So long stethoscope -- hello hand-held ultrasound

This column first appeared at annemullens.com on March 17, 2014

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For more than a 100 years, the stethoscope has been the one personal piece of diagnostic equipment that every physician carries, slung around the neck or curled in the lab coat pocket, for the prompt listening to the gurgles, rasps, lub-dubs and whooshes of patients' tell-tale body sounds.

But now hand-held ultrasound devices, about the size of a large cellphone, will soon be in every physician's pocket. Each hand-held unit costs about $8,000 and is designed to be used and owned by a single physician. Ultrasounds can easily give more detailed information about a patient’s condition, allowing a physician to more quickly respond to the patient’s needs. And two groups of BC physicians across the province are now being trained in their use.

"It is game-changing technology. It is portable and it provides information well-beyond anything you can hope to get from the stethoscope," says Dr. Danny Myers, general internal medical specialist who splits his practice between Salmon Arm, Revelstoke, and Victoria.

Myers' research into the devices, their growing use in remote locations like Africa and rural India, and the training requirements needed to achieve competency in their use, prompted him to apply for funding from the Specialist Services Committee (SSC) to establish a pilot program that trains rural and community internists in hand-held echocardiology — ultrasounds of the heart.

The SSC is a joint committee of the BC Ministry of Health and the Doctors of BC (formerly the BC Medical Association) and it supports the improvement of the specialist care system throughout the province through targeted funds from the Physician Master Agreement. 

Myers can pinpoint the moment when his enthusiasm for hand-held ultrasounds first took hold. It was the 2010 Vancouver Olympics, and Myers saw a news item that physicians at the games would be the first in history to use the devices in the mobile medical units. Athletes or spectators with chest and abdominal pain or any multi-system injuries would be assessed with the devices as part of their initial exam. 

"It struck me how valuable something like that would be for my specialty in remote BC communities, where we have limited access to diagnostic technologies for our patients," said Myers, who at the time was president of the BC Medical Association's Section of Community and Rural Internal Medicine (CRIM). CRIM has more than 200 members, all of whom all internists practicing in various communities across BC.

 "Our members have a need in particular for echocardiology. It can be days, even weeks — or hours away in another city — to access a formal echocardiogram. With this technology we can see most of the heart functions, fluid around the heart, and valve functions right at the bedside."

 Emergency medicine specialist, Dr. Michael Ertel, of Kelowna, also applied around the same time to the SSC for funding to help cover training costs for ER doctors to upgrade their skills in the use of a bedside ultrasound for emergency diagnosis. In emergency departments the ultrasound technology includes both the personal devices, as well as laptop-sized ones used by multiple physicians which cost about $60,000. 

"These are wonderful instruments that we use a lot in the emergency department for rapid assessments of trauma. We can see collapsed lungs, internal bleeding, free fluid, fetal heart beats and more. It is revolutionizing emergency medicine," says Ertel.

 The technology is also avoiding the need for CT scans, which require radiation. "Patients love it. But since this is an emerging technology, most emergency physicians over the age of 40 have not had the opportunity for training," said Ertel.

 Both proposals received funding from the SSC this past year. Any emergency physician in BC who wants to attend the ultrasound course, as well as two other skills-upgrading programs put on by the Canadian Association of Emergency Physicians, can have the course costs covered by the SSC funding. "The result is a huge benefit in patient care for BC," said Ertel, who says the aim is to eventually have every ER doctor skilled in bedside ultrasound.

The echocardiology course for rural internal medicine specialists also has  been going on this past year, taking place over four, two-day weekends in the spring and early fall. Developed and delivered by internal medicine specialist Dr. Jean-Paul Lim, who splits his practice between Terrace BC and Vancouver, the course is not only training eight physicians on the use of the devices, but subsidizing by up to 50 per cent the cost of the hand-held units.  And it is already having an impact in patient care.

 Dr. Chester Morris, an internist in Port Alberni, who has no local access to echocardiology, diagnosed a critically-ill patient with pericardial effusion — fluid around the heart — after the first weekend of training. "I am now using the device every single day in my practice," says Morris.

 Myers is, too. "I take mine everywhere I go. I love it. But more importantly, it is improving patient access to timely care."