Careers for Characters - Sonographer

      I was delighted when Joan Swan offered her expertise for this feature, because I'm pretty tired of doctors and nurses being the only people from the medical field to get any serious stage time. I can think of so many ways a sonographer's job could add drama, especially now that my awareness of what they do has been broadened.


What don’t people know about the job of a sonographer?

A sonograher’s job is critical to a patient’s well being, regardless of the type of facility one works in.  This position is completely technologist dependant, which means an ultrasound is only as good as the technologist performing it.  Because there is no way to completely image everything we see, our job is to evaluate the patient in regards to the reported illness and take representative pictures of organs/areas of the body in question.  If we don’t see the problem, we may or may not image the problem.  If we don’t image the problem, the radiologist (physician who reads the scan) will not see the problem. 

In that way, ultrasound is different than CT or x-ray or MRI or mammography.  Those modalities have certain techniques employed in the same fashion with each exam.  In that situation, a technologist needs to understand his/her equipment and basic patient positioning to perform an adequate exam.  Ultrasound is completely different.  A technologist must understand not only the equipment and patient positioning, but anatomy, physiology and pathology—of every organ we image.  If we see something pathologic, we then need to make a decision regarding what to image next, what to highlight or what to investigate further.  Unlike other modalities (CT, x-ray, etc.) various techniques can be employed to get better images.  Those techniques differ depending on the patient, their illness/condition, their body build…the list goes on.  A good sonographer is skilled and diligent.

A sonographer’s job is extremely physically and emotionally demanding.  I can’t tell you the number of people who think we simply sit in a chair all day, put some “jelly on their belly” and “move a wand” around. 

Physically, scanning is tough on many parts of the body just as any job with repetitive or strenuous action.  We stand most of the day and put a great deal of pressure on our feet, hips, shoulder, elbow and wrist joints, not to mention the muscles and tendons in those areas.  Every career sonographer I know has some physical job-related injury.  Carpal tunnel, rotator cuff, pulled muscle, misalignment of hips, pelvis, spine and shoulders are only a few problems.  The more demanding the work environment, the more injuries a sonographer will have.  Ergonomics are a pipe dream in the field of ultrasound. 

Emotionally, a sonographer must employ a combination of professional distance while maintaining a personable nature and butt-load of compassion.  No matter where a sonographer works, they will discover/see terrible tragedy—miscarriage, trauma, internal bleeding, cancer.  People (aside from happy pregnant couples – which, by the way, do not make up the majority of obstetrical scans I’ve performed across the board in my 20 years as a sonographer, regardless of the facility type) come to sonographers because they are in pain or a doctor suspects a problem.  They are generally not happy or pleased to be there.  And of course, it is difficult to see anyone in pain, but to watch children suffer is often unbearable.  Pain and suffering are an all day, every day reality for sonographers. 

Sonographer have a lot of education and training.  Many people assume sonographers are “technicians”, trained to run equipment and little more.  Sonographers have as much or more training than Registered Nurses or RNs.  Two years of specialized training in ultrasound is required, which encompasses not only anatomy, physiology and pathology of the human body, but intense knowledge of physics.  To become a registered sonographer (just as nurses become registered nurses), a sonographer must pass medical boards in both physics and whatever specialty they desire.  Additional board tests must be passed to for various specialties.

What is a typical day like?

Daily routines vary according to the type of facility.  Clinics generally schedule patients every half hour or so.  Hospitals may schedule outpatients (patients who come from outside the facility) as well as handle whatever inpatient (or in-house patients) scans are requested.

Where I work, shifts are staggered so the hospital is covered from 7am until 8pm.  The early person scans all neonatal heads, which is an ultrasound of a newborn’s brain.  My facility has a huge Neonatal Intensive Care unit, so the morning sonographer can spend up to 4hrs just scanning babies. 

If a sonographer takes call (which is often a requirement of the job, not an option), their day doesn’t end there.  They either stay until all studies are performed or they come back at all hours of the night and morning to perform urgent scans.  Then return to work the following day for their regular schedule—regardless of how little sleep they’ve gotten.

Our day consists of handling medical paperwork, intensive patient care, the actual scan of the patient, reviewing the study with radiologists, and transport of that patient to and from their room (or out of the hospital if they are an outpatient).  We pre-scan, prep and assist with procedures such as biopsies, thoracentesis (drainage of fluid from chest), paracentesis (drainage of fluid from abdomen) and abscess drainage (infected fluid collection anywhere in the body).  General maintenance of machinery and stocking of supplies occupies our non-existent free time.

My day at UCSF typically starts as soon as I hang up my jacket and doesn’t stop until I get the last patient back to their room.  I spend the day juggling portable scans in the several ICU units including the neonatal ICU, the operating rooms, the recovery room and patients sent to us by the emergency room or any one of the 10 patient care floors.  I often don’t sit down most of the day, never take regular breaks and am thrilled if I get a lunch away from the department.

What type of people would you associate with in this job?

A sonographer regularly associates with doctors of every specialty known to the medical field, nurses, fellows (radiology physicians who have completed residency and are specializing in ultrasound), residents (radiology physicians going through residency), patients, a patient’s family, fellow sonographers, other radiology technologists, hospital transporters, secretaries, housekeeping, maintenance workers.

What are the differences between facility types?

Clinics are generally orderly with only “walkie-talkies” or patients who come into the facility by their own steam (outpatients).  They are typically nicely appointed, calm and quiet.  Patients are scheduled every half hour to every hour with an occasional add-on patient request from a doctor’s office.  Hours run 8am to 4:30-5pm with a 30-60 minute lunch (rarely missed).  Overtime is rare.

Radiologists in these locations are generally quite personable, people-oriented, skilled and knowledgeable in ultrasound.

Small or rural hospitals can be as quiet as they can be chaotic.  This typically depends on the physicians practicing at the facility, how liberally they order studies, how well they understand what diagnoses ultrasound can and can’t provide.  Outpatient exams are generally scheduled on the hour with inpatients and emergency room studies accommodated as they come up during the day.  A lot of juggling and triage by the sonographer is necessary, deciding whether an ER patient must be scanned before the schedule outpatient, etc. 

There is typically little to no support from attending radiologists within these facilities, as I find most radiologists at small hospitals are either not interested in ultrasound and/or not skilled within the field.  Because the modality requires practice, many radiologists will not scan, but will depend entirely on the sonographer’s proffered study and their opinion.  Often, in these facilities, studies the sonographer deems “normal” or not imminently troublesome will not be checked by the radiologist prior to the patient being released.

These facilities can also vary in appearance, depending on available funds and allocation of those funds and can range from nicely kept with well-appointed surroundings to run-down, barely passing JACHO inspection. (Joint Commission of Accredited Hospital Organizations—kind of like an OSHA for hospitals.)

Large hospitals or teaching medical centers are typically busy to the point of chaos.  Patients come from every direction—emergency, outpatient, inpatient, operating room and recovery room.  Several sonographers work as a team to coordinate and juggle.  The radiologist or sonologist (a radiologist specializing in sonography) are very involved in all scans and procedures.  Generally all studies are checked prior to release of the patient and the radiologists are also skilled at scanning.  In these facilities, radiologists place great trust and pride in their sonographers, as these locations only tolerate the most skilled and knowledgeable technologists.  Excuses for substandard studies are unacceptable and rejected by radiologists in this setting.

These locations can also vary in appearance depending on their funding, but generally are well-kept if not new and carry high-quality equipment.

When I think of sonograms, I think of expectant mothers and pictures of their fetuses but I'm sure your work has a wider range than that and that there's a variety of challenges. Can you share some of those with us?

Sonography can be used for more purposes than I can name.  We can scan every surface of the body, although penetration (visibility) depends on the contents beneath the skin.  Ultrasound cannot penetrate bone and scatters in the presence of air or gas, which means we can not scan intestines or bowel very well.  Ultrasound is used as a powerful, non-invasive, non-radiating and completely safe tool to visualize the abdomen, pelvis, unborn fetus, vasculature, heart and even the newborn brain.

Other than fetuses, ultrasound is used extensively in the following areas:

• In the abdomen we scan liver, kidneys, vasculature, ducts, pancreas, spleen and limited view of stomach in babies. 
• In the pelvis we can view the uterus, ovaries, bladder and prostate.
• “Small parts” include testicle/scrotum, thyroid and breast.
•  Neonatal head sonography visualizes a newborn’s brain through the fontanel (soft spot) of the skull. 
• Vasculature ultrasound can visualize arteries and veins throughout the body.
• Other types of scans are performed throughout the body in search for and/or evaluation of fluid pockets, bleeds, aneurysms, blood flow, abscesses, etc.
• Procedures include utilizing ultrasound to localize and mark a spot for fluid drainage as well as guide for a “real time” biopsy of many organs and any mass which can be viewed sonographically.
• Of course the heart can also be visualized extensively with ultrasound, but that is done in the Cardiac/Vascular department, the studies reviewed by cardiologists.

As a top transplant facility, at UCSF we scan a variety of transplant patients—liver, kidney and pancreas mostly. 

95% of the fetal ultrasound that are performed at UCSF is referral from other centers or doctor’s offices.  Patients come from all over northern California on a regular basis for “targeted” or “level two” sonograms because either a sonographer or physician noticed something wrong on a prior study.  Therefore, the fetal scans we perform are typically worrisome, troubled and problematic.  Many require in-utero surgery.  Many don’t survive.

What kind of qualifications would someone need to get into this field?

To qualify to sit for the board tests, a sonographer must have over 2000 hours of internship or scanning experience in a given specialty.  That is one year of full-time scanning experience in addition to two years at an accredited sonography program.

Is there a particular "personality type" that gravitates toward this field?

2 types of people seem to gain interest in becoming a sonographer:

1—Someone who has worked in the radiology field and has knowledge of the profession, such as an x-ray technologist, who would then go back to school to gain the necessary education and experience to practice and obtain a job as a sonographer.  These people are generally intelligent, compassionate, people-oriented hard workers who understand the demands of working in a medical facility.

2—Someone who sees the profession as a quick fix and/or easy money.  These tend to be young people searching for a vocation in lieu of attending college or adults who are being sponsored to retrain for a second career as part of a worker’s compensation rehabilitation-type program—usually due to injury on previous job.  These types of people usually underestimate the intense requirements involved in becoming a competent sonographer and lack the work ethic to persevere.

Where do sonographers fit within the medical heirarchy? In other words, who do you answer to?

Ultrasound is within the radiology department.  In smaller locations we really have two bosses -- the manager of the radiology department and the radiologist. The radiologist usually pulls rank when there is a conflict.

What kinds of things go wrong?

You name it.  Patients can code (heart stops beating), decompensate (drop in respiration, blood pressure, or oxygenation) or become combative during an exam.

I have had two newborns code on me.  I have had one adult pass away immediately after I had scanned him and he’d been returned to his hospital room.  More recently, I had a woman miscarry during an exam.  I have been sworn at, pushed and hit by patients.  Once a man threatened to kill me.

Patients can be in too much pain to tolerate a study.  A variety of medical conditions and drug side effects can cause hallucinations, which generally cause the patient to become uncooperative at best, violent at worst.

Exposure to bacteria, viruses and a patient’s bodily fluids are a constant risk.  I’ve been coughed on, sneezed on, spit on, peed on, puked on, pooped on, oozed on, leaked on, and bled on.  If you can imagine a bodily fluid, I’ve been exposed to it.

As disturbing as all that is, what troubles me most is how easily life-threatening problems can be missed.  An inexperienced, or simply careless, sonographer can miss something as crucial as an ectopic pregnancy, an aortic aneurysm or internal bleed.  All of those oversights can be lethal.

Less immediately life threatening, but equally as devastating in the long run, is the possibility of a sonographer missing a small cancer or enlarged organ which could be intervened upon relatively successfully in the early stages, but deadly if allowed to metastasize or worsen.

What are the emotional rewards of this job?

• Touching a patient’s life in a positive way during one of the darkest times.
• Helping uncover the source of a patient’s pain.
• Knowing my time at work makes a positive difference in the world.
• Camaraderie of quality physicians and technologists.
• Respect of renowned specialists.
• Taking pride in my work.
• The challenge of every scan.
• Continued learning.

Can you give us a ballpark idea of where sonographers make?

Registered sonographers start off at anywhere from $20/hr to $45/hr depending on their level of experience and specialization as well as the area of the country in which they work.  Experienced, multiple-specialty sonographers working at a top-notch facility in a highly populated area for a long period of time average between $50-$90/hr. 

A sonographer that works full time and takes a considerable amount of call can make between $100k and $175k a year – but sacrifices are inevitable and the results cumulative.  (Aging sucks.)  Lack of sleep leads to illness, stress, reduced happiness and shortened life span.  Lack of free time takes its toll on one’s personal life, family life and sanity.  Overwork produces multiple physical problems including spine, joint, limb and neck problems.  Most career sonographers live with some level of physical pain. 

Is there jargon that would be useful for a novelist to know?

There is too many to list!  It’s such a specialized field within the huge field of medicine.

*** To make this even more interesting, Joan will randomly choose one commenter to award a $10 ITunes Card. The comment must be made on this blog post between now and midnight PST Sunday February 27th. Be sure we have the means to contact you.

NOTE: This video gives a nice view of the equipment which would be useful for writing the scenes and it gives a sample of the language one might expect to put into a character's mouth. Joan reviewed it before I included it, and said that it worked for those purposes, but cautions that it's a simplistic depiction of the job. Youtube has a number of these videos for various scans which could be useful in supplying your character with the right jargon for specific areas.

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I hope y'all are finding this feature useful or at least interesting. The more folks who contribute, the better this will be, so if you've worked an unusual or interesting job and you'd like to tell us about that job, I'd love to hear from you. Please leave a post HERE.