Are There Too Many Radiography Grads?

There is quite the controversial discussion going on around town.  I have heard complaints from several students across the country, some of my own students, technologists in the hospitals and imaging centers, and even online in Radiology forums about how many new grads there are in the Radiologic Sciences Programs when there are "so few jobs" out there.  I have heard comments like, "the schools are saturating the job market" and "it all comes down to greed with college administrators."  I have even heard allegations that the hospitals pay off the schools to have students there, and vice-versa in a conspiracy to keep technologists who are already employed stuck in their current positions.  I think it's time to set the record straight on a few things.

I have never heard of any hospital or school having financial gain for their professional contracts.  That would be a huge conflict of interest.  To be perfectly realistic, there are some schools that don't look at the job market saturation and fill the seats in the classrooms with the motive of greed... but I think this is probably less than 1% of the cases in the United States.  The problems that hospitals and schools are facing on an administrative level has to do with a couple of things:  The upcoming surge of baby boomers retiring and the reduction in medicare reimbursement.

Baby boomers were born anywhere between 1946 and 1964, which means that by 2011, the first boomers will have reached age 65 - retirement age.  Unlike the last three decades, the healthcare field has made an effort to try to anticipate this reduction in work force, since the boomers make up the largest population of any age group in most hospitals.  They also make up most of the executive and administrative bodies.  Once they start retiring, there's going to be a large need for qualified employees to fill their shoes.  Also, the number of geriatric patients is expected to increase exponentially with this change.

How do the proactive efforts of the hospital systems contribute to increased graduates?  Well, most schools (typically community colleges) have a symbiotic relationship with the hospitals in their area.  For Radiography programs, there needs to be enough technologists to take on students, and there needs to be enough jobs when the students graduate in order to employ 75% of all new grads within 6 months of exiting their respective programs (JRCERT requirement).  The hospital administrators regularly communicate with college administrators to determine exactly how many graduates should be pumped out annually.

This all sounds great in theory... here's the problem.  More and more people are continuing to work into and beyond the traditional retirement age.  People are unsure about social security payout, and with the economy the way it is, a lot of people have lost money on their stocks, 401k's and other investments; basically, a lot of people cannot afford to retire yet.  The efforts made between the hospitals and schools are valiant and I commend those institutions that have been proactive, but these efforts relied upon information that was incomplete at the time.  Preparation for this scenario was started years ago and some of the variables have changed.

I have no doubts that this was a wise move, but it was conducted a few years too early.  Unfortunately, our market is rather saturated at the moment.  Those who do find jobs out of school are settling for undesirable positions as casuals for multiple employers and usually second or third shifts, weekends, and holidays.  Those unwilling to take these shifts or relocate are not able to find work.

The reduction in medicare reimbursement is a wild card.  It could serve to increase or decrease the demand for technologists... I happen to believe it will increase it.  One could argue that the more expensive studies like CT or MRI will not have the same reimbursement rate after reform officially kicks in.  Less expensive exams like diagnostic x-ray will increase in number, and reimbursement is more likely to be paid for the cheaper studies.  This may bring back additional volume to gen rad departments and take some volume away from advanced modalities.  Even if advanced studies are ordered, x-rays will probably have to be done first in order to show prudence that the cheaper study was attempted and found unsuitable to diagnose adequately.

Now is an awkward time for those who just graduated from a Radiography program.  I truly believe that the market saturation problem will slowly diminish over the next 5 years or so.  Now is the time to accept those unfavorable shifts and positions that require sacrifices that you might not have anticipated.  Get your foot in the door.  It will definitely pay off when the slump goes away and the more desirable positions need to be filled.  It's very competitive out there right now, but there will soon be room to grow and you will be thankful that you persevered through this difficult time.

Continuing Education Courses

I've been tossing around the idea of creating continuing education courses to place on this blog, but before I get carried away, I'd like your opinion... In the side-bar, I have placed a poll asking if my readers would like to see CEU's offered on my blog.  I would appreciate it if my readers would take the poll to give me an idea of whether or not the courses would be well-received here.

Any time I have seen CE credits offered on a website, it seems to be in one format only.  If you answer "yes" in the poll, and if you could spare a minute, please let me know what kinds of formats you would be interested in.  If this all works out, I would like to offer multiple formats, but I want to make sure it's something that my readers would appreciate.  Also, if you feel so inclined, I would like to know what kinds of topics you would be interested in, as well as if you would be more likely to recommend this site to a fellow Technologist.

Of course, I would probably start out offering courses slowly into 2012, and would more than likely do a one or two unit free CEU course to kick it all off just to see what kind of response I get.  Thanks in advance for your input!

Rheese View for Orbits

Sorry about the length of time between my posts.  Lately I've been pretty busy with work, but I've been wanting to do a video on the Rheese view for some time.  I used a google chrome app called biodigital human.  Hope you enjoy:

Looking for a Bachelors of Science in Radiologic Science?

There are a lot more options to acquire a BSRS degree today than ever before.  One of those increasingly popular options is an online program.  I had an opportunity to interview Nancy Daugherty, MA, RT(R), the BSRS Program Director from PIMA Medical Institute with some important questions you may want to research if you are thinking about continuing your education:

Who is eligible to enroll in the BSRS program at Pima Medical Institute?

Students can transfer into the BSRS from most U.S. Radiography programs, both certificate and degree. Admission to the program requires that an applicant hold a registration by the ARRT and currently employed in radiography, or if not currently employed in the field, graduated from a radiography program within the last five years.  Applicants will need to have completed a total of 70 semester credits of specific coursework at the postsecondary level. The content of these 70 transfer credits shall consist of 15 general education credits and 55 radiography technical credits. Additional transfer credit may be accepted as determined on an individual basis by the campus director and program director. Pima Medical Institute has additional online radiography courses for applicants not transferring 70 credits. 

How long is the program?

The B.S. Radiologic Sciences program consists of 60 weeks of content, or 70 weeks including semester breaks. Students can Fast Track the program by receiving up to eighteen optional transfer credit for general education courses. Individual completion time may vary by student depending on individual progress and credits transferred.

What methods of instruction are used?

Pima Medical Institute’s online radiography course programs are taught online allowing for schedule flexibility to help students balance school, family, work and other personal commitments. These programs feature a rigorous curriculum and dedicated instructors and staff. Each online class is led by an instructor, and you will be part of a virtual class of other students. The courses are varied with different types of activities, quizzes, assignments and discussions to enhance the learning experience.

Is there any travel involved?

None at all.  The program can be completed 100% online.

What is tuition for the B.S. Radiologic Sciences program?

$250.00 per credit hour.

How many students are selected for each class, and how often are classes started?

We have chosen to keep our classes small and limited to 25 students. A new program begins each January, May and August.

What is unique about the B.S. Radiologic Sciences program at Pima Medical Institute?

I think it is the personal touch we try to provide to each student. Each enrolled student receives a one-on-one phone conference with the Program Director and the Financial Aid Advisor to answer any questions about the program.  I tell the students all the time to feel free to contact me with any questions.  I like to say I have an open door policy; even ONLINE.

What kinds of jobs have some of the graduates of the B.S. Radiologic Sciences acquired?

Our graduates are working in Medical Imaging as managers, technologists and medical sales representatives.

What are the advantages to obtaining a Bachelor’s of Radiologic Science?

Today it is almost a requirement to hold a BS degree for advancement. 

Who accredits the B.S. Radiologic Sciences program?

The program is accredited through Accrediting Bureau of Health Education Schools (ABHES)

Can classes count toward a Master’s Degree at a later time?

Yes. We currently have articulation agreements with Chadron State College and University of Phoenix. Students can contact other colleges to see if they will accept these classes towards a Master’s.

Can the program be completed while working a full-time job?

Yes.  Most of our students are working full time while completing the program. The semesters are set up in a 2 + 2 format so they take 2 classes at a time. Only the last course, the Professional Capstone is 15 weeks in length.

What does Pima Medical Institute do to remain competitive with other B.S. Radiologic Sciences programs?

What sets PMI apart from other B.S. Radiologic Sciences programs is one-on-one rapport that we build with our students as well as our curriculum. PMI has an instructional design team that works alongside subject matter experts to create online courses that captivate and engage.

Is there a Master’s Degree program in the future for Pima Medical Institute?

There are no current plans for this right now, but watch out! Anything could happen.

For more information or to inquire about enrollment, please visit www.pmi.edu 

Q&A: ARRT Preliminary Test Scores

Following up on a post almost 4 years ago... still getting questions about how accurate the scoring is.

Please feel free to comment... especially if you found that your preliminary score did NOT match your official score once received in the mail.

T-Tube Cholangiogram

Thanks Lori for sending me this.  I couldn't find any information about the author/creator, but here is the link for it and you can check out some additional material at the bottom of the embedded presentation:  http://www.slideshare.net/ricksw78/ttube-cholangiogram

T-tube Cholangiogram

View more presentations from ricksw78

Ask Me - Question and Answer Sessions

I've been getting a lot of great emails lately from my readers asking questions about various topics, and I'm finding that I spend a lot of time writing email responses that could (should) have been blog posts or YouTube video productions.  I'm missing valuable opportunities here... the obvious opportunity to post content, the opportunity to get to know you, and make myself know by you more, as well as to find out what kinds of topics I need to be visiting more to help you out.  Here's what I propose:

I would like to begin a question/answer session on the blog here... if you have a burning question about something related to radiography, post in the comment section here, send me an email, or comment on my YouTube Channel, and I will respond with a video answer.  I don't claim to know it all, but if I don't know something related to general radiography, chances are that I know someone who does and I can direct you to the right place.  The world of radiography is a small community and we have valuable resources among ourselves... I hope this can help to be a more interactive experience for everyone.

New Video: Townes Skull

Video discusses positioning criteria and critique of over and under-angulation of the x-ray tube on the radiograph.

Click here to watch this video and more on YouTube

10 things JCAHO looks for in Radiology

1.  HIPAA compliance - Is there patient information left out for passers by to view?  Make sure that your monitors displaying patient info are not in public view.  Paperwork should be face down if anybody can just pass by and be able to read it.  Patient identification and history should be verified verbally once in the exam room (you can check the armband prior to entering, but ask the patient behind closed doors).  Proper identification of patients with at least two identifiers.  Proper charting of procedures and checking Physician's orders is important as well.

2.  Crash cart checks - the crash cart in your department should be checked daily.  There must also be proof that it was checked.  A log including date, time, lock number, first drug expiration date, first equipment expiration date, who's checking the cart, and records of defibrillator tests (usually the test strips) must be available on the cart.  If you're missing a day... ding!

3.  Pharmaceuticals - need to be under lock and key - this includes contrast media.  Techs need to know where the key is also.  Make sure you do not have expired drugs/contrast.  Multi-use vials and bottles need to have an "opened on" date, as well as an "expires on" date.  These are usually 28 days after opening for expiration for most containers.  Barium tablet bottles can be saved for one year after opening.  If you see an open container that is not dated, chuck it out.

4.  Waste disposal - every type of waste has its place.  Sharps containers should be locked up and removed after they are 3/4 full.  Contrast has its own special disposal container.  Linens and trash go in separate places.  You know the drill.

5.  Fire drill!!! - know what to do in case of a fire... evacuation routes, how to locate and operate a fire extinguisher and alarm pull stations, and where to find the nearest gas and oxygen shut off valves.

6.  Hand sanitizing - this has been a big one at every JCAHO site visit I have been a part of.  Wash your hands before and after every patient, or use hand gel if your hospital provides it.  Please make sure not to use the same gloves on two patients.  Gloves should be used in the exam room and disposed of prior to walking out of the room with the patient.  Segway to...

7.  Isolation precautions - know your hospital's methods for communicating isolation protocol.  Know the proper precaution per disease type, as well as the proper method for gearing up for an exam.

8.  Quality Assurance - there are many things that a radiology department is responsible for regarding equipment, radiation monitoring etc.  The ones that JCAHO may be interested in are probably going to involve radiation protection.  Make sure you have your lead aprons cataloged and checked for cracks once a year.  Make sure that your staff is wearing their radiation badges.

9.  Incident response - what does your department do if an incident/occurrence report needs to be filed?  How are safety concerns and policy violations reported and followed up on?  Who is responsible for filling these reports out?

10.  MSDS information - they might say, "what would happen if you came across an unknown chemical that was spilled on the floor and you haven't heard the name of the chemical on the label?"  Know where to find your Material Safety Data Sheets... usually you can access them online, but do you know the website? Or do you know where your facility might have paper copies?  This is your homework ;-)

Remember, you may not have all the answers to these questions... especially under pressure.  You should know who does have the answers though.  The absolute worst thing you can say is "I don't know" followed by a blank stare or an apologetic look on your face with a shoulder shrug.  You can, however, say "let me ask my supervisor" or "let me find out for you."  

SMV Skull and Sinuses

http://www.youtube.com/user/TopicsInRadiography

Medicare Cuts for Imaging?

We all sit and wait for a glimpse at the ugly head of healthcare reform.  Nobody knows exactly what it looks like or what it will mean for their own care, the care of their families, or for us Radiographers, our jobs.  This article from the Wall Street Journal was posted in July:

http://online.wsj.com/article/SB124646885862181139.html

It outlines plans for Radiologists to receive up to 20% cuts for reimbursement for MRI and CT scans.  It also mentions Cardiologists receiving 25% reduction in cardiac catheterization procedures and 42% cuts for echocardiograms.  These are among just a few of the cuts that are reported to be re-channeled toward primary care in hopes of attracting more medical students by increasing GPs' wages.

The American College of Radiology has been fighting President Obama on some of these changes with the backing of U.S. senators on both sides of the isle, including Kerry (Democrat from MA), Kohl (Democrat from WI),and Alexander (Republican from TN).  The imaging community has already seen cuts of $5 billion over the last 5 years, and as of September, we are now facing increased expectations of not 20%, but up to 60% cuts for CT and MRI reimbursement from Medicare.  The last time I checked, most hospitals are already in the red.

According to Obama's Deficit Reduction Plan (page 38), patients will even need "prior authorization" for the more expensive imaging studies starting in 2013 in order to patrol the actual necessity of more expensive studies.  There is a common opinion going around that too many CT and MRI exams are being ordered when they are not really necessary in order to make the pockets of Physicians a little bulkier.  The pre-authorization is supposed to prevent this sort of thing, but what concerns me is that the plan does not identify WHO would be doing this pre-screening.

I can't think of too many people who would not be biased in the pre-screening process.  A Physician panel may side on lining the pockets of their own.  Insurance companies are going to find a way to make a buck off of it themselves.  The most likely responsible party will be Big Gov - and now we open the can of worms that everyone's been talking about for some time... government regulated health care.  Is this the beginning of a long-term agenda to force everyone to switch over?  Who knows... but I would like to encourage everyone to write their Congressmen and Senators and support the ACR.

What will this mean for Radiographers?  It could mean more plain x-ray exams being performed - we may continue to be the work horse of the imaging department.  It could also mean less Physicians specializing in Radiology.  We live in interesting times in the health care field.  I have serious doubts that plain x-ray examinations are going anywhere soon.  I do think, however, that we will most likely see a slower growth in imaging technology if this goes through.

Free Category A CE Credits

This is primarily for Nuclear Medicine techs, but you never know who may need them and how soon:

http://www.advanceweb.com/EBlasts/2011/9/NOINSERTION/2964IR20110923.html

New Twitter and Facebook

Hi everyone,

Just a quick note to say that due to some recent privacy changes on a particular social networking site, I am changing some links in attempt to separate some private vs. blog-related material:

New Twitter... Please feel free to follow.  There are just some things that I would like to share with family or friends, and there are some things that are Radiography-related that my family and friends just don't want to hear about.  Freedom of expression is great, but freedom to "un-follow" is also available and I would like to avoid that.

New Facebook... Please feel free to add me.  If you were a personal friend on my old facebook page, you can find me on Google+... I have kept a facebook page just for the blog/youtube topics and related material.  I'm much more pleased with this because instead of the old facebook page, I will now be able to receive messages directly instead of having to check the page periodically, allowing me to have better interactions with you all.

Note:  YouTube, LinkedIn, Feedburner, and E-mail have all remained the same.

Thanks to everyone who has continued to follow along all of these years, as well as my most recent connections.  I hope these changes can be more beneficial to all of my readers to avoid having to sift through some of my more personal content.

MIC-KEY Gastrostomy Tube Kit - Package Opening and Content Discussed

If you haven't seen one of these yet, please make sure to watch.  I have started to see these more and more in California, and they're really great because of the no-mess feeding.  In order to inject through one, you need a special extension/port that comes in the insertion kit.

Here's some of the better images from the package insert:

Balloon Inflation:

Cross-section of balloon inflated through gastrostomy:

To connect tube to MIC-KEY, line up black line on button and black line on extension (provided with kit).  Push tip of extension into one-way valve and turn clock-wise to lock:

Lateral Skull and Sinus Positioning and Film Critique

Please visit my YouTube Channel to view in High Definition.

Oblique Rib Views: Which Views Should be Performed and Why?

I just received an email today asking for an explanation on obliques... I'm fairly certain that it was about ribs, but I thought I would go ahead and post this because it can be difficult to understand why we position oblique ribs the way we do.  The rule of thumb for most obliques is to simply place the anatomy of interest closest to the image receptor to visualize the most detail possible.  This does not apply with every oblique view of the ribs, however.

Reasons vary for why we position most body parts in certain obliques, and ribs are very different as well.  Typically, if an area of interest is anterior, an anterior oblique is performed (RAO or LAO), and if an area of interest is posterior, a posterior oblique is performed (RPO or LPO).  

Posterior rib pain:  If your patient is complaining of right posterior oblique pain, you would perform RPO.  If the pain is left posterior, perform LPO.

Anterior rib pain (this is where it gets tricky):  If there is right anterior rib pain, perform an LAO.  This seems like the opposite of what should be done, but if a RAO is performed, the thoracic spine will superimpose the area of interest.  You need to move the spine out of the way with an LAO.  This position still places the anterior ribs closer than a posterior oblique would, providing better detail by getting the anatomy closer to the image receptor, and still prevents the superimposition of the spine.  If there's left anterior rib pain, perform an RAO for the same reason - get the part of interest closer to the image receptor, and move the spine out of the way.

It's always a good idea to mark the area of interest with a bb marker or annotate some arrows on the image just to help out the Physicians viewing the images as well.

PA Caldwell Skull

For HD, please visit my YouTube page.

Interpersonal Communication: A Missing Necessity

When I first started the clinical rotation through my Radiography program, I remember how amazed I was those first few months about interacting with the Radiologists.  I saw the staff techs showing the Radiologists images on plain film, discussing patient history, and even receiving criticism on the quality of images that were being presented.  My fellow classmates and I learned quickly that a student could absorb valuable knowledge simply by having the opportunity to listen to a dictation taking place on a film in front of us while patiently waiting for a chance to speak with a Radiologist about a procedure.  Some of the docs would even quiz us and encourage us to find the answers to the questions they were asking, contributing greatly to the learning environment.

Today, with the advance of PACS technology and portability of computer systems in general, we seem to have lost that interaction with Physicians.  The only time most of us see a Radiologist is when we need a signature on a consent form or during a fluoroscopic procedure.  Any criticism we see on our image quality is typically negative, and only in email form weeks after the exam was actually completed, if we get any feedback at all.  The streamlined efficiency that can be achieved by the Radiologist has improved with the ability to rarely have to leave the reading room, or in some cases, the comfort of their own homes.  Just getting a Physician on the phone in an attempt to ask a question can prove to be quite time consuming.  Although these technological advancements have their definite advantages, we have to wonder if they are better.

This trend is not limited to Radiology departments.  A particular occurrence comes to mind when I think of other environments that these conditions may apply to.  When I first began teaching and would take a 10-minute break every hour, I would usually take this time to get to know some of my students by having a short conversation with them.  I would make a point to engage a different student each day, so that I could understand their perspectives and potentially even relate to them during my lecture.  Within the past 5 years, I have seen a slow transition during these breaks.  As soon as the class lets out, most students grab their smart phones and head out the door with head down and thumbs blazing a trail to social networking sites or to text their friends.  I have not yet gotten used to the many students outside my classroom in absolute silence when just a few years before I had to tell them to be quiet and respect the other classroom sessions that were going on down the hall.  I have noticed these differences in my personal life as well.  Long-term friends that I used to have hours of dialogue with hardly have time to text you these days.  Everyone is in constant “high efficiency” mode and we simply can’t do without instant gratification.

The rise of access to information has us all hungry for more knowledge, keeping informed up to the minute, and is making us all capable of accomplishing more using less time.  So how are we to retain (or regain) our interpersonal relationships that we once had?  Despite all of the new technology we have access to, it is my belief that we will need to place even more conscious effort toward bridging those relationships in our Radiology departments, as well as interdepartmentally throughout the hospitals. 

If you’ve been a technologist for even a short amount of time, you know that there can be many frustrating phone calls to and from other areas of the hospital like the ER, ICU, and other nursing units about coordinating services and any required screening forms, lab work, consents, etc.  What I have noticed is that I need to make it a point to speak to individuals that I regularly have these conversations with in person from time to time.  Doing so allows people on the other end of the phone to know my face.  It is much easier be upset at a faceless person over the phone and lose your temper.  It’s even easier to trash another person’s reputation to their superior over email.  But how often is this really necessary, or even warranted?  Before we resort to measures this extreme, perhaps we should begin trying to handle these difficult situations in person rather than with a medium that fails to portray sincerity, emotion, or intentions.

It is entirely possible to perform our jobs and interact with our coworkers and Physicians with the utmost productivity, and with as little inter-personal communication as possible.  But we have to ask ourselves what opportunities are being missed when we all avoid that interaction and resort to the “more efficient” methods of communication. Being physically in front of someone while having a discussion will not be necessary 100% of the time, but even though it may be less efficient for a moment of your day, how much of a positive affect do you think this can make for your entire institution if this becomes a frequent practice?

Joint Commission Sentinel Event Alert

Expect the Joint Commission to have Radiology departments within their sites on future inspections and audits.  This alert, published today, notes the increase of radiation doses to patients nearly doubling over the last 20 years.  As we all know, there is a relationship between the amount of radiation someone receives and the risk for developing some kind of physical effect.

What does this mean for us as technologists?  You can expect to have more intensive protocoling for CT exams, increased requirements for physicians to discuss necessity of radiation-producing exams, physicists being consulted regarding patient dose prior to individual exams, and more thorough documentation of radiation dose per exam to patients, including free-standing imaging clinics.   More education about the principles of ALARA and the operation of these complex machines, as well as ways to document and measure all of these goals.

Looking at the big picture, all of these things may influence work flow, so there will naturally be some resistance and a period of adjustment.  However, these new measures are also going to be necessary in order to ensure Medicare and Medicaid reimbursement.  Most importantly, this will serve to protect our patients from unnecessary radiation dose for exams that have alternative screening methods.

Click here to read the full Joint Commission Sentinel Event Alert

Determining Pregnancy Before X-Rays

During my routine work week, I am often asked by new staff, and even by some veterans, how we should handle radiographic examinations on patients who state that there is a "possibility" that they could be pregnant.  My answer is typically in the form of a question; "What does the hospital's protocol state?"  The new grads have probably seen several examples in school and may not be used to our protocol yet, and the veterans have more than likely seen the policy change over the years multiple times, and both are just looking for reassurance that they're doing the right thing (I can't fault anyone for that).

I know it's a bit annoying to my staff when I answer them in this fashion.  They probably feel how I did when I was a child and asked my mother the meaning of a word.  She would say, "look it up... you know where the dictionary is."  It's not what you want to hear at the moment, but it certainly is a good learning experience.  It will not only lead to the answer they are looking for, but it will also show them how and where to find policies in a pinch - something you might need to do when working alone on a 3rd shift or during a JCAHO inspection.

I have seen several policies with minor variations across the board, but if you are unsure, and if your imaging department does not have a written policy or protocol for you to reference, here are some easy steps you can follow to ensure that you are protecting your patient and your license:

1. In the most unsure of circumstances, ask the Radiologist.  The worst thing you can do is assume responsibility to assess the risk involved with performing the exam and go on to perform it.  As long as you ask the Radiologist, you can rest easy knowing that someone who is much more qualified than you as a technologist is making the assessment... and document who you spoke with and what they said.

2.  Find out if your facility follows the "10 day rule."  Some facilities have a standing order that means if the last menstrual cycle was within the last 10 days, you are protected by that standing order when you perform the exam - note that a lot of hospitals are moving away from this rule, however.  Once again, document the patient's response.

3.  Order a pregnancy test - if there is no Radiologist in the department, you can always ask the ER Physician if they could order a pregnancy test when a patient is unsure if they are pregnant or not.  It may take a few minutes to get back, but we're focusing on quality of patient care, not quantity.  Keep in mind that if the exam does not place the fetus in or near the primary beam, they may not be so concerned about ordering a pregnancy test.  It is up to the patient and the doctor to weigh risks vs. benefits in these situations.  

We need to be very thorough in asking for an LMP and pregnancy risk.  Know your policies and know where to get information in your Radiology department.  We should always double-shield patients that are pregnant and we need to document that we did so (I hope you are absorbing my theme of documentation).  Also, make a note of any conversations with Physicians who approved the x-rays, or any pregnancy test results that we may have access to.  Don't forget to inquire about any mothers or female family members that may be asked to hold a patient or stay in the room during the exposure if they are pregnant as well.  

Optimum kVp

I've been getting a lot of questions on the side lately about "optimum kVp" and "how to choose what kV to use."  Even though there are so many variations in x-ray producing equipment and image receptors, there are two main categories that I like to separate my answers in:

1. Optimum kVp using film/screen systems

2. Optimum kVp using digital systems

Film/Screen:

A radiographer's "old-school" medium, film/screen imaging systems require precise kVp based upon part thickness, pathology, atomic number of the part, and presence or absence of air.  I would say that an "average" kVp range could be acquired for most body parts (with the exception of Chest imaging) by using calipers.  We have to be precise because with film/screen systems, kVp is our primary controlling factor for contrast.

One method an x-ray tech can use to formulate a starting kV is by measuring a body part with calipers (in centimeters), then multiplying that measurement by 2, and then adding 40 to that number.  Here's an example:  My elbow measures about 10cm.  10 x 2 = 20.  20 + 40 = 60.  Using this method, I could use 60 kVp to provide adequate part penetration and contrast using film/screen systems.  My optimum mAs is another post... as you know, generator phasing and film/screen combinations will need to be addressed for proper mAs calculations.

There are also many charts available in textbooks that will display optimum kVp ranges by body part.  You will need to produce some test images in the beginning phases of what kVp ranges you would like to use, and consult your Radiologists to find out what kind of "image appearance" they prefer before setting your ranges in stone.  If they prefer films that are more gray (less contrast), simply add 50 instead of 40 in the example above.  If they prefer higher contrast, perhaps only add 35 (recommended for extremities in an orthopedic clinic).  I would refrain from using any less than 70 kVp for spine exams.

Digital Systems:

The rules change a bit here... the primary controlling factor for contrast ceases to be kVp in CR and DR systems.  With these, we use the processing algorithm as the primary controller.  The fundamental principles of radiation physics still apply, like the more kVp we use, the more potential difference, therefore more part penetration we will cause.  But since the kVp range does not need to be as precise as film/screen systems, we have some room to play with technique a bit.

The next logical step in our reasoning is to determine if an increase or decrease in kVp will provide better images.  Because the beam physics haven't changed, we can't really lower our kVp compared to optimum film ranges because no matter how magical our computed radiography and digital radiography algorithms are, they are still dependent upon adequate exposure to the image receptor.  We can, however, increase our kVp.

How much should we increase?  In my personal experience, I have used about 10 kVp higher than film/screen systems for small extremities, and up to 20 or 25 kVp higher than film/screen systems for thick body parts like spine.  I could never use 90 kVp on a lateral c-spine with plain film because it would be too gray/washed out.  Since digital radiography adjusts the scale of contrast to be ideal for a "lateral c-spine" I have two distinct advantages when using higher kVp with these systems:  More uniform part penetration and less radiation dose to the patient.

For part penetration, you will be able to visualize the lower cervical and upper thoracic vertebrae at 90 kVp than at the traditional 70 kVp range.  Using the 15% rule, you know that using 90 kVp will require far less mAs (about 25% than at 70 kV), which will significantly reduce the exposure to the patient.  Talk about a win-win situation!

I would encourage anyone looking to make changes to their technical factors to consider a higher kV range with dose reduction.  You may be tempted to use ridiculously low mAs values like 0.5 mAs on various body parts, but remember the physics... you will get quantum mottle or image noise when there are not enough x-ray photons reaching your image receptor.  I would love to hear what you currently use at your facility, and if you try some of these changes, I would also love to hear what you think about them.  Whatever changes you make, please keep ALARA principles in mind, and remember to consult your Radiologists.

Radiology Barn

I'm trying my hand at some Radiology-themed apparel and accessories.  I have several designs in mind, and have my first few available at the store.  Just click on the Radiology Barn tab at the top of my blog to see some of the designs, or visit:

http://printfection.com/RadiologyBarn

Y-View Shoulder Anatomy and Positioning

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Pacemaker Insertion

One of the things I wish I had better training on prior to my first Technologist position is OR procedures.  Sure, most Radiography Programs give you some exposure to them, but it is unrealistic to place the expectation on a clinical rotation in your x-ray program to make you a certified guru on these procedures... and just because you can operate a majority of the features on a c-arm, it doesn't mean that you understand HOW the procedure goes, WHAT to look for, -WHEN to move the c-arm in, WHERE to center, WHO all the people are in the room and WHY they are there.

Let's break it down for a pacer insertion.  Examine the pre-op film taken the day of the procedure:

You can tell that this patient has had a history of cardiac pathology.  They have had a CABG - often referred to as a "cabbage" and stands for Coronary Artery Bypass Graft.  This means that one of the blood vessels supplying the heart (coronary arteries) had once become occluded severely enough to block blood flow to the heart causing a heart attach (Myocardial Infarction - MI).  The visual giveaway is the metal wiring that looks like twist-ties.  These are placed around the sternum after open-heart surgery to mend the sternum that must be sawed through to access the mediastinum... but that's not what this post is about.

You will be asked for live fluoro during pacer insertions to assist the Cardiologist with positioning of the pacer leads.  Remember the electrical conduction system in the heart?  Conduction between the AV (atrioventricular) node and the SA (sinoatrial) node can sometimes fail, causing an abnormal heart rhythm, hence the need for an artificial device to assist with providing the heart with a normal "pace" for beating.

So why does the Physician need you?  Without fluoro, they cannot see where the leads are being placed.  It is imperative that one lead be placed in the right atrium and the other be placed in the right ventricle.  Here's what you need to do:

Before the Doctor asks for fluoroscopy, you will know which side he is going to place the pacer (right or left).  You will most likely come in the opposite side with the c-arm.  In this occasion, the Physician inserted a pacer on the patient's left side.  So when prompted, go ahead and center over the subclavian vein on the side the MD is working:

The Physician will need to insert each of the two leads separately, and there should also be a Sales Representative in the room from the device company that manufactures the pacemaker.  The Physician and the Sales Rep will always be in constant communication about which lead is being inserted first because what they do requires active monitoring of heart function and good communication.  Just listen to their conversation in order to find out which lead is going in first.  This will have an impact on where your centering should be with the fluoroscope.

So why are we centering at the subclavian?  Well, you know that the body's vasculature has many branches, and without fluoro, the Physician could take a "wrong turn" with the lead, which could potentially be life-threatening if inserted too far through the wrong vessel.  This is why it is imperative to be ready to bring the c-arm in when he begins running the leads.  Where could they go?  Here's a picture of possible routes; green means that's where the Physician SHOULD be going, and red is where he SHOULDN'T go:

The most serious of these directions is toward the head.  The blood vessels get small really fast once the lead starts travelling north.  It would be easy to perforate a vessel if pushed too far.  Pay attention to your image as the Cardiologist is advancing the lead.  If the lead starts going up the neck, make sure to tell him because he may not be looking at the monitor in that split second that the lead turns (and you might be the only one in the room looking at it).  Keep in mind that everyone in the room is multi-tasking, so don't assume that 100% of anyone's attention is on your fluoro screen.

You shouldn't really have to move the c-arm too much until the lead turns the corner to the south and heads down the IVC (inferior vena cava) and into its appropriate chamber.  Anticipate this movement because the Cardiologist NEEDS to see where the lead is going.  If you have let the lead go below your field of view, you are not doing your job well.  This is important because as soon as the lead enters the heart, it can cause variations in sinus rhythm as it rubs the inner wall of the heart muscle.  Once the first lead is anchored, or "screwed" into the heart muscle, re-center as before and follow the same procedure.  Here's the final saved image from the c-arm:

Notice the outline of the heart, as well as the Atrail and Ventricular Lead positions.  During live fluoro, these may blur due to the heart motion, so make sure to fluoro for at least a second when the Doctor wants to see placement.  If you simply "spot" check, it might be so blurry that you can't see the tips.  Here is a portable chest x-ray done after the procedure and insertion of the pacer device under the skin (but outside the ribs):

Sometimes the Physician will require an image in PACU (Post-Anesthesia Care Unit), and sometimes not.  But equally important is if a 2-view chest x-ray is ordered within the next few days of the procedure.  Remember how I mentioned that the leads are "screwed" into the heart muscle?  The Physician will typically place a sling around the patient's neck holding the arm in place (on the side of the pacer insertion - left in this case).  This is because any extreme motion of that arm may dislodge the screws in the leads.  This is bad news - the surgery will have to be performed again if this happens and until it's completed, the lead may impair heart rhythm.  This is why it is important to AVOID raising the arms for a lateral chest x-ray after a pacer insertion.  Check with your facility's protocols to see if you are required to wait a certain number of hours or days before doing so, and encourage the patient not to raise their arms, even if they feel like they can.  A 45 degree wedge sponge may be used under the patient's affected elbow to move the arm out of the way if a 2-view is absolutely required, but no lifting should occur.

How to Improve Relationships with your Coworkers

You are Super-Tech.  Your ability to obtain those difficult trauma views is unmatched and your savvy knowledge of every feature of every c-arm in the hospital has made you the go-to guy for surgical procedures.  You are efficient, accurate, the Radiologists love your films, and you have arrived!

A Radiologic Technologist can have all the technical skills in the world, but even someone with the attributes listed above can be someone that you absolutely dread working with.  Here are 10 things you can do to improve your relationships with your coworkers. 

1. Process your coworkers' images - nothing helps reduce patient exam time like being able to focus on performing the views (especially during multiple exams), and being able to view your images immediately after shooting the last image.


2. Relieve someone for a break - most departments have scheduled break times for their employees to ensure that everyone gets to eat/rest in a timely manner.  Being aware of your own stomach grumbling is easy, but being aware of your fellow techs' is often overlooked.


3. Clean up your mess - Clean up your exam room after your procedures.  Wipe down surfaces, throw away trash, dispose of contrast containers, get rid of dirty linens and replace with clean linen.  Your mother didn't even like leaning up your messes and your coworkers most definitely are not being paid to baby you.


4. Do your job - don't mysteriously go missing or decide to take a break whenever an exam needs to be done that you don't partiularly like doing. Oh yes... this happens.


5. Talk up your coworkers - when handing over patient care to a coworker, make sure to reassure the patients that they are in good hands.  Also see #6


6. Don't talk down your coworkers - you may have a negative opinion of something a coworker did, but letting everyone know about it makes you and the department you represent look bad.


7. Restock supplies - nobody likes to be in need of supplies, especially in an urgent situation, and open the cabinet to find that it hasn't been stocked in the department.  I bet you can think of one or two techs who do most of the stocking in your department.  What happens when they're on vacation?


8. Stay until your shift is over - if your shift is over in 15 minutes, don't avoid exams because you "want to leave on time."  This is just bad patient care, you're still getting paid, and if your relief staff notices this becoming a pattern, you are sure to make enemies.


9. Be flexible - be available for shift coverage, sick calls, holidays, weekends, call.  Anyone doing this for a while without a break is sure to burn out.  Besides, you may need someone else to do this favor for you one day.


10. Be a trainer - contribute to the training of new staff and students; they may just be your supervisor some day.  Take some accountability for their improvement in skills - a student is only as good as his teacher.

It all boils down to treating your coworkers how you would like to be treated.  I'm quite sure you already know people who don't exacly live up to these simple guidelines, but don't let that keep you from abiding by them yourself.  People do notice when others go out of their way for their fellow coworkers and it can inspire them to do the same.  Pretty soon the people who don't do these things will be the minority, and you will have contributed to your department and health care system in a way that supercedes technical skill and know-how.

How to Improve Relationships with your Coworkers

You are Super-Tech.  Your ability to obtain those difficult trauma views is unmatched and your savvy knowledge of every feature of every c-arm in the hospital has made you the go-to guy for surgical procedures.  You are efficient, accurate, the Radiologists love your films, and you have arrived!

A Radiologic Technologist can have all the technical skills in the world, but even someone with the attributes listed above can be someone that you absolutely dread working with.  Here are 10 things you can do to improve your relationships with your coworkers. 

1. Process your coworkers' images - nothing helps reduce patient exam time like being able to focus on performing the views (especially during multiple exams), and being able to view your images immediately after shooting the last image.


2. Relieve someone for a break - most departments have scheduled break times for their employees to ensure that everyone gets to eat/rest in a timely manner.  Being aware of your own stomach grumbling is easy, but being aware of your fellow techs' is often overlooked.


3. Clean up your mess - Clean up your exam room after your procedures.  Wipe down surfaces, throw away trash, dispose of contrast containers, get rid of dirty linens and replace with clean linen.  Your mother didn't even like leaning up your messes and your coworkers most definitely are not being paid to baby you.


4. Do your job - don't mysteriously go missing or decide to take a break whenever an exam needs to be done that you don't partiularly like doing. Oh yes... this happens.


5. Talk up your coworkers - when handing over patient care to a coworker, make sure to reassure the patients that they are in good hands.  Also see #6


6. Don't talk down your coworkers - you may have a negative opinion of something a coworker did, but letting everyone know about it makes you and the department you represent look bad.


7. Restock supplies - nobody likes to be in need of supplies, especially in an urgent situation, and open the cabinet to find that it hasn't been stocked in the department.  I bet you can think of one or two techs who do most of the stocking in your department.  What happens when they're on vacation?


8. Stay until your shift is over - if your shift is over in 15 minutes, don't avoid exams because you "want to leave on time."  This is just bad patient care, you're still getting paid, and if your relief staff notices this becoming a pattern, you are sure to make enemies.


9. Be flexible - be available for shift coverage, sick calls, holidays, weekends, call.  Anyone doing this for a while without a break is sure to burn out.  Besides, you may need someone else to do this favor for you one day.


10. Be a trainer - contribute to the training of new staff and students; they may just be your supervisor some day.  Take some accountability for their improvement in skills - a student is only as good as his teacher.

It all boils down to treating your coworkers how you would like to be treated.  I'm quite sure you already know people who don't exacly live up to these simple guidelines, but don't let that keep you from abiding by them yourself.  People do notice when others go out of their way for their fellow coworkers and it can inspire them to do the same.  Pretty soon the people who don't do these things will be the minority, and you will have contributed to your department and health care system in a way that supercedes technical skill and know-how.

The Walk of Shame

No matter how many years of experience we gain as technologists, we all know what it's like to do the "Walk of Shame."  You know, the slothful downtrodden shuffle you do when you do perform an exam, go to check your films, and you realize you need to repeat.  These come with the job and serve to keep us humble.

Every once in a while, it's tempting to get a little bit cocky about your skills after a streak of not having any repeats.  I've heard techs say things like "ooooh, that's textbook quality" among coworkers and students.  I've also heard "check out that collimation" or "you could drive a truck through that joint space" accompanied by a self-pat-on-the-back.  I've been guilty of doing that myself on occasion, all in good fun of course.

But then some days you just don't have it together.  I find that everyone has their particular view like a Y-view shoulder or an open-mouth odontoid that a lot of techs struggle with, but you're the go-to person if someone else is struggling with that particular view.  But there are some days when you repeat that view that you are typically awesome at, and then another patient comes in for the same exam, and you end up doing a repeat on that patient.  This could happen several times in one shift, and can even last for multiple days.  I don't know if anyone reading is superstitious, but I equate this to a losing streak experienced by professional sports players.

This happened to me today.  It wasn't with a specific exam that I can normally do better than other exams... this was worse.  I had to repeat on a patient that was already upset about something.  I don't know what they were upset about, but they made it very clear during my first portable chest x-ray that the did NOT want my company.  After explaining what I was going to do for the first exam, a comment was made like, "let's just get this over with."  Even after offering to help with anything to make the patient's experience better, I was certain that the patient just wanted me to do my job and leave.

I was writing a patient history on my requisition when out of the corner of my eye, the image slowly began to scroll across the monitor.  I could already tell... clipped costophrenic angles!!!  The sinking feeling set in that I was going to need to face this patient who made me feel so unwelcome once again.  We've all been there.  I've seen techs stand in front of the image and just stare at it for a few minutes.  I can see the gears cranking in their minds; trying to rationalize a reason for not repeating the exam.  But we all eventually face the fact that no  matter how long we stare at the monitor, it simply won't fix it.  We're just delaying the inevitable... walk of shame.

So I returned to the patient with my portable x-ray machine, and as soon as I made eye contact with him, he rolled his eyes.  I knew I was in for it.  He said, "what happened?  Did you screw up?"  I said "I missed the bottom of your lungs on the first x-ray, and the Doctor really needs to see the rest of the lungs in order to be able to provide a thorough evaluation.  In other words... yes."  Admitting your mistakes is one of the more difficult things to do in life, let alone to disgruntled patients.  This  actually payed off.  His response:  "that's the first straight answer I've received since I came through the doors."  I opened up a dialogue with the patient leading to the explanation about why he was upset.  A bunch of tests had been ordered and performed, and he wasn't really kept in the loop.  I was able to chat with the Doctor and told him what the patient had expressed and he began speaking with the patient as I was wheeling out the door with my x-ray machine.  Thankfully, the repeat image included the missing anatomy from the first film, and I did not need to return.

Don't get me wrong... admitting your mistakes not typically a good experience, and rarely will it result in a positive outcome, but mistakes do happen.  They remind us that we're human, as well as our patients in this case.  The best thing we can do when confronted with them is to act with integrity.

Equipment Review: FUJI FCR Go 2

One of the things that I don’t see very often on radiography blogs is (honest) equipment review. The longer I am in this field, the more exposure I am having toward equipment purchasing, and I am being asked for my opinions as a “direct patient care” representative – someone who will be using the equipment that we are thinking about purchasing. I have to tell you what a nice feeling it is to be working for such an institution that involves the workers in the trenches in these decisions and not solely considering cost as the deciding factor. Thank you Scripps!

I recently had the opportunity to demo a FUJI FCR Go 2 as our facility is in the market for some new equipment. I have been primarily using GE’s AMX4 series for the last 10 years, so that is the kind of perspective I am writing from while telling you what I think about the Go 2.

On first appearance, the Go 2 is visually pleasing to the eye. It has a slim design left to right, and you can’t tell until you drive it, but it is slightly longer than the AMX series. It feels light-weight because of the drive-assist, and it can go pretty fast with less noise than I am used to. I have to say that it took a few minutes to get used to the feel of driving it. I started out lunging forward and slowing down like when I was 16 and learning to drive a manual transmission. That feeling quickly left though after driving down to our ICU a couple of times. The boom for the x-ray tube also resides in a much lower vertical position than most portable machines I have used, so I can imagine it would be ergonomically easier to use for people who aren’t as tall as me at 6 feet. Even with that feature, the push-bar seemed to be located higher than what I am used to, preventing me from having to hunch over in an uncomfortable position while I drive.

One thing that I noticed when aligning my central ray is the increased length of the telescopic boom. I could park the base pretty far away from the bed and still pull the tube head past the center of the bed if needed. The x-ray tube controls feel natural when aligning the central ray, and the tube swings horizontally 360 degrees around to the cradle position. The collimation and exposure controls are easy to use, and anyone who has ever operated a portable x-ray machine would feel comfortable operating these.

There is an on-board CR reader that functions with the same software as the stationary IIP, so that felt very familiar as I was processing my Image Plate. There is a line of FUJI DR receptors that I did not demo, but I did try out the “gridded” CR cassette. It was very light and I probably wouldn’t have even noticed that it was gridded unless the sales rep informed me that I didn’t need a grid-cap when we were heading out for an exam. There is a touch-screen interface that is spill-resistant above the push-bar which allows you to wirelessly pull up the work list and select your patient. The images appear with what seemed like the same speed as the stationary processors as well.

Here is one major drawback to the post-image production: In order to annotate, there is a stylus pen attached to the unit used on a small keyboard that pops up on the touch-screen when prompted. The keys are small and I found the calibration of our demo unit to be inaccurate. The angle of the screen compared to where my eyes were when viewing the screen seemed like I was pushing the letter “P” and the letter “O” would be typed.

The other major drawback was one I learned the hard way. I went to the ER to perform a portable chest on a code blue patient. One the Physician waved me in to take the exposure, he noticed that I had a sales rep with me and inspected the Go 2 saying “can I see the image now?” I was excited to show off this feature and told him he could. He waited patiently for me to clean the cassette and load it into the reader. Right after I loaded the cassette into the slot and my raw data image began to populate the screen, a nurse told me she needed to get where the machine was. I reached for the push-bar handle and was asked to wait by the sales rep. I was informed that if I moved the machine while the plate was being scanned, that it could produce an image artifact and it was not recommended. Luckily, the Physician told the nurse to hang on while the image came up. Note for future use: pull the machine out of the work area before processing the image plate.

The only other consideration from a usage standpoint is the speed of workflow. I would highly suggest analyzing what types of patient flow you have before you decide on a purchase. If you’re leaving your department once every 30-60 minutes for a STAT portable, or if you are using this in the OR, this might be the equipment for you, especially if you don’t have the budget for a Direct DR machine. However, if you are performing 30 ICU portables in every morning, this might not be the unit you want to take. You may want to make a comparison on efficiency for your facility taking note of how long it takes you to lug CR cassettes back and forth from your closest reader to taking one cassette with the Go 2 and having to wait for processing time of each cassette between exposures. Include in your estimations possible repeats, time and effort spent annotating, and how many cassettes you would be able to carry back and forth (and how many times you would need to do so) without the Go 2.

Appearance:

Practicality:

Versatility:

User-friendliness:

Portability:

Overall Grade: B+

Advertisers: Products that I review on this blog are reviewed based on my own personal opinion. If contacted by an advertiser with offers to review a product, I will be publishing my honest personal opinion regardless of any compensation offered by the advertiser.

Density Maintenance Formula

I just didn't feel like that last video was complete after reading the original blog post it was meant to supplement, so I just had to go ahead and record the second example problem solution here:

Video Tutorial on Inverse Square Law

This video is using samples from an earlier blog post where my images mysteriously disappeared... I have replaced the images as well as created this video with additional explanations to supplement the original blog post: