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Working in a whiteout or lost in the dark, the practice of medicine in austere environments can be blinding. Not armed with our front country basic physical exam tools (stethoscope/ ophthalmoscope/ sphygmomanometer) or more definitive labs and imaging, we are faced with challenges in making a diagnosis or at least narrowing down the differential. For most of wilderness medicine, these devices and tools were never realistically considered to be a potential resource in a third world village clinic, submarine, the international space station, or the side of a remote mountain. As with many developments revealed in this column, a host of clinical resources, not previously thought available, are making their way into the backcountry practice of wilderness medicine.

In 1794, Leonardo Spallazani, a priest, physiologist, and professor gained insight into the utility of sound waves by studying the flight characteristics of blinded bats. He concluded that they could see and navigate their way in the dark via reflective sound waves which he called “echo location.” It was a discovery that carried forward into modern medicine when, in 1942, Austrian neurologist Karl Dussik implemented the use of ultrasonic sound waves to ascertain physiologic structures and their associated variant abnormalities through a process he called “hyperphonography.” Fast forward through the 20th century and the technology of an ultrasound has evolved immensely, now using a vibrating quartz crystal transducer to produce basic images that are enhanced with modalities such as M-mode, 3D, color and spectral wave doppler imagery. The above history lesson in ultrasonography was not meant to highlight the merits of ultrasound as a concept. It is already well established and is being used widely in multiple realms of medicine. Setting the stage for a review of technology requires some basic appreciation, however, in order to fully appreciate the marvel of ingenuity that is presented in the device at hand (pun, intended). Ultrasound has been implemented in assessing fetal development, tracking volume resuscitation, identifying musculoskeletal injuries, revealing signs of abdominal hemorrhage, evaluating heart failure and valvular function… The list goes on.

Still, like most modern medical devices, this tool has been limited to the front country practice of medicine – until now (cue sound effect of zipper opening on top of rescue pack). Now entering the field at a trail near you is the Butterfly IQ Point of Care Ultrasound (POCUS).

Photo Source: Butteryflynetwork.com

Whether it be a Stener lesion at the ulnar collateral ligament of the thumb or an insidious retinal detachment - in many cases, ultrasound does not “rule out” but may “rule in” a diagnosis. When pivotal decisions of evacuation timing and technique hinge on a suspected diagnosis, the use of POCUS represents a tool to further facilitate wilderness medicine decision making which may not only affect patient outcomes but also the inherent risk to providers and rescue resources. Furthermore, continued patient reassessment for worsening of disease progression is also augmented with POCUS availability. 

Photo Courtesy: Heather Beissinger, MS,PA-C

So what is so special about the Butterfly IQ? Why am I spending a whole article to review a single device? To be fair, the Butterfly is one of multiple small portable POCUS devices on the market now (see also Clarius and Lumify). Its unique technology and approach to marketplace, however, represents a novel approach to the practice of medicine that also encompasses humanitarianism, crowdsourcing, and optimal team practice. As a practicing physician assistant myself, the benefits of team collaboration to optimize patient care is an attractive attribute when seen manifested in a technology.

To speak to the technology components, typical ultrasounds use a piezoelectric or single crystal transducer to generate and receive a pulse, converting electrical energy to ultrasonic energy and back to electrical energy, thereafter producing an image reflective of the anatomy to which the energy has been applied. As remarkable as this technology is, limitations in size, weight, cost, energy requirements, and image resolution make it difficult to obtain adequate results in an ultraportable platform robust enough for the wilderness environment. The folks at Butterfly Network, however, developed an imbedded microchip in the transducer probe that hosts 9,000 tiny metal transducers to produce tremendous anatomical imagery transmitted to your smartphone/ tablet. Looking at other technical specifications, the device weighs in at 309 grams (.68lbs). For comparison, a Nalgene bottle full of water weighs in at nearly 1200 grams (2.6lbs). The built-in battery is 2600mAh and will perform more than two hours of continuous scanning. Recharging is performed wirelessly through the included wireless (Qi) charging cradle. Of note are the limited specs of operating temperature. Coupled with an iPhone which Apple recommends using between the ambient temperature of 32 and 95 degrees Fahrenheit, the Butterfly IQ has a reported operational bandwidth between 41 and 109 degrees Fahrenheit. In practice, the few times I have deployed this device in an alpine environment, storage options with a chemical heat warmer or against my core have facilitated at least temporary functionality towards image acquisition. Other components of its design reveal 4-foot drop testing resilience, IP67 water/ dust resistance, and robust but replaceable components (eg, cord).

Looking at the Butterfly Network company’s approach to business is as uniquely novel as the technology of their product. Embedded within their website are a host of training resources. While nothing replaces regular usage in front country medical practice, dedicated ultrasound fellowships or formal ultrasound CME opportunities, their website resources to support the product are quite robust. One might ask, “But what if I work in orthopedics and I’m trying to use ultrasound for evaluation of a possible pneumothorax?” In addition to their training resources online, the company has built in a HIPAA compliant data network to send images back to another collaborator such as an attending physician, radiologist, or colleague to further optimize team practice and care - a process they call “teleguidance”. This model of image collaboration and training has already been demonstrated in the EMS literature where paramedic crews were trained and deputized to implement field based ultrasound in order to facilitate care. Of course, in the wilderness medicine environment, such collaboration would be dependent upon reliable transmission of data which might not always be possible.

Giving attention to this issue, another probing question comes forward, “can you see it now?” While cellular based collaboration may have been a required resource before, it might not be as important as previously considered. As another approach to marketplace and utilization, Butterfly’s IQ+ has embedded an educational/ training resource into their ultrasound app interface allowing users to save “how-to” applications of POCUS and literally coach you into successful image acquisition. Combined with other artificial intelligence integrations, the device and its platform are a real game changer both for the front country and wilderness medicine provider.

Still, despite all of these great integrations, the use of any POCUS, Butterfly IQ included, requires a certain amount of maintenance. Not limited to charging the device and performing decontamination between patients, the skill set and knowledge base required to maintain proficiency is a perishable group of resources. Just like rehearsing your knots and rope rescue systems, practicing your echo windows and measuring things like optic nerve sheath diameter requires vigilant attention and dedication of time. Scanning the horizon of future technology with wilderness application has been an exciting endeavor but for now, I think I’m going to spend more time practicing the images at hand.

Photo Courtesy: Heather Beissinger, MS,PA-C

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