How the COVID-19 Pandemic Has Changed Your Practice

Coronavirus disease 2019 (COVID-19, also known as SARS-CoV-2) was declared an official pandemic by the World Health Organization (WHO) on March 11, 2020, with infections reported in all countries around the world. As of today, November 12, 2020, there have been almost 53 million cases of COVID-19 reported worldwide, with over 1.3 million COVID-19-associated deaths.

This pandemic is severe, and the mortality and morbidity associated with this disease cannot be overstated. Although most infected patients are either asymptomatic or experience mild symptoms, a significant number end up in serious or critical condition. This is the patient population that develops a number of complications that affect all body systems, and this group of patients should be very closely monitored in the hospital setting.

Radiology professionals play a significant role in the diagnosis of infected individuals, identification of complications that are not apparent on physical exam or laboratory analysis, and the follow-up imaging assessment of known COVID-related complications. Given that this virus is highly contagious, it became very apparent that safe methods for patient assessment had to be designed and implemented. Ultrasound serves as a first-line imaging modality for evaluation of a number of COVID-19 pathologies and related complications, including evaluation of pulmonary, hepatobiliary, renal, gastrointestinal, and cardiac manifestations. It is the modality of choice in the pediatric population and in pregnant patients. Moreover, ultrasound plays a critical role in the evaluation of patency of peripheral and central vascular systems, including both the arterial and venous circulation as well as solid organ perfusion.

Due to the highly contagious nature of COVID-19, our routine ultrasound radiology practice had to undergo dramatic changes in order to ensure proper infection prevention. We accomplished this through the establishment of control measures and good hygiene practices that were shown to limit spread of COVID‐19 and protect patients, sonographers, and physicians. In addition to following specific guidelines (established at the beginning of the pandemic by the ACR and the SRU) for cleaning and disinfection of ultrasound equipment and use of personal protective equipment (PPE), we also incorporated our own changes that we found to be beneficial in preventing spread of the infection and limiting staff exposure. 

At our institution, all patients are considered to be SARS-CoV-2 persons under investigation (PUI), including those without respiratory or digestive symptoms, and appropriate safeguards are taken while performing examinations.

Given the fact that transmission of SARS-CoV-2 occurs primarily through respiratory droplets, fomites, and possibly aerosols, we emphasize the use of portable ultrasound imaging at the patient’s bedside whenever feasible, with the radiology staff wearing appropriate PPE, including an N95 mask, gloves, protective eyewear or an overlying face shield, and a disposable gown.We request that all patients wear surgical masks during the examination.    

Equipment must be disinfected after every exposure to COVID-19 positive or suspected positive patients. According to the Centers for Disease Control and Prevention (CDC), surfaces need to be either washed with soap and water or decontaminated using a low-level or intermediate-level disinfectant such as iodophor germicidal detergent solution, ethyl alcohol, or isopropyl alcohol. Vendors should be contacted to determine the safest disinfectant for each piece of equipment. Radiology technologists should perform sanitizing procedures while remaining in full PPE.    

It is uncertain how long the air within an examination room remains infectious. Contributing factors likely include the size of the room, the number of air exchanges per hour, the length of time the patient was in the room, type of filters installed in the room, and whether an aerosol-generating procedure was performed. Use of air exchange measures vary depending on the availability of equipment. At our institutions, a 20-minute downtime is mandated for disinfection of the air in an examination room.

The keyboard and monitor of the ultrasound equipment are covered with a plastic drape or cover, and only the required probes are utilized during specific examinations. External transducers require low-level disinfection between procedures, while internal transducers require a single-use transducer cover and high-level disinfection between patients. It should be noted that products that are alcohol-based should be avoided when cleaning keyboards and track balls. If possible, a dedicated machine should be utilized for COVID-positive or suspected-positive patients. The machine should be cleaned with an EPA-approved disinfectant for viral pathogens, by a technologist in full PPE.

One of the primary changes that we implemented within our ultrasound division is the utilization of abbreviated protocols while imaging COVID-19 patients. We found that abbreviated protocols are useful and sufficient for the diagnosis of most COVID-19-related pathologies and complications, and are usually able to provide answers to the questions posed by referring clinicians. We strongly believe that abbreviated protocols have allowed us to decrease technologists’ exposure to the infection and the amount of time spent during imaging exams. When performing ultrasound examinations, we focus only on the area of interest and acquire cine clips rather than still images during the exam. It has also been shown that post processing of images, including image labeling and parameter optimization, significantly decrease the amount of time spent on scanning.

Lastly, it is important to recognize that not every patient benefits from imaging. We carefully review requests for imaging studies with the patient providers and try to weigh the benefits of imaging against the risk of exposure. The guiding principle to keep in mind is that studies don’t need to be performed unless patient management is going to be affected by the imaging findings. 

The ultrasound workforce provides a valuable clinical service but is particularly vulnerable because of the prolonged close physical contact between staff and patients. Hopefully, this blog post will serve as a resource to help practitioners improve safety and minimize exposure risk during the performance of ultrasound examinations.

From top left: Basilic vein thrombosis, chest wall hematoma, gallbladder sludge, internal jugular vein occlusion, lung consolidation with air bronchograms, lung interstitial edema with B lines, popliteal artery occlusion, and urinary bladder clot.
Lung US annotated B lines and pleural thickening.

For additional reference:

  1. Revzin MV, Raza S, Warshawsky R, D’Agostino C, Srivastava NC, Bader AS, Malhotra A, Patel RD, Chen K, Kyriakakos C, Pellerito JS. “Multisystem Imaging Manifestations of COVID-19, Part 1: Viral Pathogenesis and Pulmonary and Vascular System Complications”. RadioGraphics 2020 Oct;40(6):1574–1599. doi: 10.1148/rg.2020200149 Monograph Issue.
  2. Revzin MV, Raza S, Srivastava NC, Warshawsky R, D’Agostino C, Malhotra A, Bader AS, Patel RD, Chen K, Kyriakakos C, Pellerito JS. “Multisystem Imaging Manifestations of COVID-19, Part 2: From Cardiac Complications to Pediatric Manifestations.” Radiographics 2020 Nov–Dec;40(7):1866–1892. doi: 10.1148/rg.2020200195.

Margarita V. Revzin, MD, MS, FSRU, FAIUM, is an Associate Professor of Diagnostic Radiology in the Department of Radiology and Biomedical Imaging at Yale University School of Medicine, in New Haven, Connecticut.

Interested in learning more about ultrasound and COVID-19? Check out the following posts from the Scan:

The Best of the Scan, 5 Years in the Making

The Scan has been a home for all things ultrasound, from accreditation to zoos, since its debut 5 years ago, on February 6, 2015.MISC_SCAN_5_YR_ANN_DIGITAL_ASSETS_FB

In its first 5 years, the Scan has seen exponential growth, in large part due to the hard work of our 110 writers, who have volunteered their time to provide the 134 posts that are available on this anniversary. And it all began with Why Not Start? by Peter Magnuson, the AIUM’s Director of Communications and Member Services, who spearheaded the blog’s development.

In honor of this 5th Anniversary, here are some of your favorites:

Top 5 Most Viewed Posts


1. Ultrasound Can Catch What NIPT Misses
by Simcha Yagel
(August 4, 2015)

Sonographer Stretches2. Sonographer Stretches for an ‘A’ Game
by Doug Wuebben and Mark Roozen
(January 31, 2017)

Keepsake3. The Issue with Keepsake Ultrasounds
by Peter Magnuson
(April 30, 2015)

Hip Flexor Stretch4. 3 Stretches All Sonographers Should Do
by Doug Wuebben and Mark Roozen
(January 19, 2016)

Anton5. From Sonographer to Ultrasound Practitioner: My Career Journey
by Tracy Anton
(October 23, 2018)

The Fastest Growing Posts
That Are Not Already in the Top 5

And we have plenty more great posts, such as:

Ultrasound at 18,000 ft.

A brief history of the making of Solar‐Powered Point‐of‐Care Sonography: Our Himalayan Experience (J Ultrasound Med 2019

Dr Mark Kushinka and Dr Rob Razick are sitting at camp in Phirste La Pass at 18,208 ft. The camp is designated by banners of alternating color flags attached to the top of a pole and pinned to the ground. Mountains are shown around them with blue sky.

Dr Marc Kushinka (left) and Dr Rob Razick (right)
 in Phirste La Pass at 18,208 ft.

Full disclosure… I wasn’t actually there.  Anyone who knows me knows I am not the “sleeping with yaks, no shower for a month” kinda girl. I also have no shame in admitting that I had no chance of surviving the 80+-mile trek 3 miles high amongst the clouds. Fortunately for me, and the people who inhabit the Zanskar Mountain Range, I had 4 residents who wanted to spend several months hiking through a mostly impassable mountain trail providing care to those who live in this spectacular part of the world. Our Lumify’s passport had already amassed an impressive collection of stamps, but none of them as remote as the Himalayas. There is no electrical infrastructure in this region, and all sources of energy come from kerosene, dung briquettes, or solar power. As Dan and Zac departed for India, we had no idea if this crazy plan to operate the ultrasound solely off of a portable solar pad was going to work. Frankly, I was a bit worried that I was adding a few extra pounds to their pack for no good reason. But, after spending 30 days in one of the most remote locations on this Earth, the guys returned with some great stories, good images, and a ton more facial hair.

Dr Daniel Baker and Dr Zac Hardy are shown standing together in Phirste La Pass by a snow-tipped mountain peak.

Dr Daniel Baker (left) and Dr Zac Hardy (right) 

 As I sat curled up in my leather chair with a supple cabernet, I reviewed the data from their trip and realized just how awesome this was. There had never before been medical imaging accessible at this elevation, and its availability had a direct impact on patient care. We repeated the adventure the following year with a new set of residents and the same cheap solar pad from Amazon. After some minor modifications based on our lessons learned from our inaugural year, Marc and Rob yielded more consistent scan times and reliable use.

I truly believe solar powered POCUS can change the face of austere medicine. All you need is a solar pad, a portable ultrasound, and the desire and willingness to leave the comfort of home. Or at least have a few residents up for the adventure.

Cheers from Kashmir!

Have you performed ultrasound examinations in remote regions? What was your experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. Visit the Journal of Ultrasound in Medicine online.

Laura Nolting, MD, FACEP, is the Director of Emergency Ultrasound and the Ultrasound Fellowship Director for the Department of Emergency Medicine at Palmetto Health Richland in Columbia, South Carolina.

How Portable Ultrasound Got Me a Bottle of Wine

Well, Tuesday morning clinic was busy as usual. Hypertension, diabetes, depression, “it-hurts-here”s where troubling all my patients. My desk was across the hall from a colleague who had just seen a retired internist gentleman, 80 years old, reporting muscle weakness in his hips, fatigue, bitemporal headaches, and some odd jaw symptoms when he ate. Don (I called him that, mostly because that was his name.) was investing some quality phone time trying to arrange a temporal artery biopsy as this method for diagnosis seemed so reasonable to him and to his internist patient. I listened in on his conversation, always ready to help, invited or not.

“Don, you know, if we pull our portable ultrasound machine, look at his temporal arteries and he has bilateral halo signs, the specificity approaches 100% for temporal arteritis and you can avoid biopsy all together in 38% of patients.”  I provided him a few convincing articles. He was not quite sure as he had never heard of this before.


Both internists were game, the doctor and the patient. Portable US in the exam room showed bilateral halos around the temporal arteries. I showed them the finding. Both raised their metaphorical eyebrows.

Patient: “I practiced internal medicine for almost 50 years and I have never seen anything like this. That is pretty impressive.”

Don: “Let’s get a sed rate today… See what that shows. Start some steroids and we’ll follow-up next Tuesday.” (For those not in-the-know, sed is erythrocyte sedimentation rate.)

On Friday, after 3 days of steroids, he was starting to feel like his old self again. Headaches were resolving. Fatigue was much better. By Tuesday, with his visit to the clinic, he was ecstatic over his progress. Don reported that he kept remarking on that young man with his portable US machine (That was me.) and how that US would’ve changed his practice had he had one back then.

On Thursday, the patient wanted to show his appreciation to both Don and I by bringing in 2 bottles of red wine, 1 for him and 1 for me.

I had read about the utility of portable ultrasonography, oh, 12-15 years ago for the first time. I had drunk the cool-aid of portable ultrasonography. At our medical school, we provide 27 hours of didactics and hands-on training for our medical students in their first 2 years. Our internal medicine residents get formal didactics on echo, abdomen, vascular, as well as MSK, small parts, and many other US applications. We have provided CME for over 700 physicians in our 3- and 4-day courses. I have been convinced that we need to reach out and teach all who will listen that portable ultrasonography can fundamentally change the way we practice medicine in certain settings.

So portable ultrasound changed this patient’s experience; quicker diagnosis and quicker recovery of health. He was grateful and expressed his gratitude with the fruit of the vine.

So portable ultrasound changed my colleague’s thoughts on its utility based on one clinical exposure. Don asked me many times to use my machine for other patients of his.

So what did I get from this profound, thought-provoking intersection of patient, doctor, and too? Personal gratification of helping? An underscoring of my belief that portable ultrasonography is important?

I got a nice bottle of wine!


Do you know of an instance in internal medicine in which ultrasound resulted in a quicker diagnosis? Have you incorporated ultrasound into your internal medicine practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Apostolos P. Dallas, MD, FACP, CHCP, is Assistant Professor of Medicine at Virginia Tech Carilion School of Medicine, Director of CME at Carilion Clinic, and Associate Program Director of the Internal Medicine Residency program at the Virginia Tech Carilion School of Medicine.