Dear AMSIG members,

Many of you will no doubt be aware and indeed, have expressed concerns to myself and other members of AMSIG, regarding an ultrasound guided musculoskeletal injection training course offered by the University of Essex for sonographers. I recently met with the Dean of our college, A/Prof Greg Slater and representatives of ASA, where I expressed the collective concerns of the AMSIG membership.

Following discussion with the AMSIG executive, AMSIG drafted a letter to the Faculty Council and Ultrasound Reference Group of the college, stating our position on this matter, in effect that AMSIG is against this proposed role extension.

The letter reads as follows:

Dear Dr Slater,

Thank you for your email and request for AMSIG’s input into role extension of sonographers via the University of Essex course for sonographer performed ultrasound guided musculoskeletal interventions.

AMSIG executive held a meeting last Tuesday evening and this was discussed as part of the agenda.

It is the AMSIG’s firm opinion that the College should join AMSIG and take a position against this proposal on the basis of risk to patient care and patient safety. Our belief is based on the following observations:

  • AMSIG believes that a musculoskeletal intervention is a medical interaction between a doctor and a patient. Medical training is required to be able to interpret a request, assess a clinical situation, assess the risks and benefits of a procedure, assess the safety to inject a pharmaceutical, explain the planned intervention to a patient, obtain informed consent, perform a safe and targeted procedure, manage complications and provide guidance for post procedural care.
  • Referrals for sonographically guided injections are commonly based on radiographic, CT, MRI and/or nuclear medicine studies. Injectionalists should be able to interpret all diagnostic imaging modalities (not just ultrasound) to assess the suitability and plan for an intervention.
  • The clinical judgement of whether to perform an intervention requires medical clinical reasoning skills to assess the patient as a whole to determine that a therapeutic intervention is indicated and safe to perform and the effect that this intervention may have on future surgical procedures. For example, the injection of a septic bursa or joint with corticosteroid can lead to overwhelming sepsis, require hospitalisation, surgical intervention and even death.
  • The injection of Section 4 drugs (such as local anaesthetic and cortisone) by a sonographer is currently illegal, except in extremely limited circumstances. We believe that the assessment of safety to inject a pharmaceutical, assessment of dosages required, assessment of contra indications to proceed requires medical training and clinical reasoning.
  • Injectionalists must be trained and competent in the management of anaphylaxis and resuscitation.
  • The proposed role extension will result in less of these interventions being performed by Registrars in training centres resulting in deskilling of our trainees.

RANZCR has clearly stated that high diagnostic imaging standards need to be maintained. Ultrasound guided musculoskeletal injections are within the role of clinical Radiologist. Access to the MBS schedule requires personal attendance of a Radiologist for musculoskeletal interventions.

If there is a demonstrable deficiency in the provision of these services (which we are of the opinion does not exist) the College, Government and the Hospitals should be looking to increase the provision of services through Registrar and Radiologist training and not through role extension.

This course requires a supervising Radiologist to authorise attendance. AMSIG will be informing its members that it does not support this. As the AMSIG executive and RANZCR members, based on the risk to patient safety due to reasons outlined above, we implore the College Council to urgently take a position against this proposal and inform its Members. We believe that a negative position by the College will have influence on the sonographer societies, Government and provide guidance to its Members who are approached to authorise sonographer attendance.

Please note that the proposed start date for this course is February 15th 2016.

Yours sincerely

Dr George Koulouris
AMSIG President

Following this letter, the Ultrasound Reference Group of which I am a member and headed by Dr Cheryl Bass (also an AMSIG member), took up the matter further with the college and I am pleased to say that today they have formulated a position statement (attached, also linked here on this matter, supporting our view.

This letter from the college will be sent to the CEO of ASA, FCR Council, Standards of Practice and Accreditation Committee and the Branch Committee in each state, as well as placed in the January FCR eNews.

I would like to thank all the members for their support on this issue and those who took the time to discuss the matter with the AMSIG executive. I would also like to thank the AMSIG executive, in particular Dr Sanjay Dhupelia, for their assistance.

Best wishes,

Dr George Koulouris
MBBS, GrCertSpMed, MMed (Radiology), FRANZCR