Tag Archives: sonographer

Advancing Your Career in Ultrasound: Opportunities for Sonographers and Physicians

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Ultrasound technology continues to evolve at an incredible pace, expanding far beyond its traditional role in obstetrics and gynecology. From emergency medicine and cardiology to musculoskeletal and critical care applications, the field of diagnostic ultrasound offers a wealth of professional growth opportunities for both sonographers and physicians. Whether you’re just beginning your career or looking to take it to the next level, there are many paths to expand your expertise, enhance patient care, and stay at the forefront of this dynamic profession. 

Deepening Clinical Expertise 

One of the most effective ways to advance in ultrasound is through specialization. For sonographers, focusing on a subspecialty, such as vascular, musculoskeletal, or cardiac, can set you apart and open doors to leadership or advanced practice roles. Certification through organizations like the American Registry for Diagnostic Medical Sonography (ARDMS) or Cardiovascular Credentialing International (CCI) signals your commitment to excellence and can lead to increased responsibility and compensation. 

Physicians who use ultrasound as part of their practice can also benefit from additional training. Many professional societies now offer structured educational pathways and credentialing opportunities. For example, clinicians in emergency medicine, critical care, internal, and family medicine, and other healthcare providers can pursue POCUS certifications that demonstrate proficiency in specific applications such as vascular access, trauma assessment, or cardiac evaluation. Continuous education ensures clinicians maintain high diagnostic accuracy and stay current with best practices and evolving technology. 

Embracing Technological Innovation 

Advancements in ultrasound equipment, such as portable and handheld devices, artificial intelligence (AI) integration, and enhanced image resolution, have expanded how and where imaging can be performed. Staying ahead of these changes not only improves clinical capabilities but also helps professionals remain adaptable as the industry evolves. 

Attending professional conferences, workshops, and online training sessions allows sonographers, physicians, and other healthcare providers to gain hands-on experience with emerging technologies. Participating in research or collaborating on quality improvement initiatives can also deepen understanding of how these tools improve diagnostic accuracy and patient outcomes. Those who embrace innovation often find themselves in leadership roles, guiding colleagues through the adoption of new techniques and tools. 

Developing Leadership and Teaching Skills 

Career development isn’t limited to clinical expertise. Many professionals find fulfillment by moving into education, management, or research roles. For example, experienced sonographers can become clinical educators, training the next generation of imaging professionals or leading quality assurance programs within their departments. Similarly, physicians skilled in ultrasound often become mentors, departmental champions, or leaders in developing institutional protocols and training programs. 

Strong communication and teaching skills are key in these roles. Consider pursuing opportunities to present at conferences, contribute to educational publications, or lead workshops within your institution. These activities not only strengthen your professional reputation but also advance the field as a whole by sharing knowledge and promoting best practices. 

Building a Professional Network 

Networking is another powerful component of career growth. Joining professional organizations such as the American Institute of Ultrasound in Medicine (AIUM) or specialty-specific societies offers access to a supportive community of peers, mentors, and experts. Through committees, webinars, and continuing education programs, professionals can stay connected to industry trends and gain exposure to new career paths. 

Online communities and professional social media platforms can also serve as valuable networking tools. Sharing insights, discussing case studies, or participating in virtual learning opportunities can build your visibility and connect you with like-minded professionals across the globe. 

Shaping the Future of Ultrasound 

Ultrasound is one of the most dynamic and accessible imaging modalities in medicine. As technology continues to evolve, the demand for skilled, knowledgeable professionals will only grow. By investing in lifelong learning, embracing innovation, and contributing to the professional community, sonographers, physicians, and other healthcare providers can shape not only their own careers but also the future of patient-centered imaging. 

Every scan offers a chance to learn something new, and every professional development step helps ensure that ultrasound remains a cornerstone of safe, effective, and compassionate care. 

Therese Cooper, MS, RDMS, is a sonographer and the Chief Learning Officer at the American Institute of Ultrasound in Medicine. 

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.

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.

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:

You Won’t Be Left in the Dark at UltraCon (except during the total eclipse!)

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Have you considered how you will spend April 8 (well, April 6–10, 2024, actually)? The place to be on the 8th is somewhere you can be in the path of totality during the total solar eclipse, and what better place to be than Austin, TX, where you can see the eclipse and get your fill of everything ultrasound?

(and probably the cheapest way to get a hotel room is to register for UltraCon 2024 and grab a room while we still have affordable rooms in our block).

The AIUM brings our annual meeting to Austin, TX, for the first time, and there will be lots to take in. We are bringing back Educational Tracks. No matter where your interests lie, MSK or Fetal Echo or General US or OB or GYN, there is a track for you! There is something for you, whether you are early in your career or an experienced sonographer/sonologist. You will hear presentations from experts that will keep you up to date on changes in the field and tell you what is coming down the pike. For our members who are deep into the basic sciences, some presentations will stimulate new thinking and show you what other colleagues are up to. One of the best parts of the program is that you aren’t stuck in one track—you can mix and match to customize your experience. Check out the tracks here.

UltraCon brings you more than just the educational tracks. Is there a product that you have always wanted to develop and commercialize? Perhaps an invention, a training program, or another idea you are sure could be monetized? If so, the AIUM’s Shark Tank is for you! Put together your best proposal and present it to our panel of experts from industry, venture capital, and academia. $1,000 is up for grabs, but win or lose, you will gain valuable insights and critical appraisal of your concept, along with suggestions for what you need to do to take your proposal to the next step.

Scientific sessions run throughout the meeting, allowing you to hear cutting-edge research that will help answer some of the questions you might be having or possibly give you ideas to pursue on your own. You will hear from young researchers just starting out their careers as well as experienced scientists who have gotten us where we are today but aren’t done leading us yet.

One of the best aspects of the annual meeting is the chance to hear from luminaries and others with cutting-edge ideas, whether in ultrasound directly or in fields that will impact ultrasound, such as artificial intelligence and other new technologies. This year’s plenary sessions will be captivating as we hear from Dr Omar Ishrak on the future of ultrasound technology and from Dr Gil Weinberg on an amazing application of ultrasound to offer amputees the opportunity to play musical instruments.

Other talks will cover how CPT codes are developed, how to efficiently complete your application for accreditation, and so much more that will round out your experience in Austin.

UltraCon 2024 promises to be a Top Shelf event that you really don’t want to miss—and yes, we have scheduled a break to go outside to see the eclipse, so you won’t be asked to decide between these 2 once-in-a-lifetime events! Note that our hotel block is probably the least expensive deal in town, as our rates were negotiated years ago before many were paying attention to this eclipse. It is entirely possible we will sell out our block of rooms, so make your plans and register as soon as possible!

David C. Jones, MD, FACOG, FAIUM, the AIUM’s President Elect, is a Professor at the University of Vermont and the Director of the Fetal Diagnostic Center at the University of Vermont Medical Center.

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.

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: