November 16, 2009

Scanning in Pain — Sonographers Seek Relief
From Job-Related Hazard

By Beth W. Orenstein
Radiology Today
Vol. 10 No. 18 P. 24

It’s no surprise to sonographers that many of them are being injured on the job. To scan a patient, they often must lean across the person’s body while holding a bulky transducer attached to a heavy cord. If the sonographer is trying to view organs on a patient’s left side, his or her scanning arm can be abducted as much as 90 degrees. Sonographers also must contort their bodies to reach the keyboard while viewing the changing images on the monitors as they scan. With their workload, sonographers injure their necks, shoulders, arms, and wrists at a startling pace.

Over the years, the profession has attempted to address the issue of work-related musculoskeletal disorders (WRMSDs), but apparently it has done so to little avail. A new survey of about 3,000 sonographers and vascular technologists conducted by the Society of Diagnostic Medical Sonography (SDMS) and Sound Ergonomics LLC of Kenmore, Wash., shows that nearly 90% are scanning in pain. That’s up 9% from the last large survey of WRMSDs among sonographers, which was done in 1997. The new survey and an analysis of the results by Kevin Evans, PhD, RT(R)(M)(BD), RDMS, RVS, FSDMS, division director and an assistant professor in the radiologic sciences and therapy division at Ohio State University, will be published in the Journal of Diagnostic Medical Sonography.

Evans, the first author of the article, says the latest survey findings are rather disheartening given that leaders of the profession, including Joan Baker, MSR, RDMS, RDCS, FSDMS; the SDMS, which Baker helped found; and the Society for Vascular Ultrasound (SVU), have been bringing the issue of WRMSDs among sonographers and vascular technologists to the forefront for years. Baker went with representatives of the SVU, including Anne M. Jones, RN, BSN, RVT, RDMS, FSVU, a member of its advocacy committee and a past SVU president, to Washington, D.C., in July to discuss the work-related injury issue with directors of the Occupational Safety and Health Administration (OSHA).

Sonographers Report More Pain
“Everyone knows what we’re talking about now—the need to improve ergonomic conditions for diagnostic medical sonographers and vascular technologists—yet work-related musculoskeletal disorders among sonographers appear to be unabated,” Evans says. Jones agrees it’s alarming that “while we thought that with increasing awareness and action over the last few years we would see an improvement in the health of those scanning, it’s been the exact opposite—the numbers being injured are rising.” A smaller, more compact study by the SVU just before the Washington trip also found that 90% of sonographers are scanning in pain.

Baker and Jones cite a number of reasons why so many sonographers and vascular technologists are subject to musculoskeletal disorders. A large part of the problem, Baker says, is that as caregivers, sonographers are reluctant to take time off from work when they are injured because they don’t want their coworkers to inherit their patient volume. “As caregivers, it’s this ‘sacrifice my body’ sort of a deal,” Baker says. In the latest SDMS-Sound Ergonomics survey, as many as 57% of participants answered that they did not report their injury to their administrator or occupational health department.

Another part of the problem is workload. As sonography becomes a more accepted medical modality, physicians order more scans, increasing the sonographers’ workload. Marveen Craig, RDMS, FSDMS, was the first to describe musculoskeletal disorders among sonographers in the article “Sonography: An Occupational Health Hazard?” published in the May/June 1985 issue of the Journal of Diagnostic Medical Sonography. Baker says that when Craig did her study in 1985, sonographers thought that the articulated arm scanner, which was the equipment used at the time, caused the injuries. As the technology advanced and more departments went to real-time scanning, the number of work-related injuries seemed to decline. It turned out to be temporary, though. As workload increased and sonographers started doing 10 to 12 scans per day, the problem of injuries returned and indeed became worse, according to Baker.

Jones says that because the cost of sonography is less than that of other imaging modalities, utilization continues to increase. Vascular technologists are doing as many as 14 scans per day and, because of the severity of the disease processes being evaluated, those exams are often long and complex. Despite what their hefty workload can do to their bodies, Jones says, “The sonographers have an intense commitment to perform as many scans as they can because they know their patients are there needing scans and are waiting.”

Imaging facility design also contributes to the problem, Baker says. Because sonography is relatively new and was not part of many older facilities when they were built, many scanning rooms are converted closets furnished with tables and chairs from the hospitals’ discards. The scanning rooms’ small size contributes to the awkward positions the sonographers must get into to scan some patients, she says.

Portability Questions
Baker says another problem is that today, as sonographic equipment has become more portable and lightweight, more scans are being done at the bedside. While it’s good that sonographers no longer must help transport hefty patients to the scanning room, it’s bad because sonographers often find themselves contorting their bodies to reach patients lying in their hospital beds. Also, when scanning at the bedside, sonographers typically don’t have access to ergonomically correct tables and equipment.

Jones says vascular technologists often must go to the patients’ bedside to perform their studies because their patients are too ill to be moved. “That’s a daunting task when you think about how small the ICU is and all the equipment that’s already in there,” she says. “You have to go in with your ultrasound equipment, which can be heavy and difficult to push and adjust, and scan in a very cramped space.”

Another issue, according to Baker and Jones, is the hospitals’ and imaging organizations’ lack of support for an ergonomic environment. The institutions don’t provide ergonomic equipment—examination tables, chairs, and stools that are adjustable or have foot rests or arm support—nor do they schedule breaks between procedures, Jones says.

The environmental conditions are causing injuries mostly to sonographers’ neck, shoulders, and arms. Common symptoms are pain, loss of sensation, numbness, burning or tingling, tenderness, swelling, clumsiness, and muscle spasms. But sonographers are reluctant to report their injuries for fear of being labeled a complainer.

“You don’t want to be the one in your department complaining of pain and others having to pick up your volume because of it,” Jones says.

Researchers have done several studies of work-related injuries among sonographers, and one of the most significant was conducted in 1997. That survey was sponsored by the British Columbia Ultrasonographers Society and the Healthcare Benefit Trust of Vancouver, Canada. At the time, the SDMS asked Baker, who lives in nearby Kirkland, Wash., to represent the organization on the committee compiling the survey.

History of the Issue
The 1997 survey contained 125 questions covering five areas: demographic variables, self-reports of musculoskeletal disorders, work scheduling and tasks, work equipment, and work environment characteristics. Three thousand sonographers in the United States and Canada were randomly selected from the American Registry for Diagnostic Medical Sonography database and asked to complete the survey. “The numbers were chosen because the statisticians believed it would result in 1,000 responses, which would be a statistically significant sample,” Baker says.

More than 1,600 sonographers completed the survey—a 54% response rate. The survey was analyzed by Jonathan Berkowitz, a statistician representing the British Columbia Ultrasonographers Society, and Ian Pike, PhD, for the Healthcare Benefit Trust. The survey found that 81% of sonographers were scanning in pain, and Baker says the number was among the highest for any profession. Grocery clerks only report a 63% incidence of occupational disorders.

Baker, who helped design the latest survey, says it was modeled after the 1997 Canadian survey. For the most recent survey, more than 5,200 diagnostic medical sonographers, cardiac sonographers, and vascular technologists randomly selected from the American Registry for Diagnostic Medical Sonography, the SDMS, and Sound Ergonomics’ vendor list were sent an e-mail inviting them to take the 58-question survey posted on a secure Web site between January and March 2008.

The survey resulted in 2,963 usable responses, making it the largest survey sample to date. “The response rate was 57%, higher than expected,” Evans says. Of those who responded, 88% were female and most were over the age of 50 and had been scanning for more than 20 years. “The overall distributions of both age and years of experience of the respondents were skewed toward older, more experienced diagnostic medical sonographers and vascular technologists,” says Evans, who analyzed the data with the assistance of an occupational therapist and doctoral student, Shawn C. Roll, MS, OTR/L, CWCE.

Where It Hurts
The majority of respondents performed nine to 11 scans per shift, with the average exam lasting 20 to 25 minutes. The distribution of exams performed per shift was skewed to the lower end, and the distribution of time per exam was skewed toward longer exams, Evans notes. Only slightly more than one half (54.5%) said they had been shown how to use the ergonomic features of their new equipment.

The top areas where sonographers reported pain were the shoulder (17%), neck (15%), wrist (11.4%), hand/fingers (10.2%), and upper back (10.2%). Across all demographics, shoulder pain was the most commonly reported complaint, with older and more experienced sonographers having more finger, hand, and wrist pain than other groups. Other common causes of pain cited were pressure applied to the transducer, abduction of the arm, and twisting of the neck and trunk.

Baker says when sonographers go to their organization’s occupational health departments to report an injury, they are rebuffed and don’t push the issue because “they don’t want to rock the boat.” Sonographers can help their cause by making sure their injuries are reported to the hospital and thus to OSHA, she says. “The best thing they can do is push hard to have their injury written up and put in the OSHA log,” she says. “What we need now more than anything is the documentation of the injury and the illness data.” Sonographers also should demand that their facilities buy ergonomically correct equipment and, once it is provided, they must become familiar with and utilize it when scanning, she says.

Jones says she thought the OSHA directors were attentive and listened to what was presented with a sympathetic ear. However, she says, they said they are not likely to enact any regulatory fixes—at least not anytime soon. “Our impression is that these OSHA directors do not have the authority, the time, or the directive from leadership to act in an aggressive manner on our behalf,” she says. Part of the problem, she says, is that OSHA has other priorities. “Because they are also in charge of emergency management, their priorities are currently directed toward the H1N1 virus [swine flu] and other emergent matters,” she notes.

Seeking Standards
The OSHA directors suggested that the professional societies adopt standards and implement them on their own. Jones says the SVU and the SDMS will be working together to create standards that are required by employers. Also, she says, “We will go to the accrediting bodies and ask them to implement them and teach them in our educational programs as well.”

Jones says the problem needs to be addressed not only for the sonographers’ sake but also the patients’. “There appears to be a positive correlation between the amount of pain a sonographer or vascular technologist feels while scanning and the possibility for medical errors,” she says. “You don’t want a sonographer to make errors because she is scanning in pain.”

Everyone fears the injury problem will only continue to worsen as the demand for sonography services increases and more experienced sonographers leave the profession due to injury. The workload for the newer sonographers will increase, leaving them more prone to injuries as well, Evans says. “This is just a never-ending cycle,” he says.

Evans wants to do further analysis of the data contained in the SDMS-Sound Ergonomics survey, as well as additional studies. Of particular interest, he says, would be a study following sonographers as they enter the profession and have yet to be exposed to conditions that could cause injury. He also wants to analyze the data in the SDMS-Sound Ergonomics survey by credential to determine whether the problem is different among the different ultrasound fields. “With the increased demands being made on the profession to do more with less,” he says, “we are in dire need of more high-level standardized studies investigating solutions to WRMSDs.”

— Beth W. Orenstein is a freelance medical writer based in Northampton, Pa. She is a regular contributor to Radiology Today.