Hank Investigates: Ultrasound Mistakes
The ultrasound pictures were the best possible news for Ellen and Peter Pulley. As the ultrasound operator explained, the lines and swirls showed they were going to have twins.
"At one point she said to us, 'oh look, they're hugging, isn't that cute.'" More important, the sonographer reassured them (the soundwaves showed) the babies were healthy and normal.
"And so you went home happy?"
"Happy." The heartbreaking reality in the delivery room happened five months later. It could have been prevented, but the ultrasound pictures of the babies had been misread!
"It was completely catastrophic. To this family their lives will never resemble anything you and I would think of as normal." And what happened to the Pulleys is the result of a loophole in the medical system, a loophole threatening everyone who gets an ultrasound to check for cardiac problems, organ abnormalities or to make sure a baby is healthy. Here's why sonographers are not required to have special training, licensing, or certification:
"So who's making sure the person doing your ultrasound knows what they're doing?"
"In reality, no one." And that's a critical problem: a poorly trained sonographer who takes a bad picture can lead a doctor to a wrong diagnosis. And one study reveals 65 percent of ultrasounds reviewed were unacceptable!
"You just don't know how much training they've had." Steve McLaughlin is president of the National Ultrasound Society. He admits three out of four sonographers may not be fully qualified! Without mandatory standards, he warns, patients are vulnerable.
"They're putting their health at risk." It was only when the delivery began that the Pulleys realized their ultrasound was wrong. When the room went silent Ellen had no idea what was happening.
"They were trying to block the view so she couldn't see." Peter watched as the doctor delivered what was supposed to be his twin sons.
"The next thing is the doctor is lifting a mass of baby out of the womb and you could see there were two heads, four arms and dangling flesh in-between." Peter was horrified as the doctor confirmed the reality.
"He said, 'my god, they're joined.'" Ian and Nathan were joined at the chest. They shared a liver, a kidney, a large intestine and a leg.
"I remember finding out that day and being crushed and wondering how we were going to go on from here." What the Pulleys hadn't known was revealed later in court records. Their ultrasound operator had only minimal experience: one year of night school in an unapproved program. The Pulleys sued and settled in a confidential agreement. An experienced sonographer looking at the Pulleys pictures could have seen that they were not hugging. They were conjoined.
"It could have been found, it could have been avoided. But we were denied those opportunities." And experts like Dr. Beryl Benacerraf worry about unskilled sonographers still on the job.
"It's an opportunity for disaster." Ian and Nathan, now separated, face endless medical treatments. And since the Pulleys aren't the only ones whose lives were devastated by an incorrect ultrasound, they say it's time someone starts policing the system.
"We don't have any guarantee of level of service of ultrasound or sonographers." If you're going in for an ultrasound, experts say the best way to protect yourself is to ask if your sonographer is certified. Then you'll know they've passed a series of stringent competency tests from a national organization. But if you don't ask you can't be sure, because right now, there's no rule that requires that certification. |

