294:168–185.
  1. Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group. Am J Obstet Gynecol 2016;214(4):424–437.
  1. Van Calster B, Van Hoorde K, Valentin L, et al. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study. BMJ 2014;349:g5920.

 

Rochelle F. Andreotti, MD, is a Professor of Clinical Radiology and Obstetrics and Gynecology at Vanderbilt University College of Medicine in Nashville, Tennessee.

 

Interested in learning more about using O-RADS? Be on the lookout for the virtual course being held on September 26, 2020, New Approaches to Adnexal Mass Evaluation in North America: The Use of IOTA and O-RADS Systems; registration opens soon. Contact learn@aium.org for more information.

 

https://connect.aium.org/home

State of the Journal of Ultrasound in Medicine (JUM)

For nearly 40 years, the Journal of Ultrasound in Medicine (JUM) has served as the international journal of medical ultrasound research and education—and by all metrics, 2019 was its best year to date.

In a typical year, the AIUM reports the status of the JUM at the annual editorial board meeting, which takes place during the AIUM Annual Meeting. With the cancellation of this year’s Annual Meeting, we decided to share the State of the JUM with the entire membership.

Key Metrics

When it comes to the health of a peer-reviewed journal, there are several key metrics that the AIUM feels are important:

  • Impact Factor: In 2019, the JUM saw its largest jump in Impact Factor in more than a decade. It currently sits at 1.718.
  • Submissions: 2019 saw another record in terms of submissions, with more than 1,300 articles. That is an increase of more than 10% over 2018’s record year.
  • Acceptance Rate: With an increase in submissions, the JUM’s editors have become more discerning in what is accepted. In 2019, the acceptance rate dropped to 17.7% from 21% in 2018.
  • Time to Publication: Over the last few years, the JUM team has worked hard to reduce the time to publication. In 2019, the time to first decision dropped to 16 days and the time to final decision dropped to 21 days. In addition, the time from acceptance to online publication went from 70 days in 2018 to 50 days in 2019.
  • Digital Downloads: 2019 was a record year in terms of digital downloads. There were nearly 2 million downloads of JUM content in 2019—an increase of 38%.

Wide Reach

One aspect that makes the AIUM unique is that it is focused on all areas of medical ultrasound. That fact is also reflected in the JUM. The top article submissions categories in 2019 were:

  • Ultrasound Techniques/Physics
  • Musculoskeletal
  • Elastography
  • Ultrasonography
  • Abdominal
  • Pediatrics
  • 3D Ultrasound
  • Obstetric (Second Trimester)
  • Point-of-Care
  • Obstetric (Third Trimester)
  • Emergency Medicine

These articles didn’t just come from the United States, either. In fact, the majority of articles were submitted from outside the country. The JUM received articles from 6 continents and 19 countries submitted at least 10 articles—more than in 2018.

In a continued effort to increase the reach of the JUM, apps for both Android and iOS were launched—giving users access on the go.

Thanks

Success like this is the result of a lot of hard work from a lot of people. The Deputy Editors, Subspecialty Editors, and the Advisory Editorial Board dedicate a lot of time and energy to this journal. In fact, this group accounts for 25% of all article reviews. Special thanks go to the top performers:

  • Giovanna Ferraioli, MD
  • James Tsung, MD, MPH
  • Leeber Cohen, MD, FAIUM
  • Dolores Pretorius, MD, FACR, FAIUM, FSRU
  • Jodi Dashe, MD, FAIUM
  • Levon Nazarian, MD, FAIUM

The JUM is always looking for great reviewers as nearly half of all initial review invitations are rejected. If you would like to be a reviewer, set up an account here.

In addition to the great volunteers, the JUM’s success is also due to the Editorial Staff, Peer Review Management Staff, Production Staff, and the CME Test Writers and Editor. Working together we achieved an amazing 2019—and 2020 is on track to be even better.

 

Richard G. Barr, MD, PhD, FAIUM, FACR, FSRU, is the Editor-in-Chief of the Journal of Ultrasound in Medicine and Professor of Radiology at Northeastern Ohio Medical University.

Interested in more JUM content? Check out the following posts on the Scan:

 

https://connect.aium.org/home

Do It With Heart: Pre-Intubation Point-of-Care Echocardiography for Hemodynamic Optimization

Have you ever wondered why that patient coded after endotracheal intubation? As it turns out, it is not uncommon after critically ill patients are intubated. Approximately 60% of critically ill patients require endotracheal intubation and are at high risk for hemodynamic collapse during this procedure. Prior studies suggest that there is up to a 25% risk of hemodynamic instability even in successful critical care unit intubations. Therefore, it is crucial to prevent peri-intubation hemodynamic instability to avoid poor patient outcomes through hemodynamic optimization prior to endotracheal intubation.

Point-of-care ultrasound has evolved as a simple, portable, and noninvasive tool for assessment of hemodynamic status. It can provide invaluable information about diagnoses and direct resuscitation in critically ill patients. This bedside imaging modality can help determine the etiology of shock, guide appropriate interventions prior to patient decompensation, and assess patient response to management changes. It can also assist in the evaluation of intravascular volume status and fluid responsiveness of critically ill patients.

Endotracheal intubation is especially perilous for a patient with right ventricular failure. Performing this procedure in patients with right ventricular failure can result in catastrophic hemodynamic collapse since the right heart is very sensitive to increases in afterload. Right ventricular failure resulting in hemodynamic collapse is an underappreciated complication of patients undergoing intubation and invasive mechanical ventilation.

Echocardiography during the preparation period of intubation allows for direct and noninvasive visualization of the right ventricle at the bedside and can play a major role in the stabilization of critically ill patients. Pre-intubation echocardiography can prevent hemodynamic deterioration by identifying a failing right ventricle, which is extremely sensitive and unable to compensate for any increase in afterload or decrease in preload from endotracheal intubation. Pre-intubation echocardiography can detect signs of a deteriorating right ventricle (pressure and volume overload) such as right ventricle dilation, bowing of the interventricular septum into the left ventricle, decrease in the size of the left ventricular cavity, and decreased left ventricular filling leading to decreased cardiac output (Figures 1–4). If acute right ventricular failure is identified prior to endotracheal intubation, it can help the physician select appropriate management strategies prior to intubation and avoid hemodynamic instability.

 

With pre-intubation detection of right ventricular failure, different strategies can be implemented prior to endotracheal intubation to avoid hemodynamic collapse. Non-invasive positive pressure ventilation can be an alternative in some cases, which has a less pronounced effect on venous return and preload compared to invasive mechanical ventilation. In the setting of pulmonary embolism (or pulmonary arterial hypertension), inhaled nitric oxide can be used to decrease pulmonary artery pressure through pulmonary vascular dilation. Other strategies to avoid worsening right ventricular failure include administration of vasopressors prior to endotracheal intubation and avoiding intravenous fluid boluses.

Pre-intubation echocardiography is a crucial step in the protocol during endotracheal intubation of critically ill patients to prevent poor patient outcomes. It allows clinicians to approach endotracheal intubation-associated hemodynamic instability in a specific, targeted manner. Integration of pre-intubation echocardiography can vastly improve the management and safety of critically ill patients, in hopes of decreasing the risk of poor outcomes.

 

Srikar Adhikari, MD, MS, FAIUM, is a professor in the Department of Emergency Medicine at the University of Arizona Medical Center.

Interested in learning more about POCUS? Check out the following posts from the Scan:

 

CLEAR!

We all have come upon a machine, unplugged, with old gel caked on a probe or worse (see figures 1 and 2 attached), with the images from the patient from the last exam, labeled on the image that was not closed. Now you have to take time before you can even start YOUR ultrasound exam. It is this variation from machine homeostasis, a steady-state of readiness for the next operator, that was the impetus for CLEAR. How can the last operator help the next operator? CLEAR!Figure 1. Curvilinear probe with left over gel

The 20th-century paradigm for ultrasound was a clinician ordered the exam and the patient went to a suite and a sonographer saved images and videos. That sonographer would clean their own machine between patients as there was one machine for the same operator. Their images were read by the imaging specialist and that person relayed back to the clinician the results of the imaging study. These types of ultrasound exams still occur and are billed differently. We call them comprehensive ultrasound exams or referred ultrasound exams.

In contrast, a point-of-care ultrasound (POCUS) exam finds the ultrasound equipment more portable and accessible as the price point has lowered. There is usually one machine and multiple operators who use this same machine. In each case that the operator acquires, interprets and uses the information in clinical management at the patient’s bedside without sending them to an imaging suite. The cleanliness of the machine is up to the person who used it last.

Figure 2CLEAR is the acronym and checklist for the components necessary to keep a machine in good working order for patient care. As a provider of emergency medical services and having a strong interest in ultrasound, I have seen the utility of POCUS in the medical setting. It was not called POCUS in the early days, yet machines and operators have been using, and will continue to use, ultrasound for patient care as this movement grows.

CLEAR is about machine homeostasis, ie, getting the ultrasound machine back to a steady-state to be ready for the next patient. The tagline for CLEAR or machine homeostasis is “The last operator is connected to the next operator; YOU may be the next operator.” The message that is intended is leaving the machine in good working order for the next case that needs ultrasound. CLEAR is 5 simple steps to get the machine ready for use and in good working order:

Clean – Clean the machine. In the era of COVID, this might mean twice (in the room, outside the room, and all surfaces)
Locate the machine – Is it in the correct place?
Energize – Is the machine plugged in? Are all the connections tight and working?
Augment supplies – Do you have enough gel, packets, wipes, other supplies?
Remove patient identifiers – Each case should have an accession number and other metadata, which will need to be removed from the machine before the next use. This can usually be accomplished by ending the exam and starting a new exam.

The purpose of CLEAR is to help the operator learn the steps to perform after doing the ultrasound exam.

These can be simplified as:

Clean the machine.
Locate – Put it back to where it is supposed to reside.
Energize – Plug it In!
Augment – Replace supplies, including adding gel for the next person.
Remove – Patient information. End the exam.

The time is not yet here when all patients, or at least all providers, have their own personal ultrasound machine. In the meantime, we share the machine with other doctors and nurses and others. Remember, when sharing ultrasound machines, CLEAR the machine so the next user/operator is ready to go. Our patients will be thankful, as will the next user. You may be the next user! CLEAR the machine.

To read more about CLEAR, check out the article, “CLEAR: A Novel Approach to Ultrasound Equipment Homeostasis,” in the Journal of Ultrasound in Medicine (Prats MINelson BPGold DLBranditz LDBoulger CTBahner DP. J Ultrasound Med. 2019; 38:767–773. doi: 10.1002/jum.14757. Epub 2018 Aug 19).

 

David P. Bahner, MD, FAIUM, FAAEM, FACEP, is Professor and Director of Ultrasound in the Department of Emergency Medicine at The Ohio State University College of Medicine.

Interested in reading more tips for ultrasound use? Check out the following posts on the Scan:

 

https://connect.aium.org/home

Hey, Ultrasound! What Did I Do Without You?

I trained as a physiatrist, which means a great deal of education on musculoskeletal conditions. Over the course of my residency training, I became more and more comfortable with bony and soft tissue landmarks for examination and targeting various joints, nerves, and tendons for therapeutic injections. As I was supervised by attendings, and carefully followed their instructions, there was no doubt in my mind that the tip of my needle was at the target intended. Why would I doubt a common practice that has been in existence for several decades?Mostoufi

As I started my fellowship in spine/pain/musculoskeletal care, I found the love of my life, the fluoroscope!!  Here, I had access to a tool that made life incredibly easy. I actually could visualize my targeted hip, shoulder, or facet joint, and inject some contrast to identify the needle tip within my target. I could precisely deliver therapeutic medications to a particular nerve root, and even identify vascular uptake and avoid procedural complications.

It was then and there that I realized that there were substantial shortcomings in what I learned as “landmark-based injections”. I realized that even though I had learned the proper “blind” procedure technique, there was no confirmation that my medication had reached its intended target. More importantly, if my patient did not respond to the procedure, I could not differentiate between a medical condition that was not responsive to the treatment versus shortcomings of un-guided procedures and inadequate delivery of medications to the targeted tissue/joint. For 12 years, I confidently treated thousands of patients by performing spine and musculoskeletal injections using my fluoroscope. I enjoyed using my C-arm, and life was pretty good.

In 2011, while attending a PM&R national conference, I sat through a 15-minute presentation on overdiagnosis of trochanteric bursitis. The speaker eloquently described fluoroscopic-guided bursa injection. This was something that I did on a regular basis as a diagnostic step. He then used ultrasound (US) images to demonstrate a few cases of gluteus medius tendinopathy and also trochanteric bursitis and how US can be superior to X-ray in therapeutic sub-gluteus maximus bursa injection. While sitting and listening, I recognized that it was virtually impossible to press against the lateral trochanter and be accurate about the diagnosis. It is also not possible to use fluoroscopy and be sure that the steroid or regenerative treatments are correctly delivered to sub-gluteus maximus bursa.

Remembering how helpful fluoroscope was to identify particular bony landmarks and assist with the proper treatment of spine and joint disease, here I was discovering a new tool that can enhance diagnostic and therapeutic skills in musculoskeletal care in particular soft tissue disease (nerves, muscles, tendons). This meant a fundamental change in the way I was going to treat patients but also a change in how I train the next generations of Physiatrists, coming through our residency program.

Fig 3aFig 3b

Learning to use the US, and incorporating it into the practice was much harder than I envisioned and also very expensive. At the time, there were limited well-structured educational resources available, and the learning curve was quite steep. As I was learning, I had to beg (or pay) my kids to become my scanning subjects!!

In contrast to a fluoroscope, it is nearly impossible to recognize an abnormal structure on the US unless you are comfortable with the normal anatomy. With a ton of hands-on workshops, mentorship, practice, and with assistance from my new found love of ultrasound machine, and guidelines from the AIUM, ultrasound has become easier and more enjoyable!! The abnormal findings became more clear and treatments more effective. In this process, I found out that patients enjoy looking at the US screen and being explained about finding on a screen full of gray, gray, and grayer lines and curves.

US has transformed how physiatrists practice and teach musculoskeletal medicine. Point-of-care US imaging allows for the residents and fellows to visualize various organs or structures within an organ, recognize healthy and diseased tissue, and diagnose the problem on the spot. This, in turn, will lead to a quick and targeted treatment and satisfied patients.

Examples of musculoskeletal (MSK) conditions that US has proven to be an effective tool to workup or treat includes rotator cuff and biceps tendinopathy, small or large joint injections, upper extremity nerve entrapments, muscle and tendon tears, peripheral nerve lesions, carpal tunnel syndrome (CTS), intersection syndromes, trigger fingers, plantar fasciitis, piriformis and sciatic complaints, treatments of bursitis or tenosynovitis, iliotibial  (IT) band treatment, ischiofemoral impingement, and many diagnoses for which dynamic testing proves to be beneficial.

Fig 6

Despite its cost and extensive training/certification needs, utilization of US in MSK care is predicted to be a standard of care in the next 5–10 years. As more and more practitioners are trained, its use for diagnostic or therapeutic purposes will become the norm.

Fig 7aFig 7b

I still love my fluoroscope and prefer its use in most spine procedures. Adding US has revolutionized my practice and allows me to be a better diagnostician, a better MSK doctor and a better educator for both my patients as well as future providers that come after me. In short, US has been a game-changer.

 

Ali Mostoufi, MD, FAAPMR, FAAPM, is an Assistant Prof. in PM&R at Tufts University, and the president of New England Spine Care Associates (NeSpineCare.com) and Boston Regenerative Medicine (BostonRegen.com).  As a spine and sports medicine practitioner, his clinical practice focuses on Interventional Spine, Diagnostic US, US-based therapeutic interventions and Regenerative Medicine in spine and sports.

Interested in reading more about musculoskeletal ultrasound? Check out the following posts from the Scan:

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

https://connect.aium.org/home

 

My Sonography Experience With COVID-19

It is been almost 5 weeks since I got infected with SARS-CoV-2 (also known as COVID-19), my life-changing experience.1

The day all started, during my night shift, I started with low-grade fever, chills, and myalgia; I did not doubt for a second that I had to have the test for SARS-CoV-2. That same day, most of my mild COVID-19 patients had these same cold-like symptoms, but some of them did not have a known epidemiological contact. Without time to have any other tests done, laboratory or X-ray, I self-quarantined at home waiting for the result. And finally, it came in the midst of the night; I received the “positive”.

In the morning, as more symptoms started to appear, headache, diarrhea, anosmia, ageusia and dry cough, it was a relief to have my hand-held ultrasound device at home. With the rush, I even left my oximeter, which measures heart rate and blood oxygen levels, in my hospital locker.

There is now growing evidence regarding the imaging findings of COVID-19, but at that time, the only studies were performed via CT scan and X-ray. With my ultrasound probe, I scanned following 8 zones (2 anterior, 2 lateral of both hemithorax) plus posterior lobes. I felt relieved (didn’t last long) to see there was a normal A-line pattern. More relief came when at some point I had a dull but constant right lower abdominal pain with normal appendix and no hydronephrosis on ultrasound.

 

What impresses most about this disease is its dynamic pattern, with sudden changes during the evolution. As my symptoms waxed and waned, so did my lung ultrasound, probably in a different manner than I would have expected. As the disease progressed, I saw all the possible lung findings, from the initial posterobasal scattered B-lines, to small pleural effusions, irregular pleural line, coalescent B-lines, and finally subpleural consolidations, especially in posterior and lateral areas. My personal impression was that I wasn’t feeling worse when I had more B-lines, but when the subpleural consolidations started to appear and spread. Each time I had new subpleural consolidations, there was a worsening in my symptoms coming: more myasthenia, cough, and diarrhea. After the second week, the subpleural consolidations were replaced by coalescent and scattered B-lines. Following that, the irregular pleural line persisted longer.

March 22 still

 

Surprisingly, during the third week, things started to worsen again, and on ultrasound there was a big consolidation appearing in one lobe, that was my sign for a therapy shift towards antibiotics.

My personal feeling is that consolidations are more reliable than just the number of B-lines, and correlated better with my symptoms. Actually, after 3 weeks from the symptom onset, after recovering and testing negative for SARS-CoV-2, I still had several areas with scattered and coalescent B-lines, as well as thickening of the pleural line. We have to be more flexible and take into account other parameters (i.e. oximetry), rather than rely solely on the number of affected areas on ultrasound, to compose the clinical picture, and influence the management.

As I remarked before, what impresses me most about this disease is the ultrasound dynamism. After having recovered, I still had new areas of thickening of pleural line that appeared in the back (asymptomatic) for the following week (4th), and almost 5 weeks after, I still had one plaque. And after 5 weeks, I am still surprised to have unnoticed findings, such as an asymptomatic pericardial effusion.

As a firm sonobeliever, I found it extremely useful to monitor my disease for sonographic progression and or resolution, and quickly detect complications. After this experience and having returned to work, I would have no excuse to irradiate my patients before scanning them, in the same way I went through.

Definitely, this experience was the best lesson I could have before returning to the trenches.

 

Yale Tung Chen, MD, PhD, is an associate professor at Universidad Alfonso X El Sabio, in Madrid, Spain. He was diagnosed with COVID-19 and shared his symptoms and ultrasound images each day on Twitter @yaletung. Follow his thread at #mycoviddiary.

Interested in reading about topics that could be of interest during the COVID-19 pandemic? Check out the following posts from the Scan:

Thank you

Thank you. 

Thank you to all of the medical professionals who are working tirelessly to care for the massive influx in patients resulting from the COVID-19 pandemic. Thank you for risking your own health to care for others. Thank you for taking the time away from your families. 

Thank you to the many medical professionals who have answered calls to action. 

Thank you to all of the truckers and production and store workers who are ensuring that everyone can still get the supplies and services they need.

Thank you to everyone who is remaining safe at home, despite going stir-crazy. 

Thank you to all of the parents who suddenly had to become home-school teachers. 

Thank you to everyone who has transitioned to working from home each day.

Coronavirus

Interested in reading about topics that could be of interest during the COVID-19 pandemic? Check out the following posts from the Scan:

 

Cynthia Owens is the Content Specialist at the American Institute of Ultrasound in Medicine (AIUM).