Ultrasound: A Go-to Diagnostic Tool
By Jessica Tremayne
Posted: Aug. 18, 2011, 3:15 p.m., EDT
Using ultrasound equipment in everyday practice means offering a minimally invasive service that is growing in appeal to clients. But before making the $10,000 to $200,000 investment, experts say veterinarians need to know their clients are interested in the service and then figure the return on investment.
“Even with the economic climate over the past several years, ultrasound sales have continued to see positive trends,” says Mia Varra, marketing director for E. I. Medical Imaging in Loveland, Colo. “Much of the increase is due to the fact that veterinarians see diagnostic equipment as a revenue-generating tool.”
But earning revenue requires the right equipment and, an up-front investment in marketing, training and time.
“Veterinarians take a leap of faith with a company,” says Randy Laufersky, president of Core Ultrasound Inc. in Grand Rapids, Mich. “Looking at three companies is a standard that allows for a broader perspective on what is being offered. A good salesperson will ask the right questions that will answer which machine will meet a practice’s needs.”
|Rule-Outs Count, Too|
Veterinarians who use ultrasound say once a veterinarian learns ultrasound basics, the machine starts to be used for more complex studies.
“Often, people look for ultrasound to provide the overt diagnosis,” says Eric Lindquist, DVM, Dipl. ABVP, Cert. IVUSS, founder and CEO of SonoPath.com and director of N.J. Mobile Associates in Sparta, N.J. “However, utilization of ultrasound to rule out many differential diagnoses has an equal value to that of finding a specific sonographic diagnosis, such as a mass or pancreatitis or intestinal obstruction.”
• Abdominal disease evaluation
• Heart examination
• Urinary tract
• Pancreatic and other abdominal diseases
• Cancer screen
• Metastatic disease screen
Customer service is an often-overlooked component of the buying process. Knowing the product warranty period, repair policy and a company’s customer service hours can mean the difference between smooth operation and frustration.
“Vets focus so much on the piece of equipment, they don’t think about their life with the equipment after they have it,” Laufersky says.
“A reputable ultrasound company wants to make sure every customer is happy with the equipment they invest in and that the equipment will perform to the quality and standard that it is being used,” Varra says. “Good customer service ensures minimal down-time for a practice and subsequent loss of revenue.”
Learning about ultrasound options is half the battle, experts say, and after a veterinarian has used ultrasound in-house, the basic questions will never be a concern when it’s time to upgrade.
“Machines vary greatly in imaging quality, versatility and price, and these factors are usually positively correlated,” says James C. Brown, Jr., DVM, MS, Dipl. ACVR, a clinical assistant professor of radiology at North Carolina State University College of Veterinary Medicine in Raleigh, N.C.
“First, decide how you will use ultrasound in your practice. Most general small animal practitioners see a variety in the sizes of their patients and would benefit from a more versatile machine, perhaps with multiple ultrasound probes. For a feline-only practitioner or an equine orthopedic veterinarian, a machine with a single high-resolution probe may be sufficient.
“The veterinarian should consider what types of diseases they expect to diagnose and how frequently they intend to use ultrasound,” Dr. Brown says. “An emergency veterinarian interested in finding abdominal fluid or abdominal masses may not require higher-end equipment that would be needed by a general practitioner who wants to measure adrenal glands to help diagnose hyperadrenocorticism.”
Bailey: The left adrenal gland in this 5-year-old mixed breed dog is flattened in contour, subnormal in width, and isoechoic to surrounding fat. Sodium/potassium ratio was normal but atypical Addison’s disease was confirmed on ACTH stimulation performed based on the sonographic appearance of the adrenal glands.
Photos courtesy of Dr. Eric Lindquist
Vegas: Iliac lymph node was enlarged and heterogenic. The hyperechoic linear focus represents FNA of the lymph node. Cytology revealed metastatic insulinoma.
|Freddie: Ferret with a right adrenal mass invading the vena cava evidenced with the use of power Doppler.|
Coal: Mineralizing and invasive right adrenal adenocarcinoma causing Cushing’s syndrome in this 12–year-old Dalmatian dog.
Buddy: A 5-month-old Labrador retriever is afflicted with an extrahepatic splenocaval shunt. Extrahepatic shunts are very rare in large breed dogs.
Emma: Mesenteric root lymph nodes infiltrated with lymphoma. Color flow Doppler evidences the increased vascularity to the lymph nodes and the mesenteric artery.
Toby: Normal thyroid in a middle-aged dog. Power Doppler evidences the adjacent carotid artery.
Brown says the second step is realistically deciding the budget for the machine considering needs and expectations.
“The third step is to audition some machines,” Brown says. “Spend as much time with each machine as you can. Before purchasing, you should feel comfortable manipulating the controls and be able to get a good image on your own. Don’t buy anything without trying it out first.”
Manufacturers say an emerging concern in primary care practices is clients going to another facility that offers a service they do not, and then never coming back.
“Veterinarians feel they need to offer as many services as they can to gain new clients and keep them,” Laufersky says. “Becoming known for a specific service sets practices apart from the competition.”
Technology evolves quickly and ultrasound isn’t an exception. Machines sold today include features unavailable only a few years ago.
Eric Lindquist, DMV, Dipl. ABVP, Cert. IVUSS, founder and CEO of SonoPath.com and director of N.J. Mobile Associates in Sparta, N.J., notes that each eye and brain sees things differently and therefore finds value in different functions. So an essential feature to one practitioner might be useless to another.
“Now 3D and 4D imaging are the biggest new trends,” says Greg Stoutenburgh, vice president of marketing at Sound-Eklin in Carlsbad, Calif. “DICOM, raw data capture, harmonics, coded excitation, cross beam and speckle reduction imaging are all pretty essential features these days and everyone should ask for them and expect them in their ultrasound.”
Portable ultrasound units have advanced in recent years, Varra says.
“All digital broadband systems have improved image quality with the convenience of portability,” Varra says. “Prolonged battery run time and interchangeable transducers allow for a variety of procedures to be conducted in the field.”
While portable ultrasounds have the upper hand on mobility, their screens are typically smaller than those of in-house machines and may lack other bells and whistles. But all veterinary ultrasound machines made today are considered energy efficient and offer another diagnostic tool.
“Ultrasound serves as an extension of abdominal radiographs, answering many of the questions that radiographs cannot specifically answer,” Brown says.
“For example, ‘What is the source of peritoneal fluid and is there a mass hiding in the abdomen with it?’
Echocardiography has become the imaging modality of choice for diagnosing heart disease and evaluating cardiac function. Ultrasound is valuable in critical patients, allowing real-time assessments that can result in immediate therapy for conditions such as pericardial effusion or septic peritonitis.”
Even the most technology-savvy ultrasound equipment will not help diagnose patients if it isn’t being used properly or if evaluations are misread. Education is essential for any new ultrasound owner.
“Misdiagnosis is the biggest problem with use of ultrasound by inexperienced sonographers,” Brown says. “Not every abnormality seen on ultrasound is significant and there is a huge overlap in the appearance of benign and malignant diseases. The limitations of ultrasound, as well as personal limitations, must be realized so that conscientious and well-informed decisions about patient care can be made.”
Ultrasound training and continuing education lectures are critical in helping a veterinarian become a confident and reliable sonographer. Training can be acquired through different venues.
“Ideally everyone would plan on a two-year [training] program of a structured learning curve with organized seminars and in house training in a periodically applied regular fashion,” Dr. Lindquist says. “During this time frame, the fledgling sonographer would know his/her limitations and apply them accordingly to each case, but at the same time strive to improve to minimize these limitations.”
Stoutenburgh says The Academy of Veterinary Imaging offers comprehensive training courses for different levels of sonography education.
“A trainer may be brought onsite, but it is expensive,” Stoutenburgh says. “Sonopath.com is an excellent resource to learn ultrasound diagnostic skills. Wet lab courses at various conferences also offer training.”
Brown says most veterinarians learn quickly to consistently identify the major abdominal organs. But the learning curve for smaller abdominal organs and structures is much steeper and may take several years to master.
Lindquist notes that if all ultrasound views are obtained and the sonographer isn’t confident with making a conclusion, remote interpretation may be used to make the study valuable.
“One great thing about the age we live in is that electronics and computing power are becoming faster, more powerful, cheaper and smaller,” Brown says.
“This allows us to have incredibly portable and easy-to-use options in the ultrasound machines available. Image distribution and machines are capable of saving digital images and sending digital images via Internet for telemedicine purposes.”
To watch a vdieo of ultrasound case studies, click here.<Home>
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