A Model Citizen

“Lie down on your back, your elbow is about to get a lot of gel on it,” said the proctor during our most recent AIUM headquarter course. As staff, we often have to step in and assist at meetings in ways we had not planned. This moment was not any different, but we do it because we want to understand and enhance the attendee experience. Turns out I have a “beautiful” elbow and yes, some of you beginners are pressing too hard.

Parreco scan

Sonographer Haylea Weiss scanning Jamie Parreco’s ankle.

As I had my second joint scanned, I thought, what a cool experience; my body is going to help advance the safe and effective use of ultrasound. I found myself offering to volunteer any chance I could, having my elbow, ankle/foot, and shoulder scanned in the end. I listened, watched, and learned as attendees explored.

So why am I telling you this? As a program/meeting planner, it was valuable for me to see things from a model’s perspective:Parreco ankle scan

  • You really should wear comfortable clothes.
  • Gel really will get all over you.
  • Talking to the attendee can help them learn.

 

Here at the AIUM, we offer great opportunities for models to get involved at our annual meeting and courses, but for those of you who have not gotten on one of those exam beds as a model in a while, I encourage you to do so. Everyone learns on that bed; ultrasound grows on that bed; your future sonographers and physicians need you on that bed.

We have a unique opportunity to provide true hands-on experience in our field and I encourage you to support that in any way you can. Who knows, you may learn a thing or two about your body as well. #snappinganklevictim

 

Have you ever been a model for a hands-on ultrasound course? Share your experience below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Jamie Parreco is Director of the Events and Continuing Education Services department at the AIUM in Laurel, Maryland.

Are You Sonogenic?

Most of us who do ultrasound commonly use the disclaimer that “the study is suboptimal because of the patient’s body habitus” (we stay away from the word “limited” because this word has specific billing implications). This phrase conveys to the referring physician that we are not getting the pictures we hope to get because of something we can’t control, namely the patient’s size. No matter how we tweak the transducer frequency, adjust the time-gain compensation curve, or simply press harder we cannot achieve optimal image quality.Lev

Sometimes, however, we are either pleasantly or unpleasantly surprised. A thin individual may have soft tissues that are difficult to penetrate, leading to an image of suboptimal quality.

Conversely, a patient with high body mass index may turn out to be a breeze to scan. Clearly, there is something more than simply patient size that is at work here. After all, echoes on ultrasound are created at interfaces between tissues that differ in acoustic impedance. A larger patient with relatively homogenous subcutaneous tissues (fewer interfaces) may reflect and scatter the beam less than a patient whose tissues are composed of a more varied mixture of fat, fibrosis, and/or edema (more interfaces).

When people consistently look great in photographs, we call them “photogenic”. The implication of this word is that somehow the camera loves the subject so much that their still image “overachieves” compared to the expected output. When you think about it, that may be a subtle insult, but it is usually used as a compliment. Conversely, a person we find attractive may, for reasons that are unclear, not be at their best in photographs.

In light of the above, I would like to coin a new word, “sonogenic”. A sonogenic person is one who transmits sound so well that their ultrasound images consistently exceed expectations. A patient that frustrates us because their images are of lower quality than expected would be characterized as “non-sonogenic”.

Using this word can potentially facilitate communication. The sonographer could say to the reading physician: “Sorry for these images; the patient wasn’t sonogenic”. The physician’s reports can become shorter: “The study is suboptimal because of patient’s body habitus” becomes “the patient is not sonogenic”. The noun form would be “sonogenicity” (yes, “photogenicity is a word”). A simple grading system may even become part of the ultrasound report, i.e., sonogenicity is above average, average, or below average.

In conclusion, I hereby propose that the word “sonogenic” be added to the formal ultrasound lexicon. What do you think?

 

Would you use the term sonogenic? Do you have any other suggested new terms that could better describe an aspect of an ultrasound examination? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Levon N. Nazarian, MD, FAIUM, FACR, is Professor and Vice Chairman for Education in the Department of Radiology at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania.

Prolong Your Sonography Career

How many of you entered into the career of a diagnostic medical sonographer with the intent of eventually retiring and living comfortably after 20+ years? Me too! The reality is very few of us make it to 10 years, let alone 20 in this field. Without giving you copious amounts of statistics and a personal sob story that I am sure most of you can relate to, the fact is we are all incredibly prone to injury. After just 6 years of scanning, I have shoulder, back, elbow, and wrist pain daily. After sending out my own personal survey, I was able to verify that almost 100% of you can relate to this discomfort.

For the past 5 years, I have been a huge fitness advocate devoting my time to bettering myself and those looking to live a healthier lifestyle. Just a few weeks ago it clicked; why not incorporate my love for fitness into my love for sonography?! I took on the challenge by recording some of my upper body, specifically shoulder workouts that I had been doing lately in the gym. With increased BMIs, shorter scan durations, and increased patient loads, we need to take care of ourselves first and foremost. I feel incorporating physical training and stretching would prolong our careers and our quality of life.

Some of you are probably wondering how you can incorporate working out after a busy day, but when you make small changes daily, you do get stronger. Strength, in turn, makes scanning easier and ultimately decreases your pain. My arms are twice the size they were when I started scanning 6 years ago. Through yoga, stretching, and these upper body workouts my body now has a way of protecting my joints that are most susceptible to injury.

Can you believe the solution to our injuries has been to find a new career!!? I did not go to college for 4 years and work my butt off to just “find a new career.” Let’s work together on improving our own personal health and let’s start with these shoulder strength exercises.

I challenge you to find 3 days a week to do the following exercises seen in the linked video and listed below:

  • Resistance band warm-ups
  • Bicep and hammer curls
  • Pulley lateral raise
  • Bent over lateral raise
  • Barbell upright rows
  • Machine shoulder press

**Start with 10 repetitions and 2 sets of each exercise and increase those numbers each week.

I absolutely love posting my fitness journey, including great workouts that will have you thanking me later. You can find me on Instagram: @_sonographer_squats_ or by email: shaunadittl@gmail.com. Below, I posted my shoulder workout that will help you through the list I mentioned above, as well as the link to my survey.

Survey:

https://www.surveymonkey.com/r/fitbysonographersquats

 

Interesting Survey Results:

Gebelle_Figure 1

 

Gebelle_Figure 2

 

Gebelle_Figure 3

Shoulder Workout Video:

 

 

 

Do you do any strength training to prevent injuries? What exercises would you recommend? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.
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Shauna Gebelle, BS, RDMS, RDCS, RVT, is a Perinatal Sonographer in San Diego, California.

Sonography and the Seeds of Education in Underserved Rural Clinics

How many of us began our sonography journey thinking about the number of callbacks that we would log per shift, the number of patients that we would scan in an 8-hour day, or, even worse, the number of career-ending ailments that we would amass? Zero; we didn’t. tammySterns_2017

We saw ultrasound as a way to contribute to something bigger than ourselves.

The complex, yet simplistic, science of sound drew us to the field. Looking at the screen and seeing the images come to life was fascinating, and being the first to see presenting pathology while shedding light on the diagnosis mesmerized us. The thought that even after 20 or 30 years in the profession we would encounter images of structures that we’d never seen before was enticing, and the opportunity to be a life-long leaner was thrilling.

Patient interaction and our role in their medical experience appealed to us. Not too much, not too little, but just the right amount of patient care time that allowed us to interact with them and leave a positive imprint on their journey. We imagined we would sit by their bedsides, walk them casually back to the exam rooms, and listen as they shared.

Our patients would come first.

Instead, too often, we found ourselves in the middle of a never-ending battle between cost-effectiveness and patient satisfaction reports. We logged more hours of callbacks than we ever thought possible, sometimes having difficulty even finding the correct key to open the ultrasound office door. We strived to create the profession that we had imagined within the confines of the variables that we’d been given. We did the best that we could, often to the detriment of our own bodies.

And, somewhere along the way, we forgot the wonder of our profession.

About 10 years ago, I had the opportunity to participate in my first overseas medical trip. A group of physicians and a few sonographers, with portable machines strapped in backpacks, were intent on sharing sonography with some of our peers an ocean away. It was during this trip that I saw the purest form of ultrasound come to life. We had one of the simplest of machines and the most basic of lectures and yet they came from miles to learn. The patients sat all day in the heat waiting for the opportunity to have an ultrasound scan. I witnessed ultrasound identifying and explaining pain that had existed for years. I saw tears of relief, joy, and despair as people received answers that changed their lives.

A few years later, I was able to return to the same place. I fully expected to find that they had not utilized our lessons on sonography to their fullest. Instead, our previous pupils greeted us with dog-eared textbooks, mastered skills, and the desire to know more! The seeds of education that we had planted had flourished as they realized the potential ultrasound held for their rural clinics. It offered the ability to quickly investigate and diagnose and you could see the wonder of ultrasound that we had once experienced reflected in their eyes.

Seven years ago, my family and I had the opportunity to move to a developing country. Living in the second-poorest country in the western hemisphere with limited medical availability, I now see every day the wonder of our profession come to life. All the benefits of ultrasound that we learned as students, that are often taken for granted, are the benefits that allow lives to be changed every day.

Portability – I can scan in a makeshift clinic, under a tree in a field, or in someone’s handmade shelter while they lay on the floor.

Inexpensive – Portable machines are relatively inexpensive and diagnostically sound, making them perfect for short-term trips or as gifts to native physicians.

Quick – Within minutes, we can scan and find answers to problems that have hindered the livelihood of those who are sick and in pain. One of my first patients was an OB patient who had been in labor for several days without any progress. A quick scan revealed placenta previa.

Relatively Safe – Without the worry of radiation and chemicals, ultrasound, when utilized by those who are qualified, provides a safe method of imaging.

True, my exam room isn’t exactly ergonomically correct and there are times that chickens and roosters run underfoot. I’ve had to prop the machine on a rock and scan in the brightest sun of the day. But I’ve also witnessed a mother’s face when she sees her baby for the very first time without me having to operate under the time constraints of efficiency. I’ve held a father’s hand as he realized that the pain he’s had for years isn’t the cancer he so greatly feared but a simple fix. I’ve scanned at the bedside of a daughter who lay dying without any medical options, and I fall more and more in love with our profession every single day.

Experience the wonder of ultrasound again.

If given the opportunity, I encourage you to participate in a medically related trip or volunteer opportunity. You will see firsthand how our profession and our images impact the world one life and one scan at a time. You don’t have to move permanently as we did to a developing country. Opportunities also abound in your local community from volunteering your time as a clinical instructor to scanning for local centers. Expand your horizons and allow yourself to experience the wonder of ultrasound again.

 

How have you seen ultrasound incorporated into medical care in other nations? Do you have an ultrasound story to tell? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Tammy Stearns, MS, RT(R), RDMS, RVT, FSDMS, is Director of Women’s Ministry and Sonographer for Project H.O.P.E. in Managua, Nicaragua. She is also the President of the Society of Diagnostic Medical Sonography and an adjunct professor of Diagnostic Medical Sonography at Adventist University in Orlando, Florida, and a sonographer consultant for Heartbeat International.  She is also the author of “Know Hope” and “Living Worthy”.

The Research Sonographer

Research sonography is not a common term when talking with fellow sonographers. There is no specialty exam or formal training involved. I would like to say research fell into my lap, but I was determined to learn as much as possible about ultrasound research in my earliest days. As a student at Thomas Jefferson University, I spent a lot of time hanging around the Research Institute. During my first job at UCSD, I started volunteering with the contrast ultrasound research team. I volunteered my lunch breaks and came in early before my shift at 7 am.  An opportunity opened to work on 2 simultaneous CEUS clinical trials as a research coordinator/sonographer. Looking back, I had no idea what I was doing but I knew I was up for the challenge.IMG_1175

Together with help from my mentors, we created a research sonography position. I asked A LOT of questions. I learned how to write research protocols and submit for IRB (Institutional Review Board) review. The clinical trial monitors were gracious enough to teach me source documentation and the regulatory aspect. When the clinical trials ended, I spent nearly 10 years at Philips learning the medical device side of ultrasound. Eventually, I followed my passion and went back to clinical research when an opportunity opened at the FDA as a contractor; and now I am pursuing my master’s in clinical research management-Regulatory Science. Opportunities are always created if you follow the instincts that drive you.

The first hurdle is funding a research position. Whether funded by a clinical trial or applying for grant money, the process can be laborious. Sometimes a lapse between awards can occur but, in general, the budget is stretched so there is no loss in coverage. Every year, the project or position can be up for financial renewal. Planning for the next financial award is always on the horizon. Therefore, research sonography jobs usually hire for short-term employment, unless a Radiologist you are working with has grant money for a project. I recognize this path is not a stable one, not nearly as long-term as a departmental position would be.

Some crave the stability of 10–20 years ahead with one employer. I think the Research Sonographer is one that likes to accept challenges; is interested in science, research, and development; and has a yearning to think outside the clinical box and challenge the status quo in a way clinical sonography does not present itself. But this is not for everyone.

There are differences in clinical and research ultrasound. The investigators’ research protocol is the imaging parameters that will be followed, not The Standards, CPT codes, or departmental protocol. I ascertain this as a challenge; once you have the transducer and start driving, it is difficult to not diagnose and document images in an orderly fashion. Instead, we are examining a hypothesis and proving specific aims. There is a shift in cognitive thinking that needs to occur. Setting up a controlled environment with repetitive imaging to prove a hypothesis is imperative. It is most important to re-create the same controlled imaging environment on all subjects and then analyze the data off-line.

How does one become a research sonographer? Situations arise that are different in every corner of the country. Align with a research-based physician, coordinator, or mentor, at a university hospital or outpatient center that performs research. Start on a small project, volunteering your time and evaluate the differences. You may find research is not at all interesting for your personality type. Search for clinical trials in need of a sonographer, usually posted on on-line ultrasound job boards. A good website to search for on-going or upcoming trials is http://www.clinicaltrials.gov. Search for clinical trials that involve sonography, ie, fertility, where the exam times are usually early morning before the volunteers go to work. Remember research sonography is not the same as performing an entire pelvic exam. The sponsor will only want images on what the protocol states, so exam times and ergonomics are reduced. You might be measuring the bladder volume or the volume of an ovary, in total. Align with a mentor that will help you carve out your path, follow your instincts, and seek out opportunities that will lead in your direction.


Are you a research sonographer? Share your experience. Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Karen Alton, BS, RDMS, RVT, is a graduate student at Arizona State University, an owner of Karen Alton Consulting, LLC, and is an Ultrasound Imaging Research contractor at the US Food and Drug Administration.

Helping Correct Anterior Pelvic Tilt to Eliminate Hip and Low Back Strain

If you’re having problems with tightness in the hip area and lower back, it might not just be tight muscles, but how your hips are positioned. Here, we show you a few movements to help fix ANTERIOR PELVIC TILT.

Before we get rolling, let’s explain what anterior pelvic tilt is.

It’s when your pelvis ends up tilting forward (or anterior; see image below).

Two images of a skeleton shown from the side. The 1st is shown with good posture and the 2nd shows bad posture with anterior pelvic tilt.

When this happens, it ends up changing the position of your pelvis, hip, and lower back. It also changes the location of your head position, the curve of the spine, and can even lead to knee and ankle problems. This change in the position can cause you to end up having more stress on your hip, back, and knee, which increases the risk of injury and pain.

3 Stretches to Help LIVE PAIN-FREE and Correct Anterior Pelvic Tilt

#1 – 90/90 Hip Flexor Stretch

On a mat, kneel down with the front leg up, with the knee at 90 degrees, the back leg is on the ground, but also bent at 90 degrees. Make sure to tighten up the abdominal area. Then, move your hips forward, maintaining shoulders back. You are looking for a stretch in front of the hip.

You will feel the stretch in the front of your hip and the thigh. You are looking for a light stretch. You are not trying to rip the muscle apart. Hold that for about 20 to 30 seconds, twice on each side: first the right leg, then the left. Alternating back and forth for the two sets.

Image demonstrating the 90/90 Hip Flexor Stretch. A man is shown with his left leg kneeling with the knee at a 90-degree angle and the right leg up, as if he were sitting on a chair, with the knee at 90 degrees.

#2 – Side Lying Quad Stretch

Lying on your side, reach back and grab the foot of the top leg with the same side’s arm as the leg you are bending. As you grab the foot, bring the heel towards the butt. The key here is not to just pull the heel to the butt but bring the thigh back a little bit in order to intensify the stretch in the front of the thigh and the front of the hip. Think – PULL THE HEEL AWAY FROM THE BUTT 6–8 INCHES.

You are looking at holding the light stretch for 20 seconds and you will do it twice on each side, alternating: Right Leg, then roll to other side and do Left Leg. Repeat.

Image demonstrating the Side Lying Quad Stretch. A man is shown lying on a mat on his left side. His left arm is bent at an angle to support his head and his left leg is straight. His right leg is bent at the knee and he is holding his right foot with his right hand.

#3 – Deep Squat Stretch

Stand up tall with a wider stance then shoulder width. From that position, squat down with hips below the knees. In the bottom position, place the elbows between the knees and then push the knees out with the elbows. You are looking for a stretch in the inner thigh and hips.

This position and pressure will end up changing the position in the lower back and in the pelvis from an anterior tilt to a posterior tilt. Perform this stretch twice with a 20- to 30-second hold for each.



What stretches do you do? How do you improve your posture? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Mark “Coach Rozy” Roozen, MEd, CSCS, NSCA-CPT, TSAC-F, FNSCA, is a certified strength and conditioning specialist, a certified personal trainer, and a fellow of the National Strength and Conditioning Association (NSCA).

Doug Wuebben BA, AS, RDCS (Adult and Peds), FASE, is a registered echocardiographer and also a consultant, international presenter, and author of e-books in the areas of ergonomics, exercise and pain, and injury correction for sonographers. He has also been published on the topics of telemedicine and achieving lab accreditation.

Wuebben and Roozen are co-founders of Live Pain Free — The Right Moves. They can be contacted at livepainfree4u@gmail.com.

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.