Journal of Diagnostic Medical

Sonography http://jdm.sagepub.com

When Caring Hurts: The Silent Burnout of Sonographers

Gretchen Lee Blume
Journal of Diagnostic Medical Sonography 2002; 18; 418
DOI: 10.1177/8756479302238401

The online version of this article can be found at:

http://jdm.sagepub.com

Published by:

http://www.sagepublications.com

On behalf of:

Society of Diagnostic Medical Sonography

Additional services and information for Journal of Diagnostic Medical Sonography can be found at:

Email Alerts: http://jdm.sagepub.com/cgi/alerts

Subscriptions: http://jdm.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

Downloaded from http://jdm.sagepub.com at U. Coimbra - Faculdade De on February 14, 2007

© 2002 Society of Diagnostic Medical Sonography. All rights reserved. Not for commercial use or unauthorized distribution.
418 JDMS 18:418–421 November/December 2002

DOI: 10.1177/8756479302238401

JDMS 18:418–421 November/December 2002

JDMS 18:418–421 November/December 2002

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY November/December 2002 VOL. 18, NO. 6

WHEN CARING HURTS / Blume

FOCUSING ON THE ISSUES

When gency medical technicians, nurses, and social

workers. After 15 years of warnings, attention is fi-
Caring Hurts: nally being directed at the effects of MSI (musculo-
skeletal injury) on sonographers. Sonographers,
The Silent Burnout employers, and ultrasound manufacturers are at
last recognizing the debilitating effects of pro-
longed overuse and improper use of the musculo-
of Sonographers skeletal system. Although this current climate of
interest in sonographers’ well-being exists, it is
also important to recognize the threat of CF. This is
GRETCHEN LEE BLUME, RDMS, RDCS because CF has been proven to produce a progres-
sive loss of idealism, energy, and purpose in mem-
One of the most overlooked areas of sonography bers of the health care and helping professions. The
today is the job-related stress of today’s frenetic purpose of this article is to explore the sonographer
health care environment. The constant pressures to sources of compassion fatigue and to offer strate-
perform and conform at a faster and faster pace in- gies to address it. But, most of all, our goal is to put
evitably leads to stress. And, although stress is a at-risk sonographers in touch with the reality of CF
known normal part of life, such severe and pro- in their own lives.
longed demands can lead to sonographer disorgani-
zation, inefficiency, and even a loss of dedication Understanding the Problem
to the career.1 This phenomenon has been labeled
compassion fatigue. Many professional definitions Sonographers face stressful situations every
exist to define compassion fatigue; among the most day, from pregnant patients experiencing bleeding,
common are secondary traumatic stress, secondary absence of fetal heart tones, and suspicions of fetal
victimization, or compassion burnout. Perhaps the abnormalities to menopausal patients with
simplest definition, however, is that compassion bleeding and pain. Then, there are the patients sent
fatigue represents the emotional residue of expo- to rule out malignancy, those with life-threatening
sure to working with patients suffering either deep cardiovascular conditions, and transplant patients,
physical or emotional pain.2 suffering possible rejection, to mention just a few.
The Encarta Dictionary defines compassion as Every day, in an average ultrasound setting, at least
sympathy for the suffering of others, often includ- one patient will be scheduled whose scan produces
ing a desire to help. Fatigue is defined as mental or inner tension and thoughts of “I hope the exam
physical exhaustion, extreme tiredness or weari- turns out OK and doesn’t create any problems for
ness resulting from physical or mental activity.3 the patient or for me.” Most sonographers work
Appearing only recently in the professional litera- under the supervision of a physician or department
ture, compassion fatigue (CF) has been primarily head that sets the rules regarding how much the
associated with police officers, firefighters, emer- sonographer can say or do for and with a patient or
To Marveen Craig, RDMS, author, lecturer, teacher, sister, and client. Any policy against sharing the truth with a
exceptional friend, I thank you for your assistance, support, guidance, patient is as difficult for the sonographer as it is for
and encouragement from the conception to the birth of this article. that patient, especially when the news is not good.
DOI: 10.1177/8756479302238401
This fact is borne out by the statements of patients/

Downloaded from http://jdm.sagepub.com at U. Coimbra - Faculdade De on February 14, 2007

© 2002 Society of Diagnostic Medical Sonography. All rights reserved. Not for commercial use or unauthorized distribution.

clients attending grief and loss conferences that
routinely state the following:
It was more difficult to handle not knowing, when
we were confident that the person performing the
ultrasound study knew what the answer was but
wouldn’t tell us.
Many of us are passed around—sometimes for 2
or 3 hours—before our own doctor finally tells us
the baby is dead! Why can’t the sonographer just
be honest with us? We just want answers, no
matter what they are, so we can face any problems.
I had to wait until the next day to find out if my
baby was alive.
Much has been written about the stress and
hassles involved in a sonographer’s daily work
environment. Managing their own stress is one of
the toughest aspects of practicing as a sonographer.
It is now understood that when stressful condi-
tions become very cumulative, the victims will be-
gin to experience physical fatigue, sleep disruption,
headaches/body aches, and an increased suscepti-
bility to colds or other infections. As a practicing
sonographer, I face the risk of CF with every client
whose outcome is not what they expect or want. In
1 year, I scanned 1,084 obstetrical patients, with
410 patient studies scheduled for problematic preg-
nancy. Of those 410 patients, 128 resulted in fetal
loss, miscarriage, or ectopic pregnancy.
Let me share an actual example of severe patient
and sonographer stress. I worked with a client for 3
years. She had 1 child but wanted another, and she
had been referred to evaluate the probability of
miscarriage in her current pregnancy. The
sonogram confirmed that suspicion. I saw her 3
months later to confirm viability of a new preg-
nancy and found no fetal heart activity. She cried. I
saw her again, about 5 months later in yet another
pregnancy, and once again there was no heartbeat.
We cried. This scene was repeated 3 more times
over a period of a year and a half. Each pregnancy
was confirmed at 5 weeks, only to reveal absence
of any heart activity at the next examination. We
cried, we talked, and we hugged, but she became
noticeably less excited and more apprehensive with
each visit. My heart felt heavy each time I saw her
name on the schedule. She was crying before we
even began to scan her in her eighth pregnancy at-
Downloaded from http://jdm.sagepub.com at U. Coimbra - Faculdade De on February 14, 2007
© 2002 Society of Diagnostic Medical Sonography. All rights reserved. Not for commercial use or unauthorized distribution.
WHEN CARING HURTS / Blume 419
tempt, when suddenly I found a heartbeat! Al-
though she was 6 weeks pregnant by fetal pole and
gestational sac measurements, the heart rate was
only 99/bpm. I spoke with her health care provider,
and she gave the patient information regarding low
heart rate. We set up an appointment for 3 days
later. At that examination, the fetal heart rates were
88, 87, and 80/bpm. Her health care provider re-
quested another appointment for 4 days later. The
next exam revealed fetal heart rates at 60, 62, and
66/bpm. By this time she was emotionally upset 24
hours a day. Another appointment was made for 5
days later. It was very hard for her to come in and
see the “baby” still alive, knowing that the end
would soon be near. By now, all she wanted was for
it to be over. She told me she felt on the edge of san-
ity from the grief she felt for all of the miscarriages.
Watching this baby barely clinging to life was al-
most more than she could bear. She arrived for the
next appointment with tears rolling down her face.
The fetal heart rate was 34, 36, and 33/bpm. Fetal
growth had lagged and the gestational sac showed a
marked decrease in fluid.
She begged me to tell her there was no heartbeat,
but we both could see it on the monitor. Referred
for a repeat scan 2 days later, she looked me in the
eye and said “Tell me there is no heartbeat today.
Lie to me if you have to. I can’t take it anymore.” I
did not have to lie to her. This all took place 14
years ago, and I still feel remorse when I think of
her. I have seen her outside the office a few times
over the past few years. She never got that second
child. Now, when we meet, we hug but don’t have
very much to say. She is only one of hundreds of
patients I have worked with, gotten to know, and
cried for. Few sonographers are trained to endure
being placed in such situations day after day, or
even advised how to handle such pressure. Our
teachers and supervisors seldom give advice or
guidance about where to go to get the training nec-
essary to care for these special patients in a profes-
sional manner. How many times have you, the
sonographer, had to stand by as a physician coldly
tells the patient the results of their exam and
quickly walks out leaving you to deal with the sob-
bing patient? How many times have you yourself
cried after the patient has left the room, or even
cried with the patient? How many times have you
had to say “I’m sorry”? What do you do with these
420 JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY November/December 2002 VOL. 18, NO. 6
feelings of compassion, helplessness, sadness, and
remorse knowing that the next patient expects a
pleasant and professional sonographer to perform
their exam and give undivided attention to them?
All patients deserve healthy, happy, alert, and com-
petent professionals to perform their sonograms.
To become better equipped to handle problem
cases, sonographers need to be trained not only to
perform the duties a study calls for but also to pro-
vide care to the patient in whatever situation pres-
ents itself. Practicing sonographers are often
confronted by pregnant patients simply wanting to
know the sex of their baby and if it has all its fingers
and toes. In stark contrast, the very next scan may
have been ordered to rule out severe fetal anomaly.
In many cases, we face anguished patients who
want to know now if there is any chance their baby
will live. And, we are expected do this every day, in
no specific order, essentially ignoring the traumatic
effects on our minds and hearts. Supervisors may
appear to have no idea of the daily emotional toll
sonographers may face if they do not acknowledge
it in themselves. Even when they do, many supervi-
sors refuse to discuss it or face it themselves.
Sonographer coworkers may know what is going
on, but how many work in an environment where
there is time to talk about feelings and to get input,
encouragement, or even a comforting hug from one
another? How many sonographers are expected to
face their patients at the completion of the scan and
report the truth? What do they do when the patient
reacts to the message they have just delivered?
Recognizing Symptoms
It has been postulated that burnout is the cost of
high achievement brought about by devotion to a
career that no longer produces the expected re-
ward.4 Sometimes, a vacation or job reassignment
can alleviate such burnout. However, especially in
sonographers who have personally experienced
problems similar to those of their patients, there is
great risk of countertransference, the act of taking
on the emotional reactions of their patients.
A frequent sequel to both burnout and counter-
transferance is a condition called belief alteration,
in which the sonographers’ perceptions of them-
selves diminish while their feelings of a loss of au-
tonomy in both actions and thoughts increase.2,4 CF
Downloaded from http://jdm.sagepub.com at U. Coimbra - Faculdade De on February 14, 2007
© 2002 Society of Diagnostic Medical Sonography. All rights reserved. Not for commercial use or unauthorized distribution.
is not burnout, although burnout and belief alter-
ation can contribute to its development. Nor is the
source of CF merely the afflicted sonographers
overextending themselves. It comes, instead, from
the attitudes and the perspectives that drive them to
overextend themselves. Sonographers suffering
burnout may share the symptoms of helplessness,
loss of idealism, and the development of a cynical
negativism, but the distinguishing feature of CF is
the inability of sonographers to distance them-
selves from the pain of their patients.4
Those who develop CF often develop satisfac-
tion fatigue and watch their job performance go
down as their mistakes go up. Once their morale
drops, all of their personal and professional rela-
tionships will suffer. CF victims lack the energy to
relate to others. The relationships they traditionally
enjoyed with coworkers, friends, or family simply
evaporate. Sonographers who suffer from CF may
exhibit increased levels of cynicism, anger, hostil-
ity, and irritability. They begin to label anxious pa-
tients as overly demanding.1,4 If left unattended, the
effects can cause deterioration of their home life,
eventually leading to an overall decline in general
health and/or clinical depression (Table 1).
Working Toward Solutions
Addressing CF involves sonographers changing
their view of the needs they try to meet and their
own needs for nurturing and supporting them-
selves. There are positive actions to eliminating the
risk of CF, but tackling the problem is a team effort.
Sonographers must begin to pull together and care
for each other, as well as their patients, in order to
relieve the stress associated with their professional
activities (Table 2).
Supervisors can protect their staff by providing a
nonthreatening work atmosphere. In return, staff
sonographers can repay their managers by using
creative problem-solving behaviors. But, both
groups must be patient with one another and realize
that all of them carry heavy daily assignments.5–7
Educators also have a role to play by consciously
guiding their student-sonographers with care, ex-
posing unrealistic goals, and alerting them to the
CF pitfalls discussed in this article.
Where can sonographers go to get help? Some
ideas are the following:
 WHEN CARING HURTS / Blume 421

TABLE 1 TABLE 2
Effects of Extended Distress Necessary Strategies for the Prevention or Treatment of
Compassion Fatigue (CF)
Physical: Insomnia, stiff muscles, fatigue, diarrhea,
palpitations, and clammy hands, dry mouth 1. Understanding the causes of CF and how to distinguish
Emotional: Depression, fear, frustration, anxiety, it from burnout.
feelings of powerlessness 2. Understanding the high-risk factors for CF.
Behavioral: Short attention span, overactivity, irritability, 3. Developing resiliency skills to prevent CF.
grinding teeth, taking risks, “power 4. Learning when and how to say no.
tripping,” crying

one another. A chat room is being established for

that purpose. For more information or discussion,
• Organize a group within their hospital, town, please contact Gretchen Lee Blume, RDMS,
or city and to meet regularly once a month. RDCS, at (907) 357-2158, vsu@alaska.net, or
• Organize weekly lunches within their realtime@alaska.com.
department to share difficult experiences.
• Select mentors to listen, share, give advice, References
comfort, and encouragement, changing the
roles of giver and receiver each week. 1. Hutton T: Caregivers need to care for themselves too.
• Use the Internet to access sonography lists Neurology Research and Education Center. Accessed
July 10, 2001, from: http://www.neuroresearch.com.
and write about their experiences and ask 2. Pfefferling JH, Gilley K: Overcoming compassion fa-
questions of other sonographers. tigue. American Academy of Family Physicians, Family
Practice Management. Accessed July 10, 2001, from:
Discussion http://www.aafp.org.
3. Encarta Reference Library: Microsoft’s reference library
includes dictionary and thesaurus, plus an atlas and more.
I consider myself a privileged sonographer be- 2002. Accessed from: http://www.encarda.msn.com.
cause I am able to talk freely and honestly with my 4. Malugani M: Surviving stress: coping skills for health
clients about their sonogram results. The referring care professionals. Accessed August 5, 2001, from: http://
physicians have allowed me not only to tell their www.monster.com/articles.
5. Gilley K: Leading From the Heart. Boston, MA,
patients when there is no fetal heartbeat but also to
Butterworth-Heineman, 1997.
choose whether or not to share the truth with them. 6. Elliott N: Surviving stress. NurseWise Inc, 1998. Ac-
They know that I am prepared to give their patients cessed May 28, 2001, from: http://www.nursewise.com/
information on the grieving process and how to courses.
work through their losses by providing literature 7. National Institute of Mental Health: What to do when an
employee is depressed. 1995. NIH Publication no. 96-
and details about organizations geared to help 3919. Accessed May 28, 2001, from: http://
them. They know that I am equipped not only to www.nimh.nih.gov/publicat.
provide the patient comfort but also to call relatives
or husbands or to just let the patient talk.
Correspondence: Gretchen Lee Blume, RDMS,
RDCS, Real Time Images, Inc., Real Time II, LCC,
Note
P.O. Box 871930, Wasilla, AK 99687. E-mail:
I am interested in creating a sonographer support vsu@alaska.net or gretchenblumerdms@hotmail.
group to listen to and provide positive coaching to com.

Downloaded from http://jdm.sagepub.com at U. Coimbra - Faculdade De on February 14, 2007

© 2002 Society of Diagnostic Medical Sonography. All rights reserved. Not for commercial use or unauthorized distribution.