Redbud Medical Systems, Inc.
Custom-made beds for Supine bike stress
echo, Post treadmill imaging exercise echo, & Resting echo
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[ The following is excerpted, with permission, from the Manual for Stress Echo by Larry DeBord. ]
The Echocardiographer
The single most important component of the stress echo exam is the echocardiographer. Because ambiguity is present in every difficult study, the echocardiographer is required to make the decisions about which images to save for analysis and which images to discard. He/she must decide which images best represent the fact and which ones are misleading or non-diagnostic. Thus, by the time the cardiologist arrives to read, the echocardiographer, inescapably, has already interpreted the study and has consciously or unconsciously selected and formatted the loops to support that interpretation. Considering this responsibility, the technologist should be carefully selected, well-trained and well-paid.
Traits of the Stress Echocardiographer
• Education and experience - I recommend hiring a technologist with several years of experience in clinical practice before turning him over to this more challenging task of stress echo. I would favor a sonographer who has completed a formal program and who holds at least one certification. If nothing else, certification identifies a person with enough motivation to slog through the registry exams.
• The sonographer must enjoy the technology itself and rise to the challenge of electronic and computer "diversions from the expected." He must have a keen working understanding of the technology and controls of the frame grabber, the ultrasound system, the electrocardiograph and their integration. If he does not enjoy high tech involvement and trouble-shooting the inevitable problems, he will soon grow frustrated with stress echo and go looking for more pleasant work — a relaxed job hunting for MVP perhaps.
• He/she must have a clear understanding of the anatomy and the pathology.
The stress echocardiographer must possess:
• above average imaging skills
• skills at reading wall motion from live images and from the final digitized loops
• motivation and self-direction
• the ability to think quickly while under pressure
• communication skills - He must have the personality and the verbal skills to speak to a wide variety of patients, and to discuss the results of the exam with the doctor. He must be able to work with the staff. He must know how to listen.
The stress echocardiographer will often work alone and will be responsible for the entire operation; therefore, in addition to knowing how to scan and how to operate the frame grabber, he/she should have a clear idea of what makes a lab productive, efficient and profitable.
It is unfortunate that there are still administrators out there who believe in the Pygmalion Effect and imagine they can hire a marginal tech off the street or coax an ECG tech through on-the-job-training, pay a minimal salary, and merely wait for the hatching of a skilled, effective stress echocardiographer. This strategy has little chance of success. The cardiac sonographer’s role has become much more demanding and requires more responsibility than that of the "echo tech" of the past. Testing, choosing and purchasing the best possible ultrasound system and then turning it over to a mediocre, untrained technician is poor utilization of money and time and is guaranteed to produce disappointing results.
Responsibilities
The technologist should be recognized as essential to the team that selects which ultrasound system to purchase. The experienced sonographer's perspectives and user-experience with other systems make his observations at least as important as those of the doctors’. If the doctors do not trust his judgment in this decision, will they trust him to select the stress echo images upon which they base their diagnoses?
The technologist is solely responsible for the assembly and presentation of the data in its final form. For quality work, the technologist must be given the time to concentrate on obtaining the best possible images and time to assemble the study to his satisfaction. This assembly time can vary, as will be discussed later, especially if the technologist decides to re-acquire loops from tape, for example. The sonographer needs time to think, to identify problems, to formulate solutions and to be creative. He needs time to clear his head of the previous study. This is, of course, an ideal we seldom achieve. We miss many lunches in our office attempting to maintain the schedule, and we sometimes suffer for it. After several hours of hurrying to catch up, my level of stress rises and I make stupid errors — more than usual, that is. I forget to tape the exercise portion, forget to enter "Impost" in the Freeland, forget to change the acquisition delay for a patient on beta-blockers. I may stupidly clear RAM memory before saving the study to the archive disk, or I may tape over a previous study, etc. etc. ad nauseam. Taking only a few minutes for a break prior to each study, leaving the windowless room to study tree bark or have lunch, will reduce the number of errors.
The Sonographer’s Role in Interpretation
An important component of quality work is having the technologist read with the cardiologist. The technologist has spent more time (perhaps more than an hour) with this patient’s heart during the live imaging and may have a different and more complete perspective than the doctor who has seen only a few minutes of tape and the few digital loops. The technologist can point out imaging artifacts the doctor may not appreciate. The technologist can often provide a much-needed objectivity to the reading, for the doctor may be burdened with a familiarity with the patient’s history and previous interventional procedures and can no longer read the walls objectively. If the patient has had a history of repeated restenoses of the LAD, for instance, it can be very tempting to call the septum hypokinetic, while the same degree of contractility in a stranger’s heart would be called normal. The technologist can serve as a check against this.
Having two people read each study is not necessarily a poor utilization of time. While my doctors are reading, I am in the background, looking over their shoulders and offering my comments, but at the same time, completing the worksheet, assembling the echo folder, preparing forms for the next patient, filing, completing the billing sheet, etc. I am available to play the tape of the current study, to discuss the resting study, to load up disks of this patient’s previous studies, to answer questions and to point out what I consider the salient features of the wall motion.
A general rule says that proficiency does not come before the performance of at least one hundred studies. At my one hundredth, I thought the rule should be two hundred. Maybe five. After a thousand I was still learning.
Another small point: try not to look stressed out. You want to look like you know what you are doing and that you are in control. Don’t move about so fast that you appear to be in a panic. Don’t scare the patient. He is scared enough as it is, fearing an infarct and all. Push him with rah-rah-cheering to make him pedal harder for a better "stress," but don’t worry him with frenzied gesturing over the machinery and exclamations about the wandering baseline or dyskinetic septum. Keep a good humor. Lean back in your chair. Relax. Or at least look relaxed. Relaxed but not cavalier.
Supine bike stress echo is not easily performed with right-handed imaging. It is very difficult to circumnavigate an obese patient - tipped to his left - knees pumping up and down - to obtain the apicals. Even if you have practiced right-handed imaging for years, I strongly recommend that you learn to work left-handed for supine bike stress echo. Easier said than done, I know, I know.
A few words about gain: if you are accustomed to looking at conventional resting echoes, my stress images will look very over-gained, cluttered and noisy. But if you are interested in squeezing out every pixel of endocardium, you discard interest in pretty pictures and crank the gain up. On the other hand, I have a particular peeve about leaving the apex of the sector so over-gained it looks like a Shasta-snow-capped-mountain logo and thus destroying the apical endocardium.
As a technologist, you may feel it unfair to be asked to interpret the study while you image. You are already trying to hold together about a dozen maneuvers in your head as it is. But a better study results if you read wall motion in real time as you image. Try not to advance to the next view until you have made a decision about every wall in the current view. Ask yourself about that basal lateral wall of the apical four. Is it moving? Did I get the distal inferior wall here in the apical two? Is it contracting hypokinetic? You will read the walls again as you format the loops, and (perhaps) read them a third time with the doctor.
Be patient with your doctor when he impatiently waits for the finished study or groans about the poor images. It is impossible for him to know the difficulties you face. (Hand him the transducer occasionally. ) And consider his dilemma: he is held accountable for your performance and for the final diagnosis.
The reader is referred to this excellent paper in JDMS from which the following is excerpted.
Professional Credibility for the Sonographer - How to Get There From Here. Wayne H. Persutte, BS, RDMS. JDMS 6:336-342, November/December 1990.
Traditionally, the role of a sonographer is three fold. First, the sonographer should serve as an advocate for the patient. During an ultra sonographic examination, the sonographer may spend more than an hour with a patient. The sonographer may explain the procedure to the patient and/or support staff, comfort the patient, and provide information to the patient secondary to the procedure (in accordance with physician directives). Frequently, a bond is created between the patient and the sonographer, and a sense of trust is established. It is not uncommon for the patient to confide in the sonographer because the patient may perceive him or her as approachable. Patients may simply feel more comfortable with the sonographer. The second element of the sonographer's duties is the technical contribution. This may involve performing and interpreting the sonographic examination and providing logistical support for the ultrasonographic service. The sonographer is the only certifiable medical professional who may be qualified to interpret an ultrasonographic image. There is neither a mandate for nor a mechanism by which the sonologist may pursue certification. The third element of interest to the sonographer is in regard to medical diagnosis. This component may cause the sonographer the greatest difficulty because, in many cases, the application of medical diagnosis is believed to equate with the practice of medicine. In fact, diagnosis is defined as the art of identifying a disease from its signs and symptoms. Since the medical community is firmly opposed to anyone other than physicians serving in a diagnostic capacity, sonographers must be acutely sensitive to their role as investigators but not diagnosticians. Interestingly, this seems to contradict our title, the diagnostic medical sonographer. The sonographer provides information that the sonologist may use to generate a diagnostic impression. The sonologist is not necessarily the authority in obtaining and interpreting the images; rather, the sonologist specializes in integrating the findings . . . .
Sonographers must recognize their multifaceted roles and strive to achieve a balance among the three functions. They should be acutely sensitive to the diagnostic role of the sonologists, while serving themselves as authorities in obtaining and interpreting the sonographic image.
Many sonographers are required to perform 15 or more examinations per day. With this burden, it may be difficult to become motivated and to maintain a standard of excellence in the field. These situations result because there is an inappropriate understanding of the role of the sonographer. . . . . These conditions should not continue; however, sonographers are, in part, responsible for their perpetuation. In the interest of responsible patient care, we need to use our judgment and impose restrictions on the numbers of examinations completed and the monotony of duty involved in the responsibilities of sonographers. When I have completed eight or ten complicated examinations in 1 day, even though it may have taken me only 3 or 4 hours, it becomes increasingly difficult to concentrate. Are we serving in the best interest of the patient if we perform one or two more examinations? Clearly not. Sonographers must realize that they serve a high ideal and that a balanced approach should not be compromised. Surely, if sonographers are going to abolish the concept that they are technicians, we must establish and adhere to this ideal.
Should Sonographers be Subordinate to Sonologists Who Know Less About Sonography?
Sonographers serve in a capacity that is philosophically unique in medicine. Frequently, a radiologist, an obstetrician/gynecologist, a cardiologist, or a cardiovascular surgeon may function as the sonologist. . . . Although sonologists are better able to integrate the ultrasonographic findings with the medical diagnosis and therapy, sonographers are often more competent to describe the images adequately. After all, a sonographer may survey thousands of real-time images to obtain the 10 or 20 hard copy images that represent the current state of the patient's anatomy.* Therefore, since sonography is a new imaging science, and since physicians are constantly entering the field . . . it is not unreasonable to expect sonographers to be more skilled than sonologists in obtaining and interpreting sonographic images.
The field of sonography is undergoing an evolution that may lead to more credibility and professionalism. To achieve this, support from the sonographic community is necessary. From a scientific perspective, the sonographer is often thought of as the "silent partner" in research. It has been suggested that sonographers should wage a campaign in the professional and commercial media. Whenever an article is written that directly discusses the practice of ultrasound but does not mention the role of the sonographer, all sonographers should write that magazine and explain who we are. The sonologist, the sonographer, the scientific community, and the medical community each may benefit by recognizing and resolving these issues.
[*This is particularly true in stress echo exams. LWD]
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Content revised: January 24, 2004