SDMS Speaks Out for Sonographers at OSHA Hearings on Ergonomic Injury Rules

SDMS demonstrates its commitment to advocacy support by representing the profession at the Occupational Safety and Health Administration (OSHA) hearings on ergonomic injury. Due to the dramatic and ever-increasing impact of musculoskeletal injury (MSI) within the profession, the SDMS will take a strong stand to protect the well-being of all sonographers.

The SDMS, represented by immediate-past president, Joan Baker, MSR, RDMS, RDCS, presented the testimony to OSHA in support of the proposed rules on ergonomic injury. The proposed rules contain the most encompassing worksite interventions ever proposed by OSHA. The issues addressed in these rules directly relate to the MSI that thousands of sonographers across the world are experiencing or may face in the near future.

In addition to Ms. Baker’s testimony, two SDMS members share their experiences with MSI.

Following are reprints of the testimonies to OSHA.

Joan Baker’s Testimony for OSHA Proposed Ergonomic Injury Worksite Rules

My name is Joan Baker. I am presenting this testimony and support information to you today as one of the estimated 100,000 allied health professionals performing ultrasound procedures in the United States. I am also an official representative of the Society of Diagnostic Medical Sonographers (SDMS). The SDMS is the largest professional association for Sonographers in the world with a membership of approximately 11,000. I am its immediate Past President and have been actively involved in the profession for 40 years. My resume is attached to my testimony.

Sonographers use an ultrasound machine that emits high frequency sound waves to obtain internal views of the human body. The transducer is a hand-held instrument, which produces the sound waves. A gel is applied which provides a coupling between the transducer and the skin. The transducer must be gripped tightly so that downward force can be exerted onto the body. The equipment design as well as the width of the stretcher limits how close the operator can be to the patient.

Typically, the sonographer has to lean across the patient’s body without shoulder or elbow support to view organs on the patient’s left side. This causes the head and neck to be twisted in order to view the dynamically changing image on the monitor, which is usually located to the left of the sonographer. The monitor and the controls that must be constantly adjusted are attached to a 300-600 pound piece of equipment. The monitor and the controls cannot be detached or adjusted to accommodate the different sizes of sonographers and the different positions they assume while performing an ultrasound procedure. The transducer is attached to the equipment by cords that are quite long and heavy. The abduction and elevation of the scanning arm and the muscular forces needed to maneuver the transducer and apply downward force produce the shoulder injuries. It is the twisting that produces the neck injuries.

Photographs of these operator positions are included with this testimony, so that you can visualize the positions that I am describing Sonographers practice in a variety of medical specialty areas — the best known being the pregnant woman but also in blood vessels and the heart. Sonographers are employed to provide these healthcare services in hospitals, clinics, and outpatient centers.

After reviewing the proposed OSHA ergonomic injury rules we support the adoption of them. Ergonomic injuries have represented a crisis within our profession for about 10 years. Change in equipment design and the acceptance of ultrasound as a modality of choice, in the diagnostic work up of a patient, has led to this dramatic incidence of MSD.

Some of the documents we have provided as support for this testimony refer to injuries as repetitive strain injuries (RSI’s). I want to establish that MSI’s, RSI’s, WMSD’s and MSD all refer to the same ergonomic injury.

MSD is a major problem within our profession with a dramatic 81% prevalence rate in the United States. Which appears to be increasing in both severity and frequency. An estimated 20% of the 81% sonographers who are scanning in pain eventually have to end their career in this profession. Those sonographers, who have experienced an ergonomic injury that has created a career affecting disability, should have access to appropriate rehabilitation and work-site support without putting their jobs in jeopardy.

The cause of MSD’s in sonography is the duration of the procedure as well as the force required to produce optimal images. Scans take 15 to 45 minutes to perform and most of that time is spent in very compromised and difficult positions with no opportunity to relax from these static postures. The force required to compress the body fat and/or move bowel gas out of the field of view has been estimated at 4-40 pounds.

Damage in sonographers is related to the number of hours spent in active scanning, the number of procedures performed as well as the number of years in the profession.

In 1997, the SDMS conducted a study to determine the prevalence of MSD. This study was conducted by the Healthcare Benefit Trust of British Columbia Canada to ensure no professional bias in the conduct or analysis of the results. A detailed questionnaire asking 125 questions was mailed to 3,000 ultrasound professionals practicing in the United States.

While the SDMS study is by far the largest conducted within the profession 5 other independent surveys have been published all substantiate an incidence rate between 80-91% for an average of 84.5% for the United States. These published articles are submitted with this testimony. So many sonographers are suffering, we essentially have sonographer patients scanning and providing ultrasound services to patients.

It is very important that the sonographer can sustain a good ergonomic position while scanning. The technology and know-how exists to make ultrasound equipment “sonographer friendly”. Improved equipment such as narrow, height adjustable stretchers that go low enough, ergonomically designed chairs, and better-designed room configurations, would make a significant impact in reducing injury. Many of the stretchers that are provided are not even height adjustable. However, many employers are reported to be unwilling to consider these simple measures. We are supporting these proposed rules in order to obtain OSHA’s help. We are professionals and we are not being treated as such. Our data supports the following statement:

• 81% of sonographers have been scanning in pain and discomfort for almost half of their career.

There are certain activities that aggravate the pain. In priority order they are:

• Applying pressure
• Shoulder abduction
• Sustained and repetitive twisting of neck/trunk
• Performing studies at the patient’s bedside
• Holding the transducer (instrument that emits the sound wave)

The following parts of the body are the locations of the pain, which also correlates, well with the severity of pain. 1) Neck, Shoulder, Wrist, Lower back, Hand/fingers, Upper back, Eyes, Middle back, Upper arm.

The importance of severity should not be overlooked. For example, 70% report pain in the shoulder, with 40% describing this pain as severe.

Sonographers have typically used their own sick leave and vacation and even leave-without-pay before resorting to other options in an attempt to gain relief. Survey data indicate that 1 out of every 5 are forced to file workers’ compensation claims. 73% of these claims are accepted and approved by reviewing agencies.

The other area that is a major contributor to MSD injury is staffing and work schedules. Managers are requiring the staff to work harder and longer to overcome staff shortage. When medicine becomes a business, abuses of employees can and do occur. I believe this is one of the reasons why we have a dramatic increase in the number of injured and career-ended professionals.

At the same time technology that automates most of the support tasks for the ultrasound procedure has been developed. This permits more patients to be fit into the schedule resulting in short or non-existent breaks. Our survey showed that 50.2% receive none to only 1 break of 10 minutes or longer, in an eight hour day, in order to fit add-on or extra patients into an already full schedule. New methods of healthcare delivery have caused many managers to drive the workload to as much as double what it was a few years ago. This is in order to contain costs.

The manufacturers need to make dramatic changes in the design of ultrasound equipment. Until the monitor and the keyboard are completely adjustable and removable so that they can be optimally positioned these injuries will continue to happen. We need to require medical facilities to purchase equipment with the worker/employee and their health and safety as a significant rather than a negligible consideration.

This is why we urge the passage of these regulations, because until pressure is brought to bear on employers, no progress towards reducing these injuries will be achieved, and the costs of workers’ compensation accidents will continue to rise.

All this is doable, and is not too expensive. In fact it is cheap when compared to the cost of claims and injuries in dollars as well as emotional trauma from loss of careers.

Survey Study Research Objectives Determine prevalence of MSI and correlate known work & personal factors Develop instruments, protocols and methods to quantify risks Design and test interventions Recommend work load/procedural changes Recommend modification or redesign of equipment and/or environment

Survey Study Results - Aggrevating the Pain

SDMS Member's Oral Testimony (Susan L. Murphey)

I have been a Diagnostic Medical Sonographer since 1982. In my 18 years in the ultrasound profession, I have seen many changes and advances both in the field of diagnostic ultrasound and in the practice of medicine. It has been exciting and challenging to be in a profession that is on the cutting edge of technology. The applications and uses for Diagnostic Ultrasound have grown at a phenomenal rate in the past 20 years. As a result, we are performing more examinations than ever before.

The practice of medicine has changed dramatically, too. The focus has shifted to issues concerning reimbursement, increased productivity and minimizing expenses. Caregivers have been pressured to do more with less. These changes, along with the inherently poor ergonomic positioning required of sonographers, have been a major factor in the repetitive strain injuries that myself and many other sonographers have suffered.

The first evaluation for workstation hazards and work injury prevention strategies was done at my place of employment in 1995 as a result of sonographer complaints of pain when scanning patients. The major factor named in the promotion of injury in the report was related to poor equipment design. Many recommendations were made to improve the ergonomic situation, such as appropriate adjustable stools, foot rests, and external monitors -- all designed to improve postural alignment. None of these recommendations were implemented.

Instead, managers were pressured to increase the number of patients scanned. Schedules were adjusted to maximize the number of patients to be seen. As a result, our patient volumes went up, and our rest breaks between exams went down. Sonographers were now increasing the time spent in positions of postural dysfunction with little or no rest break available throughout the day.

In January 1999, after approximately two years of chronic neck and increasing right shoulder pain, I was diagnosed with right bicipital tendonitis and impingement syndrome of the right shoulder. I was put on light duty off and on from January through June of 1999. Despite this, I experienced increased pain and decreased range of motion of my neck and right shoulder.

A second ergonomic job analysis of my workplace was performed in April of 1999. Again, no equipment changes were made.

My condition continued to worsen in spite of extensive physical therapy, steroid injections and prescription regimens until my right shoulder range of motion had decreased to the point of being non-functional. I was no longer able to perform even my basic daily living tasks.

I lost the ability to fully care for myself or my family. I could no longer complete household chores such as cooking, laundry, cleaning or making beds. I couldn't sleep at night, I had difficulty dressing and driving my car. My children got to the point of asking if this was "the hurting arm" before holding my hand. I could no longer hug or be hugged without excruciating pain.

In July 1999, at the age of 39, I was diagnosed with adhesive capsulitis and a frozen right shoulder. After an additional eight months of intensive physical therapy including the manual "breaking" of shoulder adhesions, supervised stretching, strengthening exercises and a home therapy program, I now have approximately 85% of normal range of motion in my right shoulder. In spite of being considered "functional" at this point, it is possible that I will never regain full range of motion in my shoulder. I continue to have neck pain as a result of muscular compensation for my right shoulder injury.

Not only is the future of my professional career in question, but I also fear that I will be living the rest of my life with chronic pain and a degree of musculoskeletal dysfunction. I expect to be released to work sometime in the next month.

Meanwhile, I have lost 40% of my income for the last year and a half. I have been unable to contribute to my retirement account, and have lost medical and dental benefits for myself and my children.

An extensive work site assessment has been recently completed by an Occupational Therapist of a Work Injury Prevention team. The key factors in preventing re-injury or aggravation of my condition are working at the appropriate shoulder height and position, and providing support and rest for the shoulder from the static position required in ultrasound scanning, as well as frequent breaks. Recommendations have been made for taller, adjustable stool seating, an adjustable exam table, a foot rest, an external monitor and positioning cushions to support my arm while scanning. These recommendations are not unlike those made in the first ergonomic evaluation of 1995.

Unfortunately, managers do not have the support from their institutions to provide ergonomically sound environments for their employees even when the information is available. Additionally, there has been increasing pressure throughout the field to streamline productivity, often at the expense of their employee's well-being. This is not a local problem, but one that affects all who practice in the field of sonography, and without a final ergonomics rule, many more will continue to be injured. It is my hope that with the implementation of the proposed ergonomic rulings, there will be the support necessary to prevent additional injury to workers in professions such as mine.

SDMS Member's Written Testimony

Hello. My name is Jane Doe*. I am a Diagnostic Medical Sonographer, and I have come to this hearing today from Oregon to share with you my experiences stemming from an occupational injury. This injury has taken from me my professional career and my dream. Even more sadly, it has limited my ability to use my training and experience to help people, the very reason that I was drawn to a health care career in the first place. Unfortunately, my experiences are all too common because the health care industry has failed to take a number of precautions to prevent the kinds of occupational injuries that I have suffered.

It took a lot of soul searching and hard thought to persuade me to come here today. My injuries have brought with them a great deal of pain, both physical and emotional and it is very hard for me to speak about my experiences, but I know that I should because it is a way that I can still help other people.

Sonography, and the chance it gave me to help people, was and is my profession. I not only loved the patient care aspect but I also enjoyed teaching new students about my profession. I was at the peak of my career, teaching, lecturing, setting up schools and scanning. Unfortunately, after a long struggle that took more than two years, I have come to the sad conclusion that I can no longer be a sonographer and I have left the profession. The daily rehabilitation and toll of the constant scanning have forced this decision on me. I cannot tell you how much it hurts to say that, even now, after months of grieving over that painful decision. I loved being a sonographer; I am so very sad to have lost something that I loved so deeply.

My occupational health problems have a long history spanning more than two years. Initially I experienced pain along my right forearm with difficulty holding the transducer during long or difficult ultrasound scans. Eventually, I experienced pain during all my scanning procedures. Pain then became my constant companion during my waking and nighttime hours. Under the care of an orthopedic surgeon and after 8 months of therapy I received an MRI which showed a full thickness rotator cuff tear, a large spur and avascular necrosis in the head of the humerus or upper arm bone resulting from years of inflammation. The inflammation resulted from the constant irritation of the rotator cuff against the bone. This is the arm that I used to scan patients for as much as ten to twelve hours a day.

In the last 12 years that I worked I had less than 10 morning and afternoon breaks. Lunch time was only 1/2 hour and often that was missed. The demand was intense, with productivity paramount. This situation is common throughout the medical ultrasound profession. The physical strain that I had been under was actually destroying my tissues and bone.

Because of the seriousness of my condition, I was operated on in January of 1999. The surgery helped me with the symptoms relating to the rotator cuff tear and impingement in my shoulder. Subsequently, however, I was unable to move my shoulder to any significant degree, and I was in excruciating pain. I underwent another 10 months of intense physical therapy three times a week with hours of stretching, exercises and home therapy. During the last several months the therapy increased to 3-5 hours a day. It was so painful that it still upsets me to think about it, but it did, eventually, permit me to have movement back in my shoulder. After this, I was only able to work part time in administrative duties, and I could not scan any patients. I was extremely disappointed. I slowly progressed to scanning 2-4 short exams each day, but my employer wanted me to do more. Unfortunately, I still was unable to hold the transducer in the static position. Eventually, I not only experienced the initial type forearm pain but pain in my shoulder.

Since I continued to experience constant pain, I was scheduled for and underwent a second shoulder surgical procedure. The surgery relieved the pain from the scarring, labrial tear and bursitis but my orthopedic surgeon said that he could not fix the inflammation of the biceps tendon. After the second surgery, the pain has continued in my biceps tendon, and I now live with constant pain under my right scapula or shoulder blade. My physician has told me that these conditions are the permanent result of attempting to compensate from the pain, rotator cuff tear and the impingement that I experienced. Portions of my right hand go numb and I cannot hold anything out away from my body in a static position. This complicates and, in many cases, prevents even the most basic daily tasks like putting on make-up, ironing, typing, and folding clothes. Even the gentle tug of my grandchildren’s hand can be very painful.

My physician believes that the initial pain in my forearm and the numbness are due to carpal tunnel syndrome and he is currently attempting to determine if there is nerve damage to my elbow, shoulder, and neck. Although I long resisted taking this step, I have now had to concede that I probably will never be able to scan a patient again. My career is over.

1. My employer refused to hire adequate staff to give us the relief and breaks that we needed. We often scanned 10-12 hours a day without breaks or lunch.
2. My employer could have purchased adjustable gurneys. Many times we were forced to scan in awkward positions using the old, non-adjustable gurneys.
3. The transducers were large and heavy when other, lighter alternatives were available. (A transducer is the piece of the equipment that is held against the patient to focus the sound waves on the part of the body to be studied.)
4. My employer did not buy adjustable scanning chairs even though they were requested many times. Often we were required to stand throughout the exam or required to assume contorted positions due to chair height. Adjustable chairs are essential for a more comfortable and appropriate position.
5. My employer did not make the necessary room changes to accommodate the equipment, patient and sonographer. The equipment is often placed so the obstetrical patient can view the monitor. This forces the sonographer to scan in an extremely awkward position. The equipment and stretcher were located in a manner that I had to look one way and apply force (with the transducer) in a completely different direction. (Extra monitors for the patient were obtained only after my injury.)

All of these factors, and others, meant that my body was constantly in a tensed, strained and awkward position. My physicians have stated that my injuries are the inevitable result of those contortions and that constant strain. I hope that my experiences and my pain will demonstrate the need for real change in the way that ultrasound services are provided in this nation. I hope that my pain and my loss will have some meaning. I urge you, with all my heart, to protect my colleagues, the thousands and thousands of dedicated sonographers across the country who serve patients in need of our services.

Thank you so very much for the opportunity to speak today.

* Name withheld upon request.