transvaginal ultrasound limitations

Sue wrote:

I think you are reaching Anne. I intrepreted it different as the tech was
finding out information from the OP and because of who knows what, the tech
couldn't see anything at first with the first probe and then she went to the
second. Just because a tech has a hard time with something doesn't mean she
is at fault or needs updating. Why do you have such a hard time with the
tech using a different probe to see what is going on?

Perhaps you missed one of Lynn's followups, but it
wasn't just a matter of asking if there was any bleeding or
switching probes. There was apparently much more conversation
about how she couldn't see anything and how it could be a
miscarriage and how even the previous week's positive pregnancy
test didn't mean anything, and so on. Also, it was not a tech,
it was a midwife doing the screening.

Regardless of anything else, she exhibited poor "bedside
manner." There is no way that you start in with a conversation
as if it's a likely miscarriage without having done due diligence
to eliminate other possibilities. To have gone on about a
miscarriage *prior* to having tried the abdominal probe and
*without* making it clear that the situation could be something
as simple (and benign) as a tipped uterus or the limited "view"
with the transvaginal probe simply isn't appropriate. This
midwife is not dealing purely with clinical issues. She's
dealing with a real, live pregnant woman whose worst fear
is a miscarriage. The way she handled this situation was
very, very tactless, and that's not ok.

Best wishes,
Ericka

On Feb 8, 6:42 am, Ericka Kammerer wrote:
Sue wrote:
I think you are reaching Anne. I intrepreted it different as the tech was
finding out information from the OP and because of who knows what, the tech
couldn't see anything at first with the first probe and then she went to the
second. Just because a tech has a hard time with something doesn't mean she
is at fault or needs updating. Why do you have such a hard time with the
tech using a different probe to see what is going on?

Perhaps you missed one of Lynn's followups, but it
wasn't just a matter of asking if there was any bleeding or
switching probes. There was apparently much more conversation
about how she couldn't see anything and how it could be a
miscarriage and how even the previous week's positive pregnancy
test didn't mean anything, and so on. Also, it was not a tech,
it was a midwife doing the screening.

Regardless of anything else, she exhibited poor "bedside
manner." There is no way that you start in with a conversation
as if it's a likely miscarriage without having done due diligence
to eliminate other possibilities. To have gone on about a
miscarriage *prior* to having tried the abdominal probe and
*without* making it clear that the situation could be something
as simple (and benign) as a tipped uterus or the limited "view"
with the transvaginal probe simply isn't appropriate. This
midwife is not dealing purely with clinical issues. She's
dealing with a real, live pregnant woman whose worst fear
is a miscarriage. The way she handled this situation was
very, very tactless, and that's not ok.

Agreed, I don't think the problem with her knowledge of ultrasound,
but with knowing when to keep her mouth shut. An element that's been
left out of a lot of this conversation is that the OP was also
measuring quite small for dates, so there were two consistent
worrisome pieces of information. The midwife concluding during this 5
minute period that this may well be a miscarriage may have been quite
appropriate. She just shouldn't have said anything quite yet. Or if
she started to raise some concerns, she should have been a little more
vague and noncommittal rather than trying to reinforce her position by
replying that the positive pregnancy test doesn't mean anything.

There is a tendency among some folks (for example much of the
misc.kids community) to want medical providers to communicate
everything and think it's a grave sin if we're worried about something
but don't tell the patient/parent. At the same time, if we raise
fears that turn out to be unjustified, that's also a grave sin. And
in most practices, the misc.kids community is an extreme end of the
informed patient spectrum -- most people don't want (or aren't
equipped to remember or understand) discussions about the nuances of
the various conflicting evidence about one thing or another, they just
want the darned answer. So though I agree with Sue that this
community is very quick to come down harshly on medical providers for
what are sometime small infractions (I would call the one that started
this thread certainly a faux pas, but not a grave infraction) it
doesn't surprise me in the least.

Kate, ignorant foot soldier of the medical cartel
and the Bug, 4 and a half
and something brewing, 4/08

I don't think the problem with her knowledge of ultrasound,

Disagree. I do think it is a problem with ultrasound skill.

I am a CNM and also ARDMS certified for OB sonography. The basic CNM
training does not cover any sonography skills at all. Limited second
and third trimester sonography is commonly added as an expanded
practice skill according to ACNM procedures. First trimester and
transvaginal sonography require more specialized training and really
should be certified by ARDMS.

Blaming this incident on a retroverted uterus is a nice way to let
this CNM off the hook, but seriously alarms me about this person's
skill level. She obviously was not able to identify the pelvic
anatomic landmarks. The only way any qualified person should have
trouble finding the uterus with transvaginal ultrasound is if the
patient has had a hysterectomy. If anything, a transvaginal approach
is easier to visualize a retroverted uterus because the uterus is more
distant from the ventral abdominal wall.

Anyone who starts talking about a miscarriage without having found the
gosh-darned uterus, for gosh sakes, has shown seriously bad clinical
judgement. This is someone who does not know when they know what they
are doing and when they don't know what they are doing, and someone
who tries to "wing it" when she gets in over her head. Any provider of
any kind should be comfortable saying they are seeking a more expert
or more specialized assessment when they aren't sure what's going on.

I think there is a serious professional judgement and standards
problem going on here and I would not be comfortable with this person
taking care of me or my family.

Minimally, find out what this person's qualifications are for
ultrasound before allowing her to scan you in the future.

alath wrote:
I don't think the problem with her knowledge of ultrasound,

Disagree. I do think it is a problem with ultrasound skill.

I am a CNM and also ARDMS certified for OB sonography. The basic CNM
training does not cover any sonography skills at all. Limited second
and third trimester sonography is commonly added as an expanded
practice skill according to ACNM procedures. First trimester and
transvaginal sonography require more specialized training and really
should be certified by ARDMS.

Blaming this incident on a retroverted uterus is a nice way to let
this CNM off the hook, but seriously alarms me about this person's
skill level. She obviously was not able to identify the pelvic
anatomic landmarks. The only way any qualified person should have
trouble finding the uterus with transvaginal ultrasound is if the
patient has had a hysterectomy. If anything, a transvaginal approach
is easier to visualize a retroverted uterus because the uterus is more
distant from the ventral abdominal wall.

Anyone who starts talking about a miscarriage without having found the
gosh-darned uterus, for gosh sakes, has shown seriously bad clinical
judgement. This is someone who does not know when they know what they
are doing and when they don't know what they are doing, and someone
who tries to "wing it" when she gets in over her head. Any provider of
any kind should be comfortable saying they are seeking a more expert
or more specialized assessment when they aren't sure what's going on.

I think there is a serious professional judgement and standards
problem going on here and I would not be comfortable with this person
taking care of me or my family.

Minimally, find out what this person's qualifications are for
ultrasound before allowing her to scan you in the future.

Thank you so much for posting this, in my head I was thinking the exact
same things, I just obviously wasn't explaining them that well. She
should know what she was seeing and if she wasn't seeing a uterus then
she should know she wasn't seeing it, even if she didn't know why (I
wondered if a full bladder in preparation for abdominal ultrasound came
in to play).

Cheers
Anne