When I first began working with veterinary ultrasound, it was unheard of that a clinic would invest in an ultrasound machine without first receiving a demonstration in their practice. Nowadays, and particularly since Covid-19, in-person demonstrations are far less common, largely replaced by the dreaded loan system.

This works well from the point of view of very large medical companies. Often, their salespeople have large portfolios of a vast range of equipment, and cannot possibly be specialised enough to demonstrate an ultrasound scanner to anything greater than a very superficial level. Whether or not their ultrasound system is chosen is a bit of a lottery anyway, so participating in that lottery without the cost of paying someone for a day is definitely a good thing.

I, however, am definitely not a fan of the loan ultrasound machine from either a supplier’s perspective or a potential end-user’s. Sending a loan system puts the onus completely upon the veterinarian to figure out how to get the most out of that machine, which is actually the job of the ultrasound company (whether or not they are capable of doing it).

From the ultrasound company’s point of view, you have lost all control over that person’s experience with your system. If your client is not used to the layout of your particular system and cannot optimise their image, or even if you’re just unlucky and they scan a difficult patient, they won’t have a good experience with your machine – and you’re not there to do anything about it. From the buyer’s perspective, unless you are one of those rare human beings that enjoys discovering a new piece of technology for yourself, you have just been saddled with the job of learning a new piece of equipment inside out whilst simultaneously continuing with your actual job which is to diagnose and care for your patient. And if there’s one thing vets don’t need right now, it’s extra work.

Despite these criticisms, I cannot argue with the fact that delivering nationwide demonstrations is becoming increasingly costly and difficult, and the fact that they are no longer expected as standard comes as a huge relief. Saving on this huge cost allows clients to receive better pricing on ultrasound equipment, because the cost of doing business has been reduced. Our solution in this new environment has been to offer online demonstrations and walkthroughs – a sort of compromise to the loan machine scenario, whereby our customers purchase their machine with the knowledge that they can return it within 30 days if unhappy, and we schedule time together over Zoom to go over the machine in as much depth as they want. This has worked really well for us (nobody has changed their mind on a purchase yet!), but if you want to compare one of our systems with another make or model, or even if you have a preferred supplier that is not us (it happens!), what can you do?

How to test-drive an ultrasound machine on your own

If you find yourself taking delivery of a loan machine to test out, here are a few tips to get the most out of it – but also to discover any of its failings before you end up purchasing it.

1. Find the tissue harmonics button right away

Almost all machines over £3000 now come with tissue harmonic imaging (THI). In lower end systems, you will find that toggling this button on and off appears to do absolutely nothing. In higher end systems, it will make a big difference, so make sure you scan with it on and off to see which you prefer in different scenarios. If you spend the entire loan period scanning with it permanently on or permanently off, you will likely be doing the machine a huge disservice and may end up picking an inferior machine purely due to chance.

In the below canine pregnancy scan clip taken on the Acuson P500, tissue harmonics are initially turned off. This would lead you to believe that the nearfield image quality of the microconvex probe is poor. Hopefully, you can appreciate the difference it makes when THI is turned on!

In comparison, on this echocardiogram, THI makes little difference. If anything, the image is better at the beginning, when THI is turned off.

2. Don’t get hung up on numbers.

Someone may have told you that for cardiac scanning in cats you need a phased array probe that goes up to 9MHz. The ultrasound machine you used on your advanced imaging course may have had a microconvex probe that had a frequency range of 6-10MHz. Therefore, you want transducers that will cover these frequencies.

While frequency is important, do not see it as an absolute. 8MHz on a Siemens Acuson P500 will give you better images on a cat than 12MHz on a KX5600, so before you dismiss a scanner for not giving you the right frequency, look at the image. Is it of diagnostic quality? Can you see everything you need to see? How detailed is it? If you are testing it against another machine, compare the image, not the numbers.

3. Be unforgiving about Doppler

If you are buying a system with colour and spectral Doppler, you must be tough on it. Toggling it on and off over a blood vessel is not enough. If you will be performing abdominal scanning, use it in low flow conditions (e.g. kidneys) and faster flow (arteries). Check that colour flow is correctly coded inside the vessels with no ‘blooming’, and that it is sensitive enough to pick up areas of low flow. If you will be performing echocardiograms, stress testing the colour flow Doppler is even more important. Scan nervous cats, scan dogs with mitral valve disease, and check that the machine’s colour Doppler can keep up with the fast heart rate and provides you with genuinely useful information. Can you see the regurgitant jet on that dog, or do you only see flashes of colour?

So many ultrasound systems are marketed as colour Doppler systems, but in reality, their colour flow is clinically useless.

If you will be performing heart scans to a high level, be sure to also check tissue Doppler imaging (TDI). You will need this for your diastolic function assessments, as well as looking at systolic function of the right ventricle (S’). This is another major weakness of the vast majority of ultrasound machines sold for veterinary use at the moment.

The same principle applies to probe types, and being sure that you are testing like-for-like when comparing systems. In the below video, both the phased array and microconvex probes give excellent cardiac image quality on the P500:

When it comes to colour Doppler, however, the phased array probe performs well for echocardiography, but the microconvex probe’s colour Doppler performance is useless for this specialist application:

4. Look beyond imaging

Once you have judged image quality, think about what else you need from a scanner. Things like portability are immediately obvious, but factors which are often overlooked include ease of saving and transferring images. Are you happy exporting images and videos onto USB if you want to put them onto your practice system? Will you be using reporting software in the future that relies on images being transmitted in DICOM format? It is worth asking these questions now, because upgrading some systems to be able to save in DICOM can be costly, and the results suboptimal.

Summary

As always, our (admittedly biased) advice is always to speak to a specialist ultrasound company before choosing an ultrasound machine for your practice. Ask if they have anyone on their team who uses the machine you are interested in clinically themselves, and speak to that person. They will be able to give you all of the machine’s pros and cons, and while they will of course hope that you will choose to work with them, they are ultrasound professionals before anything: not career salespeople. Therefore, their primary motivation above all else will be their own reputation and lifelong career, and that is not something they will be willing to damage just to make a sale.

If you would like to speak with one of us at PortableUltrasoundMachines, please call us on 0203 972 2270, or email us here.

The Siemens P500 for veterinary echocardiography

I have tried and reviewed the Siemens P500 ultrasound machine in the past, but this week, I received delivery of my very own brand new unit. To be clear, I will not be replacing my Apogee 2300. The Siui Apogee 2300 is an extremely reliable ultrasound machine that has served me well now for almost 4 years, and even many years on from when I first selected this system as my number one echocardiography machine, it still beats anything else priced under £20,000 in the market today. Competitor systems have not caught up with it and, of course, it continues to be improved and developed all the time. Apogee 2300 models bought today can now come with auto EF and strain software, for example (and older models can have a software upgrade).

My Siemens Acuson P500 machine will not be a replacement, but an addition, that will work well with much of my research work. The Apogee 2300 provides stunning image quality, with fast and easy image and video saving, making interpretation and reporting a breeze. Clinically, that is what I need, and definitely what every veterinarian needs. For my research work, however, I have more time on my hands to delve into the type of detail one could never afford in a normal first opinion examination. I also require easier export in DICOM format than the Apogee 2300 allows: Siemens is one of the ‘big four’ ultrasound companies in the UK and, alongside GE, Philips and Canon, dominates in supplying the NHS. As such, by default, Siemens ultrasound machines are configured to save and export in DICOM format, although avi format is of course available (and will be preferred for the majority of veterinary users).

The anonymisation option is also a huge time-saver for me. When exporting studies, you can simply tick a box to anonymise your study, and give it an anonymisation name if you wish (some people may use a coding system – I just write the breed, “e.g. Anonymous Cockerpoo”). This automatically blacks out the top ID bar for you, resulting in an export like this:

For teaching, though, the Apogee 2300 still wins. On the Siemens machine, to store a video, you press ‘Clip Store’ – but if you freeze and then press ‘Clip Store’, it will save a very long loop (in the order of minutes, if you wish). The downside with this is that it takes a very long time for it to save this long clip – in fact, it seems to take double the time to save the clip than the actual length of the recording. Scanning for 10 seconds but needing to wait 20 seconds before you can continue with your work is impractical in most settings. On the Apogee 2300, however, you can set any key you wish as your continuous record hotkey, and even if you were to scan for 5 minutes straight before stopping it, it would take only a second or two to save.

To be clear, it is only the long loop record feature that is slow on the Siemens machine. This is something that nobody will ever use clinically. For me, though, it is important, as I often want to show people the an entire process from start to finish. To show people how to obtain a mitral inflow trace, for example, this will include finding the right view, turning on and correctly positioning colour Doppler, positioning the pulsed wave Doppler gate, adjusting the gate size, obtaining the trace, adjusting baseline and scale, and optimising gain. All of this requires me to be able to record continuously, often for several minutes at a time. I assume the difference in save speed is due to the fact that the P500 saves this entire clip at the highest possible resolution, without compression, and retaining its DICOM format. In continuous record mode, the Apogee 2300 will save as an avi only (this means you cannot perform any measurements from it later, which is why I say nobody uses this feature clinically), and compresses the clip to the point that it frequently needs to be slowed down in video editing software afterwards.

Abdominal imaging

I was very excited to be the first person in the UK to try the new microconvex probe on the Acuson P500. Indeed, it has been the lack of a microconvex probe that has stopped me buying the P500 before now. While all of my clinical work is in echocardiography, it is still important to me to be able to perform basic abdominal checks, and it’s certainly vitally important to the vets I teach or demonstrate scanners to.

I had the opportunity to try out this new probe right away at the heart clinic last week, when one of our patients came in with ascites (unusually, we could not find a cardiac cause in her subsequent echocardiogram).

Although not the greatest test for a probe, the image quality is clearly very good. The abdominal image quality on the Apogee 2300 is exceptional, and I was keen not to depart from this standard. I will be testing this probe out more thoroughly over the coming weeks, in particular to check the performance of the microconvex probe’s colour Doppler imaging (again, a huge strength of the Apogee machines is their unbeatable colour Doppler performance, easily outperforming rivals like Sonoscape, Chison or Edan).

Interested in cardiology? You can sign up to my free echocardiography newsletter here: new cases every 8 weeks.

Examining the kidneys using Colour & Power Doppler

If you have been performing any kind of small animal abdominal scanning, you will no doubt be familiar with kidneys. Even if you specialise purely in canine or feline pregnancy scanning, you will certainly have bumped into one or two in your travels.

If you own a colour Doppler machine like the Apogee 1000 Lite, Apogee 2100 or Apogee 2300, you may even have used colour Doppler to examine the kidney’s blood flow. The below clips are taken from a Shetland Sheepdog puppy with an abnormal kidney, the first with Colour Doppler, and the second with Power Doppler. Power Doppler shows only the amplitude of the blood flow signal, and not the direction. It is useful when high sensitivity is needed to detect very low flow.

Alpaca kidney

One of the greatest strengths of the Apogee series of ultrasound scanners is its highly sensitive and accurate Doppler. In this clip below, an alpaca kidney is examined first with colour and then with power Doppler:

I am getting married in August, and decided it would be nice to have handmade maracas at the ceremony (we have a lot of children attending), printed with our names and wedding date. I first searched Google for handmade wooden instruments, but with little success. Then I looked on Etsy, but began to get suspicious that all of the “craftspeople” offering engraved maracas seemed to be making identical products.

A quick search on Alibaba revealed the reason: hundreds of listings for the same exact product that these US and UK based businesses were clearly buying in from China. Do I really want mass-produced products made on an assembly line in China, with wood of unknown provenance, at my wedding? No, not really.

The mass production problem

If you have been looking for an ultrasound machine lately, particularly if it’s for small animal scanning, you might be starting to feel the same way: they’re all beginning to look rather indistinguishable. This trend has been accelerated by the pandemic, where smaller companies and/or companies with exclusive manufacturing agreements went under, unable to financially weather the harsh lockdowns in China that lasted for almost a year. This “survival of the fittest” environment meant that only the larger companies manufacturing generic shells en masse survived. The downside for consumers is that two completely different machines may end up in cosmetically similar (or even identical) housing, making it difficult for end-users to tell the difference.

For example, one transducer may contain 80 crystals and deliver average image quality. Another transducer housed in the exact same outer casing may contain a mainboard which can deliver 128-element image quality, with much better signal processing components. Until you pick up that probe and scan with it, you would have a hard time knowing which was superior.

The challenge now for ultrasound companies is whether to make significant financial investments in making their product look different from the competition, knowing it will simply be copied in time anyway, or continue investing that money in developing genuinely better technology. It’s a tough one, because companies need to make sales to survive – and sales decline if people believe they can buy the same machine half price under a different name from someone on Alibaba, or even from a local individual on Facebook.

My personal experience developing the ScanX

When I was working on the ScanX portable scanner, I spoke to an Australian consultancy that helps to connect inventors and factories. They said they’d found a couple of factories willing to manufacture to my specifications with a £40,000 setup/tooling fee (this is before any of the costs of materials). I was hesitant. “How long will I have until factories in China start to copy my design?”, I asked. “About 4 months,” he replied.

Even if you are willing to pay to look unique, it can only be guaranteed for a matter of months. Using the small animal ultrasound market as an example, this is a problem that plagued the ScanPad range of ultrasound scanners for years. No sooner does a new design come out, and people begin working on copying it. This devalues the brand, not least because complaints begin to accumulate on social media from people posting about their malfunctioning “ScanPad,” when often it is not actually a genuine ScanPad at all. The genuine machine’s brand becomes tarnished by the poor performance of the knock-offs.

The solution

No amount of investment in making a design unique will protect it for the long-term. With the ScanX, my final decision was to trademark it here in the UK, then piece it together with components from a number of different sources (many from Europe and the USA), making it more difficult to copy exactly. People who trade in fakes like an easy life: they don’t know anything about ultrasound themselves, so they want something “off the shelf,” not something they have to invest significant effort into copying. I have no doubt that one day the ScanX will be copied, but with the intellectual property protected in the UK, USA and Canada for the next 10 years, there are easier targets out there.

The new ScanPad which will launch this May (2022) is taking a similar approach. Ultimately, though, if someone really wants to con you with a copy, they will. This is where the onus falls upon you to be vigilant, ask tough questions, and make it more difficult for those who are trying to take your money. If someone really knows their stuff and is a genuine expert in ultrasound, they will be willing to earn your hard-earned money; not only by supplying you with fantastic, high-quality, genuine equipment that is worth the price, but also with their pre- and post-sale advice and support.

Protect yourself from con artists

• Looks can be deceiving. If someone is claiming they’re selling you the same machine under a different name, or that they’ve “found the factory” of the a particular make and model, be sceptical. Every seller on Alibaba claims to be a factory. In fact, manufacturers rarely (if ever) do list products openly on the internet. If an individual with no experience or credentials in the ultrasound industry claims they’ve made direct contact with a genuine ultrasound factory, and you can find this “factory” yourself on a site like Alibaba, this is immediately suspect, and should have you running for the hills.
• Ask tough questions. How has this individual or company verified the ultrasonic outputs of this scanner? Can they confidently explain to you how they know it is safe for use? For canine and feline pregnancy scanning in particular, it is essential that the equipment being used is fit for purpose.
• Verify the seller. How invested is the person recommending equipment to you in this industry? What experience and qualifications do they have in ultrasound technology? Is it their lifelong career, or is their primary motivation simply to make a quick sale?

Remember, genuine ultrasound equipment is worth the price. The profit margins people make selling fakes are higher than real ultrasound companies make from selling genuine equipment. Treat anyone promising to save you hundreds of pounds with a healthy dose of scepticism, and if in doubt, ask for help from an expert on 0203 972 2270.

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Finding the right ultrasound scanner for equine reproductive work has always been a challenge. On the one hand, excellent image quality is key to spotting problems early, but the highest resolution scanners tend not to be the most portable. Ultra-portable, durable scanners like the Siui CTS-800 are fantastic for mobile work, but there’s always a trade-off in terms of image quality.

With Sonosite set to pull out of the veterinary market later this year or next, the popular M-Turbo is yet another option that will be disappearing for equine vets, with used models also now a risky choice due to uncertainty around continued support and servicing.

Now, you’re probably thinking this is all leading up to “announcing the new Equi PerfectScan 1.0!”, but sadly not. A decision still has to be made, but with a decade of experience standing by the sides of veterinarians as they test out various scanners, listening to their feedback, let me present you with the two most successful options I’ve found to date. To be clear: equine vets are a tough crowd to please. They’re perfectionists when it comes to their ultrasound scanners, and things need to be ‘just right’, which can sometimes be completely impossible because what they are looking for is a scanner that looks and feels exactly what they are already using (but isn’t). So, “most successful” here does not mean “instant perfection” – more “best tolerated, ultimately loved.”

Where only the best image quality will do

The Apogee 1000 Lite is the best choice where image quality is the number one priority. For the price, it is completely unrivalled. It can be run from a battery if required (but battery life is limited, so mains power is required if scanning several mares over a long time period), and the keyboard is completely splash-proof, which helps not only with spills but also when working in damp environments that can be a killer for other models of ultrasound machine. The ‘full screen’ mode on this scanner is particularly impressive.

The downside is that it is still a laptop-style scanner with a 60-second boot-up time, that cannot be held in one hand. It needs to be setup somewhere safe.

When portability is key

For total portability, the previously mentioned CTS-800 is still the best choice for equine reproductive scanning. Compact, lightweight and durable, it still delivers excellent image quality for its price bracket (well under £3000). For vets who need a scanner that boots up quickly and is ready for anything, the CTS-800 is the best choice.

Review of the Siemens Acuson P500 for veterinary echocardiography

This week, I performed a side-by-side comparison of the Siui Apoge 2300 and the Siemens Acuson P500. Two months ago, I tested and reviewed the Siemens Acuson Juniper ultrasound machine for echocardiography. As amazing as it is, most of our clients require portable ultrasound systems, and cart-based machines are simply not practical for them.

The P500 is highly portable, but I wanted to see how close its performance was to the Juniper for cardiac imaging, as well as how it compared to the Apogee 2300.

My patient was a King Charles Cavalier Spaniel – a fairly typical referral to an echo clinic! – and she of course obliged, with myxomatous mitral valve disease and even some mild aortic regurgitation. Below are a series of images for comparison, with the Siemens clips shown first, and Siui immediately beneath.

Right parasternal long axis / four chamber view, with and without colour Doppler

The frame rate on the Siemens machine is slightly higher, at 29fps vs 21fps (shown as Hz) on the Siui machine. I feel as though this comes across when the clips are played, with the colour flow on the P500 appearing more responsive. However, the ultimate information gained on this particular patient is the same. The posteriorly directed jet can be spotted equally with both machines, and on both systems you would have the impression of significant mitral regurgitation.

Left apical 5 chamber view

Again, the Siemens system delivers higher frame rates, but the user’s ability to spot the small jet of aortic regurgitation from this view remains the same.

The default imaging area is larger on the P500, making you feel closer to the action, but it is worth remembering that the Apogee 2300 has a ‘full screen’ mode, which is not shown here.

Mitral inflow

I felt the Doppler traces on the Siemens machine were marginally cleaner (excuse the lack of wall filter adjustment in the P500 image – lack of familiarity with controls!).