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Posting here so as to not contribute to hijacking the other thread.
Definitely crossed the chasm. Made POCUS a smidge cool.

https://www.butterflynetwork.com/investor-webcast

Alan- lots of Q's:
-Blocks, A-lines, peri-op echo or all of the above?
-there used to be an issue getting around biomed and purchasing because they were a new vendor. Issues at your site?
-are you archiving images in their cloud, in the emr, or none?

More just curious what larger groups doing.

Ps- you utilizing ESP blocks? Pretty versatile, useful and low risk!


<< -Blocks, A-lines, peri-op echo or all of the above? >>

All of the above....and then some. Can be used for the FAST exam in the ED; central lines; just used it in the OR to check for retained POC (products of conception)


<< there used to be an issue getting around biomed and purchasing because they were a new vendor. Issues at your site? >>

Yes, we had that issue...until they realized these devices cost 5% of the older models.


<< -are you archiving images in their cloud, in the emr, or none? >>

Their app is HIPAA compliant, and we archive both on their cloud and our EMR.


Alan


I still have a difficult time accepting that this will be a "new stethoscope". First, I see people carrying around stethoscopes and except in academic centers most non-cardiologists simply aren't that good at using them anyway. You can also use a stethoscope anywhere but need ultrasound gel to use the Butterly. And I don't know how many people are going to be willing to pay a monthly fee to use a "new stethoscope" especially if they're going to somehow be held liable for any findings.

Part of why radiology malpractice is so high is that when there's a recording of what you're interpreting, you're subject to second guessing. The best radiologists might catch 99.9% of findings but even a bad radiologist can catch 99.9999% of findings in retrospect. Currently, when I use a stethoscope I can just write "lungs are clear" and nobody can really prove otherwise. Are people going to save images of the heart? Or is this just going to be for taking a peek without documenting anything? It might be clinically helpful, but we all know business drives medicine in most hospitals.

I certainly see the upside for the emergency room and proceduralists. I'd be happy to give up the business of doing basic ultrasound guided procedures. But even in our small hospitals, availability of ultrasound is usually not the issue. It's the willingness of the operator to use it.

Will med students buy one? Maybe, in med school we had plenty of people shelling out hundreds of dollars for stethoscopes and ophthalmoscopes. Most people never learned how to use them. But maybe that alone is a big enough market.

It's certainly much cheaper than even the cheapest ultrasound machines. So I certainly see the benefit of buying 5 or 10 of these instead of one traditional ultrasound for an ER or OR. Is that enough of a market to make this investable? I'm not sure. I suppose the proof will be in the sales numbers.

Alan, how are you doing your procedures? Do you use real time ultrasound guidance? Do you have a stand for the display device?
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Posting here so as to not contribute to hijacking the other thread.

Thanks! I think that's a good practice, more orderly. Easier to find stuff.

I'm not a doctor but at the price differential with traditional ultrasound I think Butterfly has a new market to serve and that is a core concept of disruptive innovation.


I still have a difficult time accepting that this will be a "new stethoscope". First, I see people carrying around stethoscopes and except in academic centers most non-cardiologists simply aren't that good at using them anyway.

My cardiologist in Venezuela commented that most cardiologist (in Venezuela?) didn't really know how to read an electrocardiogram (EKG) and that was the reason they ordered angiograms. I found this very strange. After I had an angioplasty I was in the waiting room to see the doctor and I overheard two ladies whose husbands had just undergone angiograms. Their conversation confirmed what my cardiologist had told me. The conversation went more or less like this "The doctor did an EKG and found a problem but to be sure he recommended an angiogram." BTW, my doctor did not like using angiograms except as last resort. Unlike in America, malpractice suits are practically unheard of in Venezuela. The medical profession sticks together.

Even if Butterfly is a successful disruptive technology, I would not buy the LGVW shares today or even BFLY until after the IPO when there is real data backing it instead of 2023 guesstimates. Leave that to angel and venture capitalists. They have huge gains on some ventures and many ventures that go nowhere. What's the rush?

Denny Schlesinger
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But even in our small hospitals, availability of ultrasound is usually not the issue. It's the willingness of the operator to use it.

No and yes. Just because Ultrasound is available, doesn't mean it's performed and read expeditiously. It's usually a minimum of 45 minutes from order to study to read and that's on the hyper efficient side. For many studies (dvt, ocular, soft tissue for abscess or foreign body), it takes longer to figure out how to archive the images than to do the study!

The extra steps in the workflow is why alot of phantom scanning happens. Additionally, I think youre very correct that it's the willingness of the operator. I wrote a lengthy post on a paid board about this. Were pretty pennywise pound foolish on this- no matter how optimized the health system, no way you can order, perform, and read a soft tissue study study faster than I can do and save an exam! Yet this happens on the end of the would be POCUS clinician all the time. It's a bit of pin the tail on the specialist, despite pretty good evidence that POCUS can be useful for specific indications.

Alan, Ive never really enjoyed doing procedures with the IQ, the probe head is too big- give me my sonosite linear probe! When I have, I've sort of sub-optimally positioned myself with the phone on a bedside table. I've seen some folks use kickstands of sorts to prop up their phone.

As for the mental barriers of utilizing POCUS, getting it into the hands of students flattens the curve a bit. And ease of saving and archiving helps. And butterflyIQ has done a masterful job of becoming an Apple-like company amongst the crowd with a cool factor to it. Not that it's a reason to do it, but many more EM residents know what the butterfly is, and next to none know about lumify, clarius, vscan, or Vave.
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<< ....most non-cardiologists simply aren't that good at using them (stethoscopes) anyway. >>

Well, most cardiologists are that good at using them either! ;-)

All joking aside, stethoscopes yield very little information even in the best of hands....err...ears. When you hear an abnormality with a stethoscope, what do you order? And echocardiogram (cardiac ultrasound).


<< ... (you) need ultrasound gel to use the Butterly. >>

Not really. A few drops of water on the skin work just as well. That's a trick taught me by one of our locals radiologists. But I'm guessing you knew that, right? You're moniker is IRdoc. I assume you're an Interventional Radiologist.


<< I don't know how many people are going to be willing to pay a monthly fee.... >>

As of now, the required app to use the Butterly is free; the fee allows you to use their cloud-based storage. At any rate, it's a nominal fee.


<< Are people going to save images.... >>

We save our images, but no one has ever looked at them in retrospect. For now, it's a formality.


<< Most people never learned how to use them (ultrasounds). >>

I honestly believe using an ultrasound will become part of all medical training. It is already widely taught in many (most?) residency programs.


<< Alan, how are you doing your procedures? Do you use real time ultrasound guidance? Do you have a stand for the display device? >>

I use the Butterfly for virtually all of my real-time procedures (nerve blocks: central line and arterial line placement; difficult peripheral IV starts; volume status). I just lay my cell phone on the bed/patient nest to the procedure site.


Alan
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<< next to none know about lumify, clarius, vscan, or Vave. >>

We've demo'd a number of these other devices. The quality of the images were inferior, and the cost was at least 3 times higher than the Butterfly.


Alan
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could these find a home in the field kits of first responder medical personnel?
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<< could these find a home in the field kits of first responder medical personnel? >>

Absolutely.

It is often of paramount importance to be able to administer fluids and intravenous medications in the field. And sometimes starting an IV is extremely difficult. But...

....every person has large veins that are "deep"....but (fairly) easily accessible under ultrasound guidance.

At our facility, we train our respiratory therapists to start these "deeper" IV's. To a person, they have become experts.


Alan
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Fuma said:
No and yes. Just because Ultrasound is available, doesn't mean it's performed and read expeditiously. It's usually a minimum of 45 minutes from order to study to read and that's on the hyper efficient side. For many studies (dvt, ocular, soft tissue for abscess or foreign body), it takes longer to figure out how to archive the images than to do the study!

The extra steps in the workflow is why alot of phantom scanning happens. Additionally, I think youre very correct that it's the willingness of the operator. I wrote a lengthy post on a paid board about this. Were pretty pennywise pound foolish on this- no matter how optimized the health system, no way you can order, perform, and read a soft tissue study study faster than I can do and save an exam! Yet this happens on the end of the would be POCUS clinician all the time. It's a bit of pin the tail on the specialist, despite pretty good evidence that POCUS can be useful for specific indications.


I guess I was specifically thinking about the OR or ICU where they are trying to do procedures. Our ERs generally do some scanning but don't save any images and use it more as a triage method. If they see anything they order a formal ultrasound. I suppose if those clinicians are willing to act on what they interpret then it saves time.

As for the mental barriers of utilizing POCUS, getting it into the hands of students flattens the curve a bit. And ease of saving and archiving helps. And butterflyIQ has done a masterful job of becoming an Apple-like company amongst the crowd with a cool factor to it. Not that it's a reason to do it, but many more EM residents know what the butterfly is, and next to none know about lumify, clarius, vscan, or Vave.

This is ultimate goal, I just wonder how many people will carry that through. When I was training, various services used ultrasound for procedures. Every medicine resident learns to put in a central line and do a paracentesis and an LP. But now somehow they've all forgotten how to do it (probably insurance related Alzheimer's). Maybe there's a gradual effect and some maintain those skills, but I have to see it happen. I saw it work with ISRG (urology residents who basically only looked for jobs where they could use Da Vinci). But I suspect at the end of the day it comes down to money (and by extension liability).

Alan said:
Not really. A few drops of water on the skin work just as well. That's a trick taught me by one of our locals radiologists. But I'm guessing you knew that, right? You're moniker is IRdoc. I assume you're an Interventional Radiologist.

Sure, as long as you can get good opposition of the probe with the skin and a layer of liquid in between it works. Without trying out the probe, it's hard to know. Yup, I'm an interventional radiologist.

We save our images, but no one has ever looked at them in retrospect. For now, it's a formality.

I agree, it's mostly a formality. For procedural guidance it probably doesn't matter. But if someone is doing an echo or looking for gallstones and billing for it, they probably need to save images. Then it's a real possibility that someone will find out they have liver cancer, remember some guy in the ER did an ultrasound of that area, and wonder why it wasn't picked up. Considering how many dubious indications we get for imaging (head scans for the drunk guy, ultrasound for a spider bite) it seems pretty clear that litigation is still a strong concern.

I honestly believe using an ultrasound will become part of all medical training. It is already widely taught in many (most?) residency programs.

It's certainly going to be part of the training, but to use it enough gain widespread adoption is another issue. Everyone learns to use an ophthalmoscope in med school but how many people ever buy a second one?

I use the Butterfly for virtually all of my real-time procedures (nerve blocks: central line and arterial line placement; difficult peripheral IV starts; volume status). I just lay my cell phone on the bed/patient nest to the procedure site.


I saw a video of someone who did that, just placing the phone on the bed. Most of my procedures are more involved, so using the bed is not really an option. Of course we have easy access to ultrasound machines as well.

....every person has large veins that are "deep"....but (fairly) easily accessible under ultrasound guidance.

Not every... I've had to do more than a few translumbar direct IVC punctures which are not easily accessible.

...

What's their potential market? According to Google, the stethoscope market is $500m or so. It's for stethoscopes that cost a fraction of the Butterfly, but there are a lot more stethoscopes lying around.

I'm with Denny on this one, I'd like to see them actually making sales and converting them to subscriptions before investing.
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<< I've had to do more than a few translumbar direct IVC punctures which are not easily accessible. >>

Wow! I didn't even know that procedure existed!!

I learn something new just about every day.



Alan
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<< ....urology residents who basically only looked for jobs where they could use Da Vinci. >>

Even my small, rural hospital has a DaVinci.

How'd we pay for it? Our ladies auxiliary held a bake sale, I think.


Alan
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One trick I'll do is the water-bath for hands and feet scanning: quite literally fill up those yellow or pink basins and stick the extremity on there. The probes are waterproof up to the cord.

Specifically for tendon lacs, foreign body evals, or tenosynovitis vs regular cellulitis the water bath gives a really clear image!

As for sales, I think they did 44m in 2020, expect 80 in 2021, then 140m in 2022, and 235 in 2023. This doesn't count IQ at home or any sort of wearables.

One of my concerns is if folks are continuing to pay for the subscription. You can still use the IQ if you don't pay for the year, just can't save images or get updates. You still get access to all your stored images.
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<< could these find a home in the field kits of first responder medical personnel? >>

Absolutely.

Then dare I say it?
"Ding ding ding! Winnah, winnah, chicken dinnah!"

Looks like a paradigm buster for certain. Expanding the market for this sort of imaging to a relatively more massive market. Not to mention the possibilities mentioned earlier for markets in developing countries.

I don't have to know how big that new market is to know it is in the words of a certain media personality cum Chief Executive going to be "huge. YUGE!"

A,
Seriously, thanks for that.


So do we know if they have a lock on this, i.e any moat, other than being first mover?
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"I saw a video of someone who did that, just placing the phone on the bed. Most of my procedures are more involved, so using the bed is not really an option."

This will soon have a wireless link either to phone/tablet or even better to AR glasses (e.g. Google glass).
That's an easy upgrade to imagine and another way to differentiate and sell upgrades into the customer base.
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I Googled butterfly IQ a couple days ago, and this youtube popped up today.

Butterfly IQ: Review of the portable, handheld ultrasound.
https://youtu.be/CrzW-v_5BiQ

This is not a glitzy, sales pitch.

😷
ralph
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This will soon have a wireless link either to phone/tablet or even better to AR glasses (e.g. Google glass).
That's an easy upgrade to imagine and another way to differentiate and sell upgrades into the customer base.


Admittedly I am not really the target audience but a low latency wireless augmented reality setup might be too cool to pass up.

Still, for my tastes there are far too many instances where a superior product just can’t get over the hump. Until they’re public, you still run the risk of sales hitting a wall or an unexpected inventory issue but not being able to get out of the shares. Part of the reason I’ve refrained from investing in any private companies to this point; risk of being left behind is much higher when you can’t dump shares at the early signs of trouble.
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<< So do we know if they have a lock on this, i.e any moat, other than being first mover? >>

As I understand it, the ButterflyIQ is the only ultrasound device that uses a microchip based transmitter, as opposed to a fragile crystal.

The images using the Butterfly are really good....much better than the other hand-held devices that I've tried.

And, they are very durable (initially developed for use in "the field"). This is a huge benefit.

Most importantly, their price point is a fraction of any other device I've seen....so far, that is.


Alan
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As I understand it, the ButterflyIQ is the only ultrasound device that uses a microchip based transmitter, as opposed to a fragile crystal.

They mentioned patent protection. You can patent their method of getting silicon to drum but you cannot patent the idea. Unlike Intel's x86 silicon which was the basis of a long and complex value chain, I don't see the same kind of protection as there is no similar value chain.

Denny Schlesinger
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heck, I want one of these just for kicks and grins.


<as a personal aside>
I have loved this sort of stuff ever since Dad (a small town Hospital Administrator/CEO) brought home an antique microscope in a woodcase the lab was disposing of during a move to a new facility. The orignal building was built in 1926, the scope was likely that old. Mom had been a lab tech starting in WWII as a WAVE. She got us all into prepping slides with blood samples, pond water and anything else that we could think of. No TV in the house in those years so this provided a lot of rainy day entertainment when the stack of library books had been finished.

I still get a childlike pleasure everytime I go to a microscope. The digital stuff available now is nice but just not the same as optics IMHO. Sort of like Vinyl or tape compared to digitized music.


I have two of my own personal property scopes in my office at work for the metallurgical and electronic assembly failure analysis work I do. One a nice old (now) Olympus 20-500X stereomicroscope with both bottom and top mount for backlighting x-sections and a simpler overarm 3-30x variable for looking at details like soldered assemblies and electrical interconnects.
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<< I've had to do more than a few translumbar direct IVC punctures which are not easily accessible. >>

Wow! I didn't even know that procedure existed!!

I learn something new just about every day.



Alan


Next time you’re faced with getting central access for a quad amputee (no IO access) on chronic dialysis with no traditional veins, you know where to look...
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