Training and Integrating Sonographers via Dedicated Preceptors

Hiring new staff members is risky business. Despite all the resources invested in identifying and evaluating qualified candidates, there’s no guarantee they’ll be a good long-term fit for the department. As new staff members begin to settle into a new job, there are a variety of reasons why they might ultimately leave the position. Many of these reasons can be traced back to deficiencies in orientation and training programs. With this in mind, it is of the utmost importance to invest appropriately in the onboarding process. A successful onboarding and training program provides benefits to the candidate and the organization.IMG_2125

My experience with these processes comes primarily from my current position as the Ultrasound Educator at St. David’s North Austin Medical Center in Austin, Texas. A huge portion of our sonographers are hired and contracted to maternal-fetal medicine (MFM) clinics around the Austin area; working for Austin Maternal-Fetal Medicine. Expectations for these sonographers are high. They perform all ultrasound examinations common to maternal-fetal medicine practice, including fetal echocardiography and diagnostic 3D/4D techniques. The scarcity of qualified candidates means that we often hire candidates from out of state, and integration to the department and community are among our primary concerns; having a structured training program helps with that.

New employees spend their first 2 days on the job attending facility orientation. Their third day of work is their first day in the MFM department. They’ll meet with leaders and physicians, and tour all relevant areas. In addition, I spend some time with them reviewing the training process and setting expectations. At this time, we pair them with a Sonographer Preceptor. The preceptor/trainee assignment is, of course, subject to change, but we try to limit this as part of the goal is to provide some stability and consistency during the training period.

The standard training period is 3 months in duration, although, we have extended training in some cases up to 6 months. This period may look different for various candidates based on their prior experience level. However, there are several characteristics that remain fixed:

1. One-on-one work with a preceptor

The Sonographer Preceptor is expected to directly observe while offering real-time feedback, every part of the trainees workday. This level of intensity may only be reduced after consultation with the Ultrasound Educator.

2. Weekly preceptor feedback report

This weekly report is filled out by the Preceptor and reviewed with the trainee. They review things that are working well and also plan which tasks need additional focus for the following week.

3. Image review with the Ultrasound Educator

On a weekly or biweekly basis, the trainee will meet with the Ultrasound Educator to review the Preceptor feedback report and review a selection of examinations from the prior week.

4. Didactic and written material for review

Each candidate is supplied with protocols, American Institute of Ultrasound in Medicine (AIUM) guidelines, review articles, and some pre-recorded lectures that cover essential quality standards and approaches for the department.

This high-touch training period helps to ensure that we have a strong understanding of the progress being achieved and can quickly adjust if we do not see steady growth.

Many people will recognize that it takes years to develop strong, comprehensive skills, in the performance of MFM ultrasound examinations. So what can we expect to accomplish in only 3 to 6 months? Upon completion of the training period, the sonographer should be able to:

  1. Complete normal fetal anatomic surveys, fetal echocardiograms, and other examinations in non-obese patients, demonstrating an understanding of proper technique, measurements, and optimization.
  2. Exercise professional discernment by getting help when their own efforts do not produce the answers or quality they expect.

These two goals may initially appear to be overly simplistic, but they work together beautifully in the transition out of the training period and into independent performance. Completion of normal (relatively easy) examinations proves that they understand the target. They understand what normal looks like and the essential techniques involved. The second point is key as it gives department leadership the confidence to allow them to work independently, because we know that they understand what good enough is, and we know that they have the resources they need in order to help them when they cannot meet expectations on their own. This is an important skill that never expires. This is relevant for sonographers, physicians, and other health care practitioners throughout their careers. Knowing when you’ve hit your limit and when to seek additional counsel is key to providing the best care to our patients (regardless of one’s particular level of expertise).

These two benchmarks, along with ongoing quality assurance efforts, help give us confidence in our team even as they continue to grow their individual skills and proficiencies over the coming years.

A note on Preceptor selection

Key to the success of this process is the selection of Sonographer Preceptors. These team members fill two distinct (individually important) roles: technical trainer and social integrator. With that in mind, selection of the individuals who fill this role is very important. Social characteristics we look for are warmth, kindness, extraversion, and the tendency to be inclusive. Technical expertise is evaluated based on history, quality assurance, physician feedback, and ability to evaluate and explain abnormal cases.

Full-time training in a one-on-one environment for 3 months or more at a time can be emotionally and mentally exhausting (even if rewarding). With this in mind, we try to maintain several Preceptors on our team so that these sonographers are able to work independently for extended periods between training new employees.

The social and integrative aspects of our Preceptor Program are not formally defined, yet the benefits are clearly evident. We see that our new employees make strong connections with their preceptors and other team members, frequently having lunch together and engaging in other extracurricular activities during time off.

It is important to point out that preceptors should typically be individual team members—not leads, supervisors, or managers. These formal leaders have other administrative duties that will inevitably get in the way of the one-on-one, full-time training involved in a preceptorship. Of course, leads, supervisors, and educators, may set aside time for some training of new hires, and this is certainly beneficial. For example, in our departments, I frequently set aside time to work with new hires or existing employees on specific skills such as 3D/4D, fetal echocardiography, or abnormal cases. Sonographers enjoy these sessions and benefit from them, but that does not replace the benefit of having a dedicated preceptor.

People don’t stay in jobs where they feel disconnected from the culture and community. This training program, with assigned preceptors, helps to meet the human need for connection in addition to building and verifying technical skills that are necessary for success.

For additional reading:
https://www.forbes.com/sites/forbeshumanresourcescouncil/2017/09/21/seven-ways-to-integrate-new-hires-and-make-them-feel-welcome-from-the-first-day/#1282eff640f6
https://www.thebalancecareers.com/employee-orientation-keeping-new-employees-on-board-1919035
https://trainingindustry.com/blog/performance-management/dont-ignore-training-when-onboarding-new-employees/

Does your practice have a mentor program for sonographers? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Will Lindsley, RDMS (FE, OBGYN, AB), RVT, is an Ultrasound Educator in Maternal-Fetal Medicine and Fetal Echocardiography in Austin, TX.

Ultrasound at the Zoo

Zoo medicine is quite the paradox. In one way, zoo veterinarians are specialists in that what we do daily; it is very unique and specialized and there are few licensed veterinarians that are employed as full-time clinicians in zoological parks. On the contrary, zoo veterinarians are also the ultimate general practitioners as our patients include everything from invertebrates to great apes and elephants (and all life forms in-between)… and for this wide variety of patients, we attempt to be their pediatrician, surgeon, dermatologist, cardiologist, radiologist, etc. I am fortunate to be the Senior Staff Veterinarian at the Louisville Zoo in Louisville, Kentucky.

In terms of imaging modalities, most zoo hospitals are equipped with plain radiography (film or digital) and have some ultrasound capabilities. A few of the larger zoos in the country have computed tomography (CT) in their on-site hospitals. In Louisville, when one of our patients requires advanced imaging, we make arrangements with local facilities with CT or MRI capabilities.

For ultrasound imaging, we have a portable Sonosite M-Turbo unit with both a curvilinear, 5-2 MHz transducer for primarily transabdominal imaging, and a linear array, 10-5 MHz transducer for primarily transrectal imaging. In addition, we have several donated large rolling Phillips Sonos units with an assortment of probes for both echocardiography and transabdominal imaging. One remains in the Zoo’s Animal Health Center and others are stored and used in animal areas for pregnancy diagnosis, echocardiograms on awake gorillas (through the mesh barrier), or just training/conditioning animals for awake ultrasound exams.

Zoo animals may present unique challenges when ultrasound imaging transcutaneously. In the case of fish and amphibians, imaging through a water bath (without even touching the patient!) can be very effective and noninvasive. The rough scaly skin of some reptiles makes a warm water bath similarly effective as a conductive medium for imaging snakes and lizards. Birds are not often examined via ultrasound because of the extensive respiratory (air sac) system they possess that interferes with the sound waves. For mammals, different species present different challenges. Many mammal species are thickly furred necessitating clipping of hair to establish good contact between the transducer and the skin. For transabdominal imaging, some species are very gassy (hippos, gorillas), which may complicate diagnostic imaging. Large or dangerous mammals that are examined awake via training need to be conditioned to present the body part of interest (chest, abdomen) at the barrier mesh and trust their trainer/keeper to allow contact with the probe. Often the greatest hurdle is habituating the animal to the ultrasound gel! When performing transabdominal imaging in our pregnant African elephant cow, rather than go through gallons of ultrasound gel smeared on her flank to fill in all the cracks and crevices in her thick skin, we run water from a hose just above wherever the transducer is placed.

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As general practitioners, zoo veterinarians have variable amounts of training in ultrasonography. We strive to do the best we can and are constantly learning, but the high variability in our daily tasks makes becoming an expert in ultrasound very difficult. So “it takes a village,” and we will regularly utilize specialists in our community to assist us in providing the best medical care for our patients. If I have a zebra or related species that requires a reproductive ultrasound exam, we will reach out to a local equine veterinarian that can apply their expertise in horses to a related species. Great apes have a high incidence of heart disease so whenever a gorilla or orangutan is anesthetized for an exam, part of the comprehensive care they receive is an echocardiogram by a human sonographer. Female great apes may get attention from our volunteer gynecologic sonographer as part of a reproductive evaluation. If the ultrasound exam is on a sea lion, wolf, or bear, I may contact a veterinary radiologist or veterinary internist competent in ultrasonography to assist.

In summary, ultrasonography represents a valuable, noninvasive, diagnostic tool for the zoo veterinarian.

Have you ever performed an ultrasound examination at a zoo? What was your experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

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Zoli Gyimesi, DVM, is the Senior Veterinarian at the Louisville Zoo in Louisville, Kentucky.

From Sonographer to Ultrasound Practitioner: My Career Journey

I have been a sonographer for 18 years, and this year I was awarded Distinguished Sonographer at the 2018 AIUM Annual Convention. I can say without reservation that it is the biggest career honor that I have ever received and a moment that I will never forget. My path to becoming an Ultrasound Practitioner with a faculty appointment in the Department of Reproductive Medicine at UC San Diego has been rewarding, but it has not been easy. To be honest, I wasn’t always sure that I wanted to be a sonographer for more than a few years. I remember asking myself: Is this career as a sonographer enough or should I push myself further and go back to medical school? I have an incredible husband (who is also a sonographer) and he would have supported any choice I made, but ultimately – I decided not to pursue medical school. Even though I made that choice, I also told myself that there was nothing stopping me from learning as much as I could—my degree would not limit my potential and would not be what defines me.tantonheadshotblog

Since then, I have been studying the fetal heart A LOT. I enjoy all aspects of Maternal-Fetal Medicine (MFM) ultrasound, but the heart has always been an area of fascination for me. I love that it is both dynamic and complex, and, in my opinion, the most challenging aspect of fetal ultrasound. I have taken every opportunity to learn as much as I can from the incredible mentors that I have had the privilege of working with over the years. To this day, I am still learning, and I am amazed at all of the details we can see in these tiny little hearts! I eventually got the opportunity to cross train in pediatric echo and I jumped at that chance as well. I really enjoy being a part of a team of providers that can help the families affected by congenital heart disease.

I am, or I guess I should say I used to be, terrified of public speaking. I am proud of myself for overcoming this fear. Being in an academic center, I was used to teaching one on one, but it was about 8 years ago when I really pushed myself out of my comfort zone by lecturing to larger groups in the San Diego community. Putting together lectures can be time-consuming, difficult, and even stressful. I have spent many hours on weekends and evenings working on them, but I have also learned so much in the process. I started by speaking at local societies and hospitals, but over the years I have progressed and now I am proud to be invited to lecture at AIUM, SMFM, and other CME events around the country. Overcoming my fear of public speaking has been a huge stepping stone in my career and I love representing the sonographer voice on a larger platform.

So, how did I become a Practitioner with a faculty appointment?

I had a vision of how an Ultrasound Practitioner could function in our department. After all, by that point in my career, I was a seasoned MFM sonographer with 10 years of experience and I was still incredibly driven to learn and grow. I was keen to expand my skill set to function as a mid-level provider. Ultrasound Practitioner is not a new concept; SDMS had proposed a working model for an Ultrasound Practitioner in 2001. Dr. Beryl Benacerraf, among others, had already been successfully using an Ultrasound Practitioner for years. But working in a large academic center – my vision took years to bring to reality. I knew it would never happen if I didn’t continue to push for it. Along the way, I struggled, I questioned myself, I got overwhelmed, but I never gave up. I also had the support of some key physicians who believed in me. Their support was crucial to my eventual success.

I have now been an Ultrasound Practitioner for 6 years and as our department has grown to 8 ultrasound rooms, my role has expanded. Some of my responsibilities include: checking sonographers’ cases for quality and completeness, directing sonographers to get more images, obtaining images on difficult or complex cases, deeming the exam complete, writing preliminary reports, and discussing routine sonographic findings with patients. This working model frees up the physicians to spend more time with patients with abnormal findings and also allows the sonographers to keep moving with their schedules while ensuring quality patient care. Of course, this is only a snapshot of my day to day work, I still perform many of the fetal echocardiograms. I love to scan and I wouldn’t have it any other way.

My path to becoming a faculty member in the Department of Reproductive Medicine at UC San Diego was similar to my journey to becoming an Ultrasound Practitioner: it took time, lecturing nationally as well as teaching locally, coauthoring research papers and once again, having mentors who supported my appointment.

So, when people ask me about my success, I tell them it is because of hard work, persistence, believing in myself, and having mentors who believe in me too. My advice to sonographers is to know how important your role is; you are not “just a sonographer.” You should always keep learning, take pride in your work, and don’t be intimidated by the hierarchy of medicine. Our voice is crucial to the care of our patients, and that is really what matters.

Benacerraf BR, Bromley BS, Shipp TD, et al. The making of an advanced practice sonographer. J. Ultrasound Med 2003; 22:865–867.

Lockhart ME, Robbin ML, Berland LL, Smith JK, Canon CL, Stanley RJ. The sonographic practitioner: piece to the radiologist shortage puzzle. J Ultrasound in Med 2003; 22:861–864.

Bude RO, Fatchett AS, Lechtanski RT. The Use of Additionally Trained Sonographers as Ultrasound Practitioners. J Ultrasound Med 2006; 25:321–327

Society of Diagnostic Medical Sonography. Ultrasound Practitioner master’s degree curriculum and questionnaire: response by the SDMS membership. J Diagn Med Sonography 2001; 17:154–161.

How has ultrasound shaped your career? If you are an Ultrasound Practitioner, how did you get there? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

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Tracy Anton, BS, RDMS, RDCS, FAIUM, is an Ultrasound Practitioner with a faculty appointment in the Department of Reproductive Medicine at University of California, San Diego.

Pre-eclampsia, Growth Restriction, and a Placenta Bank

Our Maternal-Fetal Medicine fellow was talking about a delivery that occurred while I was away. The fetus was growth-restricted and developed worsening indices on Doppler ultrasound of the umbilical arteries. What was initially an increased Systolic/Diastolic ratio became first absent and then reversed end-diastolic flow. As this occurred over several weeks, the patient herself had worsening blood pressures and symptoms related to her pre-eclampsia and the fetal tracing became more concerning. She was ultimately delivered and her tiny and premature baby was now in the care of the neonatologists.201500581_Hill-7

The fellow’s presentation focused on the ultrasound findings and the surveillance of pregnancies that become complicated in this way. What was known was the best current management in this case. The unknown was why this had happened in the first place. I was about to interrupt the presentation when our fellow, knowing what I was going to ask, looked over at me and said “Yes, I did collect the placenta.”

Pre-eclampsia is a common condition and growth restriction, by definition, occurs in 10% of pregnancies. The conditions are highly related. We have risk factors for both, but we seldom know the cause. Our treatments seem crude to a bench researcher; try to control the condition as long as you can, and if either patient or her fetus becomes too sick, deliver the pregnancy.

As an obstetrics and gynecology resident, I was fascinated by developmental programming in these fetuses and sent in a grant application to the American Institute of Ultrasound in Medicine requesting seed funding to look at the hormonal associations with growth restriction. Their contribution to my research was a turning point for me. I had always thought of myself as a clinical researcher and this was my first exploration of translational research. During my fellowship in Maternal-Fetal Medicine, I collected ultrasound data on growth restricted pregnancies and sampled placentas and cord blood from the pregnancies when they delivered. What I had thought would be a one-off project became a jumping off point for continued exploration into placental biology.

Five years later, I have established a placenta bank at the University of Arizona. What was a small study focusing on just one condition has inspired the creation of a bigger project. Our residents and fellows now contribute to the bank and have the ability to answer their own questions with the samples already collected. The bank is a resource to all of us and has fostered collaborations with the University of Arizona Biorepository and the department of Animal and Comparative Biomedical Sciences. My initial work focused on changes in leptin, renin, and C-reactive protein in cord blood, but as I learned more, the objective changed to include RNA analysis of the placental tissue. We noted that the structural protein expression was different in the growth-restricted pregnancies. This has led to the proposal of a whole different model regarding the causation of preeclampsia and growth restriction.

We will wait and see how this baby does in the neonatal intensive care unit. As we go about our conservative management until the risk becomes too great to continue, it is a comfort to know we are looking for reasons; if we understand possible mechanisms better, there is the potential to mitigate or reverse the development of fetal and maternal morbidities.

How has ultrasound shaped your career? Has an ultrasound study led you down an unexpected path? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Meghan Hill, MBBS, is Assistant Professor at The University of Arizona College of Medicine, Department of Obstetrics & Gynecology.

Determining Umbilical Cord Blood Flow

Umbilical cord blood flow is among the most highly desired parameters for monitoring fetal well-being. This is because cord blood flow directly reflects placental volume flow, which is considered to be as important in the fetus as cardiac output and lung perfusion are in adults.1 Yet, presently employed noninvasive methods, such as umbilical artery Doppler waveform analyses, use surrogate flow evaluation parameters, such as systolic/diastolic ratios, which do not directly reflect placental-fetal blood flow.2,3 Volume flow estimation overcomes this by measuring true flow, and it has been shown that volume flow changes in the umbilical vein occur before umbilical artery flow indices become abnormal.4

Yet, the present volume flow measurement method has severe problems limiting its utility. These include technical difficulties in flow measurement in umbilical cords and faulty assumptions employed in the measurement. The present method using spectral Doppler is

                 Q = V × A                    (1),

where Q is volume flow, V is the mean velocity through the Doppler sample volume, and A is the cross-sectional area of the vessel of interest. This formula assumes that the 2D flow profile is cylindrically symmetric with a circular cross-section, and the line of the Doppler sampling cuts perfectly through the center of the sampled vessel. The velocity estimates require angle correction, and if the vessel is tortuous, as in umbilical cords, the sampling position placement and angle correction are hard to perform. Multiple investigators have warned that small errors in volume flow components can result in large errors in the calculation of volume flow.5-7

A new, easy-to-perform volume flow method overcomes almost all of the limitations of the standard technique. The new method is angle independent, flow profile independent, and vessel geometry independent. It works as follows:

Volume flow is defined as the total flux across any surface, S, intersecting the vessel. This is written as

Eq2

where Q is again volume flow, V is the local velocity through each area element dA, and “” is the dot product which projects the local velocity V onto the normal vector for each area element. This is known as Gauss’s theorem. The intersecting surface, known as the “C” surface, is very simple to obtain using 3D ultrasound (Figure8). In order to validate this method, we obtained an AIUM EER-funded research grant.

Fig

Figure: (A) Four-panel view of a single 3D color flow acquisition of the umbilical cord. The four views are as follows: upper-left is axial-lateral, upper-right is axial-elevational, bottom-left is elevational-lateral (ie, the c-surface), and bottom-right is a rendered 3D reconstruction. Arteries are shown in blue and the vein is shown in red. The schematic in (B) illustrates the orientation of the probe and the corresponding c-surface in the elevational-lateral imaging plane. The vessel colors in (B) match the directionality in (A). The entire umbilical cord passes through the c-surface but only the cross-sections of the umbilical arteries and umbilical vein are illustrated in (B). The two arteries are separated in power Doppler (not shown). (Printed with permission from Pinter et al. J Ultrasound Med. 2012;31(12):1927-34. © 2016 by the American Institute of Ultrasound in Medicine)

We had 2 specific aims: 1) Test the reproducibility of the volume flow measurement, and 2) evaluate the relationship of volume flow to clinical outcome in a high-risk patient population.

In the first aim, we performed studies on 35 subjects between the gestational ages of 22–37 weeks, 26 high risk and 9 normal.9 We attempted to measure umbilical cord blood flow at 3 sites in the cord in each subject, and we averaged 28.3 ± 3.3 (mean ± standard deviation) samples per site. We used a GE LOGIQ E9 ultrasound system with a 2.0–8.0 MHz bandwidth convex array transducer to acquire multiple volume 3D color and power mode data sets. Since we were measuring mean blood flow, we assessed variability using relative standard error (standard error /mean) (RSE). The average RSE for blood flow at each cord position was ±5.6% while the average RSE among the measurements in each subject was ±12.1%.

For the second aim, we compared the volume flow measurements in 5 subjects that developed preeclampsia with the 9 normal subjects. Even with these small numbers, we detected a significant difference between the mean depth-corrected, weight-normalized umbilical vein blood volume flows in the two groups (P = .035). Further, blood flow abnormalities were detected either at the same time or preceded the hypertensive disorder in 4 of the 5 subjects. This is consistent with our prior publication where blood flow changes preceded the onset of pre-eclamptic symptoms in a study subject.8

With the introduction of 2D array transducers, umbilical cord volume flow estimates can be performed in seconds and given the valuable information provided by this method, umbilical cord volume flow will hopefully become a standard component of fetal examinations.

References:

  1. Tchirikov M, Rybadowski C, Huneke B, Schoder V, Schroder HJ. Umbilical vein blood volume flow rate and umbilical artery pulsatility as ‘venous-arterial index’ in the prediction of neonatal compromise. Ultrasound Obstet Gynecol. 2002;20:580-5.
  2. Newnham JP, Patterson LL, James IR, Diepeveen DA, Reid SE. An evaluation of the efficacy of Doppler flow velocity waveform analysis as a screening test in pregnancy. Am J Obstet Gynecol. 1990;162:403-10.
  3. Acharya G, Wilsgaard T, Bernsten GKR, Maltau JM, Kiserud T. Doppler-derived umbilical artery absolute velocities and their relationship to fetoplacental volume blood flow: a longitudinal study. Ultrasound Obstet Gynecol. 2005;25:444-53.
  4. Rigano S, Bozzo M, Ferrazzi E, Bellotti M, Battaglia FC, Galan HL. Early and persistent reduction in umbilical vein blood flow in the growth-restricted fetus: a longitudinal study. Am J Obstet Gynecol. 2001;185:834-8.
  5. Evans DH. On the measurement of the mean velocity of blood flow over the cardiac cycle using Doppler ultrasound. Ultrasound Med Biol. 1985;11(5):735-41.
  6. Gill R. Measurement of blood flow by ultrasound: accuracy and sources of error. Ultrasound Med Biol. 1985;11:625-41.
  7. Lees C, Albaiges G, Deane C, Parra M, Nicolaides KH. Assessment of umbilical arterial and venous flow using color Doppler. Ultrasound Obstet Gynecol. 1999;14:250-5.
  8. Pinter SZ, Rubin JM, Kripfgans OD, Treadwell MC, Romero VC, Richards MS, Zhang M, Hall AL, Fowlkes JB. Three-dimensional sonographic measurement of blood volume flow in the umbilical cord. J Ultrasound Med. 2012;31(12):1927-34.
  9. Pinter SZ, Kripfgans OD, Treadwell MC, Kneitel AW, Fowlkes JB, Rubin JM. Evaluation of umbilical vein blood volume flow in preeclampsia by angle-independent 3D sonography [published online ahead of print December 15, 2017]. J Ultrasound Med. doi:10.1002/jum.14507.

How do you determine umbilical cord blood flow? What problems have you encountered using the traditional method? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jonathan Rubin, MD, PhD, FAIUM, is Professor Emeritus of Radiology at University of Michigan.

To My Fellow Sonographers

Dear fellow sonographers,

I am proud to say that I have worked as a sonographer since 1983 and have been on an incredible journey for 34 years. I started out at the Washington Hospital Center in Washington, DC, as a radiologic technologist and had the privilege to work on the job as a sonographer. I have evolved, grown, and through my profession, I have continued to educate myself. When I passed the ARDMS certification in 1984, I decided that I would continue to set goals for myself and keep my career in ultrasound exciting and challenging.

Over the next 33 years, I worked in a Radiology office, in private practice, and in maternal-fetal medicine. Now, I am honored to be part of the American Institute of Ultrasound (AIUM). So, why am I saying all this? Because I now want to encourage all of you to use my experiences to take your profession to the next level.

My personal goal is to educate sonographers. To encourage sonographers to love their jobs and be the best. Times have changed, especially in the ultrasound world. Doing an OB exam and showing only a 4-chamber heart is no longer enough. Now, we are expected to do outflow tracts, aorta, ductus, and sometimes the infamous 3-vessel trachea view.

If you are asking what is the 3-vessel trachea view? Well, let me just tell you about this amazing cardiac image. If you can acquire and document a normal 3-vessel trachea you can rule out Transposition of the Great Arteries (TGA), Tetralogy of Fallot (TOF), and Right-sided Aortic Arch. You can also be the hero of the office when you go to your doctor at your practice and say “Hey, the 3-vessel trachea view looks abnormal, what do you think?” Not only will you impress them and possibly save a life, but you will earn respect and, hopefully, you are reminded as to why you wanted to be a sonographer in the first place.

I have always loved my job and continue to learn every day. There is a whole world of ultrasound information out there. I challenge you to go beyond what you know to get the job done, be the best, and always treat your patient as your best friend, whoever that might be. My challenge for you is to read about the 3-vessel trachea view and, if it is not a part of your daily OB routine, add it.

Please join me and expand your education!

Haylea Weiss, RDMS (AB FE OB/GYN)
American Institute of Ultrasound in Medicine

Apply for AIUM’s new Sonographer Scholarship Grant, a program that provides $500 and free registration to an AIUM post-graduate event. Applications due March 1, 2018.

Dating Pearls

Assisted reproductive technology (ART) dating trumps all other sonographic dating. If the dating is off with ART, think about asking if the embryo was put in the uterus at 5 days, and not zero days, as that is how it is often calculated. This can be important if the embryo is larger than expected, as ART pregnancies have an increased incidence of Beckwith Weidman Syndrome, which is an overgrowth syndrome. If the embryo is smaller than expected, then the embryo should be followed more closely for possible congenital or chromosomal anomalies.

If the pregnancy is not ART, dating should be based on the 2014 ACOG/AIUM Committee Recommendations (Methods for Estimating the Due Date. Committee Opinion No, 700. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 129:e150–154).

Measurement of the embryo or fetus in the first trimester is the most accurate method to determine gestational age. In the first trimester, the 2014 Recommendations state that if the pregnancy is less than 8 weeks 6 days, the embryo should be within 5 days of LMP (last menstrual period) and otherwise should be re-dated using ultrasound dates of the crown rump length. One mistake often made at this time is to include the gestational sac size in dating; the crown rump length is more accurate than the sac size and thus it should not be averaged into the estimated gestational age.

Crown rump length growth curves have been updated by Pexsters et al (Ultrasound Obstet Gynecol 2010; 35:650–655) using 4387 exams, whereas Hadlocks curves (Hadlock et al Radiology 1992; 182:501–505) were only based on 416 exams. These have some significant discrepancies in the 5–7 weeks gestational age range so we recommend using the Pexsters curves.

Crown Lump Length

From 9 weeks to 16 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 7 days and be re-dated if greater than “7-day” discrepancy.

From 16 weeks to 21 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 10 days and be re-dated if greater than “10-day” discrepancy.

From 22 weeks to 27 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 14 days and be re-dated if greater than “14-day” discrepancy.

From 28 weeks and beyond, the 2014 Recommendations suggest that the dating should be within 21 days and be re-dated if greater than “21-day” discrepancy.

We should not re-date a pregnancy in the second or third trimester if there are good ultrasound dates in the first trimester. If the patient gives “excellent dates” based on history (eg keeping a temperature chart, knowing date of conception based on specific dates of being with partner) and there is a greater than expected discrepancy of dates, then a follow-up sonogram should be recommended in 2–4 weeks, depending on the time of gestation (4 weeks in the second trimester and 2 weeks in the third trimester) so that appropriate growth can be assessed.

Serial growth is important in assessing dating. A fetus that grows 4 weeks in a 4-week period is likely dated appropriately. When the fetus grows more than 4 weeks in a 4-week period then accelerated growth should be reported, suggesting either an LGA (large for gestational age) or macrosomic fetus. History of prior pregnancies can be particularly helpful in these cases. Placement of the calipers at the outer edge of the subcutaneous tissue is particularly important in these cases. We often require 3 measurements, which are averaged to assess LGA/macrosomic fetuses.

When fetuses grow less than 4 weeks in a 4-week period then SGA (small for gestational age) or IUGR (intrauterine growth restriction) are suspected. Additional studies for well-being should be performed, such as umbilical artery Doppler, middle cerebral artery Doppler, maximum vertical pocket of amniotic fluid, biophysical profile, cerebroplacental ratio (CPR), or antenatal testing.

Do you have any tips on sonographic dating? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dolores H. Pretorius, MD, is a Professor of Radiology at University of California, San Diego, and Director of Imaging at UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.

Andrew D. Hull, MD, is a Professor of Clinical Reproductive Medicine at University of California, San Diego, and Director of UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.