Preventing Work-Related Musculoskeletal Disorders Among Ultrasound Operators

Up to 90% of sonographers and other operators of diagnostic medical sonography report having painful work-related injuries affecting the muscles, nerves, ligaments, or tendons.1 These work-related musculoskeletal disorders (WRMSDs) result from the multiple times a day the operators repeatedly make the same movements and maneuvers while performing ultrasound examinations.2 For the ultrasound operator, the most common locations of WRMSDs include the shoulder, neck, wrist, and hands, and the results of WRMSDs can lead to serious health issues, absenteeism, presenteeism, and even leaving the field of ultrasound altogether.3

The following are some of the critical factors that can lead to the development of WRMSDs:

  • Poor ergonomics, including poor posture and machines with poor ergonomic design.3
  • Poor workflow, including the positions of the machine, bed, and workstation, leads to unnecessary arm abduction and overreaching.3
  • Lengthy exams with an increasing workload and number of exams to be performed during the workday.4
  • Inadequate breaks between examinations in addition to an increasing workload.5
  • Psychological stress and psychosocial factors in the workplace.6
  • Unsupportive or inflexible environments that fail to account for the diverse abilities and experiences of individual operators.7

The Occupational Safety and Health Administration has placed the primary responsibility for protecting workers on the employer.8,9 So, when developing WRMSD prevention protocols, administrators should collaborate with ultrasound operators to create policies that support their safety.10 Such policies should take into account scheduling to limit overtime work and provide breaks, staffing levels to optimize patient care, proper ergonomic equipment and adjustable equipment, and room designs that facilitate proper ergonomics, such as adequate space for patients and equipment. The workplace culture should support wellness and also have transparent policies regarding reporting and tracking of WRMSDs.

The operator also needs to ensure their working space is set up in the best manner possible for preventing WRMSDs during their workday. They can do so by customizing their ultrasound environment to promote proper ergonomic technique.

  1. At the beginning of each examination, the operator should properly position and make adjustments depending upon the body habitus of each patient.11 Reaching movements should be avoided by keeping the operator, machine, bed, and patient as close together as possible and at appropriate heights.
  2. The operator’s head and the screen/monitor should be on the same axis, and the eye-screen distance should be at least 60 cm. The top of the screen should be aligned with the level of the operator’s eyes; then, the top of the screen should be tilted back slightly to encourage proper neck posture.11,12
  3. The operator’s neck should be straight, and neck extension should be avoided.6
  4. The operator should be positioned in order to allow the arm to be in a relaxed position with the upper arm close to the body (minimal flexion, ideally abduction <30 degrees) and the elbow at a 90-degree angle, ie, the forearm should be horizontal to the floor allowing the shoulder to remain in a neutral positionwhenever possible.
  5. A “wearable transducer cable support device,”13 such as a cable brace, can be utilized to reduce arm strain during scanning. Also, the ultrasound transducer cable should not be passed around the operator’s neck as any traction force could result in a poor neck position.11,12
  6. A scanning chair should be equipped with a backrest for lumbar support and adjustable height to mold the lumbar lordosis. Moreover, a seatback inclined between 10° and 20° is recommended. The back should be well supported on the seat. A slight gap should remain between the edge of the seat and the back of the knee, and the body should be on the axis of the screen. The chair should be height adjustable so the operator can be properly positioned relative to the patient and ultrasound system. Exam chairs should not have armrests as they may restrict access to the patient.
  7. Exam tables should be height adjustable to encourage proper positioning by minimizing extended reaching, elevated arms, and wrist deviation, and allowing operators to stand and/or sit while performing procedures.
  8. The ultrasound machine keyboard should be easy to move and adjust.
  9. Removing the transducer from the patient and relaxing the hand to allow for brief micro-breaks during the examination can help reduce muscle strain.
  10. With the exception of point-of-care imaging, portable diagnostic exams should be limited to critically ill patients and those patients who are unable to come to the ultrasound department.

Specific types of ultrasound examinations also bring unique challenges. Some of these challenges are addressed, by specialty, in the AIUM Practice Principles for Work-Related Musculoskeletal Disorder.14

Increased awareness of the magnitude of the problem and local quality improvement (QI) efforts are necessary to ensure that these standards are translated into the successful reduction of WRMSDs among ultrasound operators.

A QI program should include ongoing tracking or logging of the following:

  • Ergonomic education for employees
  • Safety and resource utilization
  • Equipment updates
  • The numbers and types of reported symptoms and/or injuries, and
  • Organizational (ie, policies and practices) changes or updates made to improve employee safety and well-being.

A review of these data, along with a status check on overall workplace culture and worker well-being, should be conducted annually. To do so, a QI team composed of individuals from all levels of the organization (eg, administration, management, staff) should review aggregated data from tracking logs and any annual workplace environment reports to identify and prioritize areas for improvement.

The protection of our frontline workforce is paramount in retaining individuals with valuable skills. This protection requires a change in industry mindset that acknowledges the shared responsibility among both employers and ultrasound operators.

This post was created from the AIUM Practice Principles for Work-Related Musculoskeletal Disorder, which was developed by the American Institute of Ultrasound in Medicine in collaboration and with the expressed support of the American College of Emergency Physicians (ACEP), American College of Obstetricians and Gynecologists (ACOG), American College of Radiology (ACR), American Registry for Diagnostic Medical Sonography (ARDMS), American Society of Echocardiography (ASE), Australasian Society for Ultrasound in Medicine (ASUM), Fetal Heart Society (FHS), Intersocietal Accreditation Commission (IAC), International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT), Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS), Perinatal Quality Foundation (PQF), Society of Diagnostic Medical Sonography (SDMS), and Society for Maternal-Fetal Medicine (SMFM). The Practice Principle was developed to expand on the “Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography”13 to include safety practices for all health care professionals who utilize ultrasound.


  1. Evans K, Roll S, Baker J. Work-related musculoskeletal disorders (WRMSD) among registered diagnostic medical sonographers and vascular technologists. A representative sample. J Diagn Med Sonog 2009; 25:287– 299.
  2. Wareluk P, Jakubowski W. Evaluation of musculoskeletal symptoms among physicians performing ultrasound. J Ultrason 2017; 17:154– 159.
  3. Bowles D, Quinton A. The incidence and distribution of musculoskeletal disorders in final-year Australian sonography students on clinical placement. Sonography 2019; 6:157– 163.
  4. Gibbs V, Young P. A study of the experiences of participants following attendance at a workshop on methods to prevent or reduce work-related musculoskeletal disorders amongst sonographers. Radiography 2011; 17:223– 229.
  5. Baker JP, Coffin CT. The importance of an ergonomic workstation to practicing sonographers. J Ultrasound Med 2013; 32:1363– 1375.
  6. Harrison G, Harris A. Work-related musculoskeletal disorders in ultrasound: can you reduce risk? Ultrasound 2015; 23:224– 230.
  7. Chari R, Chang CC, Sauter SL, et al. Expanding the paradigm of occupational safety and health: a new framework for worker well-being. J Occup Environ Med 2018; 60:589– 593.
  8. United States Department of Labor, Occupational Safety and Health Administration. Ergonomics website. Accessed November 12, 2021.
  9. United States Department of Labor, Occupational Safety and Health Administration. Solutions to control hazards website. Accessed November 12, 2021.
  10. United States Department of Labor, Occupational Safety and Health Administration. Identity problems website. Accessed November 12, 2021.
  11. Rousseau T, Mottet N, Mace G, Franceschini C, Sagot P. Practice guidelines for prevention of musculoskeletal disorders in obstetric sonography. J Ultrasound Med 2013; 32:157–164.
  12. BP Bernard (ed). Musculoskeletal Disorders and Workplace Factors; A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. U.S. Department of Health and Human Services July; 1997 DHHS (NIOSH) Publication No. 97B141.
  13. Industry standards for the prevention of work related musculoskeletal disorders in sonography. J Diagn Med Sonogr 2017; 33:370–391.
  14. AIUM practice principles for work-related musculoskeletal disorder [published online ahead of print January 24, 2023]. J Ultrasound Med.

How Our Ultrasound Practice Flourished

My name is Barbara, and I have been an Ultrasound tech for more than 30 years now. Part of my job for the last 25 years has been to get and keep our labs accredited. We recently changed the accrediting body to the American Institute of Ultrasound in Medicine (AIUM). Our initial accrediting body has always been a pleasure to work with, but inside I felt that the AIUM must be more in tune with what our concerns are, being it is strictly ultrasound.

We changed up 2 years ago, and wonderful things started to happen. First, we added more heart views, as, before, only the 4-chamber view was required. We changed that. Many of our younger techs were not proficient with all of the views, so we all pulled together. Our boss let us set up multiple hands-on training sessions from the older, more experienced Sonographers. He let us have as much time as we needed. It was beautiful to watch everyone working together.

Also, as a requirement of our Diagnostic Breast accreditation, every tech in our department got Breast certified; at least 15 techs needed to. Which everyone did willingly. The Radiologist now having to get 15 credits in breast ultrasound, did that willingly too. Everyone was on the same page.

Then what is even more astonishing is our boss came to me and asked if I would set up a quality assurance program. He realized that our exams are so tech-dependent that the techs need a resource to help them grow. And in a busy department, he wanted to make sure they all get what they need to be the best they can be.

As a part of that quality assurance program, management has allowed me to take time in my schedule to review a Sonographer’s ultrasound images. I review at least 30 exams to see a pattern or determine what the sonographer may lack. I then go over my results with the individual tech about image quality, image technique, etc. And, if we noticed the tech may need help in a certain area, we set up a one-on-one or place that tech with a tech that is more experienced to build the less-experienced tech’s confidence and skills.

I am so proud of our management and staff…Thank You, AIUM, for being a catalyst for such good things!!!!

Barbara A. Fennen, RT(M), RDMS, RVT, is a Sonographer at Beebe Healthcare in Rehoboth Beach, DE.

Where to Find What’s New in Ultrasound and Education

As the use of ultrasound is expanding at a greater rate than ever, both as a diagnostic tool and in treating injuries and diseases, keeping up-to-date on all of the changes can be a struggle. In an upcoming symposium, however, you can explore new, exciting, and current technologies in ultrasound. Identify the different approaches to diagnostic ultrasound and determine which ultrasound techniques can help you advance your practice at “Can You Do That With Ultrasound?” on March 26, 2023, at UltraCon.

This symposium is an exciting new approach to discovering the technical advancement of ultrasound and applications across all subspecialties with collaborative interactions and networking opportunities to enhance the experience. It will begin with a discussion with John Pellerito, MD, Luis O. Tierradentro-Garcia, MD, Emile Redwood, MD, and John K. Hill of three abstracts with cutting-edge content regarding assessing cerebral blood flow in neonatal hydrocephalus, analyzing gene expression, and robotics-assisted transabdominal cerclage in pregnancy.

Next, with images and clinical histories, you will be able to review cases and discuss how each specialty group would approach the systems using different ultrasound techniques and instrumentation. Jon Jacobson, MD, Humberto Rosas, MD, Margarita Revzin, MD, MS, FSRU, FAIUM, Misty Blanchette Porter, and Stephanie Gisele Midgley, MD, will facilitate the discussion on state-of-the-art scanning techniques and innovative technology. Following that, John Pellerito, MD, will assist you with networking and crowdsourcing the answers to your questions. Then, industry representatives, expert clinicians, and expert researchers will also take questions.

Another symposium, “Everyone Can Be an Effective Ultrasound Educator” will also be happening that same day. Filled with practical and effective strategies and techniques to improve your teaching skills, Todd D. Zakrajsek, PhD, the keynote speaker, will share his thoughts on the foundational aspects of learning and relatively easy ways to teach while considering the diversity of learners today, as well as dispel learning myths and traps that hinder the learning process.

This symposium will feature a total of 8 engaging and interactive sessions for attendees to rotate through in groups:

  • Active Learning, Learning by Doing,” led by Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS, FAIUM, Rebecca J. Etheridge, EdD, RDMS, and Sara Durfee, MD, will show you how to apply creative and meaningful activities designed to enhance the teaching and learning environment.
  • Case-based Teaching: Let’s Have a Shared Learning Experience,” led by Iryna Struk, MS, RDMS, RDCS, RVT, and Jennifer Cotton, MD, will offer strategies for using case-based learning (CBL), an established approach used across disciplines where learners apply their knowledge to real-world scenarios, promoting higher levels of cognition.
  • Good Job. Keep It Up. Effective and Ineffective Feedback Strategies in Ultrasound Education,” led by Creagh Boulger, MD, Lauren D. Branditz, MD, and Christine M. Schutzer, RT, BS, RDMS, will review the literature and techniques for effective feedback and assessment.
  • Designing Virtual Lectures: A Necessary Challenge,” led by Kevin J. Haworth, PhD, Petra Duran Gehring, MD, RDMS, and Jacob Avila, MD, will review concepts in lecture design to increase student learning.
  • Gaming: Trendy Buzz Word or Effective Educational Tool?” led by Creagh Boulger, MD, and Rachel Liu, MD, will be a hands-on activity to solve your needs in education and how you can apply gaming as an effective, evidenced-based strategy for assessment, learning, and engagement.
  • Old School, New School, Best School,” led by Linda Zanin, Jennifer Cotton, MD, Lee Shryock, and Michelle Haines, will help you determine which new and exciting technologies are worth the investment and how you can integrate them into your curriculum.
  • Social Media and Education,” led by Kevin J. Haworth, PhD, and Chris Fox, MD, discusses ways in which social media can be used to improve teaching and learning.
  • The Impact of Emotional Intelligence in Education,” led by Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS, FAIUM, David Bahner, MD, and Hilary L. Davenport, DO, will provide tools that can help strengthen students’ emotional intelligence, which can positively impact relationships, academic success, and work performance.

In addition, this symposium includes “Learn From Our Learners,” in which former and current students (Creagh Boulger, MD, and Jennifer Cotton, MD) will share things that have worked well, experiences that have not worked well, and ideas they have for ways ultrasound can be better utilized in education.

All of this is just what is available on the first day of symposia at UltraCon. Check out the Full Schedule to get a sneak peek at everything you could learn.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Ultrasound Education in United States Medical Schools

Although nearly every medical specialty uses ultrasound, medical schools are inconsistently integrating ultrasound education into their curriculum. According to a 2019 study (by Nicholas et al) of United States Accredited Medical Schools (USAMS),1 although integration of ultrasound into curricula has increased since a prior study in 2014 (by Bahner et al),2 ultrasound instruction is still inconsistent.

In the fall of 2019, researchers contacted 200 allopathic and osteopathic USAMS for the Nicholas study.1 Of those schools, 168 (84%) responded and, of those, 122 (72.6%) indicated they have an ultrasound curriculum.

Of the medical schools that responded, 46 (23%) indicated they did not have ultrasound curriculum. 1

Although this study did not look into why they did or did not have the curriculum, some barriers clearly still remain to incorporating it, such as those mentioned in a 2016 study by Dinh et al3: lack of funding, lack of trained faculty, and lack of curricular space.

According to the Nicholas study, it seems as though some of the schools (42) work around the lack-of-funding barrier by having volunteers as faculty. Only 35 (20.8% of those who responded) compensate their faculty and, of those, 22 (13.1%) are compensated monetarily.1 And when schools can’t afford their own ultrasound machines, some have found other means, such as borrowing hospital ultrasound equipment. 3 Other means of helping to distribute the cost of starting up a program include gradually adding classes, using near-peer teaching, and self-directed asynchronous learning using online resources and simulators.3 

As medical students who have learned about ultrasound have reported that it improves their understanding of anatomy and physical examination skills, and more specialties adopt this technology, students need to learn about it before they need to use it in clinical practice.1

Although more schools keep adding ultrasound to their curricula, it is not yet nationwide, and many who have succeeded had to struggle to make it happen. It is imperative that USAMS receive the funding and support they need to train medical students in the safe and effective use of ultrasound.


    1. Nicholas E, Ly AA, Prince AM, et al. The current status of ultrasound education in United States medical schools. J Ultrasound Med 2021; 40:2459–2465.
    2. Bahner D, Goldman E, Way D, Royall NA, Liu YT. The state of ultrasound education in U.S. medical schools: results of a national survey. Acad Med 2014; 89:1681–1686.
    3. Dinh VA, Fu JY, Lu S, Chiem A, Fox JC, Blaivas M. Integration of ultrasound in medical education at United States medical schools: A National Survey of Directors’ experiences. J Ultrasound Med 2016; 35:413–419.
    4. Tarique U, Tang B, Singh M, Kulasegaram KM, Ailon J. Ultrasound curricula in undergraduate medical education: a scoping review. J Ultrasound Med 2018; 37:69–82.

    Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

    Pick-Up-and-Go Block Bags for Fascia Ilaca Blocks

    Ultrasound-guided regional anesthesia is a mainstay of multimodal pain control and is becoming an increasingly important part of emergency medical care. Regional anesthesia allows for maximal analgesia while minimizing the adverse effects of opioids, such as respiratory depression and sedation. The fascia iliaca block is one such procedure that provides regional anesthesia in the Emergency Department (ED) for proximal femur fractures and hip fractures.1 This plane block is performed by depositing a moderate volume of local anesthetic, usually bupivacaine, into the potential space between the fascia iliaca and the iliopsoas muscle. The procedure provides analgesia in the distribution of the femoral nerve, as well as the obturator nerve and lateral femoral cutaneous nerve. 1 Patients who receive this procedure experience improved pain scores and a reduction in the need for opioid medication.2–5 The use of preoperative regional nerve blocks, specifically including older patients with hip fractures, is supported by 2022 American Association of Orthopedic Surgeon guidelines.5,6

    At Rutgers New Jersey Medical School, we developed a teaching paradigm for the fascia iliaca block, with an online didactic session followed by a hands-on simulated skills session offered to faculty and residents (Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model).

    Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
    Figure 1A
    Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
    Figure 1B

    Later in the year, we performed a quality assurance project in order to determine what barriers existed to performing this block, in order to maximize the number of eligible patients that received this valuable procedure. We found that the fascia iliaca block was performed about 16% of the time when indicated (Figure 2).

    A bar graph indicating that, of those who received a nerve block, 87 were for hip/femur fractures (~3-4 per week), 16% (95CI: 10% to 25%) received the block, and 90% (95CI: 82% to 95%) completed the survey.
    Figure 2. Percentage of eligible patients who received the block.

    The most common reason for the block not being performed was the perceived lack of time during a busy clinical shift (Figure 3), which was a factor that was present in more than ¾ of missed opportunities.7 We theorized that this limitation came from a combination of the time required to obtain consent from the patient, gather supplies, coordinate with the admitting Orthopedics service, and ultimately perform the procedure.

    A bar graph indicating the number and strength of each agreement for each response.
    Figure 3. Reasons that the block was not performed.

    To address this barrier, we created ready-made pick-up-and-go nerve block kits containing all the necessary materials for performing ultrasound-guided nerve blocks in the ED (Figure 4). These kits include sterile gloves, ultrasound probe covers, sterile drapes, spinal needles, syringes, IV tubing, nerve block reference materials, and a consent form. We placed the kits in a centralized location in the ED for ease of access.

    Figure 4A. A collection of nerve block kits ready for use.
    Figure 4B. Contents of a nerve block kit.

    As a result of this intervention, we have anecdotally noted an increased number of procedures performed, with a complete analysis forthcoming. As our program increases the scope and scale of regional anesthesia procedures offered to patients, the nerve block kits will hopefully eliminate a barrier to performing nerve blocks and thus facilitate the deliverance of high-quality patient-centered analgesia to the largest number of patients possible.


    1. Chesters A, Atkinson P. Fascia iliaca block for pain relief from proximal femoral fracture in the emergency department: a review of the literature. Emerg Med J 2014; 31(e1):e84–e87. doi:10.1136/emermed-2013-203073.
    2. Groot L, Dijksman LM, Simons MP, Zwartsenburg MM, Rebel JR. Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients. West J Emerg Med 2015; 16:1188–1193. doi:10.5811/westjem.2015.10.28270.
    3. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: A systematic review. CJEM 2016; 18:37–47. doi:10.1017/cem.2015.75.
    4. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med 2012; 43:692–697. doi:10.1016/j.jemermed.2012.01.050.
    5. Kolodychuk N, Krebs JC, Stenberg R, Talmage L, Meehan A, DiNicola N. Fascia iliaca blocks performed in the emergency department decrease opioid consumption and length of stay in patients with hip fracture. J Orthop Trauma 2022; 36:142–146. doi:10.1097/BOT.0000000000002220.
    6. O’Connor M, Switzer J. AAOS Clinical practice guideline summary: Management of hip fractures in older adults. J Am Acad Orthop Surg 2022; 30(20):e1291–e1296. doi: 10.5435/JAAOS-D-22-00125.
    7. Alsharif P, Muckey E, Lu H, et al. Emergency department workflow limits the utilization of fascia iliaca blocks for hip and femur fractures. Academic Emergency Medicine 2022; 29(S1).

    Peter Alsharif MD, Marwa Ali MD, Helen Lu MD, Robert James Adrian MD, Annette Mueller MD MBA, Ilya Ostrovsky MD, and Stephen Alerhand MD, are from the Department of Emergency Medicine at Rutgers New Jersey Medical School in Newark, New York.

    What if Ultraportable Ultrasound Devices Were the Future of Healthcare in Africa?

    The improvement and miniaturization of ultrasound devices is a result of the need to make ultrasound devices quickly accessible regardless of location. The right diagnosis at the right time in the right place can take you a step ahead in this race for point-of-care diagnosis.

    Developed countries have experienced very significant direct and indirect impacts on the quality of care for patients in acute care and those who are hospitalized. However, if in these countries, ultrasound has made it possible to bypass certain additional examinations (standard radiography, CT, MRI, etc) for certain precise indications despite the latter being nevertheless available, it can be deduced logically that under certain conditions, point-of-care ultrasound (POCUS) would have an even greater impact in settings where other modalities are simply not available.

    Indeed, developing countries and areas with limited resources often have in common a lack of diagnostic imaging means: old, non-mobile X-ray machines with little or no function at all and you’ll rarely find CT or MRI, and when you do, it is inefficient except in concentrated, large cities.

    Add to this an extremely limited electricity supply, which significantly reduces the effectiveness of the existing means even further. It directly results in the impossibility of full-time operation due to power cuts, and indirectly through breakdowns and the gradual deterioration of the equipment related to variations in electrical voltage.

    These various problems make Africa extremely fertile ground for the use of clinical ultrasound (POCUS) with exactly the same benefits as those obtained in other better-developed regions, but better still the absence of other means of diagnosis, which could lead clinical ultrasound to become the “gold standard” for clinical diagnosis in African.

    The problem, however, is the availability of the devices, especially the type of device. Indeed, the devices currently present in Africa are either static or relatively portable (more than 10kg), which poses a real problem of mobility for an imaging modality that could otherwise be performed at the patient’s bedside.

    Ultraportable devices with their small size, their resistance, their autonomy, and their low energy requirement could be a valuable diagnostic aid in Africa. However, there remains the problem of their availability (most manufacturers limit their network to developed countries) and their cost (due to the low purchasing power of practitioners in developing countries), the very idea of ​​obtaining one at its actual cost is completely illusory.

    What if the manufacturers of ultraportables developed strategies to support doctors who want to equip themselves and the educated societies with POCUS, set up conventional classroom-based training courses and E-learning free or at a reduced price for all doctors wishing to learn?

    Yannick Ndefo, MD, is a general practitioner in Cameroon and a POCUS ambassador for POCUS Certification Academy.

    Interested in learning more about ultrasound in global health? Check out these posts from the Scan:

          Live Outside of Your Comfort Zone: Ultrasound Education

          Earlier this year, I attended a new-to-me scientific meeting—the 21st meeting of the International Society for Therapeutic Ultrasound (ISTU) in the beautiful city of Toronto. As I sat in sessions immersed in topics ranging from immunotherapy of liver tumors with histotripsy, to sonogenetic neuromodulation, to focused ultrasound for alleviating the pain from bone metastases, I was overwhelmed. And I was humbled by the vast swaths of knowledge that were nearly completely foreign to me, despite being a senior academic who does research in the field of biomedical ultrasound. I know less about the immune system than I should, and I don’t quite get the nuances of genetics and the brain—well, let’s just say that I like to use mine, but I am unaware of how it all works. I spent a lot of the meeting learning the background to the background of these areas so that I could understand more and better appreciate all the amazing science.

          It was a pain and totally out of my comfort zone, but it was exhilarating! I learned so much, and I now appreciate the challenges, opportunities, and potential impact of this field much more than I did before. I met the brilliant physicians and scientists who were all more than willing to enlighten me about the details of their work and their up-and-coming innovations. It was refreshing. As I listened, I thought about the big picture and the potential impact of all this work on patient care and where the field will go in the future.

          You may be thinking—why did I choose to attend this meeting? Why did I not go to a conference that was more aligned with my area of research? The answer is simple—I wanted to learn new things. I wanted my students to be exposed to innovative research directions and world experts in a related but distinct area. I wanted to better understand the evidence supporting the research so that I can shape my views with data, not dogma or hearsay. I also contributed a bit by sharing our group’s work on nanobubbles and the lessons we have learned from mostly diagnostic imaging research with these agents that can be applied to therapeutic strategies with focused ultrasound. I am most grateful to the organizers for having the foresight to explore how our research can complement therapeutic ultrasound applications and for inviting me to deliver one of the invited talks. I walked away, ready and inspired to foray into the intimidating world of ultrasound-mediated immunotherapy. Armed with the lay of the land and having met the pioneers of this field, I think the foundations we learned at this meeting will shape the next 5–10 years of our research.

          I want to encourage all of you to expose yourself, your colleagues, and your trainees to new concepts, new science, and new clinical approaches. Be open-minded to change, think, consider the evidence, and make rational, data-driven decisions as you move forward with your clinical practice, research, and day-to-day obligations. Educate yourself in the new research and translational directions in the field. The world of biomedical ultrasound is complex, multidisciplinary, and rich with burgeoning ideas that will someday revolutionize clinical practice. Many recent innovations, like the focused ultrasound treatment of essential tremor, are doing so already.

          Live outside of your comfort zone—it will refresh and energize you, and it will stimulate new ideas that may someday save one patient, or save the world. Of course, it’s fine to do things as you’ve always done and stay where it’s cozy and comfortable, but I promise you will enjoy it if you venture beyond, even a little bit. Enjoy your summer and science on!

          Agata A. Exner, PhD (@AgExner;, is the Henry Paine Willson Professor and Vice Chair in the Department of Radiology at Case Western Reserve University & University Hospitals of Cleveland.

          Growing a POCUS Program in a Large Academic Institution: a guide and some lessons learned

          Point-of-care ultrasound (POCUS) has quickly become an area of interest within medical education. As of 2020, a total of 57% of medical schools have incorporated POCUS training within their curricula.1 Integration of ultrasound into undergraduate medical education (UME) has been shown to help students learn anatomy, physiology, and pathology in a more effective and dynamic way.2

          Indiana University School of Medicine (IUSM), which has more than 1400 medical students spread across 9 campuses throughout the state, began the process of implementing a longitudinal UME POCUS curriculum in 2018. Their journey is outlined below—for a more detailed review, see Russell et al.2

          Step 1:  Create a POCUS committee.  A POCUS committee was created to identify and coordinate with key stakeholders throughout the institution. This committee was composed of a program manager, student representatives, and faculty from the departments of radiology and emergency medicine. Under the direction of the Executive Associate Dean for Educational Affairs, the committee worked with the regional deans, course directors, key educators, and sponsors to identify space within the existing curriculum for POCUS.
          Lesson learned: Engagement at multiple levels was key to the simultaneous integration of the curriculum across all campuses and ensuring an equitable learning experience for all.

          Step 2. Consider physical space and POCUS equipment. With many learners and multiple sites, the decision was made to use handheld ultrasound devices. While imaging parameters from these devices may be suboptimal at times, decreased cost and increased portability compared to cart-based ultrasound systems proved advantageous. A check-out system was created to allow learners to easily borrow the devices for self-driven education.
          Lesson learned: Handheld devices allowed for easy to stand-up educational sessions, smaller educational groups, more hands-on time, and overall greater program flexibility.

          Step 3. Instructional material and modules. Because of limited classroom time, the didactic portion of the curriculum was delivered asynchronously. The curriculum was divided into a series of 16 modules designed to complement and augment the existing medical school curriculum (Figure 1). The POCUS modules paralleled the curriculum as it advanced from basic science to bedside care (Figure 2). Modules were divided into diagnostic, procedural, and symptom-based categories.
          Lesson learned: Take advantage of online, self-paced learning modules. Completing modules prior to hands-on instruction minimized classroom time and maximized scanning opportunity.

          Figure 1. The 16 learning modules, included in the IUSM POCUS program, divided categorically (originally published in Ultrasound J2).
          Figure 2. An approach to structuring a curriculum and progressively building upon concepts throughout the UME curriculum.

          Step 4. Phased implementation. POCUS was initially integrated into anatomy and targeted clerkships. These areas were ideal starting points as they had existing POCUS champions and already had some POCUS elements (obstetrics, emergency medicine, etc).
          Lesson learned: Identify and leverage existing POCUS opportunities, then expand.

          Step 5. Development of an ultrasound learning website. A POCUS website was created using an institutional learning management system (LMS) where all relevant information was stored. This also allowed for easy and rapid dissemination of course materials such as modules, lab facilitator guides, equipment check-out procedures, open lab times, and consent forms.
          Lesson learned: Keep critical information centralized for quick access and easy updates.

          Step 6. Interprofessional collaboration. Having an adequate number of proctors was a barrier to implementing the hands-on elements of the curriculum. The team increased its number of available instructors by using a train-the-trainer approach for non-POCUS-trained faculty.3  The pool of available instructors expanded to include senior sonography students, senior medical students who had previously completed an elective in POCUS, residents (emergency medicine, family medicine, and radiology), ultrasound fellows, as well as POCUS-trained faculty.
          Lesson learned: Interdepartmental and interprofessional collaboration multiplies your efforts and reduces the workload.

          Step 7. Continue to build upon the foundation. The team recently launched a combined graduate medical education POCUS curriculum that started with 3 targeted residency programs and will soon include more than 10 residency and fellowship programs for the upcoming academic year. The experience gained and the connections made in building the UME curriculum have made this effort within the graduate medical education (GME) realm equally successful.
          Lesson learned: The success of the UME program was dependent upon effective collaboration, support from executive leadership, and strong student interest in learning POCUS.


          1. Russell FM, Zakeri B, Herbert A, et al. The state of point-of-care ultrasound training in undergraduate medical education: findings from a national survey. Acad Med 2021 Nov 16. doi: 10.1097/ACM.0000000000004512.
          1. Russell FM, Herbert A, Ferre RM, et al. Development and implementation of a point of care ultrasound curriculum at a multi-site institution. Ultrasound J 2021; 13:9. doi: 10.1186/s13089-021-00214-w.
          1. Russell FM, Herbert A, Zakeri B, et al. Training the trainer: faculty from across multiple specialties show improved confidence, knowledge and skill in point of care ultrasound after a short intervention. Cureus 2020; 12:e11821.

          Daniela Lobo, MD, FAAFP, is an Assistant Professor of Family Medicine and POCUS Fellow at Indiana University School of Medicine.
          Josh Kaine, MD, is an Emergency Medicine POCUS Fellow at Indiana University School of Medicine and future ultrasound faculty at IUSM.

          We invite you to comment below or on Twitter (@IUEM_ultrasound) and share with us what challenges or successes you’ve faced while trying to implement a POCUS curriculum at your institutions, residencies, student clerkships, or electives.

          End-of-Residency Perspective on Early Ultrasound Education

          I remember clearly the first day I ever held an ultrasound probe. It was my second week of medical school, I knew next to nothing about medicine, and my faculty member turns to me and enthusiastically says “oh look, you have a few thyroid cysts.” I, of course, immediately thought a few things. First, how many are there, how big are they, what do I need to do, could it be cancer, and why is the faculty member so nonchalant about this.

          The next thing I thought was “what is a thyroid”.

          After the initial and very clearly unnecessary panic was over, I thought to myself that it was very interesting we were scanning things before we were taught about them in class. Throughout my training, I have come to realize how lucky I was to get such early exposure to ultrasound training and teaching. At Eastern Virginia Medical School, ultrasound was integrated into all aspects of the curriculum. This started in anatomy lab, continued into our second-year courses in pathology, and was a crucial part of 3rd year rotations where each rotation had several portable ultrasounds for students to use to scan. In the Family Medicine clerkship, we were tasked with scanning multiple people for AAA, and on surgery, we had to get 5 images of cholelithiasis. By the 4th year, faculty were using ultrasound to do procedural training and students were in the trauma bay performing FAST exams for the team. Although I thought this was the norm, I quickly found out on the interview trail that this experience separated me from a lot of my peers.

          A selfie of a very young David sent to his clerkship director as proof he did his scans for the rotation.

          In residency, we had a point-of-care or POCUS-centered curriculum. Although we all got the same instruction, I felt like my previous experience, and most of all my comfort with the probe, made me into the “ultrasound guy” of my program. While the immense clinical utility is not lost on any of my peers, the amount of time it takes to become comfortable just did not fit into the time constraints of residency.

          While I do not think ultrasound can be filed under “you can’t teach an old dog new tricks,” I do strongly believe that integrating it into medical education early on is crucial for the future of medicine. Based on my conversations with colleagues at different schools and institutions, often, ultrasound training is saved for residents and fellows, and it really shouldn’t be. Although, this surely is based on several factors including class size, cost, requirement for specialization (eg, prenatal ultrasound for OB/GYN, MSK ultrasound for Sports Medicine and Orthopedics), and availability of sufficient machines.

          One of the most frustrating things for me is the train of thought that imaging is ruining the art of the physical exam. While yes, many people will get a CT of their abdomen and pelvis in the ED, the dynamic and live view that ultrasound provides is invaluable in learning about anatomy. Multiple studies, including one that I have worked on, have shown that a longitudinal and integrated ultrasound curriculum improves procedural and physical exam skills. Many of these studies show that the biggest effect is when it is started early in training.

          After being the confused MS1 who was freaking out about his thyroid cysts (which since have gone away by the way), and being slightly frustrated at the time that more work and learning was on my plate, it’s abundantly clear to me now that this is the direction that medical education needs to go. Every first-year medical student at every institution should have their hands on probes throughout their first year, especially while learning anatomy. My challenge to medical school leadership is to find a way to incorporate or expand on ultrasound in their curriculum. At first, your students will not be confident, and they will feel like they don’t know what they are doing, but it CAN and it WILL help in the long run. It certainly did for me.

          David Neuberger, MD, is currently a 3rd year Family Medicine Resident at Emory University in Atlanta, GA. He will be pursuing a Primary Care Sports Medicine fellowship at the University of Louisville this upcoming year and has a special interest in ultrasound and ultrasound education.

          How I Brought Point-of-Care Ultrasound (POCUS) to My Family Medicine Department

          As I demonstrate a handheld ultrasound (US) machine to the eager medical students in our clinical simulation laboratory today, I am struck by a vivid recollection of my own first time seeing a handheld US machine. I was a 4th year medical student on an away rotation at a rural hospital in my home country of Peru. A visiting foreign obstetrician produced an amazing small machine, detecting fetal malposition when unsatisfied with palpation with Leopold’s maneuvers alone.

          My fascination with the clinical utility of bedside US began that day and has continued through my move to US postgraduate training in family medicine, a geriatric medicine fellowship, academic faculty roles, the completion of an accredited POCUS fellowship, and right through to my current passion for growing POCUS use within family medicine practice.

          I have learned so much along the way, have been helped by so many mentors and colleagues, that I write today to share my POCUS journey in the hopes that my story may be useful to others.

          In 2018, I joined the department of Family Medicine at the University of Michigan in Ann Arbor (AAFP). The AAFP had recently released its novel POCUS curriculum guidelines for family medicine physicians, and the department was in search of a champion to lead the development of a POCUS program for our department. I was fortunate to be chosen for this role and over the intervening 3 years have had the privilege of working with several wonderful, enthusiastic colleagues across our department, our institution, and on a national scale through the AAFP’s POCUS interest group.

          Early on in my role as POCUS champion, I realized that to be successful with this project, I was going to need a lot of help from a lot of people! My first stop (along a long journey) was to ask my department chair for time and resources. He readily obliged, providing me with the protected time to do an established accredited POCUS fellowship (which luckily was available through our emergency medicine department) and important administrative resources, which were also vital as we developed our program.

          During my yearlong fellowship, I worked hard to become a clinical sonographer, educator, academic leader, and administrator in US. These newly acquired skills have been invaluable since assuming the role of Clinical US director for my department. There have been many challenges and administrative headaches—who knew that selecting and purchasing ultrasound machines could be so complicated?!?—but countless successes.

          In terms of successes, we have defined minimum credentialing requirements for POCUS use, defined pathways for faculty interested in training in POCUS, and obtained hospital privileges for the same from our department. We have developed billing for our clinical POCUS use in ambulatory care as well as electronic health record order sets and templates for easy documentation. With regard to the POCUS curriculum that we initially set out to create, we now have a formal POCUS curriculum for family medicine residents as well as an intensive US track for residents interested in a more in-depth POCUS educational experience. Additionally, I am so excited that we will be welcoming our first Advanced Primary Care US fellow for a one-year fellowship this July.

          It has not always been easy, but I have been so fortunate with wonderful supportive departmental leadership and fantastic emergency medicine colleagues who are always eager to help with advice on regulatory or administrative requirements. Developing the POCUS program for our department has taken a lot more time than I initially anticipated, and at times, the process has proved tedious. There certainly have been times when I have doubted if it has been worth the time and effort and doubted that colleagues share my vision for the potential POCUS offers for improving our patient care in family medicine or whether they see it as a burden, yet another thing to learn. However, the excitement I felt the first time I saw the handheld US those (many!) years ago in Peru, is reflected in the excitement I see in the faces of the medical students here in the clinical simulation lab today. This shared enthusiasm and passion for POCUS tells me that in the end, it truly will have been worth it.

          An US track resident in training.
          An US track resident performing US as part of training.

          Juana Nicoll Capizzano, MD, is a Clinical Assistant Professor and Clinical US Director of Family Medicine at Michigan University.

          Interested in learning more about developing ultrasound education? Check out the following posts from the Scan:

          Getting Sonography Students Hands-on Experience

          Ultrasound Education in the Post-COVID Era

          Sink or Swim? Modifying POCUS Medical Education Curriculum During Coronavirus Pandemic

          Teaching Point-of-Care Ultrasound