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. 

Connect

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.

Sonographers and Contrast-Enhanced Ultrasound

Now that contrast-enhanced ultrasound (CEUS) has been approved in the United States for several abdominal applications in adults and pediatrics, I decided to take a deeper look into the sonographer’s role in CEUS. Traditionally, sonographers perform ultrasound examinations based on a protocol, construct a preliminary ultrasound findings worksheet, and perhaps discuss the findings with a radiologist. And now CEUS has transformed traditional ultrasound and gives physicians and sonographers additional diagnostic information related to the presence and patterns of contrast enhancement.DSC00125

Based on sonographers’ traditional scope of practice, some questions came to mind. What is the training process for sonographers to learn CEUS? How should CEUS images be obtained and stored? How should CEUS findings be communicated?

I envision CEUS training for sonographers broken down into stages, where they begin by learning the basics and eventually transition to where they can perform and record the studies independently. The first stage for sonographers is the ‘CEUS learning curve.’ In this stage, sonographers become familiar with basic CEUS concepts, eg, understanding physics of contrast agents and contrast-specific image acquisition modes, CEUS protocols, and typical patterns of contrast enhancement seen in various organs. In addition, an important part of the training is recognizing contrast reactions, and learning IV placement, documentation and billing related to CEUS.

The next stage involves sonographers performing more patient care and gaining scanning responsibilities. Sonographers place the IV and prepare the contrast agent. The scope of sonographer responsibilities does not generally include contrast injection (although it is reasonable since CT, MR, nuclear medicine, and echocardiography technologists routinely place IV lines and inject contrast). It should be noted that CEUS examination usually requires an additional person (physician, nurse, or another sonographer) to assist with contrast injection while the sonographer performs the ultrasound examination. In the beginning of sonographer training, it is very beneficial to have a radiologist present in the room to guide scanning and appropriate image recording.

In the third stage, a well-trained sonographer is more independent. At the completion of the examination, the sonographer will either send clips or still images to a physician to document the CEUS findings and discuss the procedure. Ideally, a worksheet is filled out, comparable to what is done today with “regular” ultrasound.

The majority of CEUS examinations are performed based on pre-determined protocols, usually requiring a 30–60-sec cineloop to document contrast wash-in and arterial phase enhancement. After that continuous scanning should be terminated and replaced with intermittent acquisition of short 5–10-sec cineloops obtained every 30–60 sec to document late phase contrast enhancement. These short clips have the advantage of limiting stored data while providing the interpreting physician with real-time imaging information. Detailed information on liver imaging CEUS protocols could be found in the recently published technical guidelines of the ACR CEUS LI-RADS committee.[i] Some new users might acquire long 2–3-minute cineloops instead, producing massive amounts of CEUS data. As a result, studies can slow down a PACS system if departments are not equipped to deal with large amounts of data. In addition, prolonged continuous insonation of large areas of vascular tissue could result in significant ultrasound contrast agent degradation limiting our ability to detect late wash-out, a critical diagnostic parameter required to diagnose well-differentiated HCC. Any solution requires identifying and capturing critical moments, which will be determined by a sonographer’s expertise. Exactly how sonographers can ensure CEUS will successfully capture the most important images is a critical question that must be answered and standardized.

Ideally, leading academic institutions should provide CEUS training for physicians and sonographers. I have seen and attended CEUS continuing medical education courses and they are a great way for physicians and sonographers to learn CEUS imaging. CEUS is a step forward for sonographers and will potentially transform our scope of practice. The technology will advance the importance of sonographers and diagnostic ultrasound, and importantly it will improve the care of our patients.

Acknowledgements:
Dr. Laurence Needleman, MD
Dr. Andrej Lyshchik, MD
Dr. John Eisenbrey, PhD
Joanna Imle, RDMS, RVT

[i] Lyshchik A, Kono Y, Dietrich CF, Jang HJ, Kim TK, Piscaglia F, Vezeridis A, Willmann JK, Wilson SR. Contrast-enhanced ultrasound of the liver: technical and lexicon recommendations from the ACR CEUS LI-RADS working group. Abdom Radiol (NY). 2017 Nov 18. doi: 10.1007/s00261-017-1392-0. [Epub ahead of print]

Has CEUS helped your sonography career? How do you envision CEUS being incorporated in your work? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Corinne Wessner BS, RDMS, RVT is the Research Sonographer for Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. Corinne has an interest in contrast-enhanced ultrasound, ultrasound research, medical education, and sonographer advocacy.

A Future Career Path for the MSK Sonographer

The sonographic community has the opportunity to take advantage of recent orthopedic surgeons’ interest in diagnostic ultrasound. Although much of the interest was prompted by the usefulness of guided injections, sonographers need to fully appreciate and understand the value of the information derived from an ultrasound study, which will ultimately lead the surgeon to better surgical decisions and better patient outcomes. Once you are a part of the orthopedic diagnostic team, you will be able to function as a specialist Physician Assistant member, adding a new dimension to the orthopedic practice and demonstrating the incredible value of diagnostic soft tissue imaging.

I am a Board-Certified Orthopedic Surgeon, with subspecialty in shoulder orthopedics including arthroscopy and open surgery. I incorporated diagnostic shoulder/MSK ultrasound as part of my office practice 20 years ago especially for evaluation of patients presenting with protracted shoulder pain (in addition to the traditional history and physical exam, and occasional MRI).

I have valued diagnostic shoulder imaging in my practice and determined that all Orthopedic Surgeons should be using ultrasound imaging as part of their usual diagnostic evaluation of patients (especially patients presenting with protracted painful shoulder problems affecting function). In addition, an ultrasound exam with normal findings may be more important than an ultrasound exam that finds some pathology.

I have concluded that the real-time ultrasound examination with comparison to the contralateral side available to the orthopedic surgeon, in most cases, is more valuable than the information obtained from the MRI (especially regarding soft tissue pathology, present or absent).

For example, compare the MRI detail of the supraspinatus with the ultrasound motion clip of the supraspinatus moving under the acromion (see the still MR image below and, at bottom of the page, the 1st video, which is the active ultrasound clip of the supraspinatus). MRI is accomplished with arms immobilized at one’s side, and does not benefit from the study being compared to the contralateral side. However, it produces a nice clear image. The ultrasound image in long axis can be a still image or a motion clip viewing the supraspinatus or infraspinatus moving under the acromion and the reaction causing impingement syndrome, spurs along the anterior lateral border of the acromion, dynamic sub acromial bursitis, or a rotator cuff tear, which may be attritional and similarly present on viewing the asymptomatic shoulder.

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The Math

The following statistics help to identify the future vital need for the sonographer to become part of the team working with the surgeon in an orthopedic office practice (Orthopaedic Surgeon Quick Facts, www.aaos.org; 10 Interesting Statistics and Facts About Orthopedic Practice, www.beckersspine.com; Am J Orthop 2016;45(2):66-67; 20 Things to Know About Orthopedics, www.beckershospitalreview.com).

There are approximately 28,000 (2012) orthopedic surgeons in the US, 75% of whom are in private practice, and many are in group practices of 2 or more. The general orthopedic surgeon sees an average of 70-90 patients per week, of which an estimated 12% or more have shoulder problems. This equates to 10 orthopedic shoulder evaluations per week for 1 solo general orthopedic practice, and 20 for a 2-man group (in the same office). Ten to 20 patients (minimum) per week would then benefit from ultrasound imaging information, assisting the surgeon in making a surgical decision.

The following image identifies how important the cross axis image is, as well as describes the degree of rotator cuff injury and approximates the relative number of rotator cuff muscle tendon units that have been rendered dysfunctional.

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Left, Close to the infraspinatus/supraspinatus interval and insertion site, many fibers are in harm’s way for tendon/fibril tearing. Center, The area for careful X-axis grid examination, looking for possible partial undersurface tearing, fibers losing their connection/attachment to the footplate. Right, Example of an X-axis grid examination of this full-thickness tendon tear, which should be accompanied by an x-axis measurement of the width/base of the triangular tear. Real time examination can help to identify the quality of the tissue, which may require repair. Usually, orthopedic surgeons pay more attention to the MRI reading and the coronal views (ultrasound long axis view). (See the 2nd video clip below for real-time imaging of the X-axis rotator cuff tear.) The X-axis view/measurement is the more important image. The wider the tear, the more tendon fibrils are affected and the more dysfunction to the rotator cuff area involved.

This need for diagnostic shoulder ultrasound information could be sufficient and important enough to support an entire career for an MSK sonographer. All the other valuable areas of MSK expertise that come with the MSK sonographer would be an extra bonus to the orthopedic office practice: helping with other ultrasound examinations, diagnosis, and surgical decisions.

Video clip 3 below is an MSK ultrasound examination for CTS identifying median nerve mobility or restriction within the tissue, questioning the presence of scar tissue restricting motion.

How have you used ultrasound in orthopedic surgery? What other areas of ultrasound are on the brink of emerging in a new field? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Alan Solomon, MD, is a Board Certified Orthopedic Surgeon and Honorary Staff at the Metro West Medical Center, Natick/Framingham, MA.

Sonographer Stretches for an ‘A’ Game

For our first blog we introduced the reality that there is an epidemic amount of sonographer pain and injury. Almost 90% of sonographers work and live daily with that pain and injury as a result of doing our jobs. That is an epidemic and sinful statistic. As fellow sonographers, we should be incensed that more is not being done to quell the enormous pain and injury that we suffer from.

Coach Rozy and I have the solution. In our first blog with the AIUM, we detailed and gave examples of lower body stretches and exercises that sonographers should do. The folks at the AIUM relayed that our post was very popular among sonographers. Some of the feedback that we received was that many that read our blog thought it was silly that we would suggest doing lower body work for sonographers that predominately suffer from upper body issues (neck, back, shoulders, etc…).

In our 2nd blog we explained why lower body stretches and exercises are also crucial to good sonographer health and pain-free imaging. My favorite story that Coach Rozy tells is about his time in the National Football League. A prominent quarterback in the league at the time was having pain in his shoulders, and main throwing arm. He couldn’t follow through properly on his pass mechanics due to the pain in his throwing shoulder. Not good, if you are a quarterback in the NFL and you can’t pass properly.

Rozy immediately zoned in and started working the shoulder, with little positive result. A few days later Rozy noticed that this quarterback was walking into the locker room with a limp. He hit him up and was told that he had taken a hard hit on his hip and that it had caused him hip pain. Immediately Rozy started working on the quarterback’s hip. A few days later, the hip was better. At this time the shoulder pain also stopped, and life was good. The problem wasn’t the shoulder. The problem was the hip. The hip injury translated into the shoulder. Fix the hip, fix the shoulder. That’s why when you look at sonographer pain and injury, you must look at the body as a whole, not just the area of pain and injury.

For our 3rd blog, we want to share why it is absolutely crucial that your work as a sonographer must be done at the very highest level on each and every patient that you work on. An article entitled, “Making a Difference as a Sonographer, 100% Every Person, Every Time” details my own personal battle with my wife’s diagnosis of breast cancer. As you will read, a breast ultrasound is the only test that caught my wife’s cancer. The cancer was caught early, which made her course miraculous, given such a diagnosis. Amazing things happened in Yankton, SD, the day that my wife had her ultrasound study that caught ‘something’. Enough ‘something’ that a biopsy was done, the cancer was found early, and the course for my wife was incredible.  As sonographers it is CRUCIAL that we be on our ‘A’ game for every person that we work on.

The following are a few simple, quick, easy stretches that can be easily done at work or home. Working the body as a whole is important.

Lying thoracic spine rotation

Start by lying on the ground on your side (either side). With your arms extended straight out at chest level pull your knees pulled up to your chest. The hips and knees should both be at 90 degrees. Work to have your ankles at 90°. You can use a mat, and for added comfort and support use a pillow.

To begin, keep the knees together (place a rolled-up towel or small ball between the knees if you need more support), move your top arm over your body and toward the floor on the opposite side. The objective is to get the arm and s
houlder blade touching the ground, not just the hand.

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All images courtesy of Doug Wuebben.

The goal is to do 2 sets of 8 reps on each side. Tip: You want the movement to come through the thoracic spine — not just the shoulder area.

Kneeling thoracic spine rotation

After completing the lying thoracic spine rotation, progress to the kneeling thoracic spine rotation exercise. This is a more progressive move and requires enhanced control over your posture, movement, and stability.

Begin in a 6-point (some say 4-point) position, on your hands and knees. Take one hand and put it on the base of the skull behind your head. It’s important to keep weight evenly distributed between the legs and your other arm.  Keep the bent arm locked in position. The elbow stays pointed toward the ground. Rotate your torso with motion going through the spine, ending so that the bent elbow is pointed up.  The movement should come through the back/spine — and not just the shoulder! Take the movement through as large a range of motion as possible.  The benefit comes from movement from the thoracic spine. Don’t use your shoulders or hips.

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Do 2 sets of 8 reps on each side.

Psoas lunge

Most people consider proper lunge technique to include pushing the hips forward to stretch what they feel are the hip flexors and the psoas. The iliacus crossing the hip is what is stretched in the traditional lunge, but the psoas also crosses the hip and all lumbar joints.

The best way to stretch the psoas occurs when it is isolated with a lunge that includes lateral bending of the spine and twisting and extension motions. This is a great warm-up stretch before running or doing a lower body routine. Stretch and hold for 20 to 30 seconds. Repeat several times, both directions.

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Farmer’s walk

Another simple yet effective routine is what we call the farmer’s walk exercise. Pick one or two dumbbells and hold them by your sides. Then walk around your training area. Start by walking 25 yards or you can also time yourself, say for 30 seconds, to begin with.

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If you are a beginner, perform the farmer’s walk by carrying any object that has some weight to it. Increase the weight as you progress. The farmer’s walk is a simple yet effective leg-strengthening exercise that works your calves, quadriceps, and hamstrings. The core muscles that help support your spine also benefit. It also creates intra-abdominal pressure to prevent your spine from collapsing.

To vary this routine, hold the weights overhead, use only one weight, or hold one weight overhead and one at your side.

What stretches do you do? How do you improve your posture? Comment below or let us know on Twitter: @AIUM_Ultrasound.

 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.

Mark Roozen, M.Ed, CSCS,*D, NSCA-CPT, FNSCA, is a certified strength and conditioning specialist, a certified personal trainer, and a fellow of the National Strength and Conditioning Association (NSCA).

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

 

3 Stretches All Sonographers Should Do

Have you ever thought about how you stand? Or how you hold a transducer? Or how you position yourself over your patient? Incorrect positioning in any form could increase your risk of pain and injury. Here are three easy exercises sonographers can do—even on the job—to reduce 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 tightening up the Hip flexorabdominal 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. Alternate back and forth for the two sets.
  1. Side Lying Quad Stretch
    Lying on your side, reach back and grab the foot of the top leg with the same arm as the leg you are bending (i.e., right hand grabs right foot). 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.stretch 2Think: Hold for 20 seconds as a light stretch and do it twice on each side alternating. Right leg first, then roll to the other side and do the left leg. Repeat.
  1. Deep Squat Stretch
    Stand up tall with a wider stance than shoulder width. From that position, squat down with hips below the knees. In the bottom position, place the elbows between the squatknees 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.  Doing just like the other stretches: 20- to 30-second hold, twice.

No matter what your occupation, a certain level of stretching and regular exercise will help reduce your risk of injury. This is especially true for sonographers. Please consult your physician (even if you are one) before beginning an exercise program.

What stretches do you do? How do you improve your posture? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Doug Wuebben BA, AS, RDCS (Adult and Pediatric) is a registered echocardiographer and also a consultant, national presenter, and author of e-books in the areas of ergonomics, exercise and pain, and injury correction for sonographers.

Mark Roozen M.ed, CSCS*D, NSCA-CPT, FNSCA, is a strength and performance coach and also the owner and president of Performance Edge Training Systems (PETS).