What kind of a day have you got? A sonographer's reflections

Published: 23 October 2019 Obstetrics and Gynaecology

"What kind of a day have you got today?"

My husband has asked me this question multiple times and the majority of my answers have been very similar: "I'm working in general this morning and then in maternity this afternoon, as well as a student assessment.”

My work is definitely varied. I have always known this, however one day I really reflected on what my day would actually involve and, for once, I answered him honestly...

Diagnostic ultrasound examinations need justification, whether it is for screening purposes or to assess for disease (CL1C3 and CL1C4). Although ultrasound has a good safety record, with very few side effects, any good practitioner should adhere to and support the ALARA principle, ‘as low as reasonably achievable’ and thus only scan when necessary.

The Society and College and the British Medical Ultrasound Society have excellent guidelines on what makes an ultrasound request justified and also how to perform ultrasound examinations safely.

It is helpful to have local working guidelines too, so get writing if you do not have one already. Such guidance helps us to provide a high quality service to our patients, but our expectation that referring clinicians should take and provide a good clinical history is not always met.

I have changed my practice over time, to take my own history from the patient. I use a simple open question: "Tell me why you think you are having a scan today?" Many patients will repeat the history already provided, others will give more useful information, and a small group will divulge far more information than is necessary.

In these cases, I have become good at polite interruptions. Although clinical history is important, and often maps your route to a specific diagnosis, we should think beyond the request, so we can provide our patients with the best opportunity to have their condition diagnosed. We should expect the unexpected.

I have had many examples throughout my career where my expectations of what I think I will find, giving the clinical indications for the scan, and what I've actually found have been completely different. Babies disguised as irritable bowel syndrome. Right flank pain ?renal calculi as multiple gallstones. DVTs which are ruptured Achilles tendons. ?fibroids as ovarian cancer.

So what do you do when you find the unexpected? Have a moment of disbelief, whilst wondering if you really should have gone to Specsavers?

Absolutely, self-doubt is a normal emotion and regardless of your level or depth of experience, that awful feeling of having to inform your patient of an unexpected finding is never easy. Our patients must consent prior to their ultrasound, with an understanding of why the scan is required, but having to inform them of something unexpected is extremely difficult and there is no right or wrong way to approach it.

Of course remaining calm is essential and I would recommend you complete the whole examination before you attempt in-depth post scan discussion. I speak from past encounters where I have disclosed information and my patient has left mid scan; which they are entitled to do, but they had to return later, which increased not just their's but my own anxiety further.

It may also be helpful if you can send the patient for a walk, or to the toilet. This short amount of time can assist you to seek a second opinion from a colleague, or allows you time without the patient there to think about how you are going to approach your findings with them.

One example is a patient who presented for an abdominal ultrasound with symptoms of IBS and reflux. Within her uterus was a live 24-week fetus.

"Oh no, how am I going to explain this?", was my first thought. The expectation of what I may find did not match what I was seeing on the screen. The patient was experiencing amenorrhoea, I learnt from the history I had already taken from her. A lack of menses was expected because she was consistently taking the progesterone only pill.

The unusual abdominal pains the patient had been experiencing during the past six weeks were most likely fetal movements. This was her first pregnancy and it was unplanned.

I reiterated the questions I had already asked, but focused on her menstrual cycle. I could see she was starting to wonder why I was asking these questions. I asked, “Is there any possibility you may be pregnant?”

Disbelief on the patient's face. “No, no, absolutely not,” she laughed. I had been hoping she did know; that would have been easier, but I could sense she had no idea.

“The findings on this scan today show...” I paused... ”A live pregnancy. Just one baby of around 24 weeks...”

The patient stared at me. I could see she was trying to process the information but could not. What were the right words to say to her? To this day I still do not know. I sat and held her hand whilst she cried. This is what felt right. Sometimes the right thing to do is stop talking, listen, and offer comfort. I arranged the necessary referrals and she was seen immediately by the midwifery team.

Experiences like this have taught me that in the world of ultrasound, you will never know what you will find once the unfreeze button is pressed.

Although at times it is stressful, this is what makes it such a dynamic and rewarding job, where no two days are ever the same. It is always nice to see patients at later stages during their care.

“Thank you for being so kind to me.” That’s all I needed to know; I had done the right thing for the patient.

Scroll back to the beginning and the question "What kind of a day have you got today?" The answer is, "Expect the unexpected."