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Contributors
Traci B. Fox, EdD, RT(R), RDMS, RVT Maureen McDonald, MBA, RDMS, RDCS, FASE
Assistant Professor and Clinical Coordinator Assistant Professor/Cardiovascular Clinical
Diagnostic Medical and Vascular Sonography Coordinator
Program Thomas Jefferson University, School of Health
Department of Radiologic Sciences Professions
Research Assistant Professor, Radiology, Sidney Philadelphia, Pennsylvania
Kimmel Medical College
Thomas Jefferson University
Philadelphia, Pennsylvania
Reviewers
Michael Beauford, RDMS, RVT Elena Guyer, MEd, RT, RDMS, RVT
Instructor Program Coordinator
Diagnostic Medical Sonography Diagnostic Medical Sonography
Baton Rouge Community College Delaware Technical Community College
Baton Rouge, Louisiana Dover, Delaware
Patty Braga, RT, RDMS, RVT, RDCS Tiffany Johnson, MBA, RDMS, RVT, RT
Associate Professor Program Director
Diagnostic Medical Sonography Saint Luke’s Hospital
Palm Beach Community College Kansas City, Missouri
Lake Worth, Florida
Jo Ann Lamb, BS, RDMS, RVT, RT
Erin Burns, BS, RT, RDMS, RVT Assistant Professor
Coordinator of Clinical Education School of Diagnostic Medical
Sonography Department Sonography
St. Catherine College Cuyahoga Community College
Springfield, Kentucky Parma, Ohio
Keith Farwell, MS, BS, BA Diana Martin, BS, AAS

Program Director Assistant Professor
Allied Health, School of Applied Studies Diagnostic Sonography
Washburn University Cuyahoga Community College
Topeka, Kansas Parma, Ohio
Leonardo Faundez, MA, BS Jessica Murphy, BS, RRT-NPS, RDCS, RCS, RVT
Professor Department Chair
Ultrasound Program Diagnostic Cardiovascular Sonography
The Michener Institute Alvin Community College
Toronto, Ontario, Canada Alvin, Texas
viii Reviewers
Kathleen Murphy, MBA, RDMS, RT Angela Smith, RDMS

Director Instructor
Diagnostic Sonography Medical Sonography
Central Arizona College Parker University
Apache Junction, Arizona Dallas, Texas
Ryan Parnell, ARRT, ARDMS Felicia Toreno, PhD, RDMS, RDCS, RVT
Term Instructor Program Director
University of Alaska Anchorage Tidewater Community College
Anchorage, Alaska Virginia Beach, Virginia
Sonia Rodriguez, RDMS Cara Vickery, RDMS, RT

Ultrasound Instructor Program Director
National Polytechnic College Bowling Green State University
South Gate, California Bowling Green, Ohio
Donna Rubosky, RDMS, RDCS, RVT Kerry Weinberg, MA, MPA, RDMS, RDCS, RT
Program Director Program Director
Allied Health School of Health Professions
Spokane Community College Diagnostic Medical Sonography
Nine Mile Falls, Washington Long Island University
Brookville, New York
Kitty Sheets, BA, RDMS Sonography Specialty Advisors/Contributors
Director
Diagnostic Medical Sonography Program
East Coast Polytechnic Institute University
Newport News, Virginia
Preface
P atient care is the keystone of sonography. And although the sonographer is ultimately fashioned
through the trials and tribulations of clinical practice, fundamental patient care exists as the
basis of all that we do. Before a sonographer has the ability to distinguish a subtle renal malignancy,
a small ventricular septal defect, or slight intimal thickening in a tortuous carotid artery, he or she
must be capable of providing superior patient care. Regardless of your motive behind the selection
of sonography as a profession, whether it is the result of intellectual curiosity or monetary gain, you
must accept that patient well-being is the primary obligation of the sonographer. And for that reason,
you are intrinsically required not only to provide healthcare for each patient but to truly care for the
health of each patient.
The primary purpose of Introduction to Sonography and Patient Care is to provide the sonography
student with an overview of the sonography profession and basic patient care. However, ultimately
the book provides further evidence of the essential role that sonography and the sonographer play in
medicine. Part I, Introduction to Sonography, offers a fundamental approach to learning more about
the profession and about the practitioner.
One of the primary struggles for beginning sonography students is the initial shock experienced
when he or she must combine the stresses of didactic and clinical sonography education with the
strains of everyday life. In Chapter 1, helpful tips regarding specific classroom and clinical survival
skills are provided, and an explanation of the importance of involving your support system in your
studies. In Chapter 2, the focus is on the sonographer and the workplace obligations of those in the
profession. Chapters 3 and 4 combine to provide a historical analysis of the use of ultrasound in
medicine, specialties in sonography, and professional organizations. Chapter 4 ends with leadership
roles in sonography and career establishment.
The use of proper ergonomics has gradually become more valued over the years for sonographers,
and it is encouraging to see how much research has been conducted not only to highlight the risks
for work-related musculoskeletal disorders for sonographers but to attempt to mediate this potential
personal and professional calamity. Thanks to those involved in bringing the issue to the forefront,
the sonography profession is now much more safe and sound. However, one must at the outset rec-
ognize the risks, know the consequences of flawed mechanics, and strive to use best practices every
day. For this reason, Chapter 5 focuses on the prevention of work-related musculoskeletal disorders.
Permeated through every chapter in the book are direct references to the importance of being
a professional and why demonstrating ethical behavior consistently is vital to the sonographer.
However, Chapter 6 provides more facts regarding ethics and personal values. The chapter ends with
a brief warning for students, asserting that every interaction should be viewed as a job interview and
that first impressions are vital to future success.
Chapter 7 provides a brief analysis of legal essentials for the sonography student, including patient
rights and the responsibility of the sonographer regarding confidentiality. Finally, basic principles
and common knobology are offered in Chapter 8. This is a unique chapter for an introductory book,
and though this chapter is not expansive, it will hopefully provide the reader with a succinct overview
of transducer manipulation, scanning planes, and transducer care.
Part II, Introduction to Patient Care, begins with Chapter 9. Communication elements and a
10-step process for the sonographic examination are offered, from the assessment of relevant docu-
ments to the final release of the patient. Chapters 10 and 11 offer information regarding basic patient
x Preface
care and vital emergency care, respectively. One of the most important roles in patient care for the
sonographer is to prevent the spread of infection among our patients. Consequently, in Chapter 12,
infection control objectives abound. In Chapter 13, the primary focus is surgical asepsis technique
and the role of the sonographer in invasive procedures. Lastly, Chapter 14 offers guidelines, patient
preparation, and a brief synopsis of some suggested exam specifications for abdominal, small parts,
musculoskeletal, gynecologic, obstetric, vascular, and echocardiography specialties.
For Students
Undoubtedly, the most distinctive quality of this textbook is that it is readable. It is written in a man-
ner that is overtly conversational. Accordingly, the user should find this patient care book unique,
understandable, and most importantly, applicable. Each chapter begins with chapter objectives and a
brief introduction. Next, key terms, which are highlighted in the text in bold, are briefly defined for
the reader. At the end of each chapter, following a brief summary, there is a critical thinking section.
It is provided to advance the reader’s acquaintance with the information and to allow for further illu-
mination regarding the chapter content. Lastly, this book offers chapter review questions. The ques-
tions help the student evaluate comprehension of key chapter components. For students, the online
components of this book include online cases studies and a quiz bank. To access the online resources,
please visit thePoint.lww.com/PennyIntro1e.
For Instructors
For the instructor, Introduction to Sonography and Patient Care provides you with a comprehensive
text and a vast supply of textbook and ancillary resources. Within the chapters, important images
and diagrams, “Sound Off ” boxes, and carefully constructed tables are dispersed. “Sound Off ” boxes
highlight key points within the text. The procedures section for patient care is in the back of the book.
This section provides bullet point instructions for important clinical competencies such as how to
don sterile gloves, how to open a sterile pack, and how to take a blood pressure. These procedures can
be practiced in the classroom, laboratory, or the clinical setting. Online, you will find a robust test
generator, PowerPoint presentations, lesson plans, and a complete image bank (with color images),
as well as course cartridges for learning management systems. To access the online resources, please
visit thePoint.lww.com/PennyIntro1e.
Final Note
National certification in sonography is vital to confirm competency and to ensure a high standard of
care. However, perhaps even more vital for the individual patient is the personal interaction, compas-
sion, and respect received from the sonographer. It is my strong belief that while didactic testing is
invaluable for assessing comprehension, knowledge, and retention, clinical practice is the most vital
component of becoming a sonographer, and clinical is where the most tangible testing occurs. It is
my hope that this book will outline the need to always place the patient’s welfare first.
Steven M. Penny
Acknowledgments
I would first like to thank Pete Sabatini, the primary person who created the spark, which eventually
lit the fire to begin this project. Next, I would like to thank Mike Nobel at Lippincott Williams &
Wilkins (LWW) for his guidance in the process and for providing the fuel to a nearly faltering small
flame. Thanks also to my remarkably bright product development editor Staci Wolfson at LWW for
offering her invaluable insight and editing abilities to the project. Thanks to marketing manager
Shauna Kelley, other editors, product specialists, and special minions who worked behind the scenes
at LWW to get this book to the marketplace.
To my parents, Ted and Linda Penny, thank you for providing me with a home that was strict
but forgiving, honest, and loving. You instilled in me the work ethic to take on a task as large as this.
Thanks for believing in me.
To my brother Jeff and his family, Tammy, Nick, and Mackenzie—thank you for being in my life
and for your support.
To Dr. Traci B. Fox and Maureen McDonald, thank you for offering your knowledge concerning
vascular technology and echocardiography, respectively.
Thank you to Angela Hansen for your help as well.
Thank you to my coworkers at Johnston Community College for your support. I enjoy working
with you daily and greatly value our alliance as we partner together in education.
Thanks to all of my students, past, present, and future. You are the reason why I stay in education.
To all of my past patients—I pray that I helped you in some way. I pray that my concern for your
well-being was overtly demonstrated through my actions, even when my patience and time were
strained. I pray that if and when I faltered to make you feel special or irreplaceable, that you forgive
me. Playing a small role in your care was a privilege.
Steven M. Penny
Contents
Contributors and Reviewers vii
Preface ix
Acknowledgments xi
PART I: Introduction to Sonography 1

Chapter 1: Foundations for the Sonography Student 2
• Introduction 5
• Going Back to School 6
• Stress: Inevitable but Manageable 6
oo Financial Preparedness 7
oo Emotional Stability and Support 9
oo Physical Well-Being 9
• Time Management 10
• Establishing Educational Goals 10
• Classroom Survival Skills 11
oo Pertinent Coursework 11
oo Preparing for Tests 12
oo Maintaining Motivation in the Classroom 14
• Clinical Survival Skills 14
oo The Sonographer: A Brief Overview 15
oo Utilizing the Scan Lab 17
oo Essentials of Professionalism in Clinical 19
oo Essentials of Work Ethic in Clinical Settings 20
• Clinical Orientation and Information Gathering 22
oo Understanding Workflow 23
oo Imaging Departments and Modalities 24
• Radiography 25
• Computed Tomography 26
• Nuclear Medicine Technology 28
• Mammography 29
• Magnetic Resonance Imaging 29
• Cardiovascular Interventional Technology and Vascular Interventional Technology 30
• Appreciating Critical Thinking 31
oo Student Application of Critical Thinking 33
• Summary 33
Chapter 2: The Sonographer: A Closer Look 38

• Introduction 40
• Know Yourself Before You Know Others 40
oo Identifying Your Personality Type 40
xiv Contents
oo Emotional Intelligence 43
oo Now What? 44
• Ethics at Work 44
oo Character 45
oo Competent Care and Flexibility 46
oo Courtesy and Respect 46
oo Compassion and Empathy 47
oo Accountability, Honesty, and Integrity 48
oo Self-Motivation and Enthusiasm 49
oo Hunger for Knowledge 50
oo Self-Confidence 50
oo Final Thoughts on Character 50
• Clinical Responsibilities and Workplace Challenges for the Sonographer 51
oo Sonographic Reasoning and Clinical Correlation 51
oo Appreciating Anatomy, Physiology, and Pathology 56
oo Sonographer Reports 56
oo Occupational Stress for the Sonographer 57
• Student Interaction with Sonographers 63
oo When and How to Communicate 63
oo Acquiring Scan Time 64
• Student Interaction with Interpreting Physicians 64
• Summary 65
Chapter 3: Historical and Current Applications of Ultrasound in Medicine 72

• Introduction 77
• The Study of Sound 78
• Ultrasound in Medicine 79
oo Imaging Modes and Doppler 82
• Display Options 82
• Doppler Technology 85
oo Tissue Harmonic Imaging 88
oo 3D and 4D Technology 89
• Specialties in Sonography 91
oo Abdominal Sonography 91
• Small Parts Sonography 94
oo Breast Sonography 98
oo Neurosonography and Pediatric Sonography 100
oo Musculoskeletal Sonography 102
oo Gynecologic Sonography 103
oo Obstetric Sonography 106
oo Fetal Echocardiography 110
oo Vascular Sonography (Contributed by Traci B. Fox) 110
oo Echocardiography (Contributed by Maureen McDonald) 114
• Transthoracic Echocardiograms 116
• Stress Echocardiography 117
• Exercise Stress Echocardiography 118
• Pharmacologic Stress Echocardiogram 119
• Transesophageal Echocardiography 119
• Pediatric Echocardiography 120
Contents xv
• Additional Technologies and Future Applications 121

oo Therapeutic Ultrasound 121
oo High-Intensity Focused Ultrasound 121
oo Contrast-Enhanced Ultrasound and Ultrasound-Guided Brachytherapy 122
oo Ultrasound Elastography 123
oo Fusion Imaging 124
oo Intravascular Ultrasound 124
oo Automated Ultrasound 125
oo Focused Assessment with Sonography for Trauma 125
oo Miniaturization 127
oo Wireless Technology: It’s Here! 127
• Summary 128
Chapter 4: Professional Environment, Leadership, and Career Establishment 133

• Introduction 134
• Professional Environment 135
oo Academic Accreditation (CAAHEP, JRC-DMS, JRC-CVT) 135
oo Professional Organizations (SDMS, SVU, ASE, SOPE, AIUM) 136
oo National Certification (ARDMS, CCI, ARRT) 137
• Maintaining Certification 139
oo Laboratory Accreditation 139
• Leadership Roles in Sonography 139
oo Leadership Styles and Followership 140
oo Staff Sonographer 142
oo Advanced Practice Sonographer 142
oo Management in Sonography 143
oo Sonography Educators 143
oo Travel Sonographers 143
oo Consultants or Technical Advisors 144
oo Sales/Application Specialist 144
oo Sonography Entrepreneur 144
• Career Establishment 144
oo Searching and Applying for Jobs 145
oo Resume Writing and Social Networking 146
oo Interview Tips 147
• Summary 148
Chapter 5: Ergonomics and the Prevention of Work-Related Musculoskeletal

Disorders 152
• What Are Work-Related Musculoskeletal Disorders? 154
• Ergonomics 155
• Body Mechanics 156
• Personal and Environmental Risk Factors 156
oo Posture and Body Positioning 158
oo Repetitive Motions and Force or Pressure 160
oo Room Design 162
xvi Contents
oo Equipment Design 164

oo Job Design 165
oo Underlying Predisposing Conditions 166
• Inflammatory Diseases Linked to Work-Related Musculoskeletal
Disorders 166
• Best Practices and Ergonomic Interventions for the Sonography
Student 168
oo Shoulder and Elbow 169
oo Wrist and Hand 172
oo Neck and Back 176
oo Lower Extremities 177
• General Treatment of WRMSDs and Lifestyle Impact 178
• Summary 178
Chapter 6: Ethics and Professionalism 183

• Ethics and Personal Values 184
oo Ethical Theories 185
oo Ethics in Action 186
oo Medical Ethics and Codes of Ethics 187
oo The Sonographer Code of Ethics 187
oo Ethical Issues in Diagnostic Medical Sonography 188
• Non-Diagnostic Use of Ultrasound 188
• Ultrasound Screening for Vascular Disease 190
• The Role of the Sonographer in the Abortion Debate 191
• Professionalism 192
oo Professional Etiquette 193
oo First Impressions for the Sonography Student 194
• Summary 195
Chapter 7: Legal Essentials and Patient Rights 200

• Law Basics 202
• Types of Law 203
oo Common Law 203
oo Statutory Law 203
• Administrative Law 203
• Criminal Law 204
• Civil Law 204
• Sonographer Scope of Practice 211
• Good Samaritan Laws 212
• Patient Rights 214
oo HIPAA and Patient Confidentiality 215
oo Patient Rights Related to End-of-Life Issues 216
• Sonographer Documentation 217
• Summary 217
Contents xvii
Chapter 8: Basic Principles and Knobology 222

• Directional Terminology and Patient Positioning 224
• Transducers 226
oo Transducer Manipulation 228
oo Transducer Orientation and Scanning Planes 228
• Medical and Vascular Sonography Scanning Planes 229
• Transthoracic Echocardiography Scanning Planes 230
oo Care and Cleaning of Transducers 231
• B-Mode and Basic Doppler Overview 234
• Essential Universal Knobology 235
oo Acoustic Power 236
oo Annotation Keys 236
oo B-Color 236
oo Body Markers 236
oo Calipers 237
oo Cine (Cine Loop) 237
oo Color (Doppler) 237
oo Continuous-Wave Doppler 237
oo Depth 238
oo Dual Image 238
oo Ellipse 239
oo Field of View (Extended Field of View) 239
oo Freeze 240
oo HD Zoom 240
oo Image Store/Print 240
oo MultiHertz 240
oo Overall Gain 240
oo Time Gain Compensation 241
oo Tissue Equalization 241
oo Trace 241
oo Trackball 241
oo Transducer Select 241
oo M-Mode 243
oo Pulsed-Wave Doppler 243
oo Transmit Zone or Focus 244
oo Zoom 244
• Summary 244
PART II: Introduction to Patient Care 248

Chapter 9: Fundamentals of Communication for Sonographers 249
• Primary Human Needs 250
• The Grieving Process 252
• Communication 253
oo Five Elements of Communication 253
xviii Contents
oo Forms of Communication 253

• Nonverbal Communication 253
• Verbal Communication 254
oo Additional Potential Barriers to Effective Communication 256
• Cultural Competence 260
• The Sonographic Examination: 10 Steps 261
oo Step 1: Assessment of Relevant Documents 261
oo Step 2: Examining Reports and Images 262
oo Step 3: Preparing the Examination Room and Protocol Review 263
oo Step 4: Introducing Yourself and Patient Confirmation 263
oo Step 5: Gathering Clinical History 263
oo Step 6: Patient Education 265
oo Step 7: Conducting the Sonogram 265
oo Step 8: Completing the Sonographer’s Report 265
oo Step 9: Sonographer Interaction with Interpreting Physician 266
oo Step 10: Discharging the Patient 266
• Summary 266
Chapter 10: Fundamental Patient Care 271

• Patient Assessment 273
oo Body Temperature 274
oo Pulse (Appendix 3, Procedure 10-1) 275
oo Blood Pressure (Appendix 3, Procedure 10-2) 279
oo Respiration (Appendix 3, Procedure 10-3) 283
• Patient Assistance 284
oo Evaluating the Patient’s Mobility 284
oo Transferring and Transporting Patients (Appendix 3, Procedures 10-4, 10-5,
10-6, and 10-7) 285
oo Circumstances Requiring Unique Assistance 286
• Care for Patients with Intravenous Infusion 286
• Care for Patients with Urinary Catheters 287
• Care for Patients on Oxygen Therapy 289
• Assisting Patients with Bedpans or Urinals 290
oo Portable Sonography 290
• Introduction to Electrocardiography for Echocardiography Students 293
oo Lead Placement 294
oo Simplified Heart Anatomy and Circulation 295
• The Cardiac Conduction System 296
• Normal Sinus Rhythm 297
• Summary 298
Chapter 11: Medical Emergencies 302

• The Role of the Sonographer in Emergency Situations 304
• Assessing the Patient’s Neurologic and Cognitive Function 304
• Types of Emergencies 306
oo Shock 306
oo Syncope 308
Contents xix
oo Seizures 309
oo Pulmonary Embolus 311
oo Cerebrovascular Accident (Stroke) 311
oo Diabetic Emergencies 312
oo Emergencies Requiring Immediate Cardiopulmonary Resuscitation 313
• Summary 314
Chapter 12: Infection Control for the Sonographer 318

• Infection 321
oo Conditions that Favor the Growth of Pathogens 322
oo The Cycle of Infection and Modes of Transmission 322
oo Nosocomial and Healthcare-Associated Infections 325
• Workplace Exposure for the Sonographer 327
oo Methicillin-Resistant Staphylococcus aureus (MRSA) 327
oo Vancomycin-Resistant Enterococcus 327
oo Clostridium difficile 328
oo Tuberculosis 328
oo Bloodborne Pathogens 330
• Viral Hepatitis 331
• HIV and AIDS 331
• Breaking the Cycle of Infection 332
oo Standard Precautions 332
oo Hand Hygiene (Appendix 3, Procedure 12-1) 333
oo Personal Protective Equipment 334
• Gloving 335
• Other Personal Protective Equipment (Appendix 3, Procedure 12-2) 335
oo Transmission-Based Precautions 338
oo Medical Asepsis in the Sonography Department 338
• Personal Hygiene and Dress in the Workplace 338
• Cleaning Equipment 340
• Nonsterile Probe Covers 341
• Proper Disposal of Examination Waste Items (Appendix 3, Procedure 12-3) 343
• What If You Are Exposed? 344
• Summary 344
Chapter 13: Invasive Procedures and Surgical Asepsis 348

• Surgical Asepsis 349
oo The Rules of Surgical Asepsis 353
oo Preparing for an Invasive Procedure 354
oo Skin Preparation and Draping (Appendix 3, Procedure 13-1) 354
oo Opening a Sterile Pack and Adding Items to a Sterile Field
(Appendix 3, Procedure 13-2) 356
oo Sterile Gloving 358
oo Draping a Transducer with a Sterile Probe Cover and Needle Guide 361
oo Syringe Assistance and Needle Disposal 363
• Sonography in the Operating Room 364
oo The Surgical Scrub (Appendix 3, Procedure 13-4) 364
xx Contents
• Sterile Gowning 365

• The Surgical Team 366
• Summary 367
Chapter 14: Sonographic Examination and Guidelines 371

• Quality Assurance 372
• As Low as Reasonably Achievable 373
• Abdominal and Small part Sonography 373
oo Liver 373
oo Gallbladder and Biliary Tract 373
oo Pancreas 373
oo Spleen 374
oo Bowel 374
oo Peritoneal Fluid 374
oo Abdominal Wall 375
oo Kidneys and Urinary Bladder (Renal Sonogram) 375
oo Renal Vascular Assessment 375
oo Abdominal Aorta and Inferior Vena Cava (IVC) 375
• Breast Sonography 376
• Scrotal Sonography 377
• Thyroid, Cervical Lymph Node, and Parathyroid Sonography 377
• Musculoskeletal Sonography 378
oo Shoulder Examination 378
• Gynecologic Sonography 378
oo Sonohysterography 379
• Obstetric Sonography 379
oo First Trimester 379
oo Second and Third Trimesters 380
• Vascular Sonography 381
oo Carotid Sonogram 381
oo Peripheral Venous Sonography 381
oo Upper Extremity Venous Sonogram 382
oo Peripheral Arterial 382
• Transthoracic Adult Echocardiography 382
• Summary 383
Appendix 1: Medical Terminology 387

Appendix 2: Translation Resources and English-to-Spanish Phrases 393
Appendix 3: Patient Care Procedures 398
Appendix 4: Electrocardiographic Dysrhythmias 414
Appendix 5: Laboratory Tests 416
Index 419
part I
Part
Introduction to Sonography
1
Foundations for
the Sonography
Student
Chapter Objectives
■■ Briefly explore vital concepts related to student success in sonography.
■■ Offer insight into classroom and clinical survival skills for sonography students.
■■ Understand workflow in the hospital setting.
■■ Appreciate the different imaging modalities that a sonography student will
encounter while in the hospital or office setting.
■■ Recognize how vital critical thinking skills are in the sonography profession.
Key Terms
Acoustic windows (sonographic window) – Anxiety – the general state of feeling worry
the optimal location on the body for placement and fear before confronting something
of the ultrasound transducer to demonstrate emotionally or physically challenging
both normal anatomy and pathology; the Arthrography – an x-ray procedure that
best image acquired by manipulating and utilizes contrast agent to examine a joint, such
placing the ultrasound transducer in the most as the shoulder, knee, or hip
favorable position; some organs can provide a Assumptions – reasoning based on guesses
better acoustic window for improved viewing or opinion
adjacent anatomy
Audible sound – sound range that can be
American Registry for Diagnostic Medical detected by the human ear
Sonography – an organization that offers
Brain dumping – a test preparation technique
national certification exams for all sonography
in which a large amount of information is
specialties
memorized by a test taker, and when the
American Registry of Radiologic test commences, the test taker “dumps” the
Technologists – an organization that offers information on a scrap piece of paper or the
national certification exams for radiographers test
and some sonography specialties
Chapter 1 Foundations for the Sonography Student 3
Cardiolite – a pharmaceutical agent used Differential diagnosis – a diagnostic method

in nuclear medicine imaging to examine the used to create a short list of possible diseases
blood flow of the heart based on signs and symptoms
Cardiologist – a physician who diagnoses and Fight-or-flight response – the body’s
treats cardiac and blood vessels disorders physiologic reaction to a real or imagined
Cardiovascular interventional technologist – a threat that arises from situations that cause
specialized radiographer that assists physicians fear or anger
in the treatment and diagnosis of cardiac and Fluoroscopy – an x-ray procedure that allows
blood vessel disorders under fluoroscopy direct or realtime imaging of structures within
Clinical competencies – unassisted the body
sonographic examinations which are graded to Gadolinium – a contrast agent used in MRI
determine fundamental proficiency Gold standard – the leading tool to diagnose
Clinical findings – the information gathered certain diseases; for example, mammography
by obtaining a clinical history is the gold standard for breast imaging,
Clinical history – includes signs and and sonography is the gold standard for
symptoms, pertinent illnesses, past surgeries, gallbladder disease
laboratory findings, and the results of other Heart catheterization – a fluoroscopic
diagnostic testing of a patient procedure that involves the passing of a
Clinical journal – a book used by students for catheter into the right or left side of the heart,
personal and professional reflection typically from the groin or arm, in order to
Computed tomography – an imaging evaluate and treat disorders related to the
modality that uses x-ray to obtain cross- blood flow of the heart
sectional images of the body in multiple Hippocratic Oath – a pledge observed by
planes; also referred to as CT or CAT scan physicians and occasionally other healthcare
Contrast agent – a substance that is either professionals containing some basic guidelines
ingested or injected into the body to for ethical standards and conduct between the
enhance the visualization of specific anatomy; healthcare provider and the patient
disease contrast agents may also be used to Indication – a basis for an examination; a valid
treat disease; also referred to as a contrast reason to perform a certain test
medium Inference – reasoning that is based on gained
Coupling gel – a medium placed on the skin factual knowledge using critical thinking.
to allow ultrasound waves to enter the body Infrasound – the sound range below the
also referred to as ultrasound gel normal hearing range of humans
Critical thinking skills – resourceful actions, International Classification of Disease,
judgments, and decisions based on the Ninth Edition (ICD9) code – a healthcare
combination of professional knowledge, classification system that provides a system of
experience, integrity, and ethical standards diagnostic codes for classifying diseases
Cross-training – when radiographers or Interventional radiology – a branch of
other imaging specialists are training to radiology that uses various imaging modalities
perform another imaging modality in the to treat or further characterize disease
clinical setting without specific classroom by means of biopsy or minimally invasive
training procedures
CT technologist – typically a registered Invasive procedures – procedures that
radiographer who has undergone specific include an imaging modality to treat disease;
classroom and clinical training to perform typically involves the use of catheters, needles,
computed tomography examinations and surgical asepsis techniques (sterile
Diagnostic mammogram – a targeted techniques)
mammogram, typically performed after a Investigative imaging – technique used
screening mammogram to further analyze the by sonographers by which they obtain
characteristics of a breast lesion sonographic protocol images while
Diagnostician – an interpreting physician who simultaneously searching for and identifying
provides a diagnosis abnormalities
4 Part I Introduction to Sonography
Magnetic resonance angiogram – MRI Positron emission tomography – a

technique used to visualize blood vessels technique that utilizes both the radionuclide
Magnetic resonance imaging – imaging imaging principles of nuclear medicine
modality that utilizes magnetic waves to obtain and the imaging techniques of computed
images of the human body in various planes tomography
Mammography – Breast imaging technique Protocol (sonographic) – an inclusive order
that utilizes x-rays of necessary images acquired during a
Maternal-fetal medicine specialist – a sonographic examination
physician who has specialized training Pulse-echo technique – ultrasound waves
that focuses on the medical and surgical are pulsed into the body by a transducer; the
management of high-risk pregnancies sonographic image is produced when the
Megahertz – 1 million hertz pulsed wave returns to the transducer
Mnemonics – memorization technique; Radiograph – an x-ray image
an acronym is an example of a mnemonic; Radiographer – an imaging professional
an abbreviation is formed from the initial trained to obtain x-ray images and assist the
components in a phrase or a word in order to radiologist in x-ray procedures
aid in quick recall Radiography – the imaging specialty that
MRI technologist – imaging specialist trained utilizes x-rays to obtain images of the body
in magnetic resonance imaging procedures Radiologist – a physician that interprets
Myelography – an x-ray procedure radiologic procedures and also uses imaging
that utilizes a contrast agent to identify modalities to treat disease
abnormalities of the spinal cord Radiopharmaceutical – a nuclear medicine
Nuclear medicine – imaging modality that radioactive material that the patient inhales,
employs the use of radioactive material for the ingests, or is injected with for a nuclear
diagnosis and treatment of various diseases medicine test that is capable of concentrating
Nuclear medicine technologist – imaging on specific organs or systems in order to
specialist trained in nuclear medicine evaluate organ function
procedures Realtime imaging – instant viewing of internal
Nuclear stress test – a nuclear medicine test structures
that requires the patient to exercise or be Scan (ultrasound) – to perform a sonographic
injected with a medication that stresses the examination
heart for imaging purposes Scan lab – a practice room with ultrasound
Nurse practitioner – an advanced practice machines for students to use to gain scanning
registered nurse who provides patient care experience
and has the ability to order diagnostic tests Scintigraphy – a test in nuclear medicine
under the supervision of a physician in which the radiopharmaceutical is taken
Objective – something that is not influenced by internally and the emitted radiation is
personal feeling or opinion in regard to facts captured by a gamma camera
Obstetrician – a physician trained in the care Screening mammogram – the initial
of pregnant patients mammographic images of the breast
Pathology – a disease process; also could be Signs – objective evidence of a disease
referring to the profession of pathology, which Society of Diagnostic Medical Sonography –
is the precise study and diagnosis of disease the national membership society for all
by a pathologist specialties in sonography; offers membership
Physician assistant – a healthcare professional benefits and helps set standards for the
who practices medicine on a team under the sonography profession
supervision of a physician or surgeon and who Sonographer report – typically a written
has the ability to order diagnostic tests or typed document that provides basic
Picture Archiving and Communication descriptive information of the sonographic
System – medical imaging technology that examination, including measurements
allows for the storage of digital studies for of normal and abnormal structures, the
quick access and easy storage sonographic appearance of organs and
structures, and the manifestation of any Subjective – something that is potentially

sonographically identifiable abnormalities influenced by personal feeling or opinion in
noted during the examination regard to facts
Sonographic findings – information Surgical asepsis – the absence of viable
gathered by performing the sonographic pathogenic organisms; also referred to as
examination sterile technique
Sonography phantom – a simulation object Symptoms – any subjective indication of
that provides tissue similar to the human body disease, like nausea, weakness, or numbness
that can be used to practice sonographic Transducer – an instrument that emits
examination ultrasound waves that is used by the
Stress – the body’s typical reaction to sonographer to acquire sonographic images
challenging situations that are perceived as Ultrasound – the sound range above the
demands on time, energy, or resources with normal hearing range of humans
the threat that not enough time, energy, or Vascular interventional radiographers –
resources exist to fulfill an obligation radiographers specialized in vascular
Stressors – individual events or perceived intervention
challenges placed upon time, energy, or Work ethic – effort consisting of perseverance
resources that increase stress and diligence
Introduction
Welcome to the sonography profession! If you are reading this text, you have most likely already
started pursuing a career in sonography. The sonographer is a critical part of the healthcare team
(Fig. 1-1). Before we recognize the unique function of the sonographer within the medical profes-
sion, we must first investigate where you as a student fit in and how you can plan for success now and
in your future studies. Students can perform at varying levels of competency within a sonography
department, from simple observations to completing unassisted but supervised sonographic exami-
nations. This chapter will serve as a guide for student success by providing you with some insight
into your educational pursuit and recommended skills to master as you progress through both your
didactic and clinical training. Therefore, this chapter will offer an overview of the workflow and the
layout of an imaging department, including an overview of the different imaging modalities that you
Figure 1-1. As a vital healthcare team member, the sonographer (left) must be capable of
working with other professionals, including physicians and nurses, as demonstrated here
during a transesophageal echocardiogram.
may encounter during your clinical rotations. The overarching objectives that you establish now as
you begin your training should be aimed at becoming the best sonographer that you can be. Many of
the concepts in this chapter will be returned to again later in this book. However, by initially under-
standing what is going on around you and how your environment impacts your role as a student, your
responsibilities will hopefully be more clearly defined, and your objective toward becoming a regis-
tered sonographer will not just be a far-off dream, but a rewarding journey that has only just begun.
Going Back to School

Prior to endeavoring to comprehend the life-altering obstacles that sonography school entails, we
must first recognize the blended group of students that you will refer to as classmates. For some of
you, pursuing a career in sonography is a continuation of a career in radiology, cardiology, nursing,
vascular technology, or some other medical specialty. Without a sabbatical between academic pro-
grams, you have chosen to pursue advanced studies in sonography. Your study skills may be highly
developed, and your goals may be clearly established. However, there are two other groups of indi-
viduals who may find unique challenges. Some of you may have been unemployed for several years,
or some of you could possibly be previous stay-at-home moms or dads.
First, for some students, sonography has become a secondary profession. This means that this
person may have worked in a non-medical profession before deciding to pursue a career in sonog-
raphy. These individuals may have limited patient care experience, though they find that they have
a passion for helping others. Secondly, there may be some individuals who have chosen to obtain a
degree in sonography, having recently graduated from high school. Though you may not fall into one
of these categories specifically, you all share the same goal of becoming a registered sonographer. In
preparation for a patient care environment where compassion should persist, offer support to those
you recognize as struggling in their studies, and work together to help each other succeed.
Sound Off
In preparation for a patient care environment where compassion should persist, offer
support to those you recognize as struggling in their studies, and work together to
help each other succeed.
Stress: Inevitable but Manageable

Stress is not just inevitable, but it is normal. Stress is the body’s typical reaction to challenging situ-
ations that are perceived as demands on time, energy, or resources with the threat that not enough
time, energy, or resources exist to fulfill an obligation.1 Individual events or perceived challenges
placed upon time, energy, or resources that increase stress are referred to as stressors. These stress-
ors increase anxiety and do so with consequent physiologic responses. Anxiety is the general state
of feeling worry and fear before confronting something emotionally or physically challenging. The
fight-or-flight response is the body’s physiologic reaction to real or imagined threats that arise from
situations that cause fear or anger.1 Hormones released by the adrenal glands, epinephrine (adrena-
line) and norepinephrine, cause an increase in heart rate, shallow and rapid breathing, sweaty palms,
and a surge in energy. We have all experienced the sudden rush of adrenaline that occurs when a
surprising event happens, such as nearly being involved in an automobile accident or being suddenly
awakened in the middle of the night by a telephone call during sleep. Stress can also build up over
time. Waking up late for school, getting stuck in traffic, or forgetting to complete important assign-
ments contribute to stress and cause us to feel like we have lost control. Therefore, it is important
to recognize the causes of stress in our lives, be prepared in advance, and develop intervention tech-
niques (Table 1-1).
TABLE 1-1 Dealing with stress and anxiety
Dealing with Stress and

Anxiety Explanation
Anticipate stress, and be You can do this by being financially prepared, having a good sup-
prepared. port system made up of friends and family, maintaining a healthy
lifestyle, and managing your time wisely (further details provided in
this chapter).
Recognize the symptoms. Symptoms may include feeling overwhelmed, suffocated, behind on
daily tasks, and physical symptoms like sweaty palms, racing heart,
abdominal discomfort, and shortness of breath. Try to identify and
remove negative thoughts that contribute to anxiety and increase stress.
Use positive language. Oftentimes, if you think more positively and use positive language
with self-acknowledging statements like “I can do this,” you will be
successful. Maintain a positive outlook, and watch yourself meet goals.
Practice stress-reducing Walking, running, breathing exercises, playing a sport, practicing

activities. relaxation techniques, sleep, listening to music, and starting a new
hobby are all good ways to reduce stress and distract your mind
from the stressor.
Anxiety, according to the authors of Under Pressure and Overwhelmed: Coping with Anxiety in
College,2 is fueled by three mechanisms: cognitive component, physical component, and behavioral
component. The cognitive components relate to how we interpret our circumstances. People who
experience increased anxiety characteristically expect the worst out of situations. These individuals
are generally pessimistic and constantly worry. It is important to note that less than 5% of events
that we worry about actually come to fruition.1 The second component of anxiety is the physical
component, the aforementioned physical manifestation or symptoms of anxiety. The last compo-
nent of anxiety is behavior. Of course, we all perform differently when faced with anxiety caused by
stress. Destructive behavior resulting from anxiety includes removing yourself from a situation to
avoid potential negative outcomes, dealing with stress with excessive alcohol use or reckless behavior,
or procrastinating.1 Some individuals may overcompensate to avoid anxiety and ultimately over-
prepare for tests, resulting in poor scores. For test anxiety tips, refer to the section in this chapter
titled “Preparing for Tests.”
Stress can be used as a motivator for some people. Studying harder for a difficult exam so that you
are prepared is a means to compensate for and combat against anxiety. Feeling prepared and rising
to the occasion makes you feel successful and boosts self-esteem. We have all had to face the stresses
of school. The following sections will assist you in your quest to resolve stressful situations, but also
keep in mind that your college or academic institution has resources for students and your professors
should also be able to assist you in finding help.
Financial Preparedness
Annual salaries vary per specialty within the sonography profession. In 2012, the Society of
Diagnostic Medical Sonography (SDMS) reported that the median annual income for sonogra-
phers was $78,520 (Table 1-2).3 Although you have chosen to pursue a career that is in demand, you
must be financially prepared to survive college. One of the most vital steps in the arduous process of
pursuing a new career is to consider the possible financial ramifications. This means that you must
contemplate the consequences of your educational pursuit for not only yourself but for your family
TABLE 1-2 Median annual compensation for sonographers in 2012
Registered Sonographer Median Annual Income
RDMS $77,000
RDCS $85,644
RVT $80,509
By credentials for registered diagnostic medical sonographers (RDMS), registered diagnostic cardiac sonographers (RDCS),
and registered vascular technologists (RVT) according to the SDMS annual salary survey.
From SDMS News Wave, January 2013. Retrieved from http://www.sdms.org/members/news/NewsWave/NW-January-
2013.pdf.
and others. Furthermore, economic woes can greatly inhibit your ability to focus on your studies,
resulting in anxiety, academic issues, and emotional instability. Developing a financial budget and
agreeing upon this budget with your significant other if you have one can greatly reduce the likeli-
hood of financial tension in the future. Along with all of the other expenses of life, you must consider
the ramification of the costs associated with child care, tuition, activities, technology, books, and
travel related to school when you attempt to develop a working budget (Table 1-3).
Sound Off
Developing a financial budget and agreeing upon this budget with your significant
other if you have one can greatly reduce the likelihood of financial tension in the
future.
For many, working during school to pay bills is the only option. In fact, more than half of
students attending college have a job.4 Sonography programs are highly demanding fulltime
programs, meaning your didactic workload is much like having a fulltime job. The requirements
TABLE 1-3 Money-saving tips for the sonography student
Five Tips for Saving

Money in School Explanation
Buy e-books. E-book versions of texts can be purchased, and these are typically
slightly cheaper than traditional textbooks.
Carpool. Carpooling with a fellow classmate can save everyone involved some
money, and it is better for the environment.
Bring your lunch. Making your lunch at home and bringing it to school or clinical can
save you money every week that you might otherwise be spending on
eating out.
Take online courses. Though online courses may not be cheaper than traditional courses,
you will typically save some money in travel expenses, as much of the
coursework can be completed at home.
Seek employer Some healthcare employers may assist you financially while in school
reimbursement. and even offer you a position when you graduate.
of studying for many hours each night combined with clinical and laboratory rotations can be
physically draining. Physical exhaustion can then lead to a lack of focus, and your academic
goals could be derailed. Therefore, it may be best to work on weekends and avoid night shifts
when possible.
Though additional debt is not always the appropriate solution, many students choose to take
advantage of financial assistance. Financial stability throughout school can be maintained with
support from employers and the state or federal government through low-interest loans, gifts, grants,
and scholarships. Federal student aid applications are available online at www.fafsa.ed.gov. Also,
secondary forms of savings that some may be eligible to receive include tax credits for both tuition
and fees. It would be wise to consult your tax advisor while in school to determine what tax incen-
tives exist for fulltime students, as these may vary from year to year. Seek help when needed, and take
advantage of student support services, your academic advisor, and student counseling when you
encounter financial strain.
Emotional Stability and Support

One of the most significant and ongoing struggles for many students is the challenge of maintaining
emotional stability. In preparation for time away from family to study, it is best to preemptively share
with loved ones the demands that will impact your individual relationship. Children and spouses
need time to adjust to your busy schedule just like you do. But those same individuals can also pro-
vide encouragement during difficult times. Therefore, a solid support system made up of friends and
family can provide one with the emotional sustenance needed to be successful. For some, the spiritual
nourishment found in a place of worship strengthens determination and offers a respite from the
stresses of life also.
Involving your family or friends in your studies can be both beneficial and work to strengthen
relationships. Explain to them your assignments, and utilize them while studying for tests, prac-
ticing transducer manipulation, patient positioning, or practicing new procedures. Students
can also find assistance from other students, sonographers, and faculty members. Sonography
program administrators may develop a student mentoring program between first- and second-
level students to encourage relationship development and provide additional distinctive student
support.
Sound Off
A solid support system made up of friends and family can provide one with the
emotional sustenance needed to be successful.
Physical Well-Being
Before beginning most sonography educational programs, students must undergo a physical exami-
nation, which includes immunizations, laboratory tests, and a drug screen. A drug screen tests for
various chemical in the bloodstream, including alcohol and illegal drugs. If alcohol or illegal drugs
are discovered on a drug screen, you may be dismissed from your educational program or prohibited
from your clinical assignment. If a positive drug screen is discovered when you are employed as a
sonographer, you will most likely lose your job.
Maintaining your physical well-being is strongly associated with your overall success. Your physi-
cal wellness can be maintained with regular exercise, eating a well-balanced diet, and getting adequate
sleep. Taking breaks while studying to take a walk outside or to play some basketball can provide a
quick stress release and some exercise at the same time.
Sound Off
If alcohol or illegal drugs are discovered on a drug screen, you may be dismissed
from your educational program or prohibited from your clinical assignment. If a posi-
tive drug screen is discovered when you are employed as a sonographer, you will
most likely lose your job.
Time Management
Time management is crucial while in school. For those with immediate families, finding a b alance
between spending time with family and working on schoolwork consists of developing good time
management skills (Table 1-4). Many external forces attempt to take up our time. Limit your
extracurricular activities until your schoolwork is complete in order to reach deadlines and plan
your day wisely. If you are not using electronic devices for school, put the device down and walk
away! Instead, open your textbooks and read. Delay watching television as well. Instead, if you
have the ability, record your favorite shows and use watching them as a reward after your studies
are complete.
Sound Off
If you are not using electronic devices for school, put the device down and walk
away! Instead, open your textbooks and read.
Establishing Educational Goals

Educational requirements for acceptance into sonography programs vary. Creating educational goals
starts with research into one’s chosen profession and obtaining the foundation needed to have a
successful, long-lasting career. Gregory Gottesman, author of College Survival: A Crash Course for
Students by Students,5 suggests five basic steps of goal setting (Table 1-5). Involving family members
TABLE 1-4 Time management tips for sonography students
Time Management Tip Explanation
Use watching television or This may sound impossible for some people. Many of us are
a movie as a reward, not as addicted to television, but it takes us away from schoolwork.
time-wasters.
Put the devices down, and Our day is full of seemingly innocent distractions from our
walk away. electronic devices (tablets, computers, smartphones, etc.). Most of
what is accomplished may seem important, but most likely it is not.
Plan your day and week. Your academic studies should rank high on your list of priorities.
Afford time for reading, writing, and studying. Include adequate
time in your day planning for eating, relaxing, sleeping, exercising,
and family time.
Create your own academic When you are provided assignments via a lesson plan from
calendar. your instructors at the beginning of courses, organize your test,
assignments and projects by writing them on a calendar.
Set your own deadlines for Use the deadlines provided by your professors for assignments as
assignments early. being late. Instead, set your own deadlines early so that you are
prepared in advance.
TABLE 1-5 Five basic steps of goal setting
Five Basic Steps of Goal

Setting Explanation
Make a list of priorities, and For the sonography student, your academic studies should rank
rank them. high on this list. School should be a main priority. Be dedicated,
and strive for achievement.
Set measurable and realis- Establish a realistic GPA to achieve each semester and by the end
tic long-term goals. of your academic studies.
Set short-term goals for Long-term goals are not accomplished without meeting short-term
classroom and clinical. goals along the way. Completing all lab assignments, homework,
meeting attendance requirements, and mastering specific scan-
ning skills are all short-term goals to establish from week to week.
Make social and personal Set aside some time for family and friends, and strive to reach
goals. personal fitness, financial, and spiritual goals.
Strive to meet those goals. Write your goals down and mark them off when you complete
them. If you do not achieve them at first, don’t stop trying.
From Gottesman G, et al. College Survival: A Crash Course for Students by Students. 4th ed. New York, NY: Macmillan
Company; 1996.
and fellow students in the establishment and implementation of these goals will undoubtedly help
you achieve them. Keep in mind that your achievements in school will influence your likelihood for
employment and your ability to provide sufficient patient care.
Classroom Survival Skills

There are numerous common skills that successful students have, according to Susan Roubidoux,
author of 101 Ways to Make Studying Easier and Faster for College Students. Roubidoux claims that
among the items on the list, successful students sit near the front of the classroom, have healthy
snacks before lectures begin, take good notes, ask questions when clarity is needed, and prepare for
tests efficiently.6 The didactic or classroom portion of your training can take place before, after, or
during your clinical rotations. That is, sonography programs vary as to the time during which didac-
tic training occurs. However, when one encounters a large amount of complicated information, as
found in a sonography educational program, it is easy to become overwhelmed. The following class-
room survival skills will provide you with some insight and tips to help you prepare for the challenges
of a sonography didactic education.
Pertinent Coursework
Courses relevant to your studies can strengthen your understanding of sonography. Sonographers
must have a thorough understanding of anatomy, physiology, and pathophysiology. Therefore,
these classes can provide both a foundation for your studies and reinforce information that you
will encounter in your sonography program. Public speaking or communications, writing, fine
arts, math, and basic physics courses will enhance your likelihood for success as well. Medical ter-
minology courses are crucial in understanding the vocabulary of the medical world. Appendix 1
provides a list of common medical abbreviations, prefixes, and suffixes commonly used by
sonographers.
With the growing Spanish-speaking population in North America, one could certainly benefit
from taking a Spanish medical communication course. Some clinical facilities employ interpreters or
use technology to communicate with patients who do not speak English. Appendix 2 provides some
basic Spanish phrases that may be utilized. However, utilizing a trained medical interpreter is always
the proper decision for ensuring accurate communication and providing optimal patient care.
Sound Off
Utilizing a trained medical interpreter is always the proper decision for ensuring
accurate communication and providing optimal patient care.
There may be sonography programs that require applicants to be registered healthcare profes-
sionals, like a radiographer or nurse, before acceptance. Conversely, there are also programs with
minimum entrance requirements, and these are available to individuals with very little medical back-
ground. One health occupation one can pursue to encourage the development of patient care skills
is that of certified nursing assistant (CNA). Accordingly, obtaining a CNA certification and working
in a patient care setting, even in a part-time or casual position, can provide you with some valuable
patient care experience and practice with interacting with ill patients. The following chapters will
further provide insight into how sonographers must interact with patients and how effective com-
munication helps us gather useful information before performing an examination.
Within some sonography programs, online coursework consists of testing, course lecture retrieval,
video sharing, and discussion board postings. Occasionally, online modules are provided with text-
books, and assignments are conducted by means of an online administration through Blackboard or
Moodle. For some individuals returning to school, or those accustomed to a traditional education,
maneuvering through online resources can be daunting. You should take advantage of introductory
computer training programs offered by your institution to familiarize yourself with online class-
room navigation. Purchasing a personal desktop or laptop computer would be wise as well, as online
research at home may be encouraged by your instructors. When pricing items for school, especially
higher-priced items like computers or tablets, ask the retailer about unique discounts for college
students. At some institutions, laptop computers can be checked out from the school library as well.
Sound Off
When pricing items for school, especially higher-priced items like computers or tab-
lets, ask the retailer about unique discounts for college students.
Preparing for Tests

We all prepare for tests differently. Some of us prepare well in advance for tests by studying some
every night, while others prepare only the night before. Your institution typically has study resources
for students, and Table 1-6 provides additional helpful tips for preparing for tests. Regardless of how
you study, your aim should be to learn the information, not just to memorize it. You should genuinely
understand the concepts because the information that is covered in your didactic classes is applicable
to clinical practice and consequently directly impacts patient care.
Sound Off
Regardless of how you study, your aim should be to learn the information, not just
to memorize it. You should genuinely understand the concepts because the infor-
mation that is covered in your didactic classes is applicable to clinical practice and
consequently directly impacts patient care.
Test anxiety is a common educational issue that all students have encountered at times. However,
for some students, test anxiety can affect them to the point where their test results are dramatically
altered, despite having prepared and grasped the information prior to the test.7 In fact, studies have
TABLE 1-6 Test preparation tips
Test Preparation Tips Specific Goal
Read your textbooks • Read often: Though medical literature is dissimilar, reading
for comprehension. fiction and nonfiction books can also strengthen your reading
skills.
• Take notes as you read: Highlight specific points, and write notes in
the margins.
• Take breaks: With a long reading assignment, take intermittent
breaks to relax your brain and eyes.
• Be prepared for lectures by reading the information in advance.
Take quality lecture • Be organized and prepared with pencils for note taking. If utilizing
notes. an e-book, have your computer ready to insert notes.
• Use highlighters, but remember that simply highlighting information
on a PowerPoint presentation or in the textbook is not necessarily
adequate note taking.
• Make notes of key points made by your instructor.
• If classroom drawings or sketches are utilized by your instructor,
draw them yourself in your notes.
• If allowed, make audio recordings of lectures.
Create study cards and • Developing a study method that incorporates note cards with
mnemonics. questions on one side and answers on the other is a great way to
study.
• Create mnemonics for lists of materials in order for quick recall.
Form a study group, or • Exchange e-mail addresses and phone numbers with fellow stu-
find a study partner. dents, and form a study group.
• You and your study partner(s) can meet early before tests to quiz
each other.
Develop a study • Study several times a week or some each night to prevent cramming
schedule, and take and information overload. This may help you retain information.
breaks. • Take breaks between studying, and sometimes use music to help
you focus better while you are studying.
shown the scores of students suffering from test anxiety reduce by more than 12% compared to the
non-anxious student.7
Essentially, overcoming severe test anxiety can result in an increase in test scores by a whole let-
ter grade. Some colleges offer resources and counseling for students suffering from test anxiety, and
special testing situations for students may be offered by some instructors for those with extreme
testing issues. For example, study skills courses and one-on-one behavioral counseling have been
shown to be the most effective at reducing test anxiety.7 Table 1-7 provides some test-taking tips for
all students, not just those suffering from anxiety.
Though some instructors may encourage a technique called brain dumping, it is not necessarily
the best way to approach a test. Brain dumping is a test preparation technique whereby a large amount
of information is memorized by a test taker, and when the test commences, the test taker “dumps” the
information on a scrap piece of paper or the test. Therefore, if allowed before a test, students write
down information on the test that one will most likely encounter. Some students may even be allowed
to draw quick sketches of anatomy. Brain dumping is something that should be a last resort, however,
as you should strive to learn and not memorize. And though your classroom instructors may allow
this practice, the American Registry for Diagnostic Medical Sonography (ARDMS), the organiza-
tion that offers national certification exams for sonographers, absolutely prohibits brain dumping on
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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Introduction to Sonography and Patient

Care First Edition, (Ebook PDF)

Keith Farwell, MS, BS, BA Diana Martin, BS, AAS

Kathleen Murphy, MBA, RDMS, RT Angela Smith, RDMS

Sonia Rodriguez, RDMS Cara Vickery, RDMS, RT

PART I: Introduction to Sonography 1

Chapter 2: The Sonographer: A Closer Look 38

Chapter 3: Historical and Current Applications of Ultrasound in Medicine 72

• Additional Technologies and Future Applications 121

Chapter 4: Professional Environment, Leadership, and Career Establishment 133

Chapter 5: Ergonomics and the Prevention of Work-Related Musculoskeletal

oo Equipment Design 164

Chapter 6: Ethics and Professionalism 183

Chapter 7: Legal Essentials and Patient Rights 200

Chapter 8: Basic Principles and Knobology 222

PART II: Introduction to Patient Care 248

oo Forms of Communication 253

Chapter 10: Fundamental Patient Care 271

Chapter 11: Medical Emergencies 302

Chapter 12: Infection Control for the Sonographer 318

Chapter 13: Invasive Procedures and Surgical Asepsis 348

• Sterile Gowning 365

Chapter 14: Sonographic Examination and Guidelines 371

Appendix 1: Medical Terminology 387

Cardiolite – a pharmaceutical agent used Differential diagnosis – a diagnostic method

Magnetic resonance angiogram – MRI Positron emission tomography – a

structures, and the manifestation of any Subjective – something that is potentially

Going Back to School

Stress: Inevitable but Manageable

TABLE 1-1 Dealing with stress and anxiety

Dealing with Stress and

Practice stress-reducing Walking, running, breathing exercises, playing a sport, practicing

TABLE 1-2 Median annual compensation for sonographers in 2012

Registered Sonographer Median Annual Income

TABLE 1-3 Money-saving tips for the sonography student

Five Tips for Saving

Emotional Stability and Support

Establishing Educational Goals

TABLE 1-4 Time management tips for sonography students

Time Management Tip Explanation

TABLE 1-5 Five basic steps of goal setting

Five Basic Steps of Goal

Classroom Survival Skills

Preparing for Tests

TABLE 1-6 Test preparation tips

Test Preparation Tips Specific Goal

Newala, too, suffers from the distance of its water-supply—at least

The water-supply of New Newala is in the bottom of the valley,

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

Some consolation was afforded me by a brassfounder, whom I

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

LAST SMOOTHING BEFORE

FIRING THE BRUSH-PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

MANUFACTURE OF BARK-CLOTH AT NEWALA

Chapter 5: Ergonomics and the Prevention of Work-Related Musculoskeletal