Robert M. Bramante, MD FACEP
Associate Chairman, Emergency Medicine
Director, Emergency Ultrasound
Good Samaritan Hospital Medical Center, West Islip, NY
Progressive Emergency Physicians
To start off, there is simply no perfect answer or perfect device for Emergency Department (ED) use. That’s not to say there are not great devices that meet the needs of clinicians in the ED but getting emergency physicians amongst different sites or even within the same institution to agree on a device or features is a challenge. The variety of devices from high end radiology ultrasound equipment to hand held devices allows for options for all tastes however there should be a few basic requirements and items for consideration while evaluating possible systems for your institution.
ACEP has put out an excellent resource recommending key features under their clinical and practice management resources. While having a device with all possible features may be nice in a typical ED setting you want a device that is compact and portable. This leads to 2 important points. First, the ultra- high-end radiology systems are often large and cumbersome which make ED use difficult if not impossible. Second, avoid the “donation” of old radiology equipment. Old radiology equipment is neither structurally designed for portable ED use nor programmed to be optimized for ED applications and the typical ED user. On the opposite side of the spectrum are the ultra- portable “handheld” devices. In addition to concerns about image quality and applicable uses these devices run the risk of being more easily lost or as some would say “walking away.” Luckily, for us as ED users there is a wide range of compact devices that are portable and provide high image quality. Most EDs will require at least 3 transducers (curvilinear, linear, and phased array). Depending on the practitioners training and comfort at an individual site an endocavitary transducer should be considered. The ideal setup for point-of-care imaging (due to the various studies being done) would be to have these connected via a live port rather than having to manually switch between transducers during or between examinations.
Even if a new device is not in your facilities current budget start making contacts with sales representatives from a variety of manufacturers. In addition to trialing devices and understanding what features are important in your department and with your users you can develop relationships with these individuals. When the time comes to purchase these relationships can help you to get equipment within the facilities budget or help guide you to the best deals to accommodate your situation. In addition, knowledge of the companies and products beforehand will allow you to make an informed decision. Point- of- care ultrasound is one of the fastest growing segments in United States imaging and concerns about radiation exposure will likely continue to drive that use. Having relationships with the representatives will also often lead you to know about the newest advance in technology as soon as they are available. While meeting representatives at conventions or trade fairs is not a bad idea, it is key to trial the devices on actual patients not the models who are present at these events. It is highly encouraged to trial devices on patients with a larger body habitus to evaluate image quality. As far as cost goes, your budget will often be decided by your facility when planning a capital expense plan. Having knowledge of current systems and costs will allow you to request appropriate funding rather than trying to find a system that fits a preconceived spending limit.
Additional considerations should include the durability and warranty on the system and its components. Despite best efforts ED ultrasound machines face daily abuse. Knowing the duration of the warranty (usually 3-5 years) is important. However, more important is know the warranty coverage. Does it cover all components i.e.: system and transducers, for the full warranty period, are parts and labor covered or is a service contract an additional cost? Despite how mechanically inclined you believe you may be, disassembling, changing out components and reassembling an ultrasound system is not something you want to do with your time.
While ACEP’s clinical practice document lists additional key features including quick boot time, DICOM archival, Wi-Fi compatibility, cart design/ storage, the complexity (or simplicity) of the user interface is likely one item that is very site specific. So-called “super users” and fellowship trained clinicians will often feel comfortable staring down a device with numerous knobs/buttons/dials/touch screens, however the typical ED clinician can often feel overwhelmed and may be reluctant to use that device. It is crucial to evaluate your site and the users there when considering the user interface.
In summary, try a number of devices on real patients. Be aware of costs and warranty. Know your facilities budget request deadlines, and be aware of the clinician’s ability and concerns at your site. It is never too early to start planning your facilities first or next ultrasound purchase.