Pre-amble!

So here is Part 3 of the as promised portable ultrasound reviews. The aim, to un-muddy the water a bit for you all over choice and functionality. There are so many put there at the moment, we wanted to test them on the shop floor…are they the true ITU workhorses you need to keep in your pocket?

All reviews are clearly done by myself, unless stated otherwise, so you could argue are very subjective. I can’t disagree…but I will try to be as un-biased as I can and start with an open mind on it all. I own my own GE Vscan DP device as a declaration, but I am not receiving any money / sponsorship or anything else financial from the kind companies who have agreed to allow me to review their devices. All devices in my possession for testing go back to them.

This part comes as a paired review from myself and a good friend of mine, Dr Rob Greig, who is an ED Consultant in Jersey. @drrobgreig

He had his hands on the device as well…so we we are combining our thoughts on this one. I thank Rob for all his work with this. For the purposes of this…Rob is in Red font and the rest is me. So its an ITU/ED collaboration!👍👍

1. Clarius

What they say…

Clarius Mobile Health was founded by experienced innovators who have played an instrumental role in the ultrasound industry. Our developers were the brains behind the first PC-based platform for ultrasound research. They also introduced the first touch screen ultrasound system with a simplified user interface.

“We had three clear goals when we set out to develop Clarius: to deliver an ultra-portable system for medical professionals that does not compromise on image quality; to remove the cords that get in the way, and to make sure the Clarius App offers the flexibility to work reliably with both iOS and Android smart devices,” said Clarius CEO, Laurent Pelissier.

Take a look at their site here:

What is it?

It is a wireless, handheld device used for all that is ultrasound. 1 probe in your hand, which links to an iPad or iPhone, once you download the Clarius app and get registered. So, that’s step 1 before you go.

The device comes with various probe options:

We were supplied with the C3 convex probe with our bundle, which arrived in what looks like an assassin’s case!! Clarius posted the device via UPS from Canada and when I had finished with it, I had to arrange postage back. So, no direct human interaction with them at all, but open channels on email for comms when needed. Neatly posted to us and bundled in was a battery charger, x2 batteries, the probe and the dedicated iPad mini device, with all of the software pre-loaded.

Rob’s pre-amble

“We bought the Clarius with the intention of it being the go to scanner in our resuscitation room. It would prevent clutter, we would have iPads mounted next to our defib monitors and we could scan our peri-arrest patients with the RUSH protocol. Plus my colleagues from ITU could use it to place central lines. All this in lieu of the Sonosite Edge cart that can get in the way and of course has wires”.

What’s it like then – hands on?

The Clarius app.

I like the freeze button.
- This rather irritated me, as it was easy to knock it when you didn’t want to.

I don’t like the search time but that one could ignore as whilst your inputting the patient demographics that period can be ignored. But the Wi- Fi link between a variety of iDevices can be intermittent, with red bars of the wifi signal indicating the wifi dropping in & out appearing frequently. This occurred with the new and the previous iteration of the Clarius app.
- I did not find this to be an issue with the supplied iPad, but I confess, I didn’t link it to my iPhone X.

Another issue is: thumbs, you need long thumbs (Orangutan length) to operate the interface on anything other than an iPhone, but using the iPhone with one hand makes data entry difficult and slow e.g. LUQ, deleting LUQ to write RUQ. You often find you have to place the iDevice on something which sometimes is the patient (infection control and professional issues there).
- Completely agree with this. I placed the iPad onto the patient’s bed and used it as a resting screen, although flat down, not propped up. They do supply a cart for the system. It’s fin the website. But then, isn’t that against the point of a true ‘portable’?

People need showing how to use the interface. It should be more intuitive, akin to the Amazonian child with an iPad test, us ED doctors like big buttons and obvious flow. The sliding from side to side of the data screens seems like a good idea, but then the thumb issue comes in, you can catch the sides of the screen with your thumbs and scroll out of the image acquisition screen (both iterations of the app)
- This is not a simple point and press situation. I agree wholeheartedly with Rob! After an hour or so of sole fiddling with the app, I got to grips with it. But someone who is naive to the device is not going to be able to just, get on and scan!

Auto gain is constantly on, there needs to be a setting in the menu to toggle it on or off. The reason is in the screen calibration I preferred the darker setting around 3-5 but the auto gain then rectifies this setting by turning itself right up.
- This may have been rectified for me as I fiddled with the preferences. But default is on. Annoying!

You can’t just turn on and scan. You turn on, link wait, select scan type, scroll, scan. Sometimes you just need to grab and scan.”
- I was about to state this too. You have to get the system well set-up before you can pass go. This isn’t going to be a particularly easy device to pass to other clinicians without a 30 min tutorial!

I found that once I had obtained an image I was happy with, I saved it, the screen then froze and I had to come right out of live scanning to re-select the probe again to restart. This may be my error, but it became annoying.

The scans!

These images from the site. Rather embarrassingly, I can’t feature mine, as they are for some reason irretrievable. My confession here is I may not have registered myself appropriately on the site to store images to their cloud. However, I did manage to save them somewhere on the device, they appeared to be uploading somewhere and a message saying they had all been saved appeared, then I went away for a week, now they have all but disappeared! I am sure this was my fault and not the system. Nonetheless, why oh why can’t you just pull up the scans you’ve just done and look at them on the device. You seem to have to upload them to Clarius?!

What I will say is that my images were rather grainy; certainly not to the standard of those you see above!. The in-scan image adjustments are all made on the iPad and this can be rather fiddly ad there is a lot to swipe whilst supporting this weighty behemoth of a probe! There are plenty of potentials in the adjustment array though, it’s just a case of, can you do all of this and wrist wrestle to get your perfect image! That. said, these were complex ICU patients and the views from the outset are often a challenge. I did however obtain the views I wanted with another portable device, no problem!

When fanning and scanning, baud rate drops and refresh rate falls, giving a jumpy interface. I hated this when it happened. It is difficult to know whether this is the wireless interface, or the software?

What Rob found:

The image:

I’m going to be controversial here, but in my opinion it is substandard to the Edge and I’m talking an Edge running M turbo probes. 10 year old tech!
The Rep thinks an ultrasound image should be about the whites. That’s not right in my book. It’s about contrasts. That’s how US works, each organ/ tissue has different sonographic impedance. I’m told by the Rep that I’m old fashioned, and maybe I am but I prefer a darker image with blacks, greys and whites. This image seems too bright and white. Now in ED FAST scanning (very old fashioned now but bear with me) we are looking for BLACK of free fluid or shadows cast by stones. I get this “old fashioned” image style by turning the Screen Calibration to 3-5 and the Autogain off which in turn delays the image acquisition with a sick patient.
The image calibration recommendation shouldn’t be 12 in my opinion
The image is akin to a 1960 Black and White TV screen: the 405-line monochrome system. Its more pixilated than I would like. Its refresh rate is poor.
I did not feel happy that I saw the renal parenchyma in enough detail to exclude Hydronephrosis or Renal Calcification. The definition of the aortic edges was poor.

The Probe

For me, the balance is rather odd, but the device sits nicely in your hand. After a while, it becomes bulky and the large footprint of the C3 is hard to manoeuvre into tighter spaces (cardiac views in particular), making life very difficult!

Then, there’s the clip on coolant fan! What on earth! They advertise the probe as fully submersible, well I suppose it is, then the cool water will do the job of cooling the probe. But it certainly won’t be submersible with the fan on!! You need to be mega careful not to get the US gel, or any patient based secretions into those fans / vents as well. This could be growth and infection central!

Rob says:

The heating up doesn’t worry me.
- It wasn’t too bad for me TBH.

The charge time is great, the battery length is more than adequate.
- It is, but should be when you consider the size of the probe. Also, wired devices sap more power, running the probe and the software application side in unison. An iPad battery will last a while.

If you have small hands its heavy and clumsy
- Definitely! Aside from running it on the iPhone, but then your screen size safety hammock is gone!

The length of the probe means FAST scanning or scanning someone that can’t roll over means left upper quadrant, left renal, splenic scanning is exceptionally difficult because the non-probe end of the device impinges on the bed.
- Yes, I agree here!

Our Cardiologist couldn’t even get a parasternal long axis view with the probe, it struggled on a paediatric chest. It’s just not a point of care ECHO device other than it can show presence or absence of cardiac movement in cardiac arrest. I wouldn’t trust it to tell me if the LV is empty, full, akinetic or if there RV dilation (suggesting I should reach for a thrombolytic) – in cardiac arrest management.
- My points made above. I use FICE scanning as my primary 1st part scan of all ICU patients. Then move onto CUSIC (chest, abdominal, DVT etc.). It just is not fit for cardiac scanning purposes. I struggled to get decent images of the chest, particularly the upper zones and without rolling a little, posterior- basal points are almost un-scannable!

The verdict!

Below, is the review template we came up with in order to fairly assess portable devices (mainly credit to Adrian Wong for this).

Criteria for the perfect handheld POCUS device

General

Portability

It’s wireless, hoorah! But unfortunately not. Unless you bolt this probe onto your iPhone, it still relies on carriage of a largish tablet with you. And strap on the back, or no strap on the back, this is cumbersome. The probe itself is heavy, so not entirely pocketable.

Number of probes

There are 3 to purchase, and each comes at a cost! SO this is not going to be a cheap option for anyone. And, they are all large devices. There is also the need to disconnect and re-connect,a s there was with the Sonon device.
The probe supplied is a rather curvilinear option, so was just not able to cut the butter on small space scanning.

Screen – dedicated or linked to tablet/phone

Mentioned already. You have to bolt it onto your iPhone or use an iPad.
Again, this doesn’t make it a particularly portable device. You will need strong trouser/scrubs elastic to carry more than one probe around with you!

Battery life

The batteries charge in around 2 hours from flat and you get a decent amount of life out of them, over an hour with heavy scanning (excuse the pun there!)
It gets hot, and the coolant fan whirrs in! This will inevitably sap more power.

Interface logistics and ergonomics – touchscreen, user-friendly software

We have covered this above.
For me, connection and disconnection re-connection is irritating when you need to fire it upon / swap probes.
The fact you really have to be linked to WIFI and their cloud / app to do anything with the images is annoying. Getting the images off the device is hard and cumbersome. Hard storage seems to have been excluded (may be fear of governance flaws on images and patient data etc). It has PACS link options.
The fact you need to be bolted onto the probe, and wifi for storage and true app. integration means that unless your trust gives you access to fast Wifi, you are going to be emptying out your personal data plan if bolted onto your phone.

Cost

£5000+ for the C3 convex and upwards of £7000 for the L7.
This sits at a little under the GE Extend / Vscan price, but they give you a dual probe in one. So you can see where I’m going here.

Warranty

There is a 2 year warranty supplied

Echo probe

No specific phased array probe!

Curvilinear probe

The one we used.

Linear array probe

Ergonomics – weight, feel

Available, but not trialled. There is also a micro-convex probe available.

Image quality

Grainy, low refresh rate, wifi dropout all add up to a rather less than satisfactory experience in my opinion. Rob (excuse the pun again – echoes this).
Storage is a nightmare…unless I am missing something blatantly obvious!

Features

Cloud storage / sharing / Clarius app / demo capability are all there. But this, in my opinion, is all rather a gimmick to cover up the cracks an inferior probe offers us.

Video’s of the device in action

Promo Videos

Design Video

Score and conclusion

This device scored 5/10 for me.

The fact is, the probe is unbalanced after a while, too big a footprint means intricate spaces are difficult to get to. Cardiac scanning is out here! I wonder whether the images on the Clarius site are simply the best that could be found, on the best day, with the most unbelievable sonographers, in the fittest, slimmest people!

Rob says:

Directly compared to a SonoSite Edge 1 (released 2011) using probes designed 13 years ago, I’m getting worse images on this device!

So based on image quality, slow boot up, faffing about with WiFi, user interface designed by a non-user and finally price: 4/10 max for me.

I preferred to wait for the SonoSite to be available rather than grab the Clarius. Also the fat battery end made splenic scanning very difficult in trauma. It was also pointless for lines.

The Rep did ask me to go back time and time again to retry the probe. He informed me that 1000s have been shipped without complaint. At ‘Das SMACC’ it was being used in an US station during breaks, I have spoken to that doctor directly (who was trained by one of my colleagues) and he loved it. He liked the image quality. So I tried it. I fiddled with it but I just couldn’t resolve my final concern: A sick person came in, the department Sonosite was being used by a colleague and I waited. I waited until the Sonosite was available because I wasn’t willing to make an acute clinical call based on the data that the Clarius gave me. That made my mind up, I returned the product after 2 month’s trialling”

Also, see this from the Clarius site: