Patrick D. Coon, RCCS, RDCS, FASE

Lately there has been a fair amount of discussion in the adult echo community about adult sonographers who are expected to learn how to scan infants and children for congenital heart disease (CHD) in nurseries and neonatal intensive care units. I actually chose these words with a purpose. Firstly I would not personally use the term “expected” but rather, I would use the phrase “given the opportunity” to learn a new skill. This truly is an opportunity to add a new and rewarding skillset and increase a sonographer’s marketability. As a hiring manager, I would always place great value on a sonographer who has this ability to expand the reach of the echo lab. In addition, it offers the sonographer a great deal of personal and professional satisfaction to become an important part of the care for such a fragile patient population. I also would not think of the opportunity as “scanning congenital heart disease.” I would think of the opportunity as “screening” for CHD as the infant who does have an abnormal echocardiogram in this setting will be further scanned by a fully qualified and fully trained pediatric echocardiographer further down the line. It is unrealistic to expect a sonographer who has not had years of training to comprehensively document all of the abnormalities that are possible in every anomaly seen in pediatric cardiology. Perhaps an example can further illustrate: an adult sonographer who is presented with an infant with transposition of the great arteries should not be expected to also delineate the course of the coronary arteries as the possible configurations are too complex and far too varied. Even seasoned pediatric echocardiographers have difficulty at times in these cases, and it is not uncommon for these infants to undergo coronary angiograms prior to surgical palliation. If the adult sonographer is capable of delineating the coronary arteries then this an added bonus, but I know very few pediatric cardiologists who would expect this level of expertise from an adult sonographer screening the infant in the neonatal Intensive Care Unit.

Training the adult sonographer to screen for CHD should start with a plan and a clear-cut set of measurable goals over a prescribed time period. As such, here is a possible plan that I would recommend:

• 1.
  

  Get support and guidance from the interpreting pediatric cardiologist. I would recommend meeting with the pediatric cardiologist and developing a plan to learn these new skills and develop a reasonable set of expectations. This is first and foremost the most important step.

  
  
• 2.
  

  Learn to scan “anatomically correct.” One of the most difficult aspects is to learn a new way of looking at images but once the sonographer has developed this skill, it becomes much easier to determine situs and spatial relationships by viewing images as if one were looking directly into the body.

  
  
• 3.
  

  Learn to become comfortable scanning very small patients. Scanning a 1000 gram neonate demands a delicate touch. There are some very useful skills needed with respect to this bit of advice. For example, if the heart rate begins to drop suddenly, the sonographer may be pressing too hard and occluding the inferior vena cava. Use a light touch and remember that gel is our friend. Use lots and lots of gel.

  
  
• 4.
  

  There are many useful textbooks, DVD’s, and courses one can utilize to learn the complexities of CHD. An even better approach would be to spend one day a week in a pediatric lab and work directly with the pediatric echo team, although this approach is not always possible or practical. Set a goal, and learn everything you can each week. Start with the “simple” cases of CHD such as ventricular septal defect, patent ductus arteriosus, or atrial septal defect. Perhaps setting a goal to study and learn everything you can about one anomaly each week is reasonable.

  
  
• 5.
  

  Unless you are scanning patients with surgically palliated CHD, forget about all the surgeries…for now. While it is helpful to be able to tailor your initial scans based on the possible surgical interventions, the vast array of pre-operative evaluations is better left to the experts in the pediatric labs.

  
  
• 6.
  

  Read the ASE’s guidelines on the performance of pediatric echocardiography. Not only will reading this document help you set up reasonable goals, it will also help you set reasonable goals with your own hospital administration as it contains very specific core competencies for the performance of pediatric echocardiography. This is a terrific document written by the most respected thought leaders in pediatric echocardiography.

  
  
• 7.
  

  Take a deep breath, relax, and remember no one is expecting you to be the expert. Look at the opportunity as a challenge and to advance your skill sets. Remember that at the end of the day, you are primarily screening infants for ductal dependent lesions. It will take a long time to become comfortable in this new role so take each small success and enjoy it.

Screening the infant for CHD is truly a challenge, but with persistence, patience, and proper clinical and administrative support, this new skill set will prove to be rewarding and fascinating. At the end of the day, you will become the front line clinician who helps very sick children lead a long and healthy life.

Scan on and good luck!

Patrick D. Coon, RCCS, RDCS, FASE, works at Virtua Voorhees West Jersey Health Systems and is the immediate past Chair of the ASE Council on Cardiovascular Sonography Steering Committee.