As a prehospital and disaster EMS physician specializing in prehospital response, I already have the best job in the world. I get to wake up every day and take a fly car outfitted as a mobile emergency department/trauma bay with lights and sirens to any prehospital emergency in my two-tiered EMS system. When I arrive on scene to rendezvous with a crew of expertly-trained paramedics, I provide on-scene medical control and bring a physician’s perspective to the most challenging situations. I did not think my job could get much better or run more smoothly, until I discovered the personal Butterfly iQ ultrasound device.
Opening the sleek black box, no bigger than the box my iPhone arrived in, my first thought was how compact and sleek it was compared to other portable ultrasounds I’d used. The device is less than six inches long and weighs under a pound, allowing it to easily fit into the cargo pocket of my BDU pants. It’s encased in rugged aluminum and has a thick wire on the end to connect to my cell phone, which acts as both the monitor and control center for the device. For additional protection, I used an old stethoscope case to house the Butterfly iQ along with lubricant packets and the wireless charging dock so I’m always ready to use it on the road. I’m looking forward to a protective case being developed in the future to make it easier to organize and slip into a jump bag.
Historically, there are three different kinds of ultrasound probes used most frequently in the emergency department and the field. They use a crystal structure to provide images when a lubricant water-based gel is applied between the probe surface and skin of the patient. There is the linear probe which provides a skinny, rectangular view to see blood vessels, nerves, lungs, and musculoskeletal structures close to the surface of the skin to help obtain IV access. The curvilinear probe is shaped like a rainbow to examine the deepest abdominal and pelvic structures of the body like the liver, spleen, kidneys, uterus, and aorta (to look for blood in the belly) or a ruptured aorta. Finally, the phased-array, or “cardiac probe,” is used specifically to evaluate the intricate motions and structure of the heart including the presence of cardiac activity, pericardial tamponade, and pulmonary embolism. So how could one probe do all three of these things at once?
The answer lies in a single silicon chip, instead of the traditional crystals. This enables the user to switch instantaneously from one “probe” to another, instead of having to carry a bulky device with multiple probes (in addition to my monitor, primary jump bag, and disaster airway kit). It’s all in my pocket next to my cell phone, ready to act as the monitor for the handheld whole-body imaging probe.
Now, let’s address the most important question of all—how well does the Butterfly iQ work?
I arrived on scene of a motor vehicle crash with extrication to find a female in her 50s, diaphoretic and altered already on the stretcher of the BLS ambulance. Taking the stethoscope case with my Butterfly iQ and lubricant inside was an easy addition to my equipment. Her primary survey revealed an intact airway, bilateral breath sounds, and intact distal pulses and a blood pressure of 105/70. A quick fingerstick gave us a very helpful piece of information: her blood glucose level was 37. Tourniquets to both arms revealed no veins, and her external jugular veins were flat. I unzipped my case and connected my Butterfly iQ to my cell phone and set the device to “Vascular: Access” mode through the Butterfly iQ App. With a click and a scroll, I selected “linear” probe. Suddenly, there the veins were! Access issue solved, medics worked on treatments, and the patient improved.
But I wasn’t done just yet. As the patient was being treated, a single scroll and click on the app immediately switched my single probe to the “curvilinear” setting of “FAST”—optimized to identify free-fluid (blood) in the belly. The FAST (Focused Assessment with Sonography in Trauma) exam is the same exam immediately performed upon arrival in trauma bays to rapidly identify patients who need to go to the OR, and I was able to get it done in seconds in the ambulance. Luckily for our patient, her FAST exam was negative. Had it been a positive exam, we could have made a pre-arrival notification to the trauma center and the OR would have been ready and waiting for her.
A few days later, I arrived on scene with my Butterfly iQ to find an elderly male speaking few-word sentences and unable to provide his medical history. His sister said she was visiting from out of town and found him this way when she arrived, but that he’d never had any medical issues before and was only on antihypertensive medication. Bilateral lung auscultation reveals he was wheezing bilaterally with very faint crackles at the bases. He was tachycardic at 117 bpm and his blood pressure was 160/92.
Once the patient was started on CPAP and IV access was obtained, one of my medic partners asks me, “Push-dose nitroglycerin, or nebs and SoluMedrol?” I now know that I can answer that question definitively. Ultrasound allows us to differentiate between COPD and CHF exacerbations with a sensitivity of 100% and specificity of 92%.1 I plugged in my Butterfly iQ and scrolled to the “Lung” setting to perform functionally as a “linear probe.” This lung exam can be performed in under two minutes. I was able to teach my paramedic partner how to adequately perform it by simply watching me perform it on the left lung while he performed it on the right lung. The patient’s lung exam revealed many “B-lines” between his rib spaces, indicating that his lungs were filled with fluid. As the paramedic treated our patient with 500 mcg of push-dose nitroglycerin, I switched to the phased-array “Cardiac” setting and looked at his heart. It was not squeezing briskly despite his tachycardia with weak motion of his walls, indicating that the cause of his dyspnea was most likely due to heart failure.
Our patient’s intercostal retractions slowed with CPAP and two more doses of nitroglycerin, his tachycardia and hypertension resolved, and by the time we arrived in the emergency department he was able to speak full sentences and provide us his medical history—he said he was supposed to get a cardiac catheterization but never followed up. He was admitted to the hospital for a formal echocardiogram and cardiac work-up and was transitioned off Bipap in a few hours on a nitroglycerin drip.
As an EMS physician, I am constantly looking for ways to provide the most efficient and cutting-edge patient care from the emergency department into the field. With the Butterfly iQ, I can do that now—and it can all fit in the pocket of my BDUs. Butterfly iQ made it significantly easier for me to diagnose patients and make treatment decisions, but it will also make transport decisions easier if FAST exams are positive.
I look forward to a future where every paramedic is able to have one of these devices and perform an ultrasound assessment on scene, upload images to the HIPAA-compliant Butterfly Cloud, and have them reviewed by a physician in real time using the commenting feature to provide our patients exceptional, accurate, and safer on- scene evaluation, treatment, and transport. Until then, I will continue taking my Butterfly iQ with me in the field and educating paramedics on how beneficial and important this device (and ultrasound in general) is for EMS.
1. Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med, 1998; 24(12): 1,331–4.