The Complex Learning Environment for Diagnostic Ultrasound Students

Posted by tinas

November 12, 2019

How To Navigate Ultrasound Training

Recall your preschool or kindergarten years when you watched a friend practicing to tie their shoe. Somehow it seemed you were taught differently. They would tie their shoe, putting the sting over the other string when you were going under the other string, and they would use two loops while you used only one. And then there would be someone that tried to learn all the different ways to tie their shoe. Getting your shoes tied was the goal. No matter which method you chose, the shoe eventually got tied with practice. Performing an ultrasound examination is no different. Everyone has a unique way of scanning. No two sonographers are alike. However, it is necessary to learn some basic skills to master the art of the ultrasound.

Performing ultrasound examinations is like the art and skill of tying your shoe, creating a painting, planting a garden., or rehearsing on the piano. There are many approaches to getting the job done.

The Job: A Fluid Protocol Using The Best Acoustic Windows

There is a set of images to acquire to make sure that patients are getting the same standard of care. In an attempt to assure that patients are getting sufficient ultrasound examinations protocols have been developed. To achieve the desired protocols used in ultrasound sonographers use anatomical landmarks to make the best attempt, they are observing all the parts of each organ necessary for the radiologist or cardiologist to make the best diagnosis possible.

Making your Art Ultrasound

Humans look similar on the outside, but we are all unique in size, shape, and structure location. This is true for our inside parts. We do not all follow the schematics drawn in textbooks, and our anatomical blueprints vary from person to person. Circumnavigating the internal structures of so many different designs takes a highly skilled sonographer who understands these differences exist and how to use different acoustic windows to view entire anatomy. The surface of the patient affords many acoustic windows the sonographer can choose from. Like a blank canvas, the sonographer artist decides where to start moving the transducer over the patient.

Every sonographer should be using multiple acoustic windows to view anatomy if possible. You never know what mass might be lurking around the bend.

About "The Angle"

Since handheld transducers became the new tool on the block in the mid 1980s, the ways to look at anatomy become infinite. A small footprint transducer controlled by the hand of the sonographer has the potential to go through many infinite angles in 3 dimensions. The goal is to adjust angles to find the longest to the shortest axis of patients’ organs. Sonographers start the examination using the acoustic window of their choice, and then the movements they make create angles of the beam pointed towards the targeted organ tissue. For example, 30 degrees longitudinal and 20 degrees transverse may be what it takes to get the long axis of the gallbladder on one patient while 34.20195 degrees longitudinal and 10.09818 degrees transverse on another patient. The change of angle can be just micro-millimeter adjustments all from different vantage points.

The movements are dynamic. A well-trained sonographer is using a heel-toe technique, pivot motion, rocking motion, and twisting motion repeatedly throughout the exam while changing acoustic windows and identifying anatomical landmarks to find any existing pathology.

Muscle memory and Photoreceptors

Muscle memory for scanning is a key component to becoming a skilled sonographer. Repetition of quality strokes to scanning is the best way to becoming the best sonographer one can be. But practicing doing it wrong can be the fastest way to missing pathology during an ultrasound examination.

Muscle memory is required to make sure all possible techniques and motions are being used to find the longest to the shortest axis of all organs. There are two parts of the brain that are activated for sequence learning: the basal ganglia and the cerebellum. The goal is for the hand to perform an action effortlessly without conscious thought. It is taxing for students to learn the strokes while learning protocols and appearances simultaneously.

Once muscle memory is achieved, the numerous motions used become an automated response. The brain can now activate other parts of the brain more efficiently to recall knowledge of the location of anatomy, how that anatomy looks under ultrasound, how pathology looks under ultrasound, and what associated pathology can exist for clues to disease processes.

You cannot guarantee a student will learn how to perform an ultrasound in a set amount of time. Each student is at the mercy of their brain capabilities that control muscle memory functions.

Furthermore, it is necessary to continually correct mistakes, mainly students forgetting how to use all the techniques, motions, and correct acoustic windows to see complete organ tissue. The tricky part is making sure students do not develop a muscle memory that is incorrect.

There are about 720 of shades of gray a human eye can see. It can take some time and the right environmental lighting for a person to acquire a sensitivity to levels of gray. In order to obtain correct measurements of anatomy structures, one must be able to see the shades of gray the machine provides.

Common Student Conundrums

Brain Fatigue

Meet Sandra. She was in the lab, learning how to scan for the first time. When she began to scan through the complete abdominal protocol, her instructor asked her what veins drain into the IVC. A question Sandra knew the answer to at the beginning of day one of hands-on training. On day two, she was asked the same question and could not recall the answer. This was due to the brain fatigue she was suffering from using the many facets of skill necessary to complete an examination. She was scanning with her right hand, annotating and adjusting the machine with her left hand. At the same time, she was exercising the muscle memory parts of her brain to get the correct angles to acquire the images. Moreover, she had to recall the names of the anatomical organs she was looking at.

Sandra, like most students, became easily frustrated that she couldn’t recall the answer to the question. The next day, she was able to untangle her thoughts and performed better.


Meet Betty. She had been training at a busy ultrasound department and had more than one tech training her. One preceptor taught a different method of scanning than the other two instructors she had. She came to me frustrated because she felt she couldn’t learn ultrasound correctly. I explained to her the art of the scan and how everyone does it slightly differently. While she was learning, she could take the tips from each preceptor and use them to her advantage in creating her own style.

Ready or Not

I’ve had many meetings with students trying to convince me they were ready to work independently. Feeling that have made enough strides to tackle any examination with any patient successfully.

A good measure if a student is performing well is that they will take the time to adjust the machine, themselves, and the patient for good ergonomics. Without good control of the transducer, it is difficult to scan. The patient should be as close to the sonographer as possible so the sonographer can keep their arm bent at relatively 90 degrees. The patient should be turned to access correct acoustic windows, and the patient should be asked to take a breath and hold it when appropriate.

Finally, they take the picture when it is in view. They do not hesitate to take the best picture possible. They recognize that not all patients will yield textbook images due to body habitus, pathology, and anatomical variations. All the protocol images are taken using the correct depth, focus, and gain for each image along with other adjustments that may be used for the best image possible.

Autonomous at Last

When a student can scan independently without having to seek the help of a trainer and feels confident about writing a report on what they have visualized, they are ready to become an autonomous sonographer.

In difficult scenarios, it is encouraged to ask the help of a colleague.

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