Your First Job - Keys to Success

So you've landed your first job as a new grad... congratulations! In today's job market, this can be extremely difficult to do immediately after the completion of your radiography program, and it might even be a few months before you start working. This may leave you feeling like you have forgotten everything you learned... and then some! Here are a few helpful things that will start you off in the right direction:

Most facilities have some type of orientation program, which will vary widely. Some might have you orienting in several rooms for a predetermined amount of time, while others might have you scheduled as an extra body, and ask you to float to all areas. In either case, use this time wisely! After this time period, you are going to be expected to perform independently as a technologist.

You may be tempted to avoid fluoroscopy, OR, or combative patients... this is the exact opposite of what you should do. Stepping up to perform these exams will familiarize you with the facility's equipment, exam setup and protocol, and even possibly some hospital policies and procedures that you were previously unaware of even if you trained there. You will be learning new things for a while still, and learning is supposed to feel a little uncomfortable until you build some confidence. Remember your first day in your clinical site as a student?

It will take you very little time to realize that there are techs who prefer or avoid certain exams. It's a good idea to become efficient at these - they are typically the more time-consuming exams. OR is another one to familiarize yourself with. You have probably had the least practice with this, and even seasoned techs can become intimidated, and avoid the OR like the plague. If a physician becomes frustrated with how slow you might be moving, just explain that you are new, and ask them to communicate their needs so that you can do a better job for them next time. You will win the respect of the physician, as well as your coworkers when you go into the OR the next time with improved performance.

**as a side note to the above paragraph, techs who avoid certain types of exams are most likely to be flexed out early or laid off first if the hospital is asked to make budget cuts. A manager/supervisor will always prefer to have a team who is versatile and has a positive attitude.

Take some time to learn your hospital's policies, which may be very different from that of your clinical rotations. Good ones to learn are attendance policy, dress code, sick leave, performance expectations and evaluation, timekeeping, and scheduling requirements. You will probably be presented with all of these things up front right at the beginning, and you will be asked for your signature to confirm you have received them... make sure you read the fine print! You will be held accountable to all of these things, and saying "I didn't know" simply won't fly; they have your signature, remember.

Start to learn about JCAHO standards and how they affect your department. JCAHO inspects the hospital periodically to ensure patient safety, among other things, and can induce anxiety when inspection time comes around. There is a lot of information to learn, but it doesn't have to happen all at once. Learn little things every week. Start checking supplies for proper storage and expiration dates. Make sure patient privacy is upheld with paperwork, computer programs, and even while speaking with patients. Learn the safety procedures and locations for safety equipment for your department. This is only the tip of the iceberg, but these things will not typically change. You should know them anyways as part of your job description, so if you learn them quickly, you will not have to panic when inspection time comes around.

Be personal - introduce yourself to staff members all throughout the hospital. The radiology department receives lots of phone calls regarding services rendered. After some time, you will probably have a good phone list of people that you have regular interaction with. Make special note of these people because introducing yourself to them will make every interaction more pleasant for everyone. It will also assist you in knowing who to call for what you need. You will be working more independently now, and there may not be someone around to simply ask... soak up the knowledge like a sponge.

Try to be flexible with scheduling. Most techs who have been in one position for a while have learned how to acquire the schedule that suits them most. Of course, when you first start, you will be asked to work sporadic shift assignments. Take this with a grain of salt because everyone has been there. So many new grads think they will be working Mon-Fri 7am - 3:30pm, and that is just not realistic. Those are the easiest hours to fill, so expect to be pulling hours in variable shifts, holidays, weekends, and possibly call. This is just a normal part of the health care field. Give it some time, and you will gain some seniority with better options for hours down the road.

Finally, continue learning... it is easy to believe that since school is over, you have "arrived" and have nothing left to learn. I honestly learn something new just about every day I work. There is always a different challenge that will require a different way to do the same job. If there's not, then you can always find ways to improve your quality, efficiency, or patient care standards. Nobody's perfect, so there should always be something to strive toward. Losing your initiative is the quickest way to technologist burn-out.

Funny or Insulting?

I ran across this video posted throughout the medical blog realm... feel free to watch. I am not certain I like this video getting publicity by me posting it here, but I think it needs to be addressed by other people in the medical field:

The Too Informed Patient from Marketplace on Vimeo.

I'm not sure in what context this video was posted, but here is what I see... a patient with concerns that are not being addressed by the physician, the physician not really considering the patient as a valid member of the "team", and a sad, growing trend in the face of healthcare reform - that of quicker and less thorough exam times. This video could have been posted by a frustrated patient who doesn't feel like they are getting the care they need. Or it could have been posted by an arrogant physician who is tired of self-diagnosing patients. The sad fact is, patients are empowering themselves by researching what information they should be getting provided by their doctors... unfortunately, there is a lot of misinformation out there, and not everyone knows how to perform research from credible sources, which leads to videos like this one.

Having been on both ends of healthcare myself, it is easy to see both perspectives... the physician is being cut out of the loop of patient care when patients self-diagnose, and can easily be offended by this... and the patient may not feel like the physician is there to do anything but collect a copay when diagnosis continues to be made without testing of any kind. These common things combined provides a lack of clarity in the identification of roles by each participant that will only increase in the next few years as we see healthcare reform roll out. The "team" effort in healthcare today faces rapid degradation in the near future.

Cost-effectiveness, efficiency and time management utilization are going to be the focus in our field, if they are not already at your institution. If you are working in a busy x-ray department, taking the extra 5 minutes to explain a procedure or let a patient simply voice a complaint can back up your exam flow to where it can take half the day to catch up to where you were. So how are we to handle these things in the face of being more cost-effective and increase productivity?

My suggestion as a giver of patient care: Take one thing at a time. Offer quality health care to the best of your availability to everyone that you encounter. If we allow ourselves to be stressed out and rush our performance for the sake of numbers on paper, that is when the quality of care is decreased, and mistakes can be made. If we continue to do a thorough job, we may have a small dip in the equation of efficiency, but if we attempt to strive toward quantity rather than quality, the risk of serious mistakes that could hurt you, your patients, and your institution increase. An appropriate balance must be sought.

There is a powerful message in this video which depicts an entire doctor's exam in under three minutes. Regardless of the motives behind the maker, everyone watching can understand at least one perspective being presented. It is our duty as healthcare providers to ensure that this does not become our standard of practice, and that we continue to care for our patients with the oath in mind that we all took at the beginning of our careers.

Calculate your X-ray Risk!

This website may be a good source for educational purposes, or even to recommend to your patients who have questions and concerns about radiation dose risk. I learned about this link from Dave's Page.

Ten Important Things to Rember as a Radiologic Technologist (learned the hard way by a few techs close to me)

1. Correctly identify your patient, as well as the study you are performing on them... nobody wants a surprise barium enema who thought they were coming in for a chest x-ray.

2. Wear a mask in the O.R... especially when chewing gum... and sneezing... and having your gum-wad land on someone's open spine.

3. Never, under any circumstances, place your face near the enema tip when pulling it out after a BE. Even though you think you have all of the remnants drained into the bag, it's just not a good idea. If you've seen "The Matrix" where Neo first learns to dodge bullets, you'll understand what I mean.

4. Always ask if there is a "chance" a patient might be pregnant. Even though some may appear to be six months pregnant, it's the safest policy (for you and your patient) to give the benefit of the doubt and just ask.

5. Repeat of #4, but for age consideration. The oldest pregnant woman to date was 66 years old. The worst that can happen is patient flattery.

6. Inform a patient that you are going to "lightly slap" their veins prior to starting an IV. Simply not telling them what you're doing can get you in a lot of trouble (this one is for Nancy D.)

7. Wear gloves with every patient. Take it from someone whose hands have touched a variety of unknown wet consistencies from the most unsuspecting of patients.

8. Get used to the naked male elderly body. Something happens to male patients over 65 years old... there is an inverse relationship with age and modesty. Even though you offer a gown, be prepared for the refusal by the patient to wear it.

9. You don't have to perform mouth-to-mouth during a code in a hospital setting. Most hospital staff will let you do this until the oxygenated amboo bag arrives, and laughter will be pointed at you for eternity after your patient has revived.

10. (for the guys) Remember your anatomy. If someone in a state of panic runs to you and asks you to get a set of sterile fallopian tubes from central supply STAT, don't fall for it. I'm one of the few who hasn't, but I've been witness to many new students who do.

Shout Out

Every once in a while, I will be searching for tutorials and/or how-to articles or blog posts in the radiography realm, and I continue to find postings by M.J. Fuller, who has consistently contributed his knowledge and experience in the field for free across the web... you can start checking his stuff out with his wikiradiography page, called Applied Radiography.

Great work, lots of time and effort spent on this site, and three thumbs up from me! That's two of my thumbs and one that I x-rayed today.

Guidelines for Acquiring Patient History

Alright, so I'm a history channel buff, and I couldn't resist uploading their logo :-)

How many times have you received a requisition or a Physician's order for an exam without any patient history or diagnosis? Or even worse, there is a symptom listed that has nothing to do with the body part ordered, i.e. a Chest x-ray order that states "pain in left foot." Here are a few guidelines to acquiring a good general history to help the Radiologist and to create warm fuzzies throughout the department:

Talk to your patient. It sounds so simple, but we all know that chatter can be somewhat limited during a busy day. Take the time to ask them why they were admitted into the hospital or why their doctor ordered the exam.

Be a 3 year-old. Have you ever noticed that 3 year-olds ask you "why" a million times. You can do the same thing with your patients, but maybe tone it down just a bit. For example, ask "why are you having a chest x-ray?" If the patient says, "I have a cough," don't simply stop there and write "cough" on your requisition. What kind of cough? Dry or productive? Clear sputum or thick yellow gunk? Blood in sputum? Are you a smoker? Any history of asthma or emphysema? How long have you been coughing? Have you had a fever since you started coughing? If they are having a foot x-ray for pain, ask where... don't simply write "pain on the side of the foot." The Radiologist should be able to tell exactly where the pain is without looking at any annotated arrows on your image. "Pain at the base of the 5th metatarsal s/p trauma 1 week ago. Contusion at the site and soft tissue swelling present."

There's always the chance that the patient states they have no clue why they are having an x-ray. There could be a couple of reasons for this... it could mean that the physician has not communicated the reason, in which case it should be written on the prescription. If it is not, take the time to call the physician so you can provide an adequate history for the Radiologist. Checking the patient's chart can also be a very simple, yet easily overlooked option. You can also go back to the beginning... just ask why the patient originally went to see their physician to begin with. Some history is better than no history.

There's always the challenge of the non-english speaking patient. A good way to acquire a history from these patients would be to enlist the assistance of a family member or coworker who might speak english and the language you don't know. Nobody around who speaks that language? Most facilities will have a contract with a 24-hour phone service that will translate for you. It might take a little bit of time and effort, but taking this time prior to the exam being performed could save you a lot of time, frustration, and energy later.

Histories for studies involving contrast or invasive procedures are extremely important. Of course, when injecting or ingesting contrast, it is important to note any allergies, prior surgeries (date, type, and location) and any current medications the patient is on. Depending on the answer to these, you could quite possibly identify a contraindication for the study you are about to perform, and the Radiologist will really appreciate your thorough history-taking skills. Common contraindications may include the following:

Possible perforation of bowel on barium studies - we don't want cement-forming barium leaking into the mediastinum or peritoneal cavity!

Patient on anticoagulants for arthrograms or myelograms - it will take quite a bit of effort to get any bleeding to stop, and if you are puncturing the dural sac, you will risk spinal fluid leak after the patient leaves.

Patient on glucophage when performing a contrast injection - this could over-work the kidneys and glucophage should be avoided for at least 48 hours post contrast injection (check department policy and patient's physician to ensure they can go without the medication for that long).

Patient had recent biopsy of colon prior to BE - any additional pressure on the bowel wall of contrast and/or air could cause a perforation in a weakened region of the bowel.

Patients in renal failure - we don't want to further contribute to the workload of the kidneys by injecting our syrup-like contrast... if the patient is on dialysis, contrast injections may be able to occur if dialysis immediately follows the injection and should be coordinated with the ordering physician and radiologist.

General allergies - we all know what can happen if we don't screen for allergies appropriately.

All of these things in combination will keep the patient safe, the order physician happy, ensuring trust in you by the Radiologist, and increase your level of competence as a Radiographer. A few minutes prior to a procedure for a thorough history can prevent a life time of trouble for all.

The Angry Patient

So how do you deal with an angry patient? Well, it kind of depends why they are angry. Usually patients become angry when the unexpected occurs. Whether it is a long wait time or their physician did not explain what we would actually be doing for their BE, there is typically one or a combination of unexpected events occurring that usually sets them off.

Big mistake - avoid the angry patient. This may seem like the more comfortable thing to do because you really "don't have time" or "don't want to be a target." Patients will continue to grow in frustration if they feel like their concerns are not being dealt with. How do you know what their concerns are? Ask them.

Communicate - find out why they are angry... and apologize to them for the experience they are having. Even if it is not directly your fault, most of the time it is the fault of someone in your organization, which you represent as well. Once you know why they are angry, you can move forward with an action plan.

If it is within your power to do so, resolve the issue. If you cannot resolve it, direct the patient to someone who can. Not by pointing to someone in a crowd of course, but by introducing them to the person and explaining their problem. If that person is unavailable, follow up with the patient a few minutes later. A good amount of time to wait to address the patient again is around 10 minutes, but use good judgment... some patients may require a shorter span.

There are many patients who seem like they are just angry. They may not be able to identify a problem when approached, nor express the desire to. They just seem to be royally peeved and they are going to take it out on YOU! Does this give you an excuse to treat the patient in the same manner? Of course not. Put yourself in their shoes. They might have just received horrible news about their health or had an indication of what their bill for the hospital stay will not be covered by insurance.

Always act professionally. You still have a responsibility to treat that patient with dignity and respect. Continue providing quality patient care. Speaking in soft tones is one way to deflate tension in a room. And ask direct concise questions when acquiring a history.

The best thing you can do is show the patient that you care. Listening is one of the most therapeutic things within our power to do. Slow down and remember that every patient should have the opportunity for quality care, including a sanity break. They may feel 10 times better after getting something off their chest.

Of course, there are patients that become hostile... spitting, biting, screaming, punching, slapping, kicking, etc. For these patients, I recommend security. Always stay a good arm's-length away from these, and never ever turn your back on them!

In closing, we all have busy days and moments when we don't feel like going the extra mile. But remember, our patients are not only paying for a service, they are depending on the quality of work we do to evaluate and treat their health. Wouldn't you want that same type of effort on your family member?

Shoe Fitting Fluoroscope

I found this link that was posted on one of the AuntMinnie forums that I was reading.

The Shoe Fitting Fluoroscope is something that you might hear about from an older generation (or two... or three), but it is something that I have commonly referenced during lectures and received more than a few blank stares.

This is a great article, explaining some of the dangers of radiation exposure to the extremities in severe cases where feet or entire legs had to be amputated due to excessive radiation burns.

The construction of the machine has a viewing device similar to what Spock (oldschool Spock, Leonard Nimoy) used to look through on the bridge of the Enterprise when Captain Kirk asked him for a status report, and he would spout out a completely logical, statistic-based answer... my rambling is showing how much of a geek I am.

Back to the point, which is the absence of Image Intensifiers... basically, the x-ray beam is pointed straight up at the viewing eye station; yikes! Anyhow, I found this to be a fun, interesting read.

Topics in Radiography listed in "Top 50 Radiology and Sonography Blogs"

What's funny about this is I didn't even know until I was browsing Dave's Place.

So two thanks go out: one to Dave for enlightening me on this, and one to Radiology Technician Schools for listing me in the "Top 50."

Goodbye X-ray Tubes???

One of my former students presented me with this link, which proposes some groundbreaking changes in the world of Radiography.

The MAX (microemitter array x-ray) is a flat-panel source of x-ray photons that produces a parallel beam from solid state technology, rather than the traditional x-ray tubes that we currently use.

Radius Health is testing equipment with the assistance of UCLA to eventually produce a flat-panel source for ionizing radiation at the diagnostic range. They believe that the MAX will reduce cost, allow equipment to be smaller and lighter, while allowing for maximum portability.

I'm excited to see where this goes!

Would you like to see my colon?

Not my real one of course, but my low-budget study tool you can use to visualize the large intestine when studying positioning for Barium Enema! You can make your own with a large paperclip or pipe cleaner... here's how:

Step 1: Hold paperclip crosswise with open end on the bottom.



Step 2: Unbend the bottom portion about 90 degrees so that it is vertical.



Step 3: Unbend the other portion so that it is parallel to the prior side.



Step 4: Unbend the final portion so that it is parallel with the longest side. It should look like an incomplete square now.



Step 5: Curve the top/longest side toward you in a "C" shape. The bottom should be pointed at you now.



Step 6: Bend the now curved to portion down.



Step 7: Place your finger half-way between the bends on the right side and make a new bend, turning toward the left.



Step 8: Bend the shortest portion into a "C" shape so that the end of the paperclip is facing you.



You now have a colon for everyone to see... show your parents, your friends, your classmates, and even your instructor! Show everyone!



Twist and turn to see how gravity would shift contrast and air! Use a flashlight to examine your colon!

*Supine AP





*Lateral Rectum



*Decubitus images demonstrate barium side down, air side up.





*Cephalic angele - demonstrates sigmoid colon in profile



*RPO - demonstrates the splenic flexure open





*LPO - demonstrates the hepatic flexure (not so well in the radiograph, but better in the second image)





Study your colon regularly to master positioning skills for BE!

Reducing Radiation Dose in Diagnostic Radiography

One of the advantages of digital imaging systems is more tools to control image contrast. According to the ASRT's "Appendix for Digital Image Acquisition and Display" the look up table is "the default gradient curve applied to the data set of your image determining initial display contrast." Remember the average gradient used to calculate the scale of contrast in sensitometry??? There are many parallels here in regards to digital image display.

What does this mean for us though? How does it help? If you are a seasoned technologist who has mastered the art of film/screen imaging techniques, you are already familiar with the concept that kVp is the primary controller of image contrast. However, this changes with digital imaging systems. While kVp selection still affects image contrast, the new primary controller is the look up table. In other words, the algorithm you select (when you select your body part and projection) instructs the computer to apply a gradient curve (via the look up table) to tell the computer what kind of image contrast to display. Don't believe me? Try processing a hand x-ray under a PA chest algorithm... the contrast will be long-scale even though you used 60 kVp.

So is the optimum kVp range that we all learned in x-ray school still considered optimum if it is no longer adjusted to simply manipulate contrast? Let the debate begin... the principles of physics remain the same with the penetrating power of the beam in regards to kVp selection. You still need enough kVp to penetrate a body part to acquire an optimum radiograph. Along with my students in imaging class, we decided to see just how much image contrast varied (or remained the same) with a CR imaging system. The following images were taken of a lateral knee phantom (note the annotated technical factors):









A film/screen imaging system would show a dramatic change in scale of contrast when comparing technical factors between images 1 and 4. On our CR system, there is not too much difference between the knee exposed at 70 kVp and the knee exposed at 110 kVp.

We all know that if we can produce images at higher kVp values, the mAs can be reduced, giving the patient far less radiation exposure. I think this is something that should be considered at all facilities operating digital x-ray equipment. Other than saving on radiation dose, there are other advantages and precautions that we need to consider.

If you look closely, there are subtle changes in the most dense regions of the bone, as well as the least dense regions, specifically the soft tissue surrounding the patella. I am an extreme advocate for magnification at the QC station... doing this routinely will give you a better idea of what the Radiologist is going to be seeing in the reading room that you might not see from the low resolution QC station monitor. I have magnified the 1st and 4th images below for further evaluation.


70 kVp 7.3 mAs


110 kVp 1 mAs

Because the dynamic range of the CR image plate is wider than that of film/screen, we are able to achieve diagnostic quality images outside the traditional technical factor parameters. This does not, however, mean that any old technique will work. As you can see in the 110 kVp image, we are beginning to see some image noise, otherwise known as quantum mottle. This is due to a lack of x-ray signal to the plate. The CR system is great at receiving exposure, with a wide range of kVp and mAs values, and transforming the remnant beam into a beautifully displayed manifest image. But... if there is not enough exposure to the plate, all bets are off. We see image noise and quantum mottle when there are not enough photons (signal) to the image plate. In order to maintain density at 110 kVp, the mAs has to be decreased severely. Eventually, we will lower mAs values so much that even though our 15% rule calculations are correct, the quantity of photons striking the image plate are simply insufficient to produce a good signal to noise ratio.

The tricky part is balancing image quality and dose to the patient. As always, the Radiologist will need to have a say in what kind of images they wish to see, but keep these things in mind the next time you are performing a lateral C-spine x-ray on the Incredible Hulk. If you have trouble visualizing the C7-T1 junction, you may want to consider increasing the penetrating force behind your beam with 80 or 90 kVp (don't forget to adjust your mAs) and feel comfortable that your scale of contrast will not be as severely altered as with a film/screen imaging system. You will have more uniform part penetration, giving you better visualization of the lower cervical anatomy, and you have reduced your patient's radiation dose by 50% - 75%. Not bad for a 10-minute exam!

The Ongoing Debate With X-Ray Examinations

After recently participating in an online discussion board forum on the topic, I thought I would post the topic here to gain some additional perspective. Here's my question:

Do you believe that general radiographic exams should be performed by unlicensed/unregistered individuals?

In other words, people who may have medical backgrounds like Medical Assistants or Chiropractic Assistants who may have been trained on the job, but have no formalized education as an X-Ray Technician other than what someone else has shown them in the field.

Some states do not have any restrictions on who can or cannot perform radiographic examinations, and there are other states that have extreme restrictions. I know there are going to be several variances of what happens in your own state, which I would love to hear about as well, regarding qualifications. There are also some limited licensure programs that provide certification in chest, extremities, etc. that are formally structured. Having lived in states on either side of the spectrum, I have my own opinions on the topic which I will refrain from stating at this time, but I am interested in yours. I plan on posting a poll on this blog, and I also invite comments to this post explaining your reasons for your opinion.

If the responses here are as mixed as they were on my recent discussion board experience, it will prove to be very interesting.

It's always nice to see former students in the paper!

From the News and Observer in North Carolina.