Preamble!

So, here is part 5 of the promised portable device review series. And, this may be one of the most anticipated yet!!

I can’t get my hands on this device, as I am firmly anchored down in the UK! I, like many, are on their waiting list and man the emails eagerly in pursuit of a positive sign mine might just get a confirmed delivery date. There are still issues with shipping to Europe, which we will explain later on. This is a shame, and reflects the sheer volume of red tape we have over here!

**update 3/12/18…they are sending me a probe to look at for myself!!!👍👍

We have comments from the company in addition to the review too….which is novel. We would not ordinarily do this as part of a review series, it’s just there were several things that needed clarification. We are NOT about publication of inaccuracies. You will see comments in orange from them….a very helpful team!

Reviewer 1 – ED physician

My good friend Yale Tung Chen (@yaletung) agreed to do a review for us, so we snapped his arm off and agreed!!!! Obviously we didn’t do this….as he’d be a useless sonographer! He is an EM physician and describes himself as an ultrasound addict!

His disclosure:

I own a GE Vscan DP as a declaration, but I am not receiving any money/sponsorship or anything else financial neither from G.E or Butterfly (or any US companies).

Reviewer 2 – advanced paramedic researcher and sonographer

And… making another appearance, the lovely Mr Aidan Baron (@Aidan_Baron)!

We will feature Aidan’s review first, which doesn’t have the detail in it that Yale’s does. But, he went to a lot of effort to send me a transcript of his review and for that, I am grateful. He always spends time, takes care on his reviews and is one of the best monographers around! A final point to note was that Aidan did not review the Gen 2…but the Gen 1 probe. Yale’s was done on the latest version (2)….and the company are very dynamic with updates…..so…on we go!

What the company say

Take a look at the website here:

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So all of this with just one probe?!!! The tech is in the chip apparently

What Aidan said…

I am cautiously optimistic about the Butterfly. This company appear to be able to move and improve very rapidly, moving from version 1 to the now version and 2 probe. They are innovating and advancing faster than any other manufacturer in this space, which is exciting.

But, at the moment, the Butterfly is just not that not great for cardiac. When I say this, I mean it is unreliable. So, you go to scan most thin patients and you know you should get a good cardiac view, you are expecting it. But with this device, and this may be to do with the way the beam steering works, you just don’t get what you’d expect. I couldn’t even see the septum or the valves when I scanned a young, thin, and healthy patient. All I could see was the gross movement of the pericardium and the outer ventricular wall. This happened twice in a row on two young, thin healthy guys with great windows and who had clear images on every other machine I used. I thought I might have been doing something wrong, so I had a colleague who is an echo-expert have a try, they got the same result. Disappointing. Hence my caution regarding cardiac scanning with this device. In saying that, the company have acknowledged that this is its Achilles heel at this point in time are rapidly fixing the issue. I used a first generation probe so I can’t speak about the abilities of the Generation 2, (though I have heard the issue isn’t entirely resolved). I should mention that the Artificial Intelligence automatic EF calculation is nowhere near ready for prime-time yet. But that doesn’t really concern me very much, (I’m not calculating EF on a hand-held device and don’t believe actual quantified values have a role in most POCUS).

Butterfly comments

This is somewhat inconsistent with scans we’ve performed where valves are clearly seen. One physician who does cardiac echo regularly thought it good enough to screen ~500 cardiac patients!

It’s abdominal scanning was gorgeous and the obstetric views really nice. As good as most handheld POCUS devices when looking at the abdomen. No issues there.
The soft tissue images were not as clear as probably the top 50% of POCUS devices out there on the market, in that the discernment of facial planes was not clear. But, the needle visualisation was far superior to most products out there. Could this be due to a thicker beam being emitted, which allows the whole needle to be seen so clearly? Perhaps. For needling, I’m impressed; but, I’m not convinced I’d be able to use it to do detailed MSK exams; looking for tears, ruptures, haematomas or fractures (although I haven’t played with it extensively on those yet).

Here is the BIGGEST issue for me. The cloud, where images are stored is located in America. So, you send your images to that cloud, then they are beamed back down to the servers in your country, where you can interrogate them. This isn’t acceptable in any Commonwealth care context (Australia, New Zealand, UK, EU etc). It is also NOT GDPR compliant and won’t be until they change the way images are saved. This may mean they have to change the entire way they do their software package. At the moment, you buy the probe AND you have to pay the monthly subscription. I am told they are looking at this and working on a solution for the rest of the world. I’m patiently awaiting it. Clinical data that cannot be stored or processed locally, poses significant information governance risks for organisations and EU certified or not, the device wont be GDPR approved until this is fixed.

Butterfly comments

Images taken in foreign countries will be stored in clouds appropriate for the geographic location, not the US.

What is quite cool is that you can telemed conference with someone in real time. This is awesome and only the Lumify react can currently do that. Fantastic potential here for expanding POCUS use and distanced mentoring.

The probe gets quite hot after 35-40 minutes. That is quite a long scan time in fairness. It’s not the probe head, but more towards the tail end and the area you grip the probe. The battery is pretty good; 45 mins to 2 hours! Because of this and the heatsink issues, it may be difficult to teach with the device. As far as longevity goes, we don’t know. The wiring on generation 1 is fragile but I haven’t seen generations 2, or 3. So we shall see.
It charges rapidly, twice as fast as many of the competitors. This is via a wireless charger, which is cool, though it can be a bit fussy with correct alignment on the charging plate.

Butterfly comments

It’s exactly designed to draw heat away from the probe head (sensitive electronics) towards the main handle

If the company makes the changes they are promising, and the probe can help me acquire images with comparable quality to the other POCUS products out there, then I can guarantee you I would seriously consider buying a 3rd or 4th generation device. I’m not sure I would want to buy a generation 2. I would want to see their cardiac exam improve a lot more. I also didn’t love the current user interface. I do like the way the probe handles though. Well weighted and nice finish. Also, who doesn’t love black? It’s definitely more ‘tacticool’.

Cardiac 4/10
Abdomen 9/10
MSK 6/10
Procedures 9/10

I don’t want to give it an overall rating because I haven’t used the latest version yet.

What’s it like then? Hands on…Yale’s review!

Unboxing Day!!

The butterfly team came to our unit to deliver the probe and show us how to use it personally. Their customer service was impeccable and came with a pleasant, professional and engaging delivery

Inside the beautiful case, you find the probe with the battery charger. It resembles an iPhone case, and the (contact) charger even works with apple devices.

No satchel for the moment, according to what the butterfly team told us. They are still working on that, and even accepting suggestions. What about a tool belt…?

How will it endure drops, the cable being trodden on or tangled… we don’t know yet.

They gave us a quick session on the in’s and out’s of the machine… and how to start scanning. I couldn’t wait to get going… (as you can imagine, after 2 years waiting for this thing!)

When you log for the first time, they suggest you to create a Gravatar (Globally Recognized Avatar – https://en.gravatar.com/support/what-is-gravatar/), which is then linked to your email. Anytime you then use your email, the associated gravatar follows you.

I uploaded several clips comparing the views from the Butterfly with my trusty Vscan DP (GE Healthcare). I scanned different body areas with both probes, right after a meal, in order to keep as like-for-like as possible.

The machine and the software

It is a wired device, which you plug straight into your iPhone or iPad. The probe is instantly recognized once you open the App on your device (<10 sec for the whole process).

The App menu is intuitive and the functions are really easy to operate. With little initial guidance, you can pretty much crack straight on scanning.

Scan menu – this has different buttons on the bottom: freeze, back scroll, save still image/clip, measure options (area and diameter, can perform up to 4 measures of diameters in different color labels), and then the buttons of modes: allowing to switch between 2D, M and Color.

Depth – There is a caliper in the right side of the screen. By sliding your finger vertically (at any point of the screen), you can adjust depth.
Gain – by sliding your finger horizontally (at any point of the screen), you can adjust gain (overall or by 1/3 fields). Everything designed so you can do it with one (non-dominant) hand.
Zoom – by double tapping you can zoom in or out in 2D.
Colour doppler – when using Color Doppler, you can adjust the gain, the size of the box or move it.

M-Mode – when using the M-mode, the screen will split vertically: Upper – M-mode image, Below – 2D (where you can still move the M-mode line while scanning, adjusting depth and gain).

Measurement – to do the measures, and be more precise, there is a magnifying glass, which helps you to place the line… I haven’t found it very useful, but it is innovative.
- There is a tool to measure area, by adjusting a circle into the structure.

Saving images – once you start saving images, there is a counter in the right upper corner, clicking on it, will display saved images (in your phone), by selecting them all or one by one, you can upload them to the cloud, assigning it to a patient and giving a description. ***

In the left upper quadrant, there is a picture of yourself (Gravatar®), which takes you to the Cloud. Once there, you have the option of searching by folders, name of the study (if done before uploading to the Cloud, you can’t change these retrospectively, as far as I know).

Configurable – in settings, you can change probe configuration, such as the battery left, the ID of the probe, software updates or run diagnostics.

*** Cons: once uploaded, you cannot delete individual clips, but the whole study (you might have 50 videos, and 3 are from another patient, missed,… you will have to delete the whole study). I don’t understand why this is the case?!

The scans!

In my humble opinion, the images are not as good as other portable devices, (of course this is at the cost of a higher price to pay, so it is fair…).

There are 18 presets (not really sure if it is meant to make things easier):

Abdomen
Abdomen deep
Aorta and gallbladder
Bladder
Cardiac
Cardiac deep
FAST
Lung
MSK
Nerve
Obstetric
Pediatric abdomen
Pediatric cardiac
Small organ
Soft tissue
Vascular: access
Vascular: carotid
Vascular: deep vein

You can adjust every preset: erase them from the preset menu, set thermal index display, acoustic power setting, probe marker orientation, high or low color Doppler flow, trace scroll speed.

After using it for several days, it now feels a little bit more comfortable. I have found I only use a few of the presets, and I don’t have to do much ‘in-image’ adjustment. It has become more of a switch on and scan device! I have to say, this is usually always the case with any new device…takes some bedding in time.

Just to review a few of them:

Cardiac (Normal and deep)

Performs well. You have the option of cardiac or deep cardiac, (is it for different patients body habitus?). Allows M-mode, to calculate TAPSE/EPSS and even heart rate.

Lung

The quality of image is good. Allowing you to get a fair image of the pleura, and deep enough to see the artifacts underneath. If you want a better image of sliding, you can switch to a superficial preset.

Abdominal

Fair images of most of the important intra-abdominal structures, although I found it hard to see the branches of my aorta with the abdominal or cardiac preset, (this could be why there is an Aorta preset? The image improved just a little).

MSK

Probably not the best, the resolution was a little bit low, giving rather greyish images. I wonder how it will fair when used to do guided IV insertion or regional blocks, (has a fancy option to visualize a midline across the screen)? Also, if the needle will be easy to visualize, (the resolution of the first 0.5 cm seems to be ok). The probe isn’t the lightest.

Vascular

Good images and the ability to easily drag colour across the screen is fabulous!

The Verdict!

General:

Portability

Definitely one of the most portable. A wired device that will fit into any white coat pocket, easy and ready to use in any setting, (out of hospital, the ED, on the wards, in outpatients etc.).
Very robust (the butterfly team emphasized this).
Waterproof (only to the lightning cable, so don’t waterbath in your fishbowl)!

Number of probes

1 probe.
18 clinical presets that you can adjust. I haven’t noticed any detectable lag switching between modes and presets.
Remarkable!

Screen – dedicated or linked to tablet/phone

The screen is very clear, and large enough (iPhone X in my case). You can plug it into iPad as well, but what you get is a bigger version of the iPhone APP.
As soon as they upgrade the software to have an iPad version, my feeling is that iPad mini would be a nice option to balance between screen size and portability (pocketability?)
Touchscreen, to do the measures and switch presets, activate modes…

Battery life

The battery life is more than reasonable (one of the BIG PROS but shadowed by the heating problem… what’s the point if I cannot scan properly?).
The battery takes around 5 hours to charge, and then you can scan for several hours (I haven’t tested the limit of the battery yet).
And even when it heats up, there’s plenty battery to keep scanning… getting me through around 40 scans (quick views) with only 1/4 of the battery.
There’s a button for the battery indicator lights, which tells you in 1/4’s the remaining battery left.

Interface, logistics and ergonomics – Touchscreen, user-friendly software?

The interface is brilliant, user friendly, simple and very iPhone happy. I like it!
The App menu is intuitive and the functions are really easy to operate. Anyone with little guidance at the beginning can start to scan on their own.
The touchscreen works very well (it’s on my iPhone after all!)
The Software itself, is really cool, works smoothly, everything is designed to be practical for those on the coal face.
There are no noticeable pauses or delays when switching between presets, or changing modes.
It is really easy to retrieve the images. You can either download them to your computer, (by login into the cloud), or view them directly on the iPhone. Just tapping the share button allows you to copy a link to send to others.

I have obviously reviewed this system, using myself as the scan guinea pig. In the real world hospital ICU / ED / ward setting, it could be an entirely different situation.
- For now, there is no direct transfer into the PACS system (or Qpath), you might need first to upload it to the Cloud, and then transfer it to your hospital system (once you got the permissions).

Cost

Case with 1 probe and the battery charger.
- 1,999$ (VAT exemption).
The App can be downloaded free through APP store
- We are not yet sure about costs for license of the software, and whether the company plan on charging for upgrades etc etc???
- They have been rather quiet regarding this?

Warranty

Probe

After scanning for a while, you feel the fatigue in your hand.
If I am pushed, the probe is a little big (144 x 53 x 26 mm) and not too lightweight (around 300g)
Repetitive strain injury is becoming a real phenomenon amongst sonographers!

Deep/Low FQ:

Good images (not excellent though).

Superficial/High FQ:

Good images (not excellent again though).
You can adjust the screen down below to 2 cm depth.
- Next week, I will try to place lines using the device. Maybe that would be an advantage to others, (or maybe the probe or the footprint are a little too big).
- It will be really interesting to see how this probe tracks a needle.

THE BIGGEST CONS FOR ME

The probe overheats really easily, (especially in the cardiac preset and using colour Doppler).
- Then it freezes around 7-10 seconds, allowing you to scan again (from the beginning if you didn’t save the image/clip).
- But…it overheats even quicker the next time unless you leave it to cool down for a good while, (even without colour on).
- You need to leave it to cool down for several minutes (at least 3-5 min).

Features

The Cloud and App are brilliant. Probably the best part of the Butterfly IQ. My personal feeling is that they really invested in detail. HIPAA compliant, in this country. You can access it from your computer or phone.
No storage limit….yet!
Easy to upload (takes less than 2 minutes to upload around 50 videos).
Easy to share. Copy and paste links with the tip of your finger or by downloading it directly to your computer/phone (deidentified).
Easy to comment and review.We can easily comment on others scans from our research group, our chief is the administrator, and he can create different folders. Creating a discussion forum.You can tag other users in your studies.
- Positive: Learning and teaching resource.
- Limitation: you cannot rename files or change it to another folder once uploaded. No post-processing options (that I am aware of).
Waterproof (to the base of the lightning cable).
No satchel at the moment, you can carry it in your backpack or elsewhere.
The iPad version App works, but would benefit from upgrade/update.

*** MAIN PROBLEM: the mandatory subscription of 35$/month (individual) or 100$/month (team/group of 10).

Butterfly comments

This is still much cheaper than any other ultrasound system for the value provided to the customer.

Score and Conclusion

Quick words from JW

This has been one of the most heavily anticipated devices in the POCUS world to date!!! One probe that does it all-in-one! How is this possible, you and pretty much all of us POCUS obsessed folk have been asking? Well, it does seem to work, and very well. I doubt from day 1 of the concept did Butterfly envisage they would have the best image quality of any of these systems, that’s not realistic and would be frankly impossible from one probe. The ‘Others’, after all, are offering different plug and play probes to perform individual scanning tasks. The ‘others’ are like the specialist players in an American football team, solely focussed on their 1-2 tasks…but could this be the complete all-rounder in the team. If it’s all about ease of carriage, lack of faffing about, decent enough image set and great price….they’ve done it!!

There has been rather a lot of ‘cloak and dagger’ over various facets of the release and what it can do. There also seems to be a rather set pool of Butterfly happy scanners showing images on social media….but they don’t own their own device. Have they been cleverly planted there as part of the marketing campaign?? If so…..the marketing campaign is working….well!

There has been a storm on Twitter with excited parties exchanging frustration at the fact theirs hasn’t been delivered yet and utmost curiosity flowing from groups such as us..the ‘Ultrascoundrels’. I have been following the progress with avidity, as things seem to be as secretive as MI5 at times. That said, we are all gripped.

We have never really had the chance to do a review, nor to compare thoughts with each other on what this kit can really do! Until now!!!👏

Yale’s final thoughts:

Overall, I like the device for all the new features they have introduced. There has been a huge amount of research, development and investment behind this. The interface is practical, the logistics behind personalisation of settings is clear and easy and the software is a dream!

The one gripe I have it that it gets too hot. This may be a teething issue that the company will iron out over time. After all, this is the first of it’s kind….1 probe covering the whole spectrum!

The software license and repeat payment plan may put many off. But, the company have to make their money somehow and when you consider the price and the research involved in its development, this seems like the only way. A shame though….but there is a principle of, ‘you just can’t have your cake and eat it’, here. We also do not know what the lifespan of one of these probes will be?

My mark… 8/10

The reason I can’t give it 10/10, is down to the fact I believe they should release a final improved, upgraded version of the product before launching it world-wide. And unfortunately, that means having a probe that won’t overheat as avidly as this seems too.

Aidan’s mark:

Cardiac 5/10
Abdomen 9/10
MSK 7/10
Procedures 9/10

Average 7.5/10

So, there you have it. Essentially, an absolutely blindingly exciting concept. Brilliant in functionality and app support, portable as can be and versatile. But…perhaps not quite there yet and a little hot to handle!

I will also be receiving a probe to review for myself shortly….I can’t wait! I will update this review with my thoughts….

Main review – Dr Yale Tung Chen

Second Review – Mr Aidan Baron

Peer review and editor / comments – Dr Jonny Wilkinson