Transcript
- Good afternoon.
Welcome to the Fujifilm Sono site
behind the scan webinar series.
Today's topic is the new SonoSite PX
and we will be discussing diagnosis two procedures
for the MSK physician.
Our presenter today is Bill Medford.
Bill Medford joined Fujifilm SonoSite 10 years ago
as the lead musculoskeletal clinical specialist.
Bill is certified in stenography
with credentials including RDMS and R-M-M-S-K.
Bill brings 42 years of experience
with 22 years in musculoskeletal.
Bill has held numerous invited faculty
positions over the years.
He is a member of the A IUM
and has been an AR D-M-S-M-S-K subject matter expert
since 2015 and we're super lucky to have him on our team
and to be scanning live for you today from his home studio.
Here's our Bill Medford himself.
- Hello everybody. It's a pleasure to be here
and I'm excited to present the Sono site px,
which I feel it
represents a significant advance in ultrasound.
The PX is designed
to help you be more efficient
and help you be more confident.
In particular, where with advanced image clarity,
which I think is one of the greatest highlights,
the system has to offer image clarity.
That is beyond what I've seen in the industry
ever and with the advancement of transducer technology,
we've taken it to a new level.
I love the system design
that we can transition from a vertical to a horizontal
presentation, assist in bedside ergonomics
and the outpatient space.
We all know we have tight rooms
and the need to get position the machine up against the edge
of the bed and to get between the exam table
and the wall at times can be a problem.
I believe that we've addressed that with our new ergonomic
trend and vertical to horizontal design.
Workflow efficiency is improved if you look at the base
of the system, we have incorporated
cord management tools
that remove the cords from entanglement
and getting in the, in the wheel well
where they can be damaged.
We've also repositioned the gel holders
and the antiseptic wipes have separate tubs for those
that are easily accessible
and as I was mention mentioning it,
it it represents our most advanced image clarity date
as well as what you saw there.
Our color doppler is improved.
Our color sensitive sensitivity is much improved
and we think we'll, we'll demonstrate
that in the live scanning session.
Our transducers, our broad array
of transducers have been upgraded in technology throughout
the breadth of what we have to offer.
The transducers that we will
showcase today include the L 15
to four megahertz transducer, the L
and the L 19 to five megahertz transducer.
They all represent, added an added number
of channels which improve frame rate as well
as res resolution.
Also, we see
that when you're looking at the system from the side,
how slim and trim it can be
and with, with the ability to raise
and lower the system either from in front of the system
by a foot, foot bar there that can be depressed added
to this platform are
foot pedals off to either side of the base of the system
that can be depressed to raise
and lower the system from either side.
So let's talk a little bit about image clarity
and the L 19 to five.
Here we have an image of the,
of the ulnar collateral ligament with the linear 19
to five megahertz transducer, the image resolution
and the margin definition, the ability
to define interfaces
and the axial plane is greatly improved the insertion
of the ulnar collateral ligament onto the sublime tubercle
of the ulnar, the ability to differentiate small amounts
of fluid in the joint recess
and again, just the clarity
with which you can define the margins
of the anatomy we're looking at
same, same patient.
Well here here's a couple of,
here's an what we have.
Here's an image with the L 15 to four transducer
and what I wanna point out to you is the clarity
with which we're able to define the labrum of the hip.
This is with a linear 15 to four megahertz transducer.
The again, lower frequency range is four megahertz,
which gives us added penetration to get
to structures like the hip with the resolution
of a linear array transducer.
This is the same patient, the same image
of the lateral collateral ligament with the L 15
to four megahertz transducer.
The 50 millimeter footprint unchanged from our previous,
what was referred to as the high frequency linear 50
of millimeter footprint.
Inducer again gives us the ability
to highly resolve a structure like the ulnar collateral
ligament and we can see the small slip
of fluid again in the joint recess.
- We're now gonna turn this part of this part
of this session to the live demonstration.
We will have Bill Medford scanning at his home studio.
So we will scan as as many things as possible,
but if you would like to see something in person,
we can always accommodate those needs as
- Well.
Thank you Joy. I think the first thing I'd like to do is
highlight a couple of things about the user interface.
This user interface came about as the result
of a great deal of feedback that was sought after
and received by our engineers.
What we've in, what we've incorporated
or our engineers incorporated was what folks
that had used our legacy products liked about the
tactile keys as well
as the touchscreen user interface.
So with the tactile key,
we have a little bit of both worlds.
They have the tactile keys which allow us
to have the most frequently used functions that
that we're going to refer to most often, always present
as physical buttons, things like the game,
the depth of the image, the touch pad,
calipers, a button for
for annotations, freeze save, saving video clips,
and then the various modes of scanning.
When we go up to the touchscreen user interface,
this will look very familiar to folks
who have used the export.
We can go directly to scan the patient
or we can go to en enter patient information
or we could select the transducer
and exam type as the first thing that we do.
And also as we had on our export system,
we have learning modules
and we've increased the number
of learning modules in MSK from 75 to 150.
So we've doubled the number of videos that are apparent.
Let's review one of those.
Let's look at the lateral shoulder.
You see that the, you see the different sort of subjects
that we have along the top
and the specific topics
that are covered as well.
We can scroll from side to side to go through ankle,
knee, hip
and pelvis, wrist, hand, elbow, as well
as three different columns for the shoulder.
Let's look at the lateral shoulder.
I'm gonna let this loop for just a second.
What I think's good about these videos is the narration
that goes with 'em as well as we're able
to see the transducer placement
and the ultrasound image as well.
We can scan along, we can freeze an image
and scan as we're watching the video,
- I'm the patient and the transducer is placed
posteriorly over the head of the humerus
with the orientation marker directed
to the patient's, right.
The examination begins
by locating the glenohumeral joint space which lines,
- So this gives you an idea of what you would have available
as a source for learning with the, with the XP
- Can be seen on the right of the screen
as a rounded bright image.
The transducer is adjusted
so it is centered over the glenohumeral joint
line, the needle.
- Also, when we get to the user interface, when we're ready
to begin scanning, we're going to go to
our user interface for the most commonly used functions,
whether it's needle profiling,
steep needle profiling,
and if we go to steep needle profiling,
we have an advanced feature of steep needle profiling
as well that we'll discuss a little bit later.
But an it automatically is able
to detect the advancing needle
and make the adjustment from steep to medium
to shallow without the user having to make that selection.
We'll cover that in a little more detail.
You can change dynamic range.
Here's where you change from resolution mode
to general mode.
The zoom feature on the transducer is now right zoom so
that when you and zoom in on, on anatomy,
you don't lose resolution.
Resolution is maintained to be constant.
We have dual imaging again so that you can
compare affected side versus contralateral side
and this is where you would also go to your patient list
for archival and and the like.
More controls are listed here where you can
see more controls that you might less frequently use,
but the system is designed to be adaptable
to make your experience more efficient,
more effective and efficient.
So let's do a little bit of scanning.
I'm going to begin by using the fif L 15
to four megahertz transducer
and we'll take a quick peek at the couple
of structures in the shoulder.
Here we're looking at the supraspinatus tendon.
Notice that you can bring an arrow up.
We have, you can bring up to five arrows that you can use
to point out anatomy.
So what I want to point out is
how little artifact there is in the image, how crisp
and clean tendon fibers are.
How well defined the bursa is, the fatty layer of the bursa
as well as the actual bursal space.
Notice all the interfaces that we see
and the echoes return back from the deltoid muscle
as well as the superficial tissue.
How clearly defined even the skin layer is in the first few
millimeters of the image.
And what impresses me is how crisp
and clean the cortical
surface of bone is.
And if we look at articular cartilage, we note
how little artifact there is
and how clearly defined the articular cartilage interfaces
as well as the myotendinous junction of the supraspinatus.
If we take a peek at the bicep tendon in the short axis,
again just the resolution
with which we see the bicep tendon in the
short axis.
If we turn in the long axis,
the resolution with which we identify
and recognize individual tendon fibers of the bicep tendon
as well as muscle.
If we go down to the elbow,
problematic structure to to scan is
the distal bicep tendon
we see very clearly there down to its insertion
on the
radial tuberosity.
Notice the adjacent branch of the ulnar artery.
If we go to the medial elbow
and go more superficial,
we see the ulnar collateral ligament.
So let's switch over to
the L 19 five megahertz transducer
with a simple tap of a button.
We, it brings up our transducers.
We're gonna select the ex MSK exam type
and notice how quickly it transitions from one
transducer to the next.
We're going to change our depth.
It quickly makes that adjustment
and I'm going to focus here on on
the distal insertion of
of the ulnar collateral ligament, which we see
right there.
So again, I wanna point out how clearly
we see the margins of the anatomy that were put
to task to demonstrate
- Phil, we're seeing lots of finite structures there.
How is the ability of the color flow
with those smaller vessels?
- Well, it's increased color sensitivities,
everything in MSK
and to to see tendinopathy,
to recognize neovascular,
especially when we talk in rheumatology
and we're looking at synovium, we want to be able to grade
degrees of synovitis
and the ability to have advanced color sensitivity certainly
aids in the confidence of which we're making any
of our diagnosis, whether it's with color doppler,
with just the gray scale image.
- Perfect. Are you able to show me a general color picture
as well as maybe a color doppler picture of a small vessel?
- Well, let's go down to, it's a smaller vessel.
Let's go down and look at the radial artery real
quick and the wrist.
I'm gonna switch to the L 15 four megahertz transducer
and there's actually a little bit
of pathology in this wrist.
As we see there.
We see a ganglion cyst and the anatomic snuff box
and just superficial to that
we see the radial artery.
A couple things to point about the out about the radial
artery in this particular model is
how we see the intimal lining of the artery speaks
to the gray scale resolution and image clarity.
Let's go to color doppler
and with the touch pad we'll
lift more superficial our color box
and also available to us
with our adaptable touchscreen is a single click
to color power doppler.
So the color sensitivity is quite good.
I think you'll see outside
that radial artery you see a couple
of smaller vessels there, joy
As well.
What we can do and what is a new feature
with the PX is the ability to color compare.
So we can split the screen.
We have the ability to demonstrate our anatomy
and gray scale on one side of that image
and as well look at the area of vascularity in
that same location on the other side.
So with areas of tendinopathy,
when we're looking at tendon degeneration,
we wanna know if there's neovascular associated with,
with the OID degeneration phase of tendinopathy we,
we can put our gray scale image say
of the patellar tendon in that zone of hypo echogenicity,
scan it and at the same time know that we're scanning in
that same precise location to see if the,
if there is neovascular pres present.
This will also be very helpful
and very useful for rheumatology
and looking at areas of synovitis to be able
to demonstrate the gray scale appearance of synovitis
as well as the color doppler response in
that in those areas.
Let's go to the dorsal wrist real quick again,
with linear 15 to four megahertz transducer,
here we are seeing listers tubercle.
We're gonna go a little more superficial with our image
and so here we see listers tubercle,
and you see my extensor lysis longest tendon
artifact off to either side is is frequently present when
we're looking at structures
that are very small like the wrist, we will eliminate
that once I go to the L 19 to five megahertz transducer.
So if we look at the EPL
and we go to the second compartment where we
have the two extensor carpi radialis tendons,
we can see, and again this is the 15
to four megahertz transducer,
we see the retina aum coursing over the top.
We see the skin layer
- Bill when you're scanning these images are amazing.
How, how easily is it to acquire an image
or maybe if you wanted a live clip of something
that you could review.
- There's a, you talking about the video clip feature.
So video clips can be,
can be recorded retrospectively
or prospectively
for most commonly in MSK they're recorded retrospectively
and you have the ability to do it either way.
You can set your video clip recording so that it,
so that it can be recorded in anywhere from two seconds up
to 60 seconds at various intervals.
If we wanted to record a little video clip of
what we have here on the touch screen
or on the tactile buttons, right
above the freeze button is a video button
that can simply be pushed when you hear the beep right away.
That means you've done a retrospective clip store clip save
and then you can go review that at your leisure.
Let's, let's go to the L 19 to five transducer
and look at this same anatomy to demonstrate
the resolution
that is possible in the image clarity that's possible.
With the L 19 to five, we're going
to take our transducer to the most superficial setting
and now we see the same anatomy.
I'm gonna flip my transducer around.
So we're we're oriented the same way as we were
with the L 15 to four
and we see that tendon see how much easier we see that,
how better resolved that is, how crisp
and clean the bony interfaces are.
And if we come across a very important structure,
very difficult to see in the past when we get over
to the first compartment is this little structure right here
called the superficial radial nerve with de veins.
This is a little nerve that we want to avoid hitting
and it has been difficult
to clearly define before.
And now with the image clarity of this device,
it's very easy to see
and follow it over to be sure that
as we drive a needle into this space
to separate these two tendons
and deliver injection that we don't do damage
to this very tiny superficial nerve.
This is the first time I've been able
to actually see individual fales in the superficial radial
nerve with any technology that I've ever used before.
- Bill, this nerve looks incredibly superficial.
Can you tell me how far underneath the surface
of the skin that is?
It looks very within a few millimeters.
- I'm looking at the
graded markers to the right
and it's at three millimeters.
So again, here's the endoderm layer
right here, the ectoderm, I can't even get the arrow up that
that high and the mesoderm.
So we're able to see the skin with the kind of resolution
that we haven't ever seen before.
Right underneath the skin there is
that nerve, you can see the, so with this
- New L 19 to five bill, you mentioned
that it had a very superficial scanning depth.
What is the most minimum scanning depth that we can achieve
with this transducer?
- Well right now we're set at one cm
or at one cm, which is where I'm I'm at right now.
So if I'm scanning something that's superficial,
that's the depth I'd want to go to.
You see it there sitting right on top of that, that tendon,
whoop, see it just snap over.
- That's incredible. - Yeah, see it's snapping back
and forth there so it will still go
to six centimeters though, which reflects really
an amazing feature.
This transducer that
its broadband frequency range is 19 megahertz
to five megahertz, five megahertz on the lower end
of the frequency range allows a depth of penetration
that we haven't been able to show.
Let me go back real quick.
Joy to,
to our models distal bicep tendon,
something I wouldn't imagine that we'd be able to see
and oops, I just moved the machine.
Okay,
let's look at the distal bicep tendon again real quick.
I'm going to increase my depth
and notice that even at a depth that
we typically have to go to see the insertion
of the distal bicep tendon, we can visualize it
and get the advantages
of image clarity at higher frequencies to assess areas
of tendon tear or degeneration,
something historically difficult
to see in the distal bicep tendon
with this kind of resolution
- Bill.
I think on this image the clarity is amazing.
Are there any other new features on the PX that we could use
to enhance that image just a little bit more?
- Well one, one of the advantages of having multiple
adv more channels in transducers is that our frame rate,
you'll notice, let's go back to the 15
to four megahertz transducer.
- We can show that as well
or bill, if you wanted to just toggle through the TGC
and show them live
how we can adjust the TGC from the near
field to the far field.
- Sure we'll do that here is, that's better demonstrated
with a wider footprint transducer, so,
- Okay, perfect.
- We will, we will do that
while we're looking at the distal bicep tendon here.
So you notice that with the 15
to four megahertz linear array transducer,
how our frame rate, you don't even notice a frame rate.
It keeps up with my sliding of the transducer,
no washboard appearance at all.
That's one advantage to your point
adjustable TGC and I'm glad you brought that up
because that is a new feature on the
PX that we have not incorporated in the past.
And what it does, it gives us the ability to adjust
our gain anywhere along the depth
of the image that we're scanning.
So right now you see that I'm adjusting, raising
and lowering the superficial gain
and if I grab the center
toggle I can take it more superficial
or less superficial and selectively raise
and lower the gain anywhere along the depth of the,
the image that I choose.
Or I can just grab the far gain and raise
and lower selectively the deepest part of the image.
So that gives us an added image optimization feature
not present on prior devices.
The bottom one here is your total gain.
So you can adjust your total gain there
or you can come down to your tactile GI keys
and adjust your total gain by
turning either clockwise or counterclockwise.
Auto gain is still a feature
that remains present on this device as well.
Those are the primary ways.
Joy, I mean there are other things such as being able
to change your dynamic range,
familiar on prior devices to folks
to either more contrast the image
or a less contrast the image still have the ability
to go from resolution mode
to gen mode to achieve a little more depth of penetration.
One last thing I'd like to leave with regard leave folks
with, with regard to image clarity is a comparison
of looking at the median nerve in the carpal tunnel.
Something many MSK
users take a peek at.
So again, I'm, I'm using a wider footprint,
thus the image dropout on either side
of the transducer down in the wrist
and we see the median nerve right here.
So notice how clearly defined the fascial are.
No longer is it difficult
to differentiate a nerve from underlying tendons.
It's very clear that we see fascial here
and we see tendon fibers here. Let's switch
- Bill with this high frequency transducer.
Can you show us what
that minimum scanning depth would look like on
that median nerve?
- Minimum depth on the L 15
to four transducer is 1.5 cm,
which we see down in the lower right hand corner.
It will scan at a depth up to six centimeters.
But what I really want folks
to see here is let's again look at the median nerve
and let's switch to the 19 megahertz.
Again, notice how quickly we can transition from one
transducer to the other.
Going to go to my sup most superficial depth
and there we have the median nerve with the L 19
to five transducer.
Notice how clearly defined the,
the fassal in the nerve are.
Also, I would like to point out how clearly visible the ulu
covering the carpal tunnel is
right above
Joy.
Do we have any questions?
- Let me just check real quick.
So I have a question for you. Bill.
In your many years
of musculoskeletal experience in ultrasound,
there's been many, many changes in technology and advances.
How would you describe the advancement in technology
of the PX and its helpfulness in diagnosis
in disease process?
- I feel the PX represents one
of those quantum leaps forward
in ultrasound technology, one
of the most significant quantum leaps forward
that I've seen in my career
and it's what's got me so excited about this product.
Several things, both system design
that aids the efficiency of the user.
Most of all though image clarity,
which gives the end user the ability
to be confident in what they're seeing quicker.
Being a i I think back joy several times
and I think we've reached the zenith in image quality
or image clarity
and thinking that we can't get any
better resolution than what we already have.
Well, I think we've done it again
and PX represents that
another level quantum level forward from
what we've had in the past.
But the ability with the, it's all about the image
and to be able to be confident in subtle findings
in small occult fractures
of ribs and, and tendinopathies
and small rotator cuff tears are those,
or what we see in, is it, is it real or is it artifact?
Just having the confidence quicker
of those observations that we make means everything
to the end user.
And I know as a sonographer I think image clarity is
what you want to achieve the most,
but little things like being able
to snuggle it up against the side of the bed
and have everything right there at your fingertips
and an easy to use interface, all those things
adapt, are adaptable and aid the efficiency of the end user.
- Thank you Bill. That's amazing.
I know sono side's legacy products have always been known
for their five-year warranty, including transducers.
Does the PX offer the same warranty even
with these high frequency new family of transducers?
- It does. It does.
And as always
the tra the transducers are expected
to withstand dropage.
Our biggest customer is the US military
and the pounding that all of our systems take has to reflect
that use model
and so we are able
to offer a legitimate five year warranty based on the
durability of our products. Absolutely.
- That's amazing. That is amazing.
As far as the education, I'm fascinated
by the learning modules that you offer on this system.
They seem to be sort of at a beginner level,
it may be a little bit over two minutes per video.
Can you tell me about any other education offerings
that Sono site has for those folks wanting
to improve their Ms K skills
or keep up with trending procedures?
- Sure. I know right now in, in a couple of days
my colleague Daniel Shelton
and I are wrapping up our hip webinar series
with a specific review of the posterior anatomy of the hip.
But we have covered the shoulder and the elbow
and we'll be presenting those on a monthly basis,
maybe even twice a month.
Those are available on Sono Side Institute.
They're recorded and available to view at your leisure.
Not only are the webinars that Daniel and I have done there,
but even far more videos, a plethora
of videos, educational videos
and training videos for for our summer site customers.
- Perfect. Thank you so much Bill.
I wanna thank you all for attending today's webinar.
For those attendees you will be sent a link
where you can record this or review this webinar
and also if you would like an in-person visit, we're happy
to come in-house and scan live and let you touch and fill
and use the system on patients and
or we can schedule a personalized Zoom video
for your practice needs.
So thank you very much for attending
and have a wonderful afternoon.
Join Fujifilm Sonosite experts for a live demonstration of the all new Sonosite PX point-of-care ultrasound solution. Learn about the unique advantages of our most advanced image clarity and Auto Steep Needle Profiling for more accurate needle guidance and treatment effectiveness.
What You'll Learn
- How our most advanced image clarity helps you to better visualize anatomy
- Using Auto Steep Needle Profiling to visualize the needle from multiple angles for more precise injections
- We’ll take a closer look at the new family of advanced digital transducers, including the L19-5, the highest frequency transducer Sonosite has ever produced
- New, improved color performance to help you detect the telltale signs of inflammation
Audra Upton is the Director of the Clinical Applications team with more than 13 years of experience with Fujifilm Sonosite. She graduated from the University of Oklahoma with a degree in ultrasound and is a registered cardiac and vascular sonographer. Audra and her team remain customer-focused and are specialized in providing top-level point-of-care ultrasound education.
Kim Warren is the Clinical Applications Specialist for Fujifilm Sonosite in Minnesota. She has been a sonographer for 10 years and is currently registered in vascular and abdomen.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.