Can You Fake an Ultrasound in Real Time?

Gerard Asks:

I came across your blog as I was googling my question. This week, I was watching Grey’s Anatomy (Season 14, episode 18) in which an unscrupulous (or maybe it he was just a fraud?) doctor was giving false diagnoses for breast cancer through ultrasound—I think to sell treatment?

Knowing a little about computers, I wondered how that could be possible. Can an ultrasound store the millions of images or 3d imaging from another patient to be “played” on another patient? Of course, I wrecked the show for my wife by questioning the episode she was enjoying.

So, in case I’m all wet in my assumptions, is it possible to fake an ultrasound in real time?

Jordyn Says:

Hi Gerard! Thanks for submitting your question to me. The perfect person to answer your question is Redwood’s resident medical expert, Shannon Moore Redmon.

Shannon Says:

Today’s ultrasound technology does offer the ability to record video clips that an extremely unethical doctor could replay while pretending to scan a patient with a probe. Most patients would not know the difference between normal breast tissue compared to a malignant mass and the shape of the entire breast isn’t really a factor on the ultrasound screen, since we’re only scanning a small section at a time.

With that said, the hoax displayed in the Grey’s Anatomy episode – Hold Back The River, would be difficult to achieve in real medical life.

Gold Standard

First, ultrasound is not the Gold Standard for detecting breast cancer. That role belongs to mammography (x-rays of the breast). Highly trained technologists position and complete several different mammography views. Ultrasound simply supports suspicious lesions first detected on these images. Doctors use the scan to provide more information and ultrasound should never be used alone to detect malignancy. I hope most patients would not simply take a doctor’s word based on an ultrasound alone when determining whether they have breast cancer or not.

When a mass is identified on a mammogram and followed up with ultrasound, these images or video clips do not give a complete diagnosis of cancer. We can suspect cancer by the appearance of the mass we see, but the only way to know for sure if the mass is malignant, is through a biopsy. Stereotactic breast biopsies are often performed at imaging centers or hospitals. A large needle is used to take samples of the mass and then send them off for pathology testing. Those results tell if a mass is cancerous or not. If the patient is not a candidate for stereotactic breast biopsy, then the mass can be removed in surgery and sent to pathology for testing.


When a sonographer finds a suspicious mass on ultrasound, we look for several factors in the appearance. Is it solid or fluid filled? Does is have smooth borders or finger-like spiculations extending into normal tissue? Does a shadow present posterior to the mass? The mass shown during the episode did not meet the specified criteria for malignancy. Let’s break the moment down:

The doctor shows the female character a mass on the screen. There was no shadowing posterior. The borders were smooth and looked like the normal tissue adjacent to it. The area the physician suggested was solid but had a Cooper’s ligament running through the tissue which is typical for a normal lobe of the breast. I’ve included an ultrasound image of a true malignant mass, so you can see for yourself what a true breast cancer might look like on ultrasound. I think you’ll find the video clip played in the scene looked nothing like the true cancer below.




Exam Inaccuracies

During the scene, a swishing heartbeat noise can be heard in the room. Grey’s Anatomy seems to think that when an ultrasound is being used, every machine creates this noise. Let me assure you, that’s unrealistic.

The noise heard in the background is created by a Doppler sample of a vascular structure, such as an unborn baby’s heartbeat or blood flowing through an artery. Neither of these were being scanned during our breast exam.

When no Doppler is activated on the screen, this sound cannot be heard. But yet, we have the heartbeat noise once again. I wish someone at Grey’s Anatomy would update their sound effects team.

After the blond female doctor goes back to Seattle Grace, she has her doctor friend scan her breast to make sure there is no cancer. The doctor who performs the scan and supposed to be knowledgeable enough to detect breast cancer, is holding the wrong probe. She should be holding a linear transducer used in high frequency imaging and provides a rectangular footprint on the screen. Instead, her probe is curved and used for abdominal and pelvic scanning because of the lower frequency range.

Another flaw in the episode is how all these doctors are experts at performing scans in every area of the body. In real life, trained, registered sonographers and technologist work in these modalities. They would be the ones to execute the imaging. Then a radiologist would read the exam and communicate with the surgeon or other physicians. But once again on TV, we see the Grey’s Anatomy doctors performing all the imaging exams. No sonographers or technologists around anywhere. So unrealistic and a little insulting.

I think it is time for the Grey’s Anatomy team to hold back more than the river— they need to hold back on performing any more ultrasounds until they consult a living breathing registered Sonographer.

Shannon Moore Redmon writes romantic suspense stories, to entertain and share the gospel truth of Jesus Christ. Her stories dive into the healthcare environment where Shannon holds over twenty years of experience as a Registered Diagnostic Medical Sonographer. Her extensive work experience includes Radiology, Obstetrics/Gynecology and Vascular Surgery.

As the former Education Manager for GE Healthcare, she developed her medical professional network across the country. Today, Shannon teaches ultrasound at Asheville-Buncombe Technical Community College and utilizes many resources to provide accurate healthcare research for authors requesting her services.

She is a member of the ACFW and Blue Ridge Mountain Writer’s Group. Shannon is represented by Tamela Hancock Murray of the Steve Laube Agency. She lives and drinks too much coffee in North Carolina with her husband, two boys and her white foo-foo dog, Sophie.

Author Question: Treatment of Teen Suicide Victim (2/2)

Today, we’re continuing our discussion of the medical treatment of a fifteen-year-old male suicide victim who slit his wrists at school. You can find Part I of the discussion here. In this post, we’ll focus on more of the mental health aspects over the medical treatment.

Pink Asks:

Upon examining a patient, and if sexual abuse is suspected, what is the hospital protocol? How do the hospital staff work with police and the victim’s family?

Jordyn Says:

If outward physical exam of the skin shows injuries concerning for sexual abuse, this can be handled several ways. In order to answer this best, I’d need to know what kind of hospital your patient/character is at in order to give advice as to how that community would likely respond but I’ll give thoughts as to how my institution would handle it—which is a large, urban pediatric medical center. A rural hospital would likely handle it much differently.

One thing I want to say is that no sexual assault exam would be done without the patient’s consent (or parental consent—a court can order if needed)—so this would not be done on an unconscious person. What you can see from the outside would be the limit. For instance, in girls and women no internal vaginal exam.

There might be an extreme outlying caveat to an internal exam if the patient were near death, concern for loss of evidence, or other victims were at risk, but it would have to be VERY PRESSING circumstance and likely the courts/law enforcement would be involved in order to move forward.

Regarding the suicide attempt, the next thing to keep in mind is that the patient’s medical needs are always addressed first. In fact, the patient must be “medically cleared” by a physician before they can participate in a mental health evaluation.

If there is a concern for sexual abuse, we would first contact social work through our hospital to develop a game plan. If a sexual assault exam needs to be done, we have health care professionals that are very experienced in doing these with kids/teens and we want the most experienced professional to do the exam and collect any evidence. Social work will do a couple of things if they think the concerns are valid. One, report it to the state (Department of Children and Family Services—something along those lines depending on the state) and second, report it to the police if they believe a crime has occurred. The incident is reported to the police jurisdiction where the crime took place and not the location of the hospital where the patient is receiving care.

As an example, if a woman is raped in Anchorage, AK, flies to Seattle and seeks treatment there, the hospital in Seattle is going to have to call Anchorage, AK police to report the crime. Local police can help determine the appropriate jurisdiction if it’s not clear.

The timing of the sexual assault is important in collecting evidence. If a person was just raped, we’d be very anxious to encourage the person to have a sexual assault exam done ASAP. If they are reporting something that happened more than three days prior (it’s 72 hr for us)—it’s not as pressing that an exam should be done immediately but plans can be made with the patient and family for follow-up exam and care.

Larger police departments typically have victim advocates that can help families through processes like this, but it is up to them to call that person in. Contrast this with a more rural hospital that may “hotline” the concern for abuse to the state, call the police, and depend on state social workers to determine the course of action.


Are patients who attempt suicide always sent to a mental health facility for treatment? I know patients speak with a crisis counselor, but what if the attempt wasn’t caused by being under the influence of drugs, or a mental illness, but due to a desperate situation (domestic violence)?


The most important determination about whether or not someone will receive psychiatric care is whether or not they are a current danger to themselves (and/or others) and how likely are they to act on it. This is determined by a mental health professional and not the medical staff. The reason for the attempt doesn’t necessarily differentiate potential lethality—it’s what the patient is thinking about in their mind and how at risk they are to act on it.

I think you’re trying to make a distinction that a desperate situation caused by domestic violence leading to a person’s suicide attempt would be seen as less lethal and it wouldn’t. If a person is trying to kill themselves because their home situation is driving them to do that—that is very significant and taken as seriously as someone who swallows pills, or slits their writs, or is having a psychiatric break. Someone attempting suicide due to domestic violence will likely have other co-existing mental health issues like anxiety and depression.

This is a very serious topic and definitely worthy of fiction to help foster discussion of suicide. Good luck with this novel.

Author Question: Gunshot Wound to the Chest

Virginia Asks:

I’m putting the final touches on a romantic suspense novel in which my hero is shot. The most important part of this is that he has to continue to function until he saves the day, then falls and has to be treated. The wound cannot be bad enough that he can’t pass the physical and qualify to become an FBI agent within a few weeks.

My fit male character (34 years old) is in a shootout. He’s shot with a 9mm handgun but the bullet ricochets, grazes his chest, and fractures a rib. He doesn’t notice initially. He begins to feel some pain after about five minutes. Then feels woozy and has a head rush. I want him to fall after the action is over, but be able to talk a little with some struggling.

He’s far from a hospital when he’s shot, but a military medic is there with his kit. The hero can be medevaced to a hospital on a military helicopter. What would the medic do in the field? I don’t want the bullet to penetrate the chest wall, but would the medic check for pneumothorax and if so how?

What would happen at the hospital? How long would he be hospitalized?

I’ve read and re-read about pneumothorax and hemopneumothorax, but think that might require too much recovery time and be too much for him to qualify and be able to pass the physical. I’ve done some research on pulmonary contusion but am a bit overwhelmed with the possibilities of the use of continuous positive airway pressure and high-frequency chest wall oscillation. And the long term recovery.

Since I really don’t know what would be best as a gunshot wound that my hero can recover from and pass a physical in a few weeks, I really need some guidance and specific information that can easily be explained in a romantic suspense novel. I’m hoping this “bullet grazes the rib” scenario is workable. If not, what should I consider instead?

Jordyn Says:

Thanks so much for sending me your question, Virginia.

I think the simplest thing to do is to have the bullet graze his chest. It could potentially hit the rib, break it, and ricochet away. Leaving a nasty gash with a broken rib underlying but nothing else injured. Generally, a fractured rib will heal in 4-6 weeks so he will have pain and limited movement until then. The worst pain will probably be in the first 1-2 weeks and then should taper off after that.

As far as the military medic assisting off duty. I think it’s fine if he has a small first aid kit that he could dress the wound with. He likely would not be carrying an oxygen tank, etc. So the dressing to control bleeding is necessary. Lots of emergency medical types might have a small kit in their car (I do), but not an oxygen tank or a way to deliver oxygen to the patient.

The military medic could check for a pneumothorax by listening to your hero’s breath sounds. Clear and equal breath sounds bilaterally generally indicate no pneumo (though a small one could still be present). It will hurt to take deep breaths if his rib is fractured.

If he’s transported by a military medevac then they could start oxygen, an IV, and give some IV fluids. Place him on a monitor to keep tabs on his heart rate, breathing, oxygen levels, and blood pressure.

In the hospital, he’ll get chest and belly films and possibly a CT of his chest and abdomen. If it seems like a fairly benign wound, the wound could just be irrigated with a lot of saline and sutured closed. He needs an updated tetanus shot if he hasn’t had one in over five years.

If his breathing is good and he suffers just one cracked rib, there is likely not enough injury criteria for him to be admitted into the hospital. He’d likely be observed in the ER for several hours to make sure everything is okay. He’d be sent home with a short course of narcotics (like three days) and instructed to take over the counter pain relievers to help with the pain as well. He should have limited activity but not be bedridden. He’d be encouraged to take deep breaths (usually at every commercial break if watching TV) to prevent lung complications because patients don’t like to breathe deep when they have a cracked rib.

Hope this helps and good luck with your story!

Author Question: Scythe Wound to the Chest (2/2)

We’re continuing with Sue’s question regarding a scythe injury to the chest to a seventeen-year-old male. You can find Part 1 here.

Sue Asks:

I have a few follow-up questions regarding the surgery. Is it possible for a thoracotomy to be done by two people? The hospital in my story is severely understaffed and only two doctors are available to perform the surgery. There are not enough nurses on staff either, and it’s the middle of the night. Is that feasible or should I tweak the story so more people are available to make sure the teen makes it out alive?

And lastly, what kinds of medications would be pushed through the IV to sedate and/or paralyze him for surgery?

Jordyn Says:

This was a great question to ask my OR expert friend, Kim Zweygardt, who works as a CRNA.

Here are her thoughts.

Most hospital’s policy states that an RN must be in the room for assessments and patient safety. The bare minimum OR staff would be a circulator (RN), scrub tech, anesthesiologist, and surgeon. If you want chaos in your story— take out the scrub tech because the doctor will have to figure out the instruments for himself versus calling out and them being handed to him.

A patient this unstable would be intubated in the ER. Generally they are given a pain medication (Fentanyl), a benzodiazepine (Versed) for the amnesic effect, and the paralyzing agent will vary but Succinylcholine was common in your time frame of 2006.

Once in the OR— they would give him anesthetic gases to keep him down. I don’t see your scenario playing out without a anesthesiologist on hand.

Hope this helps and best of luck with your novel.

Author Question: Scythe Wound to the Chest (1/2)

Sue Asks:

The year is 2006 and a seventeen-year-old male gets stabbed through the right side of his chest all the way through to the back, but the blade (a hand scythe) that could potentially stop him from bleeding out gets removed. Naturally, he starts bleeding out.

I already know a lot about what goes into stabilizing him: Checking the ABCs, IVs for blood and fluid replacement, intubation (an endotracheal tube), but my question is, what is the exact treatment for this type of injury in a surgical theatre? What are the indications that he may need a thoracotomy or a lobectomy? Or is it as simple as a chest tube to treat the hemopneumothorax, connecting him to a ventilator, and then suturing the lacerations in his lung?

Jordyn Says:

Thanks so much for sending me your question, Sue. Very intriguing scenario you have here!

Let’s first clarify some of these medical terms for readers. A thoracotomy is a surgery that involves removing the lung. Lobectomy can be removal of any lobe of organs such as your thyroid, liver, or lung. In this case, you’re referring to the lung. A hemopneumothorax is a collection of blood and air inside the chest wall that is usually relieved by placement of a chest tube. Pneumothorax is an abnormal collection of air in the chest between the lung and the chest wall– also typically relieved by placement of a chest tube (though some very small ones may just be watched).

I asked a physician friend (thanks, Liz!) her thoughts on your questions.

She says the following:

Since the patient is unstable, he needs a thoracotomy by default. Other indications for surgery would be blood draining from the chest tube at greater than 100 milliliters per hour. The lungs cannot be sutured. Generally, bleeding vessels are either tied off or cauterized and the bronchi (the larger breathing tubes) are repaired. If the lobe is severely damaged then it does get removed.

What is the Glasgow Coma Scale?

Often times on television and in movies, you’ll hear a medical character exclaim, “His GCS is 5!” or some other variation. What is this score? What does it mean for the patient?

The Glasgow Coma Scale (GCS scale) is one way to gauge the significance of brain injury. There are three components to the measurement. Eye Opening. Verbal Response. Best Motor Response. In general, the highest score is 15. The lowest score is 3. You can be dead and still score a 3 so the higher the score the better.

Eye opening looks at four components and each is given a score:
4: The patient opens their eyes spontaneously.
3: The patient opens their eyes after being spoken or shouted to.
2: The patient opens their eyes to a painful stimulus.
1: No eye opening at all.

Verbal response looks at five components:
5: The patient knows person, time and place.
4: The patient can speak but is not oriented.
3: Speaks unintelligibly.
2: Moaning.
1: No verbal response.

Best motor response looks at six components:
6: The patient can obey a two part request such as touch your nose and then your shoulder.
5: The patient moves to push away a stimulus. For instance, if I’m starting an IV in your left hand, you take your right hand to push it away. This is called localizing pain and the patient usually needs to move across their midline or above their clavicle (if the stimulus is placed to the head) to score here.
4:  Pulls extremity away from pain.
3: Abnormal flexion.  Also referred to as decorticate posturing.
2: Abnormal extension. Also referred to as decerebrate posturing.
1. No motor response.

Initially, we might look at the overall score to determine whether or not a patient needs to be placed on a breathing machine. Generally, a score equal or less than eight is used as a cut off point. The lower the initial score, the more likely the patient will be intubated. Over the long term, the GCS can be used to trend improving or worsening neurological status.

Have you ever heard this scale used on television or in a movie?

Should You Videotape a Healthcare Worker Without Their Consent?

Recently, I became aware of a story that broke my heart. Perhaps you heard of it, too. A WWII veteran called for help multiple times and when the call light is finally answered, the nurses delay giving him lifesaving measures and are even seen laughing at his bedside. Two nurses, appropriately so, lost their licenses. You can view the video and read about the story here. Also, this case that just aired on ABC news within the last few days of elder abuse by nursing staff  caught on hidden camera as well.

This is a very touchy subject and I don’t necessarily have a strong statement to make, but I do have a cautionary tale. I understand both sides and I’m glad these nurses were caught so that no other patient suffered needlessly. However, I also know that I would feel completely violated if I was videotaped or recorded without my knowledge.

When I worked as a Pediatric ICU nurse, a family chose to videotape the staff without their knowledge. The family was critical of the staff in general and it really was a no win situation. Then news came out that they had been videotaping the patient’s care. Our managers at the time approached them and requested they stop. In all the footage, and I don’t know how much there was, the staff wasn’t seen doing anything inappropriate.

In writing fiction, we always talk about increasing tension and conflict. I can tell you from personal experience that this will definitely do it.

In real life, if you or a family member make a decision that this is a necessary step to take, I would ask yourself why you’re making this choice. Considering this means you already think something is wrong. If that’s the case, is this the right doctor or hospital to be working with?

Taking this step is very serious. At the very least, it will likely destroy any trust between you and the medical staff. Sometimes, that’s hard to get back. Legally, you should discuss whatever option you’re considering (secretly recording a conversation, etc) with a lawyer. Different states look at this issue differently. There might be a hospital policy in place against. There are patient privacy concerns (the recording picking up another patient’s information). Also, it might actually have the reverse effect. When medical people know they are being more scrutinized, the added stress can make it more likely for them to make a mistake.

I think several things can be done before this to allay or address a family’s concerns. Any good hospital will take a family’s concerns very seriously. If they don’t, then there are places to go with your concern. For instance, concerns for elder abuse can be reported to state regulatory boards.

Here are my thoughts if you’re concerned your family member is not being taken care of appropriately.

1. A family member should be at the bedside 24/7. I know this may not be feasible for everyone, but having a family member at the bedside does keep staff on their toes. Ask questions. Keep notes. One problem I do have with the current state of medicine is that the providers don’t seem to read one another’s notes so important facts may not be shared. I had a personal experience with my husband with this very thing. If you can’t find someone to sit at the bedside, check in a couple of times per shift via phone with your loved one’s bedside nurse and try to be there in the morning when they make rounds.

2. Tell your nurse that you have a problem right when it occurs. State it clearly. Plainly. Rationally discuss what your concern is. If the response from the bedside nurse isn’t satisfactory, then ask to talk to the charge nurse. If that doesn’t help, ask to talk to the unit manager or nursing supervisor. You can speak to a patient care representative. If it’s a concern about the doctor, your bedside nurse should be the one who will advocate for you in that situation. Do not stay silent about your concerns. Big or small— please speak up.

3. You can request alternative staff to take care of your loved one. This is easier on the nursing side. Sometimes, your personality and the nurse’s personality don’t mix. That’s life. We don’t get along 100% with everyone. Is it a personality issue or do you think the nurse is providing bad care? Making a distinction between the two will help the charge nurse or supervisor decide what the best action is to take. For instance, a conflict of personalities, maybe it’s not best to put the same type of nurse in there.

4. Pay attention when you are admitted to the hospital about calling an RRT. An RRT stands for Rapid Response Team. Usually they are made up of a team of ER doctors, ICU doctors, and critical care nurses who will come to the bedside an do an independent evaluation of the patient and suggest a treatment course. Bedside nurses can call these, but many hospitals are making sure families know they can do this as well. The time to use this is when you feel your family member is getting sicker, but the bedside staff isn’t listening to your concerns in a way that makes you comfortable. It allows another set of eyes and ears on the patient and more medical opinions can be discussed.

5. If you’re a medical provider, you should report sub par staff to that person’s supervisor. This is all of our responsibilities. If you feel you can’t do that, then leave an anonymous message to your organization’s corporate compliance hotline. As they say, document and report.

What do you think about videotaping medical staff without their knowledge? Are you for it? Against it? Why?