Cardiac Sonographer Injury Prevention
Patient Positioning and Ergonomics for Echocardiography
©Walter Rasmussen, R.D.C.S.
The best imaging results when the sonographer is able to apply various transducer manipulations with as little strain to the hand, wrist, elbow, shoulder and spine, as possible. While it may not be possible to prevent some discomfort or strain all of the time, any of the following simple precautions can prevent minor and major cumulative injuries which are a serious occupational hazard of the trade.
- Try to keep the wrist neutral (straight), neither over-contracted, nor hyper-extended.
- Support the elbow and brace the forearm with a small pillow (rolled-up patient towels placed inside a pillowcase).
- Maintain a relatively strait and balanced body posture. Don’t lean sideways over the bed rail.
- Use a chair that facilitates a solid seated position (avoid using chairs with wheels).
Effective patient positioning is also of great importance both for avoiding injury and for obtaining the best possible ultrasound images. Ideally, the chest should be easy to access while holding the transducer without straining the wrist, elbow, shoulder and spine.
From the supine position, have the patient turn on to the left side. The chest should be made to angle toward the sonographer by having the patient slide the hips back, toward the opposite side of the bed and then guiding the chest forward, so that it is at a slight diagonal toward the foot of the exam table. This allows for the sonographer’s hand to stay close to a neutral position and to be able to manipulate the probe and apply pressure more effectively.
Strained patient positioning
Good patient positioning for less strain
The goal is for the sonographer’s wrist to be in a relatively neutral position as much as possible, thus preventing excessive hand and wrist strain.
The patient’s left fore-arm should be moved out of the work area by bending the arm at the elbow and raising the upper arm at the shoulder joint, with hand next to the head and arm resting on or tucked under the pillow. Most patients will be able to slide the elbow upward, until it is out of the sonographer’s working area. This positioning of the left arm relaxes and thins the left pectoral muscle, which overlays the parasternal window and with females, allows the left breast to fall as far as possible to the left side, thus also helping to thin the chest wall. The pillow should completely support the head and neck and the patient should not be allowed to support their head propped-up with the hand and elbow because this causes tension in the chest.
Positioning for better imaging and sonographer comfort
An exam table that is specifically designed for Echocardiography is usually equipped with a flip-up back support. The disadvantage to the back support on an echo table is that it does not angle the patient’s chest toward the sonographer as described above, so that the wrist is not as likely to remain in a neutral position and this can lead to the development of increased wrist, elbow and shoulder pain. A firm pillow behind the back (hospital blankets rolled-up and placed inside a pillow case) works very well and can support a wider range of patient positioning.
Another step to the positioning technique which is of high importance for obtaining higher quality images with less effort is to have the patient tilt their right hip toward the back of the bed while shifting the left buttock slightly forward. If the right shoulder rests against the back support, the slight twist to the spine helps to open the rib spaces and separate the breasts.
Not every patient images well while leaning back on the pillow and if after positioning the patient, the image is still not clear, it can be helpful to bring the chest to a more vertical position, even to the point that the chest might almost seem to be facing a bit downward toward the surface of the bed. This position can help when images are not clear and when respirations are causing the image to briefly disappear with each breath. In addition to positioning, working with the breath, as described in detail later, is of great assistance in clearing and sharpening the image.
Transducer Grip Variations
- Vary the way the transducer is held. Avoid using a pinching grip for long periods of time. Hold the transducer so that the wrist stays as neutral as possible. Avoid flexing the wrist to the extreme or for long periods of time.
Above: Good neutral wrist position.
Above: Strained, hyper-flexed wrist position
- Patients who are in a supine position should be imaged with the sonographer standing. Adjust the exam table or bed so that the shoulder, elbow and wrist stay in a relaxed position while scanning.
- When scanning patients from a sitting position, use a small, firm pillow to support the elbow raising the elbow up and providing leverage. When using a small pillow, the shoulder is able to remain relatively relaxed and pressure can be applied with as little strain as possible. A small pillow can be readily made from rolled-up bath towels, patient gowns or blankets. A plastic-coated support can be purchased from sonography accessory and supply companies however it is easy to lose an is an expensive item. On patients with wide chests, place the support pillow up against the chest lengthwise to support the elbow and forearm.
- Take the time to adjust the height of the bed or chair as needed in order to help support the various arm positions necessary during the exam.
- Sit in a chair that firmly supports the lower back. A chair without wheels provides more stability and prevents stress to the lower body caused by trying to keep a wheeled chair from rolling away.
- Avoid back strain by getting close enough to the patient that it is not necessary to lean to the side for long periods.
- The chair should be turned partially toward the patient so that the spine is not twisted for long periods of time.
- Use the whole body to support application of pressure, including providing solid contact with the floor with the feet.
- Find alternate ways to perform repetitive activities so that no one part of the body is over-stressed. If any part of the body start to feel strained, find alternative ways to perform the task causing the problem.
- A common ergonomic problem is that patients tend to want to lie on the exam table with their chest angled back and away from the sonographer. This is even more of a problem when scanning obese patients or those with barrel chests because it then becomes necessary to tensely hyper-extend the elbow and wrist sideways against resistance, often for a sustained period of time.
- Acquire images in as little time as possible and do not extend transducer time by holding the transducer in place for more than a few seconds while measuring.
Do the bulk of the more time-consuming measurements and calculation package after finishing the imaging or after releasing the grip on the transducer.
How to reduce symptoms and move toward healing:
After consulting a physician and utilizing any medication and treatment which might be prescribed, here are some good ways to permanently heal your symptoms.
If you are having a lot of pain, this is called a ‘ “flare-up”. It will subside if you change your habits.
First of all, follow the instructions listed above. The reason you are having symptoms is that you have not trained yourself to take care of your hand, wrist, elbow, shoulder or spine. Don’t be self-conscious about scanning with an elbow support. Everyone should be using one to prevent and treat injury.
The next part is to reduce the stress that you are unconsciously putting on those same areas during the time you are not at work. It is important to realize that once established, tension becomes a habit in everyday life.
Hands: Consciously check for ways that you are holding tension in your hands. An easy example is to observe how you grip the steering wheel while driving the car. If you are holding on to the wheel too tensely, then you are not resting your hands and wrists in your off-work time.
Wrists: When tension and pain in the wrists becomes chronic, activities that cause it become habitual at home, as well as at work. Stop the unconscious contraction (forming an angle) at the wrists by training yourself to straighten and relax your wrists whenever you notice it. Don’t spend a lot of time at a keyboard or any other activity that stresses your wrists while off work. This gives them time to recover.
Sleep posture has a great deal to do with the recovery process. Imagine if you work all day, stressing your wrists and elbows, and then sleep with them in a state of contraction all night! The wrists would never get a break. When going to sleep, don’t fold up your elbows and contract your wrists while lying on your side.
Keeping your arms and wrists straight feels awkward at first, but with practice, is a breakable habit. Some people need to re-train with the assistance of custom-made splints.
Elbows: Consciously relax the elbows. Avoid the tension generated by folded arms. This is especially a problem while sleeping. Train yourself to keep your arms straight while sleeping. Do not tensely fold the arms up while lying on your side. You might notice that while in this position, you are also contracting your wrists. Keep the wrists neutral. If sleeping or resting on your back, allow the arms and wrists to lie straight at your sides.
Shoulders: Much of the tension and harm generated in the shoulder is due to straining to hold the ultrasound probe unsupported for long periods of time. This causes tension all the way up the arm with a great deal of tension to stabilize in the shoulder.
Use a pillow to support your forearm and elbow while scanning. Stand while scanning a supine patient at the subcostal, parasternal and suprasternal windows. While off work, avoid performing activities that require shoulders being held in tension such as bicycling. Consciously think of and lower the shoulders. You may be surprised at how high you are holding them!
Back Pain: While away from the job, back pain can be perpetuated by holding tension and pain. Take stock of how you are holding your back while sitting and standing. Are you habitually arching your back, causing lower back pain? Do you tend to stand in an awkward way, making your back bend to the side when it doesn’t need to?
Lifestyle: If you are already in chronic pain, it doesn’t make sense to spend the weekend playing a sport that further stresses the area or digging a trench for that new flower bed. Once you have a flareup, it is time to slow down and allow the area to heal.
When combined with medical supervision, conscious correction of poor posture and reduction of repetitive strain can ease and reverse chronic pain, allowing you to carry on with your career.