Joan Baker

“Formal ultrasonic instruction programs are just now beginning at a few medical centers. Such programs are quite encouraging since in medicine, as in any other discipline, a new status is reached when the educational process recognizes the need to instruct its newest members in the latest achievements.” – Erikson KR, Fry FJ, Jones JP. Ultrasound in medicine – a review. IEEE Trans Sonics Ultrasonics 1974; Su-21(3):144–170.

Medical Ultrasound Awareness Month seems a great time to celebrate the mentoring and collaboration that fuel the success of this profession. In fact, the very existence of the modality is thanks to collaboration among physicists who found the science, physicians who saw the medical application, and engineers who harnessed the science to the medicine. After several decades of this remarkable cross-pollination, diagnostic medical sonography emerged in the 1970s to become a vigorous player in medical diagnostics.

Particularly in light of its unique technical challenges, the problem at sonography’s precipitous start was in teaching enough people to perform it, so with no formal educational system in place, collaboration and mentoring continued to play a crucial role in securing the future of the modality. Collaboration among early practitioners grew the body of knowledge, and mentoring dispersed that knowledge to diagnostic medical sonography (DMS) newcomers. But rapidly accelerating need for well-trained sonographers quickly outpaced the capacity to train enough practitioners on the job and through informal schooling.

It would be impossible to overstate the importance of Joan Baker, Kenneth Taylor, and other luminaries who brought order to sonography education, who defined its content and devised “formal ultrasonic instruction programs.” Thanks to their work, formal ultrasound programs were born, and mentorship in our profession acquired a new dimension as teacher role models appeared. For me, there was Cathy Nicholas. Cathy, director of the University of Miami/Jackson Memorial Hospital (UM/JMH) DMS program I attended, was the mentor who turned me into a sonographer.

Cathy was the quintessential sonographer. Like nearly everyone in those early days, she came to ultrasound from “someplace else.” In Cathy’s case it was microbiology. An academic researcher, her concerns about increasingly limited funding drove her to explore other career options. First stop: nuclear medicine. But then she discovered ultrasound. “It was instant attraction.” A radiologist colleague agreed to teach her ultrasound, and Cathy “used every minute to read and to pick his brain.” During their association, Cathy passed the registries in physics and instrumentation, abdomen, adult cardiac, and obstetric/gynecology ultrasound.

With her academic background, Cathy was an obvious choice for developer/director when UM/JMH decided to establish a DMS program. But finding classroom teachers at that time was a challenge. Since most working sonographers trained on the job, they acquired much of their didactic knowledge anecdotally, without the benefit of formal education in basic ultrasound concepts. They were outstanding clinical mentors but not necessarily qualified for, or interested in, teaching in the classroom. Besides, sonographers were in short supply, and they were busy.

Patient is scanned by sound waves as Dr. Kenneth Taylor consults resulting photo of probe. The method saves discomfort or danger, he says. – August, 20, 1978 issue of PARADE

All things considered, teachers were hard to come by, so Cathy taught almost everything herself—probably exhausting for her, but for her students it was a gift. Cathy taught us not just information. She mentored us to think as sonographers, to “logic out” answers, and to embrace professionalism. She encouraged us to actively participate in the community’s discourse by joining the AIUM and SDMS, by reading journals, and by engaging, even as students, in research and professional writing activities. And she taught us to never forget our primary responsibility: the welfare of each and every one of our patients. Recently I asked Cathy for her take on the future of ultrasound education. Her answer: “To me, the future of ultrasound education, and of ultrasound, is somehow getting the student to thoroughly buy into the idea that every second they are using a transducer belongs to the patient and that they just have to give all they have to give, right then.” Thanks to Cathy’s leadership, the UM/JMH program became the first accredited sonography program in the southeast.

Today our rolling snowball of a profession grows ever larger, arguably lumpier, and certainly more powerful, and it is the daunting task of our professional discourse system to keep up. It seems our traditions of collaboration and mentorship have never been more important than they are now as we continue to morph sonography education to meet the needs of increasingly diverse users, applications, and venues.

Happy MUAM Everyone!

Photo of Dr Doug Mader by Geraldine Diethelm, DVM

At the AIUM Annual Convention in San Diego, Debbie D’Agostini, Frank Tessler, and I shared the rather unique experience of scanning a 20-foot python—Joan Embery’s “Joyce.” Plenty of snake for all of us, Joyce placidly indulged our group with barely a writhe as the three of us took turns probing his ventral surface, peering at his 3-chambered heart and stretched-out abdominal organs. The experience of scanning such an exotic creature, not knowing exactly what to expect to see under his scales, resonated with that catch-in-the-throat wonder that accompanied my earliest experiences scanning humans.

For veterinarians Kevin Fitzgerald, DVM, and Doug Mader, DVM, scanning snakes and all manner of slippery, scaly patients is part of day-to-day practice. For years these two experts have used ultrasound to confirm pregnancies, evaluate hearts, identify tumors, and diagnose intestinal obstructions in a variety of reptile and other exotic patients. In fact, Dr Mader’s patient waiting room at the Marathon Veterinary Hospital in Marathon, Florida, must be a veritable Jurassic Park! Florida is home to more amphibian and reptile species than any other state in the United States, and Dr Mader welcomes most of them to his examining table. Besides caring for garden-variety snakes, turtles, and all kinds of lizards, Dr Mader sadly remembers a time several years ago when he was unable to save a fire eel with heart failure. “An ultrasound exam revealed ascites and possibly an enlarged heart. I suspected some form of cardiomyopathy, like DCM (dilated cardiomyopathy), but who knows for sure? We had nothing to compare it with.”

It’s humbling to contemplate the anatomic variety our veterinary ultrasound colleagues encounter as they scan patients of various species, many of which have not yet been fully described in the ultrasound literature.

And besides the challenge of anatomic mystery, there are the technical challenges of reptilian body habitus. With turtles, the sizes of inguinal openings that serve as scan windows are the issue. With snakes it’s the scales. When imaging snakes, an ideal method for reducing scale-induced artifacts is to submerge patients under water, a technique we chose not to attempt with 150-pound Joyce, opting instead for a generous application of gel.

Despite scales and shells, ultrasound plays an increasingly important role in reptile diagnostic imaging. According to Animal Planet luminary, “Emergency Vet” Kevin Fitzgerald, radiology is great for bones and certain organs, but it provides limited tissue information in reptiles. “Ultrasound is much more sensitive and revealing for tissue imaging. The benefit of ultrasound is its increased resolution of internal imagery when compared to radiology and its relative ease, safety, and noninvasive nature. It’s a powerful tool.” Hopefully powerful because Dr Fitzgerald reports ultrasound’s recent application for finding hemipenes in Komodo dragons. At up to 10 feet in length and more than 300 pounds, the clawed members of this ancient but endangered species have sharklike teeth and a nasty bite. Not the patient I want to go poking at looking for hemipenes.

Not much danger of that, really. According to Dr Fitzgerald, diagnostic radiology in veterinary medicine is performed almost entirely by trained veterinarians. Robert D. Pechman, DVM, executive director of the American College of Veterinary Radiology, confirms: “Although some are now employing and training sonographers to physically do the exam, veterinary ultrasound is mainly done by board-certified veterinary radiologists in this country. Each one has undergone 3 years of training in diagnostic imaging, including ultrasound, and has passed a rigorous examination on all these subject areas.”

But there is one ultrasound application that actually puts the transducer in the hands of lay individuals: animal breeding. According to Shawn Fisher of Fisher BioMedical Inc, among serious snake breeders the use of ultrasound to monitor follicle length and check for pregnancy
is “the standard.” The company markets equipment directly to breeders and offers technical instruction on its website and through personal face-to-face instruction. “Ultrasound maximizes results. It is also a lot of fun if you love snakes and breed them, even as an amateur.”

Love snakes? I have to admit to a certain fondness for Joyce, which is all the more reason for my questions and alarm. Could an amateur injure a snake while scanning? What about bioeffects? Is amateur scanning even legal? What are the moral issues? Where are the overlaps and differences between human and nonhuman ultrasound practice and philosophy? I welcome a dialogue on these issues and invite your comments to the Practice Matters blog. As for the legality, there seems only to be an issue if a lay person charges for services or makes a diagnosis, which would constitute practicing veterinary medicine without a license.

Whatever the future of “lay” ultrasound use may be, diagnostic veterinary sonography will certainly continue to improve the welfare of animals and fascinate us humans with its exploration of all manner of life forms. According to James E. Oosterhuis, DVM, principal veterinarian at San Diego’s Wild Animal Park, “Virtually all zoos have ultrasound units and will use them for diagnostic evaluation of snakes with medical problems.” And fire eels and turtles, as well as Komodo dragons with identity issues.

Last week I visited George Mason University to attend a bioengineering seminar on Ultrasound Characterization of the Vulnerable Carotid Plaque. The drive to Fairfax, Virginia, through DC morning traffic didn’t leave time for coffee before the seminar, but as it turns out, the presentation proved so stimulating that I didn’t miss the caffeine. Kirk Beach, PhD, MD, delivered the course with such humor and warmth, such infectious curiosity, that in his hands technical theory sounded like a real page-turner of a mystery.

The seminar was hosted by GM’s Department of Electrical and Computer Engineering. Many attendees were engineering faculty or graduate students – not the more clinical audience I’m accustomed to – which made the seminar all the more intriguing. While clearly the biological nature of vessels was not lost on the engineers, it seemed from their questions and comments that their more compelling interest was in the mechanical details of vessel architecture. Observing hemodynamics and tissue strain through the eyes of engineers, I must say, torqued my perspective!

Dr. Beach, with degrees in medicine and in electrical and chemical engineering, is certainly at home in the blended environment of bioengineering, and so is his colleague, Mason faculty member Siddhartha Sikdar, PhD. Author of several articles on sonographic imaging of tissue vibration, Dr. Sikdar conducts research, both in his lab at George Mason and at the NIH, into novel ways of using ultrasound to investigate cardiovascular disease.  

Most interesting day! But before tackling the Beltway to go home, I hit the nearest Starbucks.

Even as applications for sonography become increasingly diverse on Earth, ultrasound imaging is propagating skyward to advance the practice of medicine off the planet as well. With the help of ground-based experts, International Space Station (ISS) crew members with minimal training are obtaining diagnostic-quality images of structures of the cardiovascular system, the abdomen, facial structures, and the musculoskeletal system. Downlinked to sonologists on Earth, images acquired by these American and Russian astronauts may make possible the onboard diagnostic capabilities essential to astronaut safety on long-duration space expeditions of the future.

The only medical imaging modality on the ISS, ultrasound seems destined to play an important role in maintaining human safety in the remote environment of space. But providing ultrasound services on the ISS is no small feat. For one thing, limited equipment stowage means the monitor, keyboard, and ultrasound system must be separated, each piece stored in “racks” lining the walls of cramped ISS quarters. The monitor and keyboard are on articulated arms, connected to the ultrasound system only by cables. Subject positioning in microgravity poses another challenge to scanning in space; a system of restraints and foot straps is necessary to overcome subjects’ irksome tendencies to float away from the transducer.

Besides overcoming the physical challenges of off-planet scanning, astronauts must apply sufficient technical expertise to capture appropriate images. For crew members training to perform multiple complex research tasks, comprehensive sonography education is not feasible. Instead, NASA is investigating the effectiveness of limited technical training for astronauts as preparation for guided scanning with direction from a ground-based sonographer. Astronaut participants in NASA’s  Advanced Diagnostic Ultrasound in Medicine (ADUM) project received ultrasound instruction through a highly efficient “Just-in-Time” training program that delivered tightly focused instruction components just at the time when each would be most useful.

In one model, crew members received 3 hours of Just-in-Time sonography training. Several months before a scheduled scan, crew members completed a 2-hour session at Johnson Space Center in Houston. During this longest portion of the training program, astronauts became familiar with equipment setup and keyboard controls, and they learned basic exam-specific imaging techniques. Also, during this 2-hour session, crew members familiarized themselves with terms guidance experts would use to guide them as they scanned on the Space Station.

Several days before performing an exam, crew members participating in the ADUM project completed a 1-hour session with an On-Orbit interactive Proficiency Enhancement (OPE) CD-ROM. A bilingual (English and Russian) tool, the CD-ROM offered multimedia components to refresh crew member–users’ memories of ultrasound principles, equipment operation, and relevant anatomy.

Real-time guidance, with a strong partnership between astronaut and sonographer or other imaging specialist, is critical to the success of ISS scan experiments. As the crew member scans and downlinks images live to Mission Control, the ground expert views the images and by means of a real-time audio link guides the astronaut to adjust the transducer orientation and system setting controls. To facilitate communication, astronaut and sonographer refer to identical sets of “cue cards” that depict anatomic and control panel features. When the scan is complete, digitally saved images and cine loops are transmitted to on-ground sonologists for review in more detail.

Results of the project have been excellent. Images acquired on the ISS are of diagnostic quality, and with continued development of ultrasound’s application in space, experts believe sonography may prove to be a useful diagnostic tool for more than 250 medical conditions. Perhaps eventually a sonographer will become an astronaut and perform ultrasound exams “in person” on a space mission. But meanwhile, ground-based sonographers and nonsonographer astronauts are finding ways to collaborate to produce useful ultrasound studies. Together these teams are achieving fine work in our profession, solving problems, finding answers, and extending medical ser-vice boundaries beyond anything we might have imagined just a few short years ago. 

As sonography teams investigate inner space in outer space, I do hope one project on their agenda is follicle studies. After all, what factor could be more important to long-term human survival in the environment of space than its effect on our capacity to procreate? In microgravity, will we have triplets or will we struggle to ovulate? Anyone care to speculate?

Sonography is morphing at the speed of sound. From static scanners to electronic arrays, from fuzzy mysterious shadows to images of stunning detail, the technology and its products advance.

In 1984, armed with a good education and impressive new ARDMS credentials, I joined the ranks of ultrasound pioneers, continuing the work begun by mid-20th century investigators whose perseverance and vision is reflected in our images. Twenty-three years later, new graduates join the profession as the next pioneers: 21st century sonographers, equipped with ever more dazzling technology. From static to real-time scanning to Doppler to 3D and beyond, just when the technological wave seems to be cresting, human curiosity, spirit, and ingenuity fuel ever larger, more powerful swells.

Of course, sonography is more than machines. What about the essence of the profession itself? With evolving technology and emerging applications, where will our challenges lie? How is the profession changing, and how do we prepare?

We sonographers are a diverse group. We are men, women, young singles, working parents, and grandparents. We scan in large medical institutions, in small rural offices, in remote villages, and on battlefields. We have associates, bachelors, and masters degrees, PhDs, and MDs. We arrived at this profession through systematic career research or quite by accident. But whomever we are, however we came to be here, we share in shaping the future of our profession, the modality, and, most importantly, human health and quality of life.

In this rich climate of medical evolution, our most critical tool will always be our initiative to stay informed. This column will serve as a forum in which we can look at our roots, share our accomplishments, examine our concerns, and explore our future. We’ve come a long way since water-filled horse troughs and motorized transducers. But however the profession morphs, whatever the future brings, together we can grow to meet the demands, to face the challenges, and to accept opportunities as they unfold.