the linear probe for IUP confirmation

Sometimes, despite some vigorous pressure on the abdomen and asking for some more bladder filling you just can’t see the yolk sac or fatal pole you need to really confirm an IUP with the curvilinear 3-5Mhz probe.  You may have the option of a trans-vaginal scan but nobody wants that, as well as increased time for signed consent, emptying bladder, chaperone and cost/time of processing the TV probe.  Since reading this blog post and looking at the article, I have been using the linear probe occasionally and it really works beautifully.

EarlyPregTASag
A classic sagittal view, seen with bladder, vaginal stripe and uterus in line.  There is the decidual ring but no definite IUP
EarlyPregTransverCurvilinear
On the transverse view there is something there – a gestational sac with a double ring, more than 8mm myometrial thickness but no yolk sac or fetal pole that can confirm a true IUP.

And then a quick swap to the GE 9L (2.5-8Mhz) and a classic engagement ring yolk sac is seen, safely confirming an IUP.

EarlyPregnancyLinearTrans

 

EarlyPregLinearProbeSag

So it really works – there does seem to be some tricks. This starts when you swap the probes – the machine will default to 1-3cm focal range, small parts pre-sets.  On my machine (GE V2) you can still change to Ob pre-sets using the linear probe.  You will have to wind the depth down, move focus and re-balance the gain (all things I am doing better since attending the UTS course).  You may have to lower the frequency a bit as well to punch down to the pregnancy.  That tiny footprint of the linear probe also gives you a very tiny torch light to see down to the pregnancy, it is easy to lose the pregnancy even with small movements and then hard to find it again.  You don’t get that classic sagittal slice of bladder/vagina/uterus to orientate yourself.  With the linear I have found it easier to orientate in transverse and sweep up from some bladder.

So if you have the option, a linear high frequency probe is a great option, helping you and the woman avoid a TV scan. This is what is exciting about POCUS – new, lateral thinking about how to leverage the machine to get better outcomes for patients.

Here is another set to wind up:

 

zoomedViewCurvilienarYS_May10th
This is a zoomed view – with the eye of faith you could probably be happy this is a true yolk sac, but if that is all you can see maybe you would be safer going to TV
LinearYSMay10th
However with the utility of the linear scanner this is definitely the engagement ring of a yolk sac – IUP confirmed!
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Ultrasound Training Solutions today – a great course

I attended the UTS 1st  Trimester Obstetric Ultrasound course today, part of their one day quick start courses.

uts-logo001

This was a great course with 1:5 instructor:student ratio for the practice sessions and three seperate practical sessions of scanning early pregnancy volunteers, which worked out to scanning 5 different womens pregnancies today, all at slightly different stages of the 1st trimester.

Having had on the job exposure and teaching from other doctors and having a bit of scanning under my belt it was still invaluable to have the sonography approach and to fine tune the image optimisation.  Our POCUS approach is to answer one question and often we stop with whatever image or window gives us this.  Todays session encourages me to bring more craft and skill development to POCUS to get the best possible image possible.

There was a large variety of machines to use as well – GE V2, GE Venue, Sonosite M-Turbo, Sonosite Edge, Claris and Lumify.  This was very useful as I think it solidified for me I prefer real buttons to a touch screen interface.  I appreciate that ability to rest fingers on that tactile button and freeze without having to glance at the touch screen and see where the touch screen button is.   The exposure to divers machines was also great as it reinforced the machine I use now the GE V2 is excellent and I am not lacking anything with it.

Lumify.jpg
hands on with the Philips Lumify

Overall an excellent session and strongly recommended.  I will be back for more sessions with UTS.

sono/gif – very easy gif creation from loops

I have just downloaded and successfully used this excellent program.  It has been created by Ben Smith from Ultrasound of the Week .  I used a Mac, there is a Windows version as well.

Screen Shot 2018-04-29 at 7.54.55 PM

The avi that my machine outputs was very easily converted into a GIF loop with the ability to trim the length and crop the size of the video. Does exactly what it says on the box in a very easy manner. A great addition if you are saving and using images for teaching.  Just don’t forget to confirm consent to use images for teaching/research!

Australian General Practice, Medicare and Ultrasound Machines

Australian General Practice, Medicare and Ultrasound Machines

This guide was written in response to several requests for information on the Australian general practice craft group GP’s Down Under. There seems to be good interest in how GP’s could start to get interested in ultrasound, discussion around choosing a machine and whether or not there are Medicare rebates for any ultrasound imaging.

Unfortunately as well as enthusiasm, there has also been significant misinformation with myths such as:
– only rural GP’s can access Medicare rebates for ultrasound
– Rural GP’s can only access Medicare rebates if they are 100km away from a radiology clinic
– No GP’s can access Medicare rebates
– GP’s can access Medicare rebates but they have to have completed the DDU (Diploma of Diagnostic Ultrasound provided by ASUM (Australian Society for Ultrasound in Medicine) or the CCPU (Certificate in Clinician Performed Ultrasound)
– Ultrasound does not add anything to GP consulting

Myth busting:
-GP’s both rural and urban can be registered so that their pt can access a MBS rebate for ultrasound scanning in your rooms
– There is no distance requirement
– You do not need a particular DDU, CCPU or other specified training, although training is an excellent idea
– An ultrasound machine can add income to your practice and extend your practice which expands you experience, challenge and satisfaction

So as at March 2018 in Australia, what is possible, what is safe and acceptable and what makes good business sense?

Point of Care Ultrasound (POCUS) has been exploding in hospital and pre-hospital care with increased use in the emergency department, theatre, ICU and paramedic and pre-hospital care. This is due to dropping cost and complexity of machines, desire to avoid ionising radiation and the benefits of being there with the patient when scanning and then having this information guide your care. “Does this hurt when I press the probe over this gall bladder?” POCUS is also introducing non-traditional uses of ultrasound to medical care that are never done by sonographers and radiologists. A sonographer will never ultrasound a lung but this is now my main use of the machine which can help discern CCF from COPD from pneumonia. A sonographer will never assess the optic nerve diameter as a proxy for rising intra-cranial pressure or scan the eyeball looking for the “washing machine” appearance of retinal detachment. POCUS is different from a formal ultrasound – often just one question is answered to allow action (which may include referral for a formal ultrasound).

apologies to the creator – taken from twitter, please let me know attribution

Primary care/General Practice will join these ranks for POCUS uptake again as machines get easier and lower cost. It behoves us to get on board this push as medical students are having POCUS integrated into medical school (Monash university students in Melbourne Australia are doing this) and we risk being left behind. There is also a significant benefit with extending your practice and remaining interested in medicine and demonstrating your innovation to the patient. I love this slide from a conference, taken from Twitter about surviving disruption in medicine:

Accessing MBS items for ultrasound
The MBS has a number of items that are called the non-referred ultrasound items. A referred item is what a mainstream radiology provider would use if you referred a pt to them – such as item 55036, ultrasound of the abdomen, paying $111 in March 2018 or item 55700 pregnancy less that 12weeks, paying $60 in March 2018.

However the item numbers that GP POCUS users are interested are the non-referred items. These are items like 55037 – Abdomen when non-referred, paying $37.85 in March 2018 or 55703 pregnancy less than 12weeks when non-referred , paying $35 in March 2018.

MBS ultrasound items for general practice
non-exhaustive examples of non-referred items, the BB incentive 64991 is for rural/remote. If you are urban, use 64990

 

Access to non-referred items is not automatic!
These non-referred MBS items are billed separately to your usual Medicare provider number. What is required is a location specific Provider Number (LPSPN) that is tied to the machine at a specific location and not a doctor. The first part of this application is very easy – the paperwork completion of the LSPN application with Medicare. In due course they will send a location specific provider number to you. A catch is that you need to confirm that you desire to update this every year although all that is required for renewal of the LSPN is an email, you don’t need to complete the forms again.

LSPN medicare ultrasound non-referred
complete the form!

The next stage is accreditation of the machine with DIAS (Diagnostic Imaging Accreditation Scheme – Dept Health). This process seems to be like conveyancing for a house – you could maybe work out how to do it yourself but hopefully you only need to do it a few times and the time saved in paying someone else to do it and get is right is worth it. I have not heard of individual doctors completing their own, if you do, get in touch. Everyone seems to use the equivalent of a conveyancer – an accreditation service. These services also accredit formal radiology services, general practices and other health clinics.
There are seem to be four groups that can accredit you – HDAA, National Association of Testing Authorities., QIP and Choice Accreditation and help you apply through the DIAS process. Talk to the group that accredits your practice – they may offer to “bundle” accreditation.

Perversely, none of the accreditation process is about you ability to use the ultrasound machine, interpret images or use the information to manage the patient. Correspondingly, no particular training or diploma is required as evidence for accreditation. Obviously training and acting within your scope of practice is excellent safe medicine, which I will cover below. However for the LSPN and accreditation of the machine, no particular training is needed. Accreditation requires proof entirely of bureaucratic processes – complaint handling, where manuals are stored, how results are communicated and how pt identification is ensured. This is an example of a table of contents of an accreditation manual:

LSPN accreditation pro forma
example accreditation paperwork

The accreditation company will have pro forma for most of this and will ask you questions about what is the machine serial number, where the machine is stored, how patient details and US reports are stored, how a pt can make a complaint, how a pt consents and how pt identity is confirmed (three items min – name, DOB, address). If you will be using trans-vaginal probes you also need to create a written consent form and demonstrate what decontamination process you will follow.

LSPN accreditation flow
LSPN accreditation flow

After accreditation has gone through, your LSPN will be registered for the machine, at that location. This single provider number obviously does not differentiate between providers so you will need a local policy to understand who charged what if more than one GP uses the machine. LSPN can all be searched online. Don’t forget to reply to your yearly LSPN details update from Medicare. Unfortunately accreditation of the LSPN for DIAS needs to be re-visited three yearly.

Accreditation costs:

I called HDAA, they suggested $498 for the first two years then you pay for the full accreditations $1600 which covers you for the next four years. When I called them HDAA stated you could also pay $405 yearly from the first year, every year which averages things out.  Calling QIP they suggested $545 for the first two years then review in 4 years for the full suite, then every 4 years after this.   There is no on-site requirement for accreditation everything being completed over email.

Too much paperwork!
Of course there is no requirement to go through this DIAS process. You can choose to not bill or privately bill the pt only around use of the ultrasound machine. Much like a dermatoscope, you can accept that the ultrasound improves you diagnostic skill and adds quality to the consultation without adding directly to remuneration. There are tax deductions and depreciations available that can lessen the sting.

Training
Currently there is no training requirement to access DIAS. However there may be local requirements – this is common in Emergency Departments. Obviously like any skill in medicine there is a requirement to obtain and maintain proficiencies . Ultrasound is much like endoscopy to my mind – a combination of physical manipulation, applied anatomy and interpretation while your eyes are looking at a screen, divorced from what you hands are doing. This challenge is best learnt from a quality provider and repetition. In Australia the RACGP provides some one day  Active Learning Modules. Dedicated training is provided by Australian Ultrasound Training, Ultrasound Village and Australian Institute of Ultrasound. The benefits of these organisations is exposure to disparate machines before you make your choice, access to model patients such as pregnant women and phantoms (ultrasound training mannequins). An area that will likely expand is training using VR such as Microsoft’s Hololens.

Currently you can decide your own scope of practice and what you are comfortable with. For example I am confident and comfortable with assessing and ruling in an Intra-uterine pregnancy if it is there. However I do not have the skills to comment on ovaries or in the setting of a positive pregnancy test and empty uterus to fully assess for an ectopic pregnancy. These people go off for an referred scan to a radiology provider.

Medicolegal

How will purchasing and using your machine be regard by your medical insurer? This is where the issue of scope of practice comes in. Could you demonstrate appropriate practice within expectations of your peers? Can you demonstrate training?   ASUM is moving to influence POCUS as it does for sonographer ultrasound. There is one coroners case that I am aware of involving POCUS – the very complex death of Mrs Dhu in detention in WA. The expert witness although not reagarding POCUS negatively (at least in the condensed coroners report) suggests a CXR should have be completed rather than just POCUS.

FOAMed
Being disciples of GPDU and Business for Doctors we believe in the power of FOAMed. There are excellent resources available:

Websites
https://gppocus.com – myself
http://5minsono.com – great quick bite tutorials
https://ddxof.com/ultrasound-in-dyspnea/ POCUS flowchart in dyspnoea
http://sonospot.com tutorials and apps
http://pocusjournal.com does what is says on the box
http://www.medicinec.si/projekt/ultrafest/ eFAST and other charts
http://scghed.com/ed-orientation/ultrasound-where-do-i-start/ US village collective

Twitter suggestions to follow
@gppocus – myself natch
@UTS_Australia @gabyblech @antwaldecho ‏@PURE_Updates @UltrasoundMD ‏

Choosing a machine
This is an area that is changing quickly. Historically machines were large cart based units made by traditional electronics companies – General Electric, Toshiba and Siemens. Machines then became smaller and portable with Sonosite, Mindray and then reverse engineered companies Sonoscape, Chison getting involved. The field is now exploding with pocket sized machines – GE Vscan, Sonosite iViz, Clarius and the announced but not delivered Butterfly.  It is not clear to me if these app based machines would qualify for LSPN – all the users I know have laptop sized or larger machines with swappable probes.

In the files of BFD there is a worksheet from April Armstrong around a possible business case for your machine if you are a member, there has also been group buys in previous years.

As well as the actual machine, there are other considerations:
– Do you move clinics frequently? Consider size/weight, fragility
– Will you store images on clinical software? Does the machine export wirelessly or via USB? Does it export via .jpg/.avi/.mpeg?
– Do you need a printer – probably not, thermal paper images impossible to scan to pt notes, unless you need to give pt images.
– Do you need a specific stand/trolley? Probably not – ergonomics different compared to a sonographer scanning all day, not moving machine much.
– If you need a trans-vaginal probe, how will you ensure decontamination? (three options for small clinics- Tristel wipes kit, cidex-OPA (aldehyde based) liquid and Revital-OX solution (peracetic based) We use Tristel.

– Some machines now sold have software restrictions about which probes it will accept – can this be expanded later? At what cost?
– Is there a mandatory service pack? Warranty of unit/probes?

 

 

back to work

Time to get going again for 2018 after a long fallow time. Some goals for 2018:

  • look into the Awesome Ultrasound Simulator
  • improve skills with the GE Logiq e machine

I started 2018 with an update yesterday:

SimonScan
myself being scanned at RACGP ultrasound update, Feb 2018

Hidradenitis suppurativa – incise or not?

I have previously been frustrated with Hidradenitis – what seems like a abscess that is going to yield pus and is worth draining was only a mass of scar when you incise it in these unfortunate people plagued by repeated abscesses. When this patient presented with two larger, very tender but non-fluctuant masses in a field of smaller inflamed nodules in the axilla the question was – is there frank pus here to incise and drain, or can I be sure antibiotics alone with resolve this?

The linear probe was very helpful here – yes there was a true pus filled collection and the registrar and myself proceeded to drainage which produced laudable pus. A small, simple POCUS win. Next time I would use a standoff to get a bit more skin definition but this image represents a nice hypoechoic collection with ring enhancement and a ring down artifact deep to the abscess.

Hidrenitis.JPG