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Content Reviewed 09/30/2008
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Sonography
Positioning Patients and Equipment |
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A successful sonographic scan depends on getting the transducer into
an accurate position on the patient and being able to maintain that
position for an appropriate period of time. Being able to accomplish
this while protecting the sonographer depends on appropriate placement
of the patient in relation to the sonographer. This placement can be
highly variable depending on:
- The procedure being performed.
- The size of the patient and the sonographer.
- The type, size and placement of the equipment used.
- The size and layout of the exam room.
Songraphers must be diligent in positioning all
equipment such as exam tables, chairs, lights, and carts to ensure the
best possible ultrasound scan while minimizing risk to the patient and
themselves. This section deals with positioning the patient and
arranging the equipment within the exam room to minimize awkward
postures.
No matter what equipment you use or building you work in, keeping basic
safe work practices in mind can help you work more safely when performing a
scan. All the work items that you use in your scanning techniques should
be adjusted as much as possible to ensure proper body positioning.
Potential Hazard
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- Tipping the head back or forward places stress on the neck and shoulders.
- Reaching that involves pulling the elbow away from the body can stress
the shoulder and back.
- Bending and twisting the torso places stress on the low back.
- Bending and twisting the lower arm and wrist places stress on the hand and
elbow.
- Prolonged standing, sitting or holding the arm or neck in a static posture can
fatigue the shoulder, leg, neck or hand, as well as create a contact stress on various
body parts such as feet, buttocks and the
legs.
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Possible Solutions
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Place the patient and equipment in a position to allow
the sonographer to work, as
much as possible, in neutral postures that include straight wrist, bent less
than 15 degrees, back straight, elbow close to the body, and head
balanced. The following can help maintain these
postures:
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- Reposition the patient and equipment to allow the sonographer to
alternate between right and left hand scanning. This provides periods of
rest for the hand/arm not used during the scan.
- Keeping the body part to be scanned directly in front of the sonographer. (Figure 1)
- Instruct patients to orient themselves to assist the sonographer
in using neutral postures while performing scans. For instance, while
performing scans on the side of a patient, have them roll
onto their side.
- Instruct patients to move as close to the sonographer as possible during scans.
- Move to the other side of the table rather than reaching over the
patient.
- Scan carotid arteries or thyroid glands from the head of the
patient rather than reaching from the side.
- Avoid working behind the mid-line of the body, especially when
performing transvaginal exams. Move to the feet for better access.
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Figure 1. The patient is close to the sonographer, minimizing reach.
The chair is higher and the sonographer’s eyes are level with the
top of the monitor.
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- Keeping the head balanced and looking essentially straight ahead.
Do not turn head to the side or look up or down.
- Keeping shoulders relaxed. Do not hunch or raise the shoulders up during the
procedure.
- Keeping the torso straight. Do not bend.
- Keeping the elbow bent at about 90 to 110 degrees and close to the body. Do not reach out and
away from the body. The elbow should not be farther from the torso than about 30 degrees.
- Keeping the wrist straight, not flexed, extended or deviated to either
side.
- Minimizing sustained bending and twisting and exertions such as
reaching and lifting.
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- Alternating between sitting and standing positions.
- When sitting, ensure that feet and back and buttocks are
supported.
- Work in a standing position when performing procedures that
require significant force or when working with bariatric patients.
When standing:
- Keeping both feet on the ground and weight evenly distributed.
- Use anti-fatigue mat or cushioned insoles when standing on hard
floors for prolonged periods of time.
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Figure 2. A natural reach zone where the most frequently accessed controls
are easily accessed in the sitting or standing position, using the left or
right hand. |
- After standing, work in a seated or sit/stand position which
provides periods of rest for the feet, legs and back.
- Grip the transducer with the whole hand as much as possible.
Minimize using only the fingers to grip the handle.
Take mini or working rest breaks.
- Periodically look away and focus at a different distance for a few
seconds to allow the eye muscles a period of rest and recuperation.
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Positioning and Adjusting the Exam
Table
The position of the table within the exam room is critical as
is the
table's design and adaptability. It should be positioned in an area where there is
access to all sides of the patient, as well as to the other tools and devices
needed for the scan. It should be adjustable a vertical height where it is
convenient for a variety of sizes of sonographers. Drop-down sections or
cutouts should be incorporated and used whenever appropriate to minimize
stressful postures.
Potential Hazard
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- Lack of adequate height adjustability for exam tables may cause the
sonographer to:
- Lean, twist and bend at the waist if the sonographer is too tall
for the table height.
- Tilt the head forward or to the side if table is too low.
- Elevate and abduct (spread) the arm if table is too high. (Figure 3)
- Use elevated arms to reach up and over patients.
- Use of awkward postures such as extended and elevated reaches or bent
wrists when accessing areas of the patient. This is especially the case if repositioning is
limited by the exam bed being positioned close to obstructions such as walls
or incompatibility of the chair and table.
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Figure 3. The table is too high, the chair too low, and the patient
too far away causing the sonographer to lean and reach. |
Possible Solutions
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- Examination tables should be height-adjustable to minimize extended
reaches, elevated arms and wrist deviation. The examination table
should:
- Elevate to allow taller sonographers or those that prefer to stand
while
performing procedures without bending at the waist.
- Lower to allow shorter sonographers or those who prefer to sit
while
performing procedures without lifting the arm to reach up and over
patients.
- Elevate or lower so most scans can be performed with a minimum of
bending of the wrist.
- Lower so that patients can get onto the table with minimal effort
and allow the sonographer to raise the table to perform the scanning task.
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- Examination tables should provide adequate access for a number of
procedures and patient applications.
- Cutouts on the side can provide improved access to the apical
(heart) region for cardiac imaging.
- Stirrups and removable dropped footboards provide improved access
when performing certain gynecological procedures.
(Figure 4)
- Provide height-adjustable equipment (e.g., monitors, keyboards and
beds) so sonographers can frequently change
from a seated posture to a standing posture while still maintaining
neutral body postures.
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Figure 4. A removable or droppable footboard provides better access and
allows the sonographer to avoid shoulder injury by keeping their arm by
their side. |
- Ensure open access from all sides of tables and consoles to provide
sonographers with sufficient space for the sonographer's legs. This allows the sonographer
to get close enough to minimize extended reaches.
- Be aware of and use ergonomic principles when moving heavy items
such as exam tables or consoles.
- Unlock wheels before attempting to move items.
- Push rather than pull unless the item moves easily.
- Try to push with the hands at about chest height.
- Enlist the assistance of others if the object is difficult to
move.
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Since scans may be time-consuming, it is often appropriate to provide some
kind of seating to allow the sonographer to have periods of rest and
recuperation. If provided, the chair must be height-adjustable and movable
to interface appropriately with the exam table and the ultrasound console.
It must also accommodate a variety of sonographers and procedures.
Potential Hazard
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- Sonographers may be required to perform extended reaches, elevated arms and
possibly need to reach behind the plane of the torso (Figure 5) if:
- Seating is positioned below the exam table or other items used during
the scan.
- Seating is improperly positioned in relation to the exam table or other
items used during the scan.
- There is inadequate room under the exam table due to obstructions that
force the sonographer to sit away from the table.
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Figure 5. Cardiac scanning without a height-adjustable table and
chair forces the sonographer to lift the arms away from the body. |
- Sonographers may experience contact stress to the back of the legs or
wrists and forearms if:
- Seating is positioned below the exam table or console so that the
forearm rests on a hard or sharp work surface.
- There is inadequate support for the feet when chairs are elevated.
- Sonographers may work with a bent wrist if the
seating is too high or low in relation to the patient or the console.
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Possible Solutions
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- Provide height-adjustable chairs and exam tables so the height
of the sonographer can be adjusted in relation to
the patient and ultrasound equipment. The height should be
adjustable so the sonographer can:
- Keep the elbows close to the torso and the forearm
approximately parallel with the floor. Reaching up to 20 inches
can fatigue the arms in as little as 7 minutes. [Handbook of Human
Factors and Ergonomics, 1997]
- Keep the back straight and supported by the backrest of the
chair.
- Keep the wrist straight and inline with the forearm.
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- Provide seating with support for the buttocks, feet and torso
(Figures 6 and 7).
- Seating should have an adjustable foot ring if the
sonographer's
feet do not reach the floor.
- Seating should have a height-adjustable backrest to
support the back.
- Seat pan should be padded and large enough to support the
buttocks and thighs.
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Figure 6. |
Figure 7. |
The knees are lower than the hips and the correct
upright position is maintained. The back and torso are supported
for a variety of procedures. |
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- The configuration of the seating should be compatible with the
other items in the exam room, such as tables and consoles.
- Seating should generally not have armrests since these limit
access to the patient and
interfere with other items in the exam room.
- A sit/stand seat or a chair with a saddle type configuration
allows the knees to be lower than the hips.
This can be beneficial in situations where there is restricted
space under the table or console.
- Provide height-adjustable equipment so that sonographers can frequently
change from a seated posture to a standing posture while still
maintaining neutral body postures.
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- Provide adequate space and maneuverability for placement of
the chair, exam table and console so the sonographer can perform
scans while maintaining neutral postures. (Figure 8)
- Ensure open access from all sides of tables and ultrasound
equipment to
provide sufficient space for the sonographer's legs. This
will allow the sonographer to get close enough to the patient to minimize extended reaches.
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Figure 8. A removable or droppable footboard provides better access
and allows the sonographer to avoid shoulder
injury by keeping their arm by their side.
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- Reposition the seating as needed throughout the exam to
minimize reaching. The chair may be the primary item for
rearrangement, since the chair is probably easier to move than the
console or exam table.
- Provide a swivel seat on the exam chair so that the sonographer can easily
turn from the ultrasound equipment to the exam table. This will allow the
sonographer to keep the work directly in front of the body and minimize
extended reaches and reaches behind the plane of the body.
- Seating should have casters for ease of arrangement around the
exam table but the casters should be lockable to prevent the chair
from rolling backward.
- Work from a seated posture to provide periods of rest for the
feet and legs. Be aware that a standing posture is often better
when performing tasks that require significant force or large
range of motion.
- Note: Use of insoles rather than fatigue matting may be preferable
since fatigue matting can make moving items around the exam
room difficult.
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Positioning the Ultrasound Equipment
The keyboard and the monitor are the principle interface points between
the sonographer and the ultrasound equipment. This section deals primarily
with the keypad, toggle, thumbwheels or devices typically found on the
keyboard. See
Positioning the Monitor for information on the monitor.
Potential Hazard
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- Repeated reaching to the keyboard while performing ultrasound exams can
stress the upper arm and shoulder.
- Repeated toggling and keystrokes with the wrist in a extended posture can
stress the wrist and hand.
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Possible Solutions
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- Provide adjustable chairs and exam tables so
the posture of the sonographer can be properly adjusted in relation to the
patient and ultrasound equipment (Figure 9). Adjustments should allow the
sonographer to:
- Keep the elbows close to the torso and the forearm
approximately parallel with the floor by adjusting the height of the
keyboard.
- Keep the back straight and supported by the backrest of the chair
by allowing the ultrasound equipment to be properly positioned
horizontally and vertically in relation to the sonographer.
- Allow the neck to balance comfortably on shoulders without
twisting, leaning forward, tilting back or bending to the side. Position the
keyboard in relation to the monitor.
- Keep the wrist straight and inline with the forearm by raising,
lowering or tilting the keyboard for both sitting and standing
operations.
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Figure 9. Sonographer can maintain the arm close to the torso while
scanning and operating the console. The monitor can be viewed without
tilting the head. Postures are maintained and the feet are firmly
supported. |
- Place the ultrasound equipment as close to
the exam table as possible to minimize the awkward postures, such as
reaching and turning of the head, that must be used while performing the exam.
Ideally, sonographers should be able to access all equipment and materials
while keeping the elbows close to the body.
- Position the ultrasound equipment as close to the sonographer as possible. The
equipment should either be pulled closer to
the sonographer or the sonographer should move the seating closer to the
console.
- The ultrasound equipment should be easily movable to allow for frequent changes
between right- and left-handed scanning.
- The keyboard should move independently of the monitor.
- Be aware of and use ergonomic principles when moving heavy items
such as exam tables or ultrasound equipment.
- Unlock wheels before attempting to move items.
- Push rather than pull.
- Try to push with the hands at about chest height.
- Enlist the assistance of others if the object is difficult to
move.
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The monitor is a critical part of the exam
ultrasound equipment. Sonographers must
view the monitor while operating the transducer to ensure that they are
obtaining the proper visual scan. Older ultrasound equipment often
provides little adjustment possibility, especially for the monitor which is
often attached directly to the console.
Potential Hazard
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- Repeated use of awkward postures due to inappropriately placed monitors.
- Repeated or prolonged looking to the side to view monitors.
- Repeated or prolonged tilting of the head up or down to view monitors
that are too high or too low. This is especially a problem for bifocal
sonographers.
(Figure 10)
- Leaning forward to view distance monitors or monitors
with image that are unclear due to poor resolution or excessive ambient lighting.
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Figure 10. Equipment and monitor at a fixed height. |
- Eye strain, blurred vision, double vision, dry eyes and headache
resulting from prolonged concentration to view images that are unclear or
washed out on the monitor.
Possible Solutions
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- Provide a fully adjustable monitor on a monitor arm which is
detached from the main console (Figure 11). It should be easily
positioned for both sitting and standing postures and for a variety of
procedures. The following can help maintain a correct body posture:
- The monitor should be placed directly in front of the sonographer to
minimize looking to the side.
- The top of the monitor should be at about eye height with the
viewing area slightly below eye height.
- The monitor may need to be adjusted downward for bifocal wearers.
- The monitor should be about 18 to 30 inches in front of the
sonographer.
- Generally, flat screen monitors are lighter and easier to adjust to
varying positions for a variety of procedures.
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Figure 11. This monitor is independently adjustable from
the console, allowing it to be ideally positioned. |
- Have a monitor on each side of the bed. These should be easily
repositionable. LCD or plasma monitors are preferable in high light
areas.
- Consider the following measures to reduce eye strain when using the
ultrasound monitor:
- Use a flat screen LED monitor that will provide better
contrast and picture in high ambient light conditions.
- Close blinds or dim lights to lower ambient lighting.
- Adjust illumination, brightness and contrast to improve visual
clarity.
- Use single vision or custom eyewear that is
appropriate for the viewing distances found in most ultrasound
procedures.
- If possible, look away from the monitor for short periods during
extended procedures.
- Do not share the monitor with patients if this compromises proper
placement of the monitor for the sonographer. Provide an additional monitor
for patients if they need to view the procedure.
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