Getting Sonography Students Hands-on Experience

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As the Program Director of a Commission on Accreditation of Allied Health Education Programs (CAAHEP)-accredited General sonography program, I have a request for all OB/GYN practices. Please open your practice to accept sonography students. The future of the OB sonographer depends upon it.

If schools cannot provide graduates with good entry-level OB skills, there will not be enough sonographers to fill the OB sonography positions within private practices and this includes the MFM specialties.

Student rotations are down because the sonographers are too busy to allow students to scan. I have been given the following reasons why they are too busy:

  1. Patients are scheduled every 30 minutes all day.
  2. Work-ins are expected to be added daily into the already booked schedule
  3. It is not uncommon for a single sonographer to perform 15–20 patients per day.
  4. There are usually no breaks except for lunch, maybe.
  5. Some practices have more than one sonographer but each performs the same amount of studies so there is no relief person to help out.

This type of scheduling (over-scheduling) sets up a whole new set of questions.

  1. How long can one sonographer sustain such a schedule without suffering from burn-out and choose to leave employment?
  2. How long can one sonographer sustain such a schedule without suffering from repetitive stress injuries that will force their retirement?
  3. If sonographers are having to rush through studies to get all of the patients through, what are they missing?
  4. What is the satisfaction level of the patient who feels they are on an assembly line when getting their sonogram?  I do believe this is one reason many “peek-a-boo -see your baby” businesses are flourishing; OB patients want to experience fetal bonding with their families, time for which the private practice schedules do not allow. (“The AIUM advocates the responsible use of diagnostic ultrasound and strongly discourages the non-medical use of ultrasound for entertainment purposes.” See The Issue with Keepsake Ultrasounds for more information.)

Although there is value in observation, which the students may be allowed to do, nothing can replace a hands-on experience with supervision and instruction. And, yes, labs help, but the accrediting bodies require our students to scan patients not models.

For at least 2 decades, educators have struggled to find OB clinical sites that would allow their students to gain the scanning skills needed to complete their clinical competency exams, which are required for graduation. With no resolution in sight, even the Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS) and CAAHEP have recognized that some General accredited programs could not meet all the standards and, therefore, have now provided us a way to separate out the specialties. This allows for the deletion of the OB specialty from their accredited programs. This is a way for educators to deal with the problem of not being able to gain access to 2nd- and 3rd-trimester OB patients for their students, but it will ultimately be bad news for the OB community in general.

I believe the sonography community is an intelligent and creative group. We can find ways to integrate students into a busy environment. I actually have some clinical sites that do a very good job of it. I encourage you to think outside of the box and let’s get creative so that the schools will be able to provide qualified graduates when they are needed. If we don’t, we will begin seeing private OB “cross-training” on the job, again.

Is that what we really want? Comments, opinions, rebuttals, suggestions are encouraged and I look forward to reading them all.

Kathy A. Gill, MS, RT, RDMS, is a Program Director of the Institute of Ultrasound Diagnostics in Spanish Fort, Alabama. Kathy has been a Registered Diagnostic Medical Sonographer since 1977 and has been involved in sonography education for 30+ years.

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

COVID Life in the Prenatal Ultrasound Suite

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It is crazy to think that we are approaching the end of the second year of the worldwide COVID-19 pandemic. If the pandemic were a child, it would be walking, talking, and soon entering the “terrible twos”. In fact, my son was born in late February 2020, so all he knows is the pandemic. To him, masks are normal. He has even started to ask to wear a mask because that’s what everyone else does—mom, dad, his daycare teachers, his grandparents, his cousins. Though once he has one on, he quickly realizes that he prefers life without a mask.

Don’t we all, Andy?

As with most people, work life since the pandemic has changed. As a maternal-fetal medicine fellow, I’ve dedicated my training to the care of pregnant people and their fetuses, and I find the most fulfillment in the ultrasound suite. As cases rose, rooms filled with family and friends waiting for the words on the screen, “It’s a girl!”, during an anatomic survey became rooms with only a masked pregnant person and a masked sonographer (and the unmasked fetus, of course). While one adult support person has always been allowed to accompany each patient at our institution, they were frequently absent, whether they were working from home, caring for other children who are not allowed at appointments, or trying to limit exposures. Sonologists that previously were in and out of ultrasound rooms, scanning and counseling patients, were reading exams and counseling remotely.

Despite all the changes, the work continued. In fact, the pandemic has reminded us all that prenatal ultrasound is a medical necessity. At the height of the pandemic, elective medical procedures were canceled across the country. But the prenatal sonographers and maternal-fetal medicine specialists donned their N95s and face shields, and the prenatal ultrasound suite continued operation. In fact, cases that would have previously been managed with twice weekly non-stress tests were managed with weekly biophysical profiles instead to minimize potential exposures for a patient. Even with a current maternal diagnosis of COVID, arrangements were made to continue weekly umbilical artery Doppler studies for cases of fetal growth restriction. Some scans just cannot be delayed for 2 weeks. Despite all the changes, our purpose was clearer than ever—to provide excellent care for our patients, maternal and fetal.

With the widespread distribution of the vaccine and the decrease in cases, work life has settled into a “new normal”. Children have returned to in-person school, and the support person has returned to the ultrasound suite. N95s have been replaced by more comfortable surgical masks. Counseling a patient and their partner is no longer accompanied by the same degree of fear of a COVID exposure. But life is still far from my expectation of normal. The smiles after receiving the good news that there is one healthy intrauterine pregnancy with a strong heartbeat are still hidden behind cloth, as is the discomfort of an amniocentesis and the anguish when informed of a lethal fetal diagnosis. The impact that the mask continues to make on my ability to connect with and care for my patients cannot be understated.

As we head into the “terrible twos”, I know the pandemic will continue on and there will continue to be ups and downs. Misinformation regarding vaccination still limits widespread acceptance, but as research continues to demonstrate the safety and efficacy of vaccination, I still hold on to the hope that one day I will again be able to sit in a room with a patient unmasked and take in the unspoken communication I’ve so missed. But in the meantime, I’ll take the “new normal” and make the best of it for myself, my family, my colleagues, and my patients.

Kathy Bligard, MD, MA, FACOG, is a loving mom and third-year maternal-fetal medicine fellow at Washington University School of Medicine in St. Louis, MO.

Interested in learning more about patient care? Check out the following posts from the Scan:

Impact of Ultrasound on Medical Imaging: 1967–2021

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In 1967, a weekly feature for medical school seniors was the ‘bullpen’ in the Charity Hospital amphitheater. Students were assigned a patient and given 30 minutes to do a history and physical exam and then present their differential diagnosis and recommendations to an attending. Diagnosis was almost exclusively based on the history and physical examination. Laboratory studies were generally confined to basic electrolytes, a CBC, urinalysis, sputum stains, and a chest x-ray.

This prepared me well for internship and residency on the Osler Medical Service at Johns Hopkins Hospital. Interns were on call 24 hours a day for 6 days a week and usually spent 16 to 18 hours a day attending patients at the bedside.

On Osler, there were no computers and handwritten or typed paper records hung on a chart rack. The wards were not air-conditioned, and yellow curtains separated each of the 28 beds. There were no patient monitors, IV pumps, or respirators, and interns performed all of the basic lab work on their patients. Nursing care was excellent; the house staff and nurses worked as a team caring for the patients. Lack of technology was compensated for by close and direct interaction with the patients and their families, and the practice of medicine was extremely satisfying and filled with empathy and compassion.

The patient was the object of all of our attention. In the late 1960s, imaging was limited and played a relatively minor role in diagnosis and management. Defensive medicine was not a concern.

Following my internal medicine residency at Hopkins, I spent the next 3 years in the immunology branch of the National Cancer Institute in Bethesda. The research centered on the new field of bone marrow transplantation and treatment of graft vs. host disease.1 Whole-body radiation prepared candidates for transplantation and my experience in dealing with near-lethal doses of radiation led me to pursue a career in radiation oncology.

After completing a residency in general and therapeutic radiology in 1975, I joined the staff of the Ochsner Clinic in New Orleans, practicing a combination of radiation therapy and general radiography and fluoroscopy. Imaging was film-based, with studies hung on multipanel viewboxes for interpretation and a hot light for image processing. Cases were dictated directly to a transcriptionist in a cubicle next to the reading room and were typed and signed in real time. The daily workload included 40 to 50 barium studies along with numerous oral cholecystograms, intravenous urograms, and chest and bone radiographs. Specialized imaging consisted of polytomography, penumoencephalography, lymphangiography, and angiography. Evaluation of the aorta, runoff vessels, and carotid vessels was performed by direct puncture. Women’s imaging consisted of xeromammograms, hysterosalpingography, and pelvimetry. Image-guided intervention was nonexistent.

That year, ultrasound was in its early clinical development and I acquired a machine and placed it in the radiation therapy department and began scanning patients from the nearby emergency department. At that time there were no other sectional imaging modalities (CT was not yet available for clinical use.).

A large part of the challenge of ultrasound was learning anatomy in a completely new way. As a result, my groundwork in understanding sectional anatomy came from ultrasound. Ultrasound, unlike CT and MR, permitted imaging not only in standardized axial planes but allowed scan planes in virtually any orientation, requiring a very detailed knowledge of anatomy.

In 1976, upon the retirement of Dr. Seymour Ochsner, I became Chair of the department at Ochsner. This provided me with an opportunity to re-equip the department at a time that the entire field of imaging was undergoing immense change. With ultrasound, new findings were being reported regularly2, and the overall quality of ultrasound images often exceeded those of early body CT scans.

The development of Doppler ultrasound in the late 1970s further expanded the applications of ultrasound, although prior to the introduction of color Doppler, this was mainly of interest to vascular surgeons, and diagnosis was based on waveform analysis rather than imaging.

An important technological development at the end of the 1970s was real-time ultrasound, leading to the rapid development of new applications in obstetrical, abdominal, pediatric, and intraoperative imaging3,4.

Developments in computers in the early 1980s led me to an opportunity to participate in the development of exciting new technologies, including a breakthrough involving ultrasound and providing a method to image Doppler information. Working with a small company in Seattle and a large prototype device, we generated the first images of blood flow in the abdomen and peripheral vessels using color Doppler5,6. Color Doppler, by allowing Doppler information to be shown in an image rather than as a waveform, was important in getting radiologists interested in Doppler. Today, color Doppler is an integral part of the ultrasound examination.

A less successful application of ultrasound in the 1980s was in the evaluation of the breast. Early breast scanners produced quality images by scanning the breast, as the patient lay prone in a water tank. Unfortunately, breast ultrasound was promoted aggressively by many manufacturers and by the mid-1980s was discredited as a useful addition to mammography. By the mid-1990s, however, advances in breast ultrasound demonstrated an important role in the evaluation of breast masses, making ultrasound an indispensable part of breast imaging and leading to the BI-RADS breast imaging and reporting system for ultrasound7–9.

Ultrasound also has had a major impact in providing guidance for minimally invasive diagnostic procedures. Fine-needle biopsy of lesions of the liver, kidney, retroperitoneum, as well as peripheral lymph nodes and the thyroid, have become a standard part of the diagnostic workup.

A radiologist of 50 years ago would not recognize the field if he or she were to return today. In fewer than 50 years, the computer has changed the practice of medicine. More precise and early diagnosis are clear benefits of the technology of the 21st century, but are accompanied by the perils of over utilization prompted by defensive medicine with interests of the physician potentially overshadowing those of the patient.

Although the contribution of these advances has benefited countless patients, many of the rewards of the practice of medicine have been diminished. In looking back at my 50 years of practicing medicine, recalling my final grand rounds at Charity Hospital, I appreciate the diagnostic skills acquired through history and physical examination, as well as the relationship I had with my patients during my clinical years. To me, this represents the real definition of being a physician. In many cases, these simple tools were often as effective, and certainly more satisfying, than today’s tendency to view the patient as the result of an imaging test rather than a person.

Christopher R. B. Merritt, MD, is a Past President (1986–1988) of the American Institute of Ultrasound in Medicine (AIUM) where he led the development of the AIUM/NEMA/FDA Output Display Standard, and served as a founder of the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL).

References

  1. Merritt CB, Mann DL, Rogentine GN Jr. Cytotoxic antibody for epithelial cells in human graft versus host disease. Nature 1971; 232:638.
  2. Merritt CRB. Ultrasound demonstration of portal vein thrombosis. Radiology 1979; 133:425–427.
  3. Merritt CRB, Coulon R, Connolly E. Intraoperative neurosurgical ultrasound: transdural and tranfontanelle applications. Radiology 1983; 148:513–517.
  4. Merritt CRB, Goldsmith JP, Sharp MJ. Sonographic detection of portal venous gas in infants with necrotizing enterocolitis. AJR 1984; 143:1059–1062.
  5. Merritt CRB. Doppler colour flow imaging. Nature 1987; Aug 20; 328:743–744.
  6. Merritt CRB. Doppler color flow imaging. J Clin Ultrasound 1987; 15:591–597.
  7. Mendelson EB, Berg WA, Merritt CRB. Towards a standardized breast ultrasound lexicon, BI-RADS: ultrasound. Semin Roentgenol 2001; 36:217–225.
  8. Taylor KWJ, Merritt C, Piccoli C, et al. Ultrasound as a complement to mammography and breast examination to characterize breast masses. Ultrasound Med Biol 2002; 28:19–26.
  9. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008; 299(18):2151–2163.

A Quick Introduction to Subharmonic Imaging and Pressure Estimation

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Our imaging field has had access to commercial microbubble-based ultrasound contrast agents for well over twenty years by now. It is well established that these agents—combined with nonlinear contrast-specific imaging techniques—improve both the sensitivity and specificity of ultrasound diagnoses across a wide range of clinical applications.

There are currently 3 ultrasound contrast agents approved by the United States’ Food and Drug Administration (FDA) for cardiology and/or radiology applications: Optison (GE Healthcare, Princeton, NJ); Definity (Lantheus Medical Imaging, N Billerica, MA); and Lumason (marketed for more than a decade in Europe and elsewhere as SonoVue; Bracco Imaging, Milan, Italy). There are other contrast agents in commercial development around the world; in particular Sonazoid (GE Healthcare) and BR55 (Bracco Imaging). Very importantly, the safety profiles of all of these agents are also well established with a severe reaction rate of less than 0.01% (based on studies of millions of dosages injected worldwide), making them the safest of all contrast media used for imaging.

Flemming Forsberg, PhD

Ultrasound agents consist of billions of gas microbubbles (typically < 8 mm in diameter) that are each encapsulated by an outer shell for stability. Following an intravenous injection, the microbubbles can traverse the lung capillaries and circulate in the blood for 3–6 minutes (under continuous imaging—longer if intermittent imaging is employed), due to their size and the higher molecular weight gasses used as filling gasses (rather than just air as was used in earlier microbubble designs), which reduces diffusion back into solution.

The acoustic properties of the bubble filing gasses (specifically the compressibility) are very different from those of the surrounding blood (by six orders of magnitude). Hence, microbubble-based ultrasound contrast agents can enhance ultrasound signals markedly with echo signals being increased by up to 30 dB. This in turn enables signals from breast tumor neovascularity corresponding mainly to vessels 20–39 mm in diameter to be imaged.

Ultrasound contrast agents not only enhance the backscattered ultrasound signals, but at sufficient acoustic pressures (typically above 0.3 MPa) they also act as nonlinear oscillators. These oscillations generate significant energy components in the received echo signals, which span the range of possible frequency emissions from subharmonics through ultra-harmonic frequency components. These nonlinear bubble echoes can be separated from tissue echoes and used to create contrast-sensitive imaging modalities such as harmonic imaging (HI), which is commercially available on most state-of-the-art ultrasound scanners.

Multi-pulse imaging strategies, such as pulse-inversion imaging or pulse-amplitude modulation, can further improve the depiction of microvascularity compared to color Doppler imaging modes. However, HI suffers from reduced blood-to-tissue contrast resulting from second harmonic generation and accumulation in tissue. Hence, subharmonic imaging (SHI), transmitting at the fundamental frequency (f0) and receiving at the subharmonic (f0/2), becomes an attractive alternative because of the weaker subharmonic generation in tissue and the significant subharmonic scattering produced by some new contrast agents. Several ultrasound scanners (from GE Healthcare and Mindray) have now been released with commercial SHI software packages. A recent multi-center study of 3D SHI for characterizing suspicious breast lesions indicates that diagnostic accuracies up to 97% can be achieved.

Ultrasound contrast agents can be used not only as vascular tracers but also as sensors for noninvasive pressure estimation by monitoring subharmonic contrast bubble amplitude variations. This innovative technique, called subharmonic-aided pressure estimation (SHAPE), relies on the inverse linear correlation (r2 > 0.90) between the amplitude of the subharmonic signals and hydrostatic pressure (up to 186 mmHg) measured in vitro for most (but not all) commercial contrast agents. SHAPE offers the possibility of allowing pressure gradients in the heart and throughout the cardiovascular system as well as interstitial fluid pressure in tumors to be obtained noninvasively. Studies indicate that SHAPE can provide in vivo pressure estimates with errors of less than 5 mmHg in the left and right ventricles of patients. Moreover, a large multi-center clinical trial of using SHAPE to diagnose clinically significant portal hypertension in 178 subjects resulted in a sensitivity of 91% and a specificity of 82% and these subjects had a higher SHAPE gradient than participants with lower pressures (0.27 ± 2.13 dB vs -5.34 ± 3.29 dB; p<0.001) indicating SHAPE may indeed be a useful tool for the diagnosis of portal hypertension.

Flemming Forsberg, PhD, FAIUM, FAIMBE, is a Professor of Radiology at Thomas Jefferson University in Philadelphia, Pennsylvania. He also serves as a Deputy Editor of the Journal of Ultrasound in Medicine and as the Vice Chair of the American Institute of Ultrasound in Medicine’s (AIUM’s) Contrast-Enhanced Ultrasound Community (2021–2023).

Interested in learning more about Contrast-Enhanced Ultrasound? Check out the following posts from the Scan:

The Potential of Elastography in MSK Ultrasound

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Elastography is a method of imaging that detects the compressibility or stiffness of tissues in the imaging field and then overlays a false-color map upon the greyscale image to indicate which tissues are hard/stiff versus soft/compressible. The science behind the technique is beyond the scope of a blog post, particularly as there are several methods by which elastography can be performed.  

In practical terms, elastography is useful in identifying lesions that are sonographically iso-dense compared to their surroundings. Such lesions, while they are therefore visually “iso-grey” (if you will tolerate a neologism), may not be iso-compressible despite their iso-density, and thus when their differential compressibility is identified by elastography it becomes possible to characterize a lesion whose greyscale appearance is not instructive. Among the most common current uses of elastography are the characterization of breast and liver lesions, and indeed the well-known Fibroscan device is, in essence, liver elastography.

There are several instances in the field of musculoskeletal (MSK)/rheumatologic ultrasound in which this technology is appealing, but more work is needed before widespread use will be advisable. I will mention only two of the most obvious examples here. 

Example One

The first example is in the interrogation of a symptomatic tendon or ligament. Such a structure, whose normal function involves incredible amounts of linear tension, when disrupted by trauma or disease, would be expected to lose integrity in the region of the insult and become softer/more compressible than normal in that area.

Traditionally, elastography is not used to measure tendons and ligaments despite the validity of the above statement. The reason for this is that the stiffness of tissue, when measured by elastography, can be expressed in terms of the speed at which a deformation (compression wave) in the tissue propagates, usually in meters per second (there are other units by which stiffness can be measured, but for simplicity’s sake, I will leave it at that).

In the classical case of breast and liver lesions, this is not an issue since the surrounding normal tissue is relatively soft and compressible, so the speed of the propagation of a compression wave is relatively slow. Thus, most elastography measurements top out at a propagation speed of about 10 meters per second, and most normal and abnormal breast/liver tissue will have stiffness values somewhat slower than this. Tendons and ligaments, on the other hand, are by nature very hard/noncompressible. Even in their “relaxed” state, these tissues are so bowstring-tight (relatively) that measuring a normal Achilles’ tendon, for example, will yield only a maxed-out value of “offscale hard” throughout the entire structure. 

It is tempting to say that one could simply recalibrate the machine to measure faster propagation speeds, but, unfortunately, we run into limitations of our current technology. It is simply not possible currently to measure velocities much faster than 10 m/s. 

While we await advancements in technology, the current workaround is to trust that a damaged region of tendon or ligament will be significantly softer, and thus transmit compression waves much more slowly. Therefore, we simply consider any propagation speed that falls out of “offscale” and into the measurable range to be an indicator of pathology.

Example Two

The second example of the potential rheumatologic utility of elastography is in the assessment of systemic sclerosis, commonly known as scleroderma. As the Greek name would suggest, this disease usually includes a characteristic hardening of the skin. The problem is that there is currently no reliable way to quantify skin stiffness. The existing gold standard is a semi-quantitative scoring of skin thickening performed by simple physical examination in which each of several predefined regions of the skin is palpated and assigned a value from 0 to 3. This results in an overall score known as the Modified Rodnan Skin Score (MRSS). Performing Rodnan scoring requires an experienced clinician, and since scleroderma is a rare disease, very few physicians have a large enough cohort in their practice to be able to consider themselves expert Rodnan scorers.

This leads to a host of problems, and one of the worst is that clinical trials in scleroderma (a devastating and potentially fatal disease for which no good treatment exists) are very difficult to conduct because one of the primary endpoints of any trial will be the degree of improvement found in this semi-quantitative and hard-to-perform examination, which is subject to severe inter-rater reliability problems.

When I first started as a rheumatology fellow, I agreed to help with a scleroderma clinical trial in the role of a blinded efficacy assessor. The sponsor brought a dozen or so of us to a hotel for training, and all morning long we cycled through a series of hotel meeting rooms, each containing a volunteer patient for us to score.

It was a disaster.

After lunch, the representative from the sponsor got up to the podium and told us to rip up our afternoon agendas—we were going back to the meeting rooms to examine the volunteers again in an effort to improve the scoring consensus.

Clearly, this situation screams for elastography. The objective measurement of skin stiffness is precisely the datum that is sorely needed. Sadly, our current technology again fails us, as present-day elastography has limitations in resolution and the skin by its anatomic location, will always be very nearly directly applied to the probe face, in a region outside the focal zone of the beam where the measurement physics work best. Further, one of the techniques for performing elastography is highly operator-dependent, because the compression waves being measured are generated by manually varying the pressure of the probe against the skin—definitely a skill that must be learned over time and one that opens the door once more to inter-rater variability.

Overall, elastography holds great promise for MSK/rheumatologic applications in the future, as described in the two examples above. For now, however, it’s currently a technology that is “not ready for prime time” in this field.

This post is intended as a companion to “What Rheumatologists Really Need for Ultrasound Is…”, which discusses advances in ultrasound technology that are sorely needed in the field of MSK ultrasound, and specifically in rheumatology.

Dr. Mandelin is an academic rheumatologist, registered in MSK ultrasound (RhMSUS) by the American College of Rheumatology and certified in MSK ultrasound (RMSK) by the Alliance for Physician Certification & Advancement. He currently serves the AIUM as secretary of the High-Frequency Clinical and Preclinical Imaging Community. Connect with him on Twitter @NU_Rheum_MSK_US.

The Eyes and Ears of The Patient(s)

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I began my ultrasound career in 2001 after graduating from the DMS program, but truth be known, it began sooner than that. I was incidentally placed at a maternal-fetal medicine clinic to do a rotation to get my clinical hours due to a preceptor being absent for an extended period of time at my “established” site, unbeknownst to me or anyone else just how much this would impact not only my career but my life.

When I was exposed to high-risk obstetrics (OB), I was instantly intrigued. I was told that I would need a minimum of 5 years of scanning experience before I could enter that field. For those that know me, know I’m always up for a challenge! I was prepared to do what it took.

At the end of my rotation, my preceptor, the one who would become the most impactful mentor I’d ever had, Ivy Myles, asked if I would be interested in returning to finish my clinicals at their practice, of course, I jumped on it.

Fast forward to today, I have learned that we, as sonographers, are the eyes and ears of the patient, and being in high risk, we are the eyes and ears of TWO patients. That is an incredible amount of responsibility and should not be taken lightly.

So, what does it mean when the job you love comes with so much responsibility? It means that we are in a position to advocate for the patient(s); we listen to them, ask questions that may seem out of curiosity to the patient, but in fact, tell a story of what may or may not be happening with mom and baby. I believe that we are not “picture takers,” we are “storytellers,” presenting our cases to the providers that have learned to trust our skills, talents, and insights.

Over the years, I have fallen more in love with this field and it has become a passion of mine. I want to learn more, teach more, and do more. I have a special place in my heart for the students and new sonographers that want to delve into the high-risk world because of how I entered this field. So, I carry on what my preceptor and mentor gave to me. She saw my skills and my heart for the field and gave me a chance. When a patient is told they are “high risk” and need specialty care at a perinatal center, this is typically not taken lightly. The patient is concerned for her baby and herself. In most perinatal centers where I have worked, the sonographers have a unique position and freedom to talk with our patients, explain the ultrasound, any concerns we may have about the ultrasound (without a diagnosis), we are able to provide a tour of their baby before they meet them, and let the family see their baby being a baby before meeting them on the outside. What a blessing for all!

Carrie Bowen, RDMS, RDCS​, is a sonographer at Perinatal Associates of New Mexico.

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

Ultrasound in Annual Medicare Wellness Visits?

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Medicare Part B covers many preventive services, such as screenings, shots or vaccines, and yearly Wellness visits, in which a patient’s heart rate, blood pressure, and temperature are evaluated. But, would it be beneficial to add an ultrasound examination?

A team that performs these Wellness visits in a clinic sought to determine whether adding a screening ultrasound examination to the visits would be beneficial for the patients. Six primary care providers, all with advanced ultrasound training, and one ultrasound examiner began a study to find out.

After screening potential patients for the study, each eligible patient gave their consent to be in the study. Note, because their pool of eligible Medicare patients had the following characteristics, they did not represent the nation-wide average:

  • Were at least 65 years old, but not over 85 years;
  • Tended to live independently in an affluent area;
  • Had relatively healthy lifestyles;
  • Had prior access to healthcare;
  • Did not have a documented CT scan of the abdomen or formal echocardiogram in the previous 2 years; and
  • Did not have greater than stage 1 obesity.

Each of the 108 participants underwent an ultrasound examination of the carotid arteries, the heart, and the abdomen, targeting important abnormalities of elderly patients. The patients were not charged for the ultrasound examination.

After the examination, the ultrasound examiner and the primary care provider reviewed the results, discussed them with the patient, and coordinated any needed follow-up care, including 30 follow-up diagnostic items. The patient then completed a 5-question survey about their experience with the ultrasound examination.

Six months later, after the patient’s next Wellness visit, the primary care provider reviewed the patient’s medical record for any follow-up based on the results of the ultrasound examination and assigned each of the 283 abnormalities detected via ultrasound a “benefit score” ranging from –4 (no short-term or potential long-term benefit but serious negative impact occurred because of subsequent care) to 4 (critical clinical benefit, worth all subsequent care). The primary care provider determined the score based on the Medicare reimbursement value of all care received as a result of the ultrasound examination.

Combining the survey results and the abnormality scores, the primary care provider then determined each patient’s net benefit score.

Of all of the abnormalities found, the majority would not have been detected by a traditional physical examination. And although none of them were considered life-threatening, they were frequently markers of chronic conditions, so the primary care provider considered their discovery to be mild to moderately positive.

In conclusion, the study found abnormalities in 94% of the participants. However, only about half of all of the Wellness patients (not just those who participated in the study) would meet the criteria for a screening ultrasound examination, so the examination could not be added to all Wellness visits. For those who qualified, however, in a setting with primary care providers who are experts in ultrasound, the benefit of the examination was rarely negative and often mild to moderately positive, including identifying some new chronic conditions.

To read more about this study, download the Journal of Ultrasound in Medicine article, “An Ultrasound Screening Exam During Medicare Wellness Visits May Be Beneficial” by Terry K. Rosborough, MD, et al. Members of the American Institute of Ultrasound in Medicine can access it for free. Join today!

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

High-Frequency Ultrasound: Photoacoustic Imaging

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Sonographers generally think of diagnostic ultrasound in the frequency range of approximately 2–22 MHz, but with high-frequency ultrasound, there is the capability to image up to 70 MHz. High-frequency ultrasound has great resolution but the main limitation is the lack of imaging depth. Today, it can be used in preclinical applications, such as nanoparticle and animal work, and in clinical applications, such as dermatologic, musculoskeletal, vascular, and rheumatologic settings.

In small animal protocols, multiple novel ultrasound imaging modes can be applied, including color and power Doppler, contrast-enhanced ultrasound, photoacoustic imaging, and more.

What is photoacoustic ultrasound?

To put it simply, light goes in, sound waves come out. Photoacoustic imaging uses light energy that is absorbed into the tissue, produces a thermoelastic expansion, and creates pressure, ie a soundwave. This sound wave is detected by an ultrasound transducer and subsequently produces an ultrasound image. An example of a pre-clinical application of photoacoustic imaging is to evaluate the oxygenation levels in tumors using the oxygen saturation calculation.

Preparing for Photoacoustic Ultrasound Imaging of Small Animals

A common use of photoacoustic imaging is to examine small animals, as the depth needed is minimal and the images can have a very high resolution.

In any small animal study, before sedating any of the animals for photoacoustic imaging, there are a few key steps to take:

  • Study the anatomy of the kind of animal you will be scanning.
  • As needed, remove hair from the area to be scanned.
  • Allow time for the laser to warm up and optimize prior to photoacoustic imaging.
  • Adjust ultrasound transducers and machine presets.
  • Set up your equipment to be as ergonomic as possible; animal scanning often takes a long time due to the high volume and may include a lot of small, fine movements.
  • Gather supplies.

It is also extremely important to align the stage and transducer before sedating the animal because animals are often compromised under anesthesia. So, keep in mind how many modalities will be needed and that the animals should remain under the anesthesia for a limited amount of time.

In addition to preparing the scanning area for the animals, prepare your own area to ensure you have good ergonomics. In many small animal studies, the long duration of high-volume, fine movement scanning without proper ergonomics could become very difficult.

Once all of the preparations have been completed, sedate the animal and secure it to the stage to ensure the animal will not move during imaging.

Now it is time to scan!

To learn more, see the American Institute of Ultrasound in Medicine’s (AIUM’s) on-demand webinar with speaker Corrine Wessner, “High-Frequency Ultrasound & Photoacoustic Scanning: Perspective From a Research Sonographer”, from which this post was adapted. AIUM members can access the webinar for free.

Interested in learning more about high-frequency ultrasound and photoacoustic imaging? Check out the following resources from the American Institute of Ultrasound in Medicine (AIUM):

Pediatric Contrast-Enhanced Voiding Urosonography Tips

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Contrast-enhanced voiding urosonography (ceVUS) is most commonly used to assess for vesicoureteral reflux (VUR) and anatomic abnormalities of the urethra. Like fluoroscopic voiding cystourethrography (VCUG) examinations, in ceVUS, contrast is administered into the urinary bladder, and images are obtained of the kidneys, ureters, bladder, and urethra during filling and voiding phases.

As a department, we have performed hundreds of ceVUS exams since we began clinical studies almost 7 years ago. I have learned to ask several questions before beginning each ceVUS to help the exam go smoothly.


Does the patient/family know what will happen during the ceVUS?

Ultrasound is a workhorse for pediatric imaging because of the inherent qualities of the modality: no ionizing radiation, patients in close proximity to family members, calm and darkened exam rooms, non-imposing equipment infrastructure, and (usually) the absence of sedation or anesthesia. Most of these attributes hold for ceVUS, but bladder catheterization changes the non-invasive use of US to an invasive examination. Even so, I have been amazed by the distances that families will travel to seek ceVUS in place of VCUG for their children.

Patient and family preparation is a vital first step for ceVUS. To best image the urethra and bladder base, the probe will be positioned on the lower abdomen, perineum, and over the genitals. Discussion of catheterization and probe positioning on the body in a manner appropriate for the child’s age is critical prior to beginning. Childlife specialists can help prepare the child and family as well as provide support and distraction techniques during the examination.

Right grade 3 vesicoureteral reflux in a 3-year-old girl. Sagittal dual display grayscale (on the left) and contrast mode (on the right) of the right kidney showing echogenic ultrasound contrast in the right renal collecting system with dilation of the renal pelvis and calyces.

How will the child void during the examination?

Prior to the voiding phase images during an examination on a young adult, the patient told us that she could not void in the supine position. Unprepared for that moment, we stretched the US unit power cord (and ourselves) to follow her into the adjoining restroom and image her kidneys while she sat on the commode.

A major benefit of ceVUS over VCUG is that the patient is not confined to voiding in a supine position when imaging with ultrasound. While a small percentage of children will not void during either a VCUG or ceVUS, making a plan for how they will void will set the patient up for success during the study. Absorbent pads, bedpans, urinals, training toddler seats, and full-size commodes are all options. When planned for, we often can still obtain urethral images while permitting the patient modesty through appropriate draping.

Which probe positions will be optimal for this patient?

Another benefit of ceVUS over VCUG is that the patient’s anatomy can be visualized even when there is no VUR. When obtaining pre-contrast images, you should start by determining the best window to visualize each kidney.

When VUR occurs, the kidney-ureter unit can be observed with probe positioning from the flank. This position may allow visualization of both the right and left refluxing unit in young children. A transperineal view may not only help to see the urethra but also the bladder base and ureteral insertions.

During VCUG, an imaging team may be accustomed to placing tape on the suprapubic region to secure the bladder catheter. However, US images cannot be obtained through tape. Anticipating the best view of the urethra will help avoid an inopportune tape placement, which will obscure visualization during voiding. In the bladder filling phase, the contrast is following through the catheter, which demarcates the entire course of the urethra. Practicing probe position from a suprapubic or transperineal window during bladder filling will help identify the best window to use when voiding begins. With these preliminaries in mind, we’ve had tremendous success with ceVUS at our institution.

Susan J. Back, MD, is a pediatric radiologist at Children’s Hospital of Philadelphia.

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

Ultrasound for Undescended Testicles: Tailoring Use

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In the early 1980s, prenatal ultrasound imaging opened the curtains to a “real-time” view of fetal anatomy. What we saw helped limit invasive diagnosis and therapy to those that benefited our unborn patient, and taught us that patiently waiting until after delivery was often the best approach to abnormalities detected in the womb. In other words, wanting to know was no longer a good reason for pursuing an immediate answer; needing to know, to benefit the child, was the rule to follow.

So, let’s skip over 40 years of “boring” fetal diagnostics, genetic testing, treatment, surgeries, and other distractions and talk about the great mystery on everyone’s mind, the hunt for the impalpable testicle—or as I call it, “following the bouncing ball”.

Every fetal sonographer knows what a testicle nestled in the scrotum looks like and will often be required to quickly gloss over the classic image in order to avoid the unwelcome or undesired “reveal”. As depicted in the diagram below, imaging after 20 weeks may show the scrotum (B) and after 30 weeks (C) may show “ball in sac” if the rest of the child behaves. If, however, the testicle(s) are not cooperative, nobody panics.

Schematic of testicular descent under normal influences with abdominal (A) position; descent to the internal ring (B); scrotal descent with patent processus vaginalis (C); descent complete with complete regression of the gubernaculum and occlusion of processus vaginalis (D). CSL indicates cranial suspensory ligament; T, testosterone; AMH, anti-mullerian hormone; S, sertoli cells; L, leydig cells, INSL3, insulin-like factor 3; GFN, genitofemoral nerve.

But after birth, if one or both testicles fail to stare the waiting observer in the eye, or happily make themselves easily ballotable in their pocket, the alarms go off and rational processes falter. In this vacuum of clinical reason, the reflex order for an ultrasound (US) emerges and sadly obscures best care of both the child and parents. Why should you wait to order an US? Because I am a pediatric Urologist and I said so! If that answer doesn’t suffice, as it never has for me at home or office, let me try and explain.

Case 1

Both testicles are absent to examination at birth. Well, if a newborn of male appearance and yet unknown genotype has no testicles, that neonate is a girl until proven otherwise. Genetic testing will answer that and other potential questions of chromosomal gender.

The lone cry in the wilderness that ultrasound can “find” nonpalpable testes, ignores the literature that shows that in an examination, a specialist will feel the previously un-felt testicle in over 80% of children, which is equivalent to US success. Add to that the false-positive rate of 15% (generous here) where an immobile abdominal or clinically absent gonad is “found” in the groin on US and we are rapidly approaching the poster-child for unwarranted examinations. I do not deny the HUGE contribution of US to the work-up of ambiguous genitalia and intersex conditions, supplanting fluoroscopy and even MRI in many centers, but please do not confuse garden-variety “lost balls” with these more complex issues.

Case 2

The infant or child has one or no balls in their pocket on subsequent examination after birth. Referral to a specialist often comes after US, MRI, and even CT scans seeking to see “where” the ball has strayed along its path to the scrotum. MR and CT for this concern are unjustified as a result of their expense and risk exposure, so I will speak of them no further.

If we go back to our rule that imaging is done to help the child or parents, how does the pre-specialty referral US play out? If the US finds a testis, I would have found it anyway, but the US will not define whether it is retractile (normal with a reflex requiring observation, not surgery), or truly undescended, where surgery is warranted after 6 months of age.

If US fails to find a testicle, I will need to do surgery for certainty (US false negatives on intrabdominal gonad are 10%—again generous) as testicular cancer is possible in undescended testes at 5 times the rate of the general population and direct surgical inspection is as near to 100% certainty of whether a testicle exists or not, as one can get.

So, tell me, where’s the harm in noninvasive, nonpainful, nonionizing, inexpensive imaging. Well? I’m waiting. Never mind. Let me tell you.

Imagine you are a parent. Testicles are absent on US, where does your mind go? Testicles are in the inguinal canal, where does your mind go? Now remember, not because I say so; not because I am some gifted guy; but because of my training and experience, I eliminate the worry after 60 seconds in the office and reverse the concerns set in motion in over 90% of visits after imaging. I would say that’s a lot of “Google-worry-stress time” avoided, so, it is therefore worth foregoing US before the specialist exam.

Finally, in the worst-case scenario, US finds testicles, and, as a result, the primary care physician tells the parents it’s OK, and an infant is denied time-sensitive surgery to maximize testicular function and possibly decrease cancer risk simply because the “presence” was interpreted as “normal”. The US window to gonadal and urogenital anatomy is evolving and brilliant, with contrast-enhanced ultrasound (CEUS), molecular imaging, and elastography promising even more advances. Our common goal is to have our tools create better outcomes and minimize the potential for harm.

Robert Mevorach, MD, is Chief of Pediatric Urology at the University of South Alabama, Mobile, and is Secretary of the American Institute of Ultrasound in Medicine (AIUM) Urology Community (2021–2023).

Interested in learning more about urologic ultrasound? Check out the following resources from the AIUM: