Category Archives: Sonography

Overcoming Common Ultrasound Scanning Challenges: Practical Tips for Sonographers

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Ultrasound is an essential imaging tool in modern medicine, offering visualization of soft tissues, organs, and vascular structures. However, even the most experienced sonographers encounter obstacles that can make obtaining clear images difficult. From excessive bowel gas obscuring structures to scanning patients with high body mass indexes (BMIs), these challenges require skill, adaptability, and technical adjustments. Here are some of the most common ultrasound scanning challenges and practical solutions to optimize imaging.

1.  Imaging the Aorta in Gassy Patients

Few things are as frustrating as trying to visualize the aorta when excessive bowel gas gets in the way. Gas scatters ultrasound waves, making it difficult to see vascular structures clearly.

Solutions:

  • Use an Intercostal Approach: Instead of scanning anteriorly, try navigating through the intercostal spaces on the right side to bypass gas-filled loops of bowel.
    • Apply Steady, Firm Pressure: Pressing gently on the abdomen can help displace gas and improve sound wave penetration.
  • Change the Frequency: A lower-frequency transducer (such as a curvilinear probe at 1–6 MHz or 2–5 MHz) allows deeper penetration, sometimes improving visibility despite gas interference.

Video Link: Watch here

2.  Scanning High BMI Patients

Larger patients present challenges due to increased soft tissue thickness, which can reduce image resolution and penetration.

Solutions:

  • Use a Lower Frequency Transducer: A 1–6 MHz or 2–5 MHz curvilinear transducer enhances penetration, even if it sacrifices some resolution. This is especially useful when scanning larger patients, such as when ruling out lower extremity DVTs. While linear probes are common for vascular imaging, don’t hesitate to use whatever transducer best visualizes the patient’s anatomy, whether it’s curvilinear, phased array, or another alternative.
    • Increase the Time Gain Compensation (TGC): Adjusting the TGC enhances contrast and clarity in deeper structures.
  • Optimize Patient Positioning: Having the patient roll onto their side allows gravity to shift excess tissue, improving visualization. Right Lateral Decubitus (RLD) positioning works well for imaging the spleen and left kidney, while Left Lateral Decubitus (LLD) positioning is ideal for the right kidney, gallbladder, and the dome of the liver.
  • Utilize Harmonic Imaging: This setting helps reduce artifacts and enhances contrast resolution for clearer imaging.
Ultrasound image showing a longitudinal view of the proximal aorta, used for evaluating vascular structures and potential obstructions.
Photo: This image shows the aorta of a patient with a BMI of 50+, captured using an intercostal approach. (Fun fact: “Intercostal” just means between the ribs!)

3.  Evaluating Deep or Small Vessels

Poor acoustic access can make visualizing small or deep vessels, such as the popliteal artery or small renal arteries, difficult.

Solutions:

  • Use Color and Power Doppler: Increasing Doppler sensitivity helps detect slow-moving blood flow in deep or small vessels.
  • Optimize the Angle of Insonation: Keeping the Doppler angle between 45 and 60 degrees improves velocity accuracy.
  • Apply Gentle Compression: This technique helps differentiate veins from arteries and optimize visualization. I frequently use this when assessing ankle-brachial index (ABI) ratios in calcified arteries near the ankle.

4.  Differentiating Cysts From Solid Masses

Distinguishing between cystic and solid structures can be tricky, especially when artifacts mimic fluid-filled lesions.

Solutions:

  • Use Multiple Imaging Planes: Scanning from different angles helps confirm whether a structure is truly cystic or solid. Always assess the kidneys from multiple planes—exophytic masses and cysts love to hide where you least expect them.
  • Apply Color Doppler: Cysts will not show internal blood flow, while vascularized solid masses will have detectable Doppler signals.
  • Adjust Gain Settings: Lowering overall gain can help differentiate hypoechoic solid structures from fluid-filled cysts.

Conclusion

Ultrasound scanning challenges are inevitable, but a skilled sonographer can overcome them with the right techniques. Adjusting transducer settings, modifying patient positioning, and using alternative scanning approaches can significantly improve image quality. By staying adaptable, sonographers can ensure optimal imaging, leading to more accurate diagnoses and better patient outcomes.

Let’s Stay Connected!

Theresa Jenkins, BS, RDMS, RVT

I hope these tips help you tackle ultrasound challenges with confidence! Connect with me on LinkedIn or check out my YouTube channel, Path2Passing, for more ultrasound insights and updates!

🔗 LinkedIn: Theresa Jenkins
🎥 YouTube Channel: Path2Passing
✍ Author: Theresa Jenkins, BS, RDMS, RVT

Theresa Jenkins BS, RDMS, RVT, is a seasoned sonographer with nearly seven years of experience, having worked in top facilities nationwide. Credentialed in general, vascular, and pediatric ultrasound, she is also an educator and author with plans to become a leading voice in sonography.

This posting has been edited for length and clarity. The opinions expressed in this posting are the author’s own and do not necessarily reflect the view of their employer or the American Institute of Ultrasound in Medicine.

Workplace Conflict in Medical Imaging

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I’m going to tell you all a secret: I enjoy conflict.

No, I don’t enjoy creating conflict, and I certainly don’t enjoy being involved in conflicts with peers or my students. But I love studying it, mainly “why” conflict happens and how it impacts our organizational systems and daily interactions. Perhaps I’m naïve and hold an idealistic view that if we solved specific problems, the world would be run more effectively, and people would have more time to improve themselves and their environments. Wild, right?

I began looking into workplace conflict in hospitals in 2019 while shopping around for a dissertation topic, combining my knowledge from two fields of expertise: Vascular sonography and conflict resolution. Little did I know this task would become Herculean in scope as I quickly discovered how allied health professionals were marginalized in literature exploring conflict in hospitals.1 I found this odd and wanted to dive into this topic, puzzled by this literature that should have known conflict did not occur in a vacuum. Additionally, all the unresolved conflicts in healthcare would inevitably spiral out of control, leading to systemic conflicts that were much harder to resolve.

Many folks use the word “systemic” without understanding complex systems theory.2 Have no fear; I won’t bore you to tears with an explanation of systems theory and the differences between open and closed systems. However, I will explain that not only are you a system, but our healthcare professions are systems, our medical imaging departments are systems, and hospitals are systems. Sometimes, these systems work in harmony, but sometimes, they do not function as intended, leading to two types of social conflict: interpersonal and interprofessional.1 These conflicts demoralize hospital staff and probably impact patient care delivery from physicians, nurses, and allied health professionals who could be suffering from stress and burnout.1

We are all familiar with interpersonal conflict; it is unavoidable and, in many ways, necessary for personal growth. It is interprofessional conflict that should warrant more attention, particularly in hospital settings, as there is a tendency for healthcare professionals to be tribal in their group behavior, meaning they stick with their “own” and have an in-group preference. Medical imaging departments are not exempt from this phenomenon.1 Based on existing literature exploring conflict in hospitals,3,4 most reported conflict is interpersonal and intraprofessional, meaning the conflict most often occurs between peers, eg, nurse versus nurse. Interprofessional conflict reported in the literature also involved nurses versus physicians and occasionally involved allied health, including medical imaging professionals.1

The origins and antecedents of conflict within medical imaging are multifactorial: They combine personal factors specific to individuals with work-related issues exacerbated by high-stress, unpredictable work environments.1 Interprofessional conflict is particularly troubling as it suggests a difference in professional values between professions or a divergence of interests between patient care and the need to generate revenue.1 In those situations, a phenomenon known as “dual agency”1 may explain some interprofessional conflicts as medical imaging professionals struggle to advocate for patients while also serving the interests of their employers. This does not explain all of the interprofessional conflict, but it does suggest a need for medical imaging professionals to consider their roles in the larger healthcare system and if they are truly serving the best interests of their patients.

So, how do we address workplace conflict in medical imaging? Unfortunately, I see no “one size fits all” solution, but I propose a template for resolving many issues that contribute to conflict: Dispute systems design.5 Dispute systems design is a tailor-made analysis of a unique, conflict-prone environment that could identify problem elements within the system and provide opportunities for long-lasting resolution. Managing conflict is a misnomer, as the key to lasting conflict resolution is collaborative conflict resolution between conflicted parties.6 I am confident that introducing dispute systems design into hospitals and medical imaging departments can elicit many positive changes, potentially reducing burnout and staff turnover.

References

  1. Moody RC. Medical Imaging Professionals Experiencing Workplace Interprofessional Conflict: A Phenomenological Study. Davie, FL: Nova Southeastern University; 2023.
  2. Meadows DH. Thinking in Systems: A Primer. White River Junction, VT: Chelsea Green Publishing; 2008.
  3. Almost J, Wolff AC, Stewart-Pyne A, McCormick LG, Strachan D, and D’souza C. Managing and mitigating conflict in healthcare teams: an integrative review. J Adv Nurs 2016; 72:1490–1505. doi:10.1111/jan.12903
  4. Kim S, Bochatay N, Relyea-Chew, et al. Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review. J Interprof Care 2017; 31:282–290.
  5. Rogers NH, Bordone RC, Sander FE, and McEwen CA. Designing Systems and Processes for Managing Disputes. Frederick, MD: Wolters-Kluwer; 2013.
  6. Katz NH, Lawyer JW, Sweedler M, Tokar P, and Sosa K. Communication and Conflict Resolution Skills. 3rd ed. Dubuque, IA: Kendall Hunt Publishing; 2020.

Robert Moody, PhD, MS, RVT, is an Assistant Professor of Cardiovascular Sonography at Nova Southeastern University (NSU) in Fort Lauderdale, FL.

Optimizing Prenatal Imaging: The Role of Maternal-Fetal Medicine Sonographers

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Ultrasound imaging is a cornerstone of care in high-risk pregnancies, providing essential insights into both maternal and fetal well-being and structural development. But who ensures that these images are not only accurate but also of diagnostic quality, capturing even the smallest details?

A maternal-fetal medicine (MFM) sonographer.

MFM sonographers are the unsung heroes of prenatal imaging, acting as the eyes of Maternal-Fetal Medicine specialists. Imagine being the first to see a tiny heartbeat on the screen of a patient with a history of multiple losses or detecting a complication early enough to save a baby’s life—that’s the kind of impact MFM sonographers have every day. Their expertise goes beyond basic imaging, making their role indispensable in managing high-risk pregnancies.

So, what sets MFM sonographers apart? Their training and skills are specialized and essential to optimizing prenatal care and improving outcomes. Below are some key aspects of their work that demonstrate their unique contributions.

Expertise in Complex Obstetric Cases

MFM sonographers specialize in handling challenging and high-risk pregnancies. These may involve conditions such as congenital anomalies that require detailed anatomical assessment, multiple gestations, where each fetus must be carefully monitored for growth and complications, and maternal health conditions like preeclampsia, diabetes, or autoimmune disorders, which can impact fetal development.

Take, for example, a case where a mother presents for a late anatomy at 32 weeks. The sonographer notices vessels near the lower uterine segment with color Doppler and decides to perform transvaginal imaging to get an optimal view. The transvaginal imaging demonstrates cord vessels crossing the cervix, which is consistent with vasa previa. The sonographer’s detection of vasa previa prompts immediate medical intervention, preventing delivery complications.

With their unique skillset, MFM sonographers can identify and recognize sonographic findings or complications early on. Their ability to provide comprehensive imaging enables Maternal-Fetal Medicine Specialists to make timely, critical decisions affecting both short-term and long-term outcomes for mother and baby.

Specialized Examinations and Advanced Imaging Techniques

In high-risk obstetrics, standard imaging alone may not be sufficient to capture the whole picture. MFM sonographers develop proficiency in various specialized examinations and advanced imaging techniques. Some examples below:

  • Doppler studies to evaluate blood flow in key vessels, such as the umbilical artery, middle cerebral artery, ductus venosus, and maternal vessels, too! (Figure 1.)
Figure 1. Doppler ultrasound.
  • Fetal echocardiography to assesses complex cardiac structures and detect congenital heart defects. (Figure 2.)
Figure 2. Fetal echocardiography.
  • Fetal neurosonography focuses on detailed imaging of the fetal brain and central nervous system. (Figure 3.)
Figure 3A.
Figure 3B.
  • In certain cases, 3D imaging may also be used to aid in diagnoses and management. (Figure 4.)
Figure 4A, Spine.
Figure 4B, Brain.
  • Detailed Anatomy (76811) and Detailed First Trimester Ultrasounds (DFTUs). (Figure 5.)
Figure 5A, Detailed anatomy.
Figure 5B, Detailed first-trimester ultrasound.

Beyond the Image: Critical Thinking in High-Risk Obstetrics

MFM sonographers must possess strong critical thinking skills to adapt to complex obstetric cases’ dynamic and often unpredictable nature. Each scan involves real-time assessment and decision-making. Sonographers must quickly discern between normal and abnormal findings, usually flagging fetal structural anomalies that may require further imaging or immediate intervention. High-risk pregnancies frequently demand deviations from standard imaging protocols, prompting sonographers to use their judgment to determine which additional views or techniques—such as Doppler studies or 3D imaging—are necessary to obtain a complete and accurate assessment. In urgent situations, such as fetal distress or signs of preterm labor, sonographers must prioritize findings and swiftly communicate critical information to the maternal-fetal medicine specialist to facilitate immediate action. These cognitive skills are essential for delivering comprehensive, high-quality imaging that enables timely and accurate diagnoses, ultimately contributing to improved outcomes for mothers and babies.

Becoming an MFM Sonographer: What You Need to Know

Sonographers typically begin their careers by obtaining Registered Diagnostic Medical Sonographer (RDMS) credentials with a specialty certification in Obstetrics & Gynecology (OB/GYN), followed by clinical experience in obstetric imaging. The more experience you gain in performing obstetric and gynecologic imaging, the better prepared you will be. Those who pursue a career in maternal-fetal medicine (MFM) undergo additional training to develop proficiency in high-risk obstetric imaging. Many also pursue advanced certifications, such as fetal echocardiography, to further validate their skills in this specialized field. The role requires a combination of technical proficiency, critical thinking, adaptability, and a commitment to continuous learning to stay current with advancements in ultrasound technology and best practices.

A career in maternal-fetal medicine (MFM) sonography is both rewarding and impactful, offering opportunities to make a real difference in the lives of mothers and babies. Sonographers play a pivotal role in high-risk pregnancies, often being the first to detect critical conditions that can change the course of care. Beyond the emotional rewards, the field also offers career growth opportunities. With advancements in ultrasound technology and an increasing focus on women’s health, MFM sonographers can pursue advanced roles as educators, advanced practice sonographers, or administrative leaders, allowing them to expand their expertise and advance their careers. For many, the opportunity to combine cutting-edge science with compassionate care makes this profession impactful and fulfilling.

Are you interested in learning more about the role of MFM sonographers or how to become one? Join the AIUM’s interactive community discussion hub, “The Ultrasound Forum: Specialized Skills of Perinatology Sonographers,” on March 19, 2025, at 7 pm EST. Hear firsthand from MFM sonographers, physicians, and other experts in the field. Don’t miss this opportunity to ask questions, gain insights, and connect with professionals shaping the future of maternal-fetal care.

Mishella Perez, BS, RDMS, RDCS, FAIUM, is a Clinical Ultrasound Educator at Scripps Health’s Division of Maternal-Fetal Medicine (MFM) in San Diego. She is also Chair of the American Institute of Ultrasound in Medicine’s (AIUM’s) Obstetric Ultrasound Community and is on the AIUM Board of Governors.

The Sonographer Scope of Practice: what you need to know

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Why is it important to read the Sonographer Scope of Practice?

  • A scope of practice clearly articulates the activities and processes healthcare professionals can perform.
  • A scope of practice limits the activities of a healthcare professional based on specific education, training, and competency requirements based on regulations, standards, and laws.
  • Very few states regulate the education, competency, and certification of sonographers.
  • The Sonographer Scope of Practice is our guiding document that describes the boundaries of our profession.

This year (2024), the Society of Diagnostic Medical Sonography (SDMS) released the latest revision of the Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer (The Scope) which encompasses the changes and growth in technology and the expansion in the roles of sonographers. I was excited to represent the American Institute of Ultrasound in Medicine (AIUM) in this revision process, and glad that the AIUM Board of Governors voted again to continue to support The Scope.

This comprehensive document sets forth the most current standards and expectations for sonographers, emphasizing patient care, safety, and the evolving role of sonographers in healthcare.

I asked colleague Jaime Taylor-Fujikawa, RDMS, RDCS, why she feels The Scope is important. Her first reason was because it is not stagnant. She stated that “the sonographer profession continues to expand and evolve, and The Scope has changed with the times.” Jaime is a sonographer of 21 years, a long-time member of the AIUM, and she lives in 1 of only 4 states that requires licensure of sonographers. She has taken certification exams in OB, Adult Echo, Pediatric Echo, and Fetal Echo.

Did you know that though certification of sonographers is considered the standard of care, it is still considered voluntary except in those states that require licensure?

The sonographer is defined as an individual who performs diagnostic exams and procedures, acquiring images and other pertinent information to provide to the interpreting physician. Sonographers do not practice independently and function as a delegate of the physician. In brief, we

  • Follow written policies, protocols, and guidelines.
  • Apply principles of safe use (ALARA) for the patient, ourselves, and the healthcare team.
  • Commit to ongoing education to increase competence with increasing advancements.
  • Acquire appropriate training and experience in examinations and specialty areas in which they perform.

This is but a brief overview of The Scope. A few areas that were added/expanded included

  • The role of the advanced practice sonographer (under physician supervision)
    • As an evolving role for those with higher levels of education, training, and experience,
    • Which may be identified with advanced job titles such as ultrasound practitioner, advanced cardiac sonographer, advanced sonographer, and/or with an advanced certification (currently there is only 1 advanced certification available)
  • The use of contrast, which has been expanded and is now woven strategically throughout the document with more succinct guidelines of the sonographer’s role.
  • The expansion of safety principles to increase focus on prevention of work-related musculoskeletal disorders (WRMSD) to encourage
    • Maintenance of an environment to avoid injuries,Implementation and participation in programs designed to reduce WRMSD, and
    • Reporting signs and symptoms of WRMSD.

A few areas of The Scope are outlined here, and it contains an overarching theme of essential commitment (from sonographers) to professional growth and development and adherence to our professional standards, regulations, and accreditation standards that guide our actions to serve our patients competently and safely. The Scope compels us to

  • Treat all patients with kindness, compassion, dignity, and respect.
  • Perform examinations only with a medical order.
    • Exceptions for educational programs, in-service training, CME activities, research
  • Perform only those examinations for which we are educated, trained, experienced, and competent, and (where applicable) certified.
  • Adhere to the scope of practice and other professional documents.

In the absence of licensure, it is imperative that sonographers follow The Scope and that employers hire certified sonographers so that patients can receive quality ultrasound examinations and excellent patient care.

Do you work with a sonographer? Are they certified? Do you know their areas of certification? You can find the complete Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer here https://www.sdms.org/about/who-we-are/scope-of-practice.

Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS, FAIUM, is currently an Adjunct Faculty at AdventHealth University. She has taken certification exams in Abdomen,
OB/Gyn, Pediatric Sonography, Breast, Fetal Echo, and Vascular Technology. She
has been a member of AIUM since 1989 and has served on the AIUM Board as 2nd
Vice President, and most recently co-chaired the Practice Principles on
Work-Related Musculoskeletal Disorders.

An Invaluable Tool in Your Practice: Musculoskeletal Ultrasound

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Musculoskeletal ultrasound (MSK US) has emerged as a powerful tool that is advancing pediatric sports medicine. Its noninvasive nature, real-time imaging capabilities, and portability make it invaluable for injury assessment and treatment planning. Let’s delve into some key points:

  • Utility in Sports Medicine: The American Medical Society for Sports Medicine (AMSSM) developed a recommended MSK US curriculum for sports medicine fellows in 2010 to help guide programs towards adequate training during their fellowship to meet the requirements of competency outlined by the American Institute of Ultrasound in Medicine (AIUM) Training Guidelines for the Performance of MSK US Examination. This was later revised in 2015 and it was where the term “sports ultrasound” was first introduced to reflect the use of ultrasound by sports medicine physicians for both musculoskeletal and non-musculoskeletal indications.  Since then, sports US has become nearly ubiquitous in sports medicine clinics, training rooms, and at sporting events across the country. Finally, in 2017, ultrasound training was formally added to the Accreditation Council for Graduate Medical Education (ACGME) core program requirements for sports medicine fellowships, including pediatric-based programs.
  • Pediatric Considerations: Skeptics may argue that ultrasound isn’t necessary for evaluating musculoskeletal (MSK) complaints in children, assuming they don’t experience the same amount of pathology as adults. However, as a pediatric sports medicine physician with a decade of ultrasound experience, I can attest that children do encounter similar MSK issues. Children exhibit both common MSK conditions (like tendinosis, ligament tears, muscle injuries, effusions, and fractures) and unique ones related to their growing skeletons (like osteochondral defects, Salter Harris injuries, apophysitis, and avulsion fractures). MSK US can play a role in evaluating all of these conditions at the point of care. 
  • Beyond Pediatric Sports Medicine: MSK Ultrasound is a valuable tool that extends beyond pediatric sports medicine as well. It is widely used in rheumatology clinics, where it helps diagnose conditions like synovitis, arthritis, and enthesitis. Emergency physicians can quickly identify joint effusions and dislocations, full-thickness tendon tears, and fractures, influencing acute management decisions. General pediatricians can benefit from MSK ultrasound, too, and this is not just ordering ultrasounds to rule out hip dysplasia in infants. Simple questions—like distinguishing between solid versus cystic soft tissue masses and assessing joint effusions—can guide primary care clinicians. When families seek answers about their child’s condition and treatment options, especially “How can we get them back to sports safely?” time is of the essence and point-of-care ultrasound (POCUS) becomes even more important!
  • Interventional Possibilities: While the volume of procedures may not match clinics focused on older athletes, there are still opportunities for the pediatrician. US guidance opens the door to injections of not only joints and their recesses but also within tendon sheaths, bursa, and perineural spaces. Therapeutic injections have their obvious role in successful treatment of pathologic conditions, but diagnostic injections can also play a crucial role, especially for patients with chronic pain. Precise targeting using ultrasound ensures accurate delivery of anesthetic injectates that can help inform the clinician of the etiology of pain, which often goes undiagnosed for years in the more challenging patient scenarios.         
  • Safety and Efficiency: Sonologists with diagnostic expertise can now confidently guide needles to precise locations, minimizing risks. Unlike radiography, which involves radiation exposure, ultrasound is radiation-free. This safety aspect is crucial, especially when discussing imaging options with pediatric patients and their families. For example, repeating radiographs or imaging contralateral sides for comparisons may be unnecessary if the pediatric clinician has POCUS in their toolbox.   

In summary, MSK ultrasound is a versatile tool that empowers clinicians across pediatric specialties to make informed decisions and provide better patient care. I challenge you to take advantage of all the great MSK US resources available through the AIUM and ask yourself how you could start incorporating this tool into your practice.

Drew Duerson, MD, RMSK, is a Sports Medicine physician in the Division of Sports Medicine at Nationwide Children’s Hospital. He is also a clinical associate professor of Pediatrics at the Ohio State University. Drew is a board-certified Pediatrician with a certificate of added qualification in Sports Medicine. He also holds a POCUS Musculoskeletal certification from the Alliance for Physician Certification and Advancement. 

Drew.Duerson@nationwidechildrens.org

@pedsmskusdoc

Drew Duerson, MD, RMSK

Interested in reading more about MSK ultrasound? Check out these on-demand webinars from the American Institute of Ultrasound in Medicine (AIUM):

Burnout, the Force Propelling Sonographers Away From Their Calling

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Amidst the bustling corridors and resonant discussions of the 2024 AIUM Ultracon conference, a groundbreaking revelation emerged from the forefront of medical imaging research. Shedding light on the intricate interplay between Work-Related Musculoskeletal Disorders (WRMSDs) and the often-overlooked specter of sonographer burnout, the collaborative inquiry of my colleagues and I sought merely to confirm existing associations but ultimately challenged entrenched assumptions. What materialized from our investigation was a surprising insight: burnout, eclipsing the physical strains of the profession, emerges as the predominant force propelling sonographers away from their calling. This revelation, underscored by the poignant narratives of our colleagues, beckons us to embark on a journey that redefines our understanding of occupational health and demands a holistic approach to safeguarding the well-being of every sonographer.

Professional research informs us that WRMSDs can cause a sonographer to leave the profession and that both WRMSDs and burnout share similar root causes. The intent of our research was to forward the discussion on WRMSDs, by determining if there is an association between the two conditions; an association we did find: burnout was the reason for a sonographer to consider leaving the profession, not a WRMSD. That eye-opening finding reshaped how we viewed our research results. What if the profession, instead of focusing on education and engineering as the way to prevent WRMSDs, looked closer at the psychosocial causes of WRMSDs? 

We were happy to see so many stakeholders, such as radiologists and administrators, express concern for sonographer burnout. While it was gratifying to find so much support from our colleagues, we were saddened by the many sonographers who spoke with us about their own experiences with burnout. During Ultracon, sonographers came up to us and expressed their thoughts of leaving the patient care environment, or that burnout was the reason they had already changed jobs. They voiced concern that pizza parties were viewed as solutions when what they really need is meaningful change to the work and professional culture that prioritizes profits and throughput over people. Sonographers are suffering in silence, and simply want to know someone cares for their well-being.  

How can we move forward knowing that burnout is an issue for the profession and that it is also a factor related to the WRMSD epidemic? Larger research studies are needed on sonographer burnout for us to fully understand not only the scope of the problem but also its root causes.

We encourage other researchers to look at sonographer burnout as a single issue in addition to exploring its relationship to WRMSDs. If we hope to attract young, talented people to pursue a sonography career, we need to show that the career is worth it to them. It is up to us, sonologists, administrators, and sonographers, to work together to ensure that our profession supports the whole sonographer, mind, and body. 

Jennifer Bagley, MPH, RDMS, RVT, FAIUM, FSDMS, is a professor and sonography program director for the College of Allied Health at the University of Oklahoma Health Sciences in Oklahoma City, Oklahoma. She also currently serves on the AIUM Board of Governors.

Interested in reading more about Sonography? Check out these posts from the Scan:

Is the Radiologist In-house Today? Optimizing Ultrasound in the Age of Teleradiology

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My dilemma: I am a radiologist at a pediatric hospital with multiple satellite ultrasound sites. Though most ultrasounds can be performed at the satellites, a small subset of advanced ultrasounds are only scheduled at our main hospital where a radiologist is available to scan. Recently, a family expected to schedule a complex scan at our satellite location near their home, so they understandably had questions when they were told to drive 2 hours to the main hospital instead. Is the quality of ultrasound services different? Would the radiologist scan if they traveled to our main hospital? Could they get the same study at a local non-pediatric, small community imaging center? They wanted answers! It was challenging to explain why it was worth their time to make such a long drive to get a “better” study. This led me to ask, what is the right answer at a time when teleradiology is commonplace?

Challenges and Potential Solutions of Teleradiology in Ultrasound

1. Retaining Clinical Context

Problem: Typically, radiologists interpret exams solely based on the images. However, additional patient history that was not in the original order and physical exam findings can be of tremendous value. For example, a sonographer might image a cutaneous vascular lesion compatible with a hemangioma. If a pediatric radiologist were present to ask additional questions, they would learn that the hemangioma only just appeared in the 2-month-old patient a couple of weeks ago, is rapidly growing, and is one of multiple cutaneous lesions concerning for infantile hemangiomas. Additionally, they could look at the color of the lesion and see if it blanches upon compression. Such additional historical and physical information warrants a recommendation in the ultrasound report for an abdominal ultrasound to assess for hepatic hemangioma involvement. If this clinical context is lost, then the full value and specificity of the superficial ultrasound could be lost as well.

Solution: If a radiologist is not present in-person for scanning or image review, the sonographer must know what questions to ask and what additional information might be helpful to the radiologist. Sonographers can add extra history and physical exam findings directly into the PACS technician notes, via institutional communication tools like Microsoft Teams, or on scanned worksheets. A radiologist might even talk directly with the family over the phone or ask the sonographer to include a picture of the patient in the medical record of the patient.

2. Optimizing Image Quality

Problem: The ability of the radiologist to provide image quality control is diminished when working remotely. There is more responsibility on the sonographer to optimize imaging and to recognize pitfalls independently. To this point, for example, consider a sonographer imaging a joint with concern for effusion and septic arthritis. However, she may not realize that the gain was set too low. Cartilage would look anechoic like joint fluid instead of the normal speckled hypoechoic appearance in cases such as this. Therefore, the images would look like there was a joint effusion when in fact there was no joint effusion at all.

Solution: Radiologists must provide feedback, ideally in real time, to sonographers. Standardized protocols, as well as in-person on-the-job training with experienced sonographers and radiologists, are also needed for sonographers to function independently at remote sites. In this case, the sonographer should ask a radiologist to review the images in real time so they can identify such mistakes, affording the sonographer opportunity to rescan the patient before they left.

3. Understanding Variability in Practices Between Institutions

Problem: Teleradiologists read for multiple sites, all with unique workflows and varying levels of sonography expertise. As a pediatric radiologist, I read pediatric studies from both pediatric and adult hospitals. There is a wide variety in the experience of the sonographers, as I learned recently when I opened a pyloric ultrasound exam only to realize that the sonographer had incorrectly imaged the gastroesophageal junction instead of the pylorus. I subsequently learned that this site did not have pediatric sonographers or pediatric sonography training.

An image of the gastroesophageal (GE) junction instead of the pylorus. The arrow points to the GE junction with gastroesophageal reflux during the exam, which can be mistaken for transit through a normal pylorus. Proximity to the spine (S) and the aorta (A) confirms the gastroesophageal junction is being imaged.

Solution: As a radiology team, we must provide additional resources to support sonographers if they are to assume more responsibility. At my institution, radiologists are available for questions 24 hours a day, 7 days a week to sonographers before, during, and after image acquisition. Additionally, we provide a free, CME-accredited, internet-based didactic series for optimizing pediatric imaging technique. We also solicit topic ideas from our affiliate institutions so that we can elevate the quality of imaging at all sites. When one person or one site has a particular ultrasound question, there are often many others with the same struggle.

After feedback and instruction between the radiologist and the sonographer, a sonographer can correctly identify a normal pylorus (arrow), which is confirmed by the adjacent duodenal bulb (D) and gallbladder (G).

In conclusion, teleradiology in ultrasound is here to stay. Our responsibility going forward is to optimize it, support our sonographers as they become more independent, and understand that while we as radiologists may not physically be there, there are many technological advances that we can leverage to optimize imaging.

Dr Lauren May, MD, is a pediatric radiologist at Nemours Children’s Health in Wilmington, DE. Her primary interests are in ultrasound and medical education. She can be contacted by email, Lauren.May@nemours.org.

Interested in reading more about ultrasound in pediatrics? Check out these posts from the Scan:

Preventing Work-Related Musculoskeletal Disorders Among Ultrasound Operators

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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.

References

  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. https://doi.org/10.15557/JoU.2017.0023.
  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. https://doi.org/10.1002/sono.12203.
  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. https://doi.org/10.1016/j.radi.2011.02.003.
  5. Baker JP, Coffin CT. The importance of an ergonomic workstation to practicing sonographers. J Ultrasound Med 2013; 32:1363– 1375. https://doi.org/10.7863/ultra.32.8.1363.
  6. Harrison G, Harris A. Work-related musculoskeletal disorders in ultrasound: can you reduce risk? Ultrasound 2015; 23:224– 230. https://doi.org/10.1177/1742271X15593575.
  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. https://www.osha.gov/ergonomics. Accessed November 12, 2021.
  9. United States Department of Labor, Occupational Safety and Health Administration. Solutions to control hazards website. https://www.osha.gov/ergonomics/control-hazards. Accessed November 12, 2021.
  10. United States Department of Labor, Occupational Safety and Health Administration. Identity problems website. https://www.osha.gov/ergonomics/identify-problems. 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. https://doi.org/10.7863/jum.2013.32.1.157.
  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. https://doi.org/10.1002/jum.16124.

How Our Ultrasound Practice Flourished

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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.

What’s Your Dialogue?

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Ultrasound image of a uterus showing the crown rump length of the fetus is 0.34 centimeters.

Beneath the paper drape of the “2:30 OB Confirmation” lies your next patient. Despite the application of the ultrasound study performed, a variety of stressors wreak havoc on a patient’s mental state prior to examination. The impact of what we say and how we say it, or the very lack of it, can shape a person’s view of testing, staff, or even healthcare as a whole. Yet, how much of an emphasis in ultrasound training is placed on effective communication? Especially in obstetrics where early pregnancy loss is prevalent, a blank stare at the monitor and averted eyes feels disconnected and insensitive. Let’s ask ourselves:

  • How do we, as ultrasound providers, communicate with our patients?
  • Do we attempt to provide comfort or empathy when needed?
  • How important is this interaction to our patients?

We owe it to quality patient care to take a deeper dive.

In settings where our patients show fear, stress, or grief, what’s your dialogue?
How should it look and sound?

Perhaps your patient, waiting nervously under the drape, presents with a poor OB history. Performing an ultrasound examination should encompass more than the stoic mechanical bedside manner. We should engage with the person behind the diagnosis code.

We see it often in OB. Despite reassurances of last week’s scan and normally-rising labs post early spotting, the patient leaves her appointment only to consult Dr. Google where she absorbs every related link about bleeding in pregnancy from previa to placental abruption. It’s been the L O N G E S T week of her life, and she’s sure fate will deliver yet another D&C instead of the child she desires. Miscarriage is the kind of trauma that leaves a woman emotionally scarred and fearful that history will repeat itself. It’s imperative we contemplate the real trepidation some patients feel for their examinations—and act accordingly.

Photo credit: Kat Jayne, pexels.com

For the brief time a patient resides in our care, we sonographers control the environment. We drive the equipment, manage the time, and guide our patients. It is completely within our power to greet them with warmth and direct eye contact, to adopt a caring tone in our explanations, to ensure comfort in our care, and to assure answers for their questions—where we can.

It’s a fine balancing act, isn’t it? …A tightrope walk between what we sonographers can share with an inquiring patient and what we cannot. Though protocols vary, we all surely must learn what information we are allowed to impart. Precisely how we convey it is up to us. After all, our patients must disrobe before a perfect stranger who is not their physician; in turn, we must overcome the propensity for a swift robotic contest against the clock to be more attentive. We may not manage a patient’s care, but for a short time, we are a patient’s provider and caregiver. The interchange with our patients is as much an integral part of our job as is concise reporting.

Effective patient communication should be a cornerstone of every curriculum and commence as early as learning sagittal versus transverse. Every veteran sonographer who relishes the confidence of cultivated skill and experience began the same way. Typically, navigating this technology for most students requires a long learning curve to perform it well and accurately. It’s quite easy for the initial focus to lie with capturing textbook images, not connecting with the patient. Learning appropriate and competent dialogue is as imperative as exam protocol. The new sonographer must observe and mimic this personal interaction before the first steps beyond the classroom.

Photo credit: Stas Knop, pexels.com

Conversely, the skillful sonographer, buried in the demands of a hectic patient load, may lose the tendency over time to prioritize this communication. Juggling the demands of a full schedule with urgent add-ons and after-hours call, we sometimes end up fanning the flames of burnout where a slide into the hurried robotic pace of patient-in, patient-out feels unavoidable. Don’t lose sight of the importance of your work and who depends on you. Every patient you scan lies on your table, and your’s alone. We are each responsible for the level of quality care we provide.

Now, examine your own daily patient interactions. Are they mechanical and rushed? Or do you take the time to employ earnest conversation? Do you attempt to allay fears or offer an empathetic tone when needed? Do you extend the care you would want, need, and expect if on the receiving end of healthcare? I challenge each of you to put forth the very same degree of consideration you’d like for your mother, your sister, your daughter, yourself…if the white coat fear was your own, if the anxiety of a test result was your own, if the pregnancy loss was your own. The appreciation our patients show can mystifyingly renew a sense of purpose in our work today and fuel our career tomorrow.

So, what’s your dialogue?

Sandra M. Minck, RDMS, is the creator of UltrasoundUnwrapped.com and @ultrasound_unwrapped on Instagram, a resource for accurate ultrasound information for expectant parents. She is the author of Ultrasound Unwrapped: A Pregnancy Image Guide, soon to be published.

Interested in learning more about communicating with patients? Check out the following posts from the Scan: