While ultrasound itself has not been shown to be clinically harmful, performing an ultrasound examination comes with certain, easily-avoidable risks.

One of the main ways you must avoid harming a patient on this rotation and "insta-failing" is to cause a patient to fall from bed or leave them in a position that increases their likelihood of doing so.

When performing a study, you may use the foot pedals to raise the bed to a height that makes it comfortable for you perform the examination.  This will involve "pumping" the bed up with a foot pedal.  

While the patient bed is being raised and while it is elevated, the railings on both sides of the bed MUST be up. 

Ultrasound examinations should be performed with you on the patient's right, just as a physical examination should be performed. While you are standing and performing a study, your body should be acting as a sufficient barrier to the patient falling from that side of the bed. Then and only then, the patient's right railing closest to you may be lowered so you can better access the patient. If you step away from the bed and are not immediately next to the bed, the railing must be re-raised.

The patient's LEFT railing should be up before starting, during, and after completing your entire study.

When you have completed your study, raise all railings, and lower the bed as low it will go.  If the patient is left on an elevated bed with the railings up, and later were to try and leave their bed, they might try to wiggle down off the foot of the elevated bed.

Some patients you encounter may be in "spine precautions," meaning they are not to be moved from their supine / flat positioning. If you have any concerns regarding this, check with the patient's nurse or caregiver.  Realize that some patients may not know their own movement restrictions.

Some ultrasound views are improved with the patient rolling to their side, or by sitting upright.  If they are in any type of spine precautions, AVOID this repositioning.

Some ultrasound views are improved by laying the patient flat.  However, some patients have medical conditions such as heart failure that make laying flat difficult.  

NEVER position a patient in a way they can not tolerate or in which they do not feel comfortable unless doing so under the direct supervision of the care team.

Performing an ultrasound exam involves exposing a patient's covered skin and applying a wet ultrasound gel that conducts heat away from the body.

Both for patient comfort and to prevent heat loss, expose only the minimal amount of skin needed, and drape dry hand towels over as much of this exposed area as possible. Towels should be positioned above and below your scanning field so as to minimize gel contact with the patient's clothing / gown.

When done examining one body area, remove the gel with hand towels or washcloths before moving onto the next body area.

If the patient's gown is uncomfortably or noticeably wet from ultrasound gel when done scanning, offer them a dry replacement from the upper cabinets in their room or from the linen supply in the department.

If you are performing a point-of-care ultrasound examination, then you are actively participating in a patient's care and expediting their workup.

However, if you are performing a training ultrasound examination, then you must make every attempt to ensure you are not impeding their care in the department and prolonging their stay.

While performing a training exam, if anybody comes into the room to speak with the patient, you must actively be aware and make sure that person does not see you performing your scan and leave.  That person may mistake your exam as a part of the patient's care, and decide to come back later.

You are the "lowest person on the totem pole" when performing a training study. If radiology comes to take the person to an x-ray, or if registration comes in to take patient information, or if dietary comes in to take a meal order, then you must either pause your exam, end your exam, or work around these administrators and ancillary staff.

Other examples include nursing coming in to draw blood, to discharge or move the patient, to take them to the restroom, etc.

While scanning, if you hear someone come in and leave quickly behind you, presume they left because they saw you performing an examination.  Quickly lower and secure the patient, and chase down that person to see what they needed, and explain that they "outrank" you and should go into the patient's room.

While we can assure our patients that ultrasound is safe and has not been shown to cause tissue damage, ultrasound is still energy, and we want to expose patients and their sensitive tissues to as little energy as possible, or As Low As Reasonably Achievable (A.L.A.R.A.).

This is particularly important for a few scans you may perform.

For ocular studies, the retina is considered a sensitive tissue, hence the probe must be in ophthalmic mode, which will decrease the energy delivered to the tissue.  Two of our machines have linear probes that possess this mode, but one does not (the green machine), and can not be used for ocular studies. The other way to remember this is that our wider linear probe on the green machine doesn't fit into the orbit that well in the sagittal plane, which should remind you not to use it for ocular studies.

For pregnancy studies, the probe (curvilinear for transabdominal, endocavitary for transvaginal) must be in obstetric mode.  All our machines have this mode.  Further, when assessing fetal heart rate, M-Mode should be used.  Using Doppler to "hear" the heartbeat results in unnecessary energy being applied to the sensitive fetal tissue.

It is important to remember that our Emergency Department is a CLOSED and LOCKED unit of the hospital.

There may be police running through the halls, violent patients, wet floors people can slip on, and chemical and pathogen exposures that could occur.

The only people allowed in our ED are either employees and students with badges on that grant them access to our ED, or patients who have been checked in.

You may not bring people into the ED who are not approved to be there to scan them, as it puts them and your career at risk.

If you would like to perform a training exam on a person who is already in the ED (such as a medical student on the general ED rotation, a resident or nurse  in the ED who has a few minutes, etc.), it is acceptable to do so, as these people are all approved and insured to be in the ED in the first place.

The ultrasound machines should also not be removed from the ED in order to scan someone outside of the physical boundaries of the department.