UNC Digital Radiography for Educators

I am very excited to be attending a conference for educators on digital radiography at the University of North Carolina at the end of this month. My supervisor and a coworker attended the last conference held in June and returned with high praise of the instructors, the information, and overall presentation given at this seminar, and I should have plenty to write about upon my return. I do believe they put this conference on every year, but there is limited room and reservations (for me) had to be made well in advance. For any educators out there teaching general radiography, you might want to check out their ITENERARY AND WEBSITE. It's a 25 unit seminar given over four days and only open to radiography educators.

The anatomy of an ERCP

A few of my students have expressed interest in learning more about the basics of an ERCP so they know what they're looking at while observing one. They are really quite simple for the technologist to perform, but there is a lot going on during them that you need to be aware of (for any other reason than to know what is expected of you during the procedure).

First, you need to know your basic anatomy.



Before you begin any fluoroscopy, the G.I. doctor will have the patient in an LAO position (usually) and under conscious sedation, will feed the endoscope into the mouth, down the esophagus, through the stomach, ultimately to visualize the duodenum. The video monitor that the GI team brings with them will display the region around the c-loop of the duodenum in hopes to visualize the ampilla - where the common bile duct empties into the duodenum.

The purpose of this exam (at least diagnostically) is to obtain an angiogram of the CBD and connecting vessels, or a cholangiogram. As we know, an angiogram cannot be done on specific vasculature without a selective catheter. The whole reason we use the endoscope is so that we don't have to surgically go in and dilate the CBD with a catheter and guidewire. We can do it with minimal invasion of the body as a same-day procedure.

So as you're watching the GI team's video monitor, they will be searching for the ampilla, and attempting to dilate it with a catheter and guidewire. In some cases, it is easy to spot because there will be bile spewing from it. You should look for a curve in the bowel with an elevated mound around the corner - this should be the ampilla.



The picture on the left is the pre-dilated ampilla, and on the right there is a catheter that is already placed in the CBD.

Now comes our part... the endoscope is too large to fit inside the CBD, so we must rely on fluoroscopy to visualize the hepatic vasculature. Once the ampilla is dilated, a guidewire and catheter are usually inserted. Fluoroscopic guidance is needed to assist in proper placement of the guidewire and catheter, and a diagnostic angiogram should be performed. The doctor will inject contrast to see if there are any stones, strictures, or any other abnormalities.





Once a diagnostic angiogram is performed, an interventional portion of the procedure can be performed based on the findings. If there are stones, they can be retrieved with a balloon or a basket, a stent can be placed or removed, or angioplasty can be done (widening of the vessel with a balloon). Keep your eyes open for new treatments on the market utilizing new technologies and selective devices.

Lordotic Much???

One of the most common errors I was guilty of as a student (and as a new technologist) was having a lordotic chest x-ray any time I did an AP view in the stretcher. There is a simple fix to this that I have yet to see in a textbook, but I have heard literally dozens of technologists use this tip: angle perpendicular to the sternum. Here's what your AP chest should look like; with emphasis on curvature of the ribs and the amount that the clavicles dip down into the apices:



And how here's what a portable chest sometimes looks like if you make your central ray perpendicular to the cassette:



I know what you're thinking... "Why is it that in a PA standing chest, this doesn't happen and I'm using a perpendicular beam?" Well, when you perform the PA standing chest, what do you do? You roll the patient's shoulders foreward so that the sternum is up against the bucky, making it parallel to the IR. Think about this... if you were to leave the patient in the same position and simply turn them around to be facing the tube, you would probably be able to make a fist and place it between their shoulders and the bucky. Let's look at this lateral projection for a point of reference:



The red line indicates the central ray passing through the sterno-clavicular joints. This patient's back is almost vertical, as it would be if placing a film behind them for the AP sitting chest, and there is not much lung field above the sterno-clavicular joint. You might have to lean this patient forward for the AP projection to demonstrate the clavicles in the lung field at all. Now if I angle perpendicular to the sternum, it will project the clavicles down into the apices as it would if I were rolling the shoulders forward for a PA projection:



Another common error that produces similar results is patient positioning in the stretcher. Ideally, you need the patient sitting upright with the stretcher at 90 degrees with your cassette behind the patient. What you want to do is have the patient scoot (or you may need to slide them before you sit them up) so that they are bending at the waist with the stretcher. You don't want a gap between their hips and the upright portion of the stretcher. This elevates the clavicles, making a lordotic position similar to the standing lordotic chest we all learned about in school and shown here:



If you combine this error with the previous error of not angling to the sternum, the resulting image could be horrid. Check out the following picture:



The first central ray would produce a lordotic image with a foreshortened lung field due to the angulation of the patient (caused by not having the hips flush against the stretcher). The second central ray would project the clavicles downward into the apices as needed, but would probably produce an elongated effect due to the patient's hips being away from the IR. The lower lung fields have increased OID, causing magnification which may cause the radiographer to be unable to include the entire lung field on the image.

For best results, keep it simple: sit the patient up as much as possible, bending at the waist where the stretcher flexes. Prevent OID on all of your film, and angle perpendicular to the sternum to avoid a lordotic projection (and don't forget to shield).

Quick-Centering for Surgical Fluoroscopy

One of the worst scenarios you may encounter is operating the c-arm for a procedure you have never done before without a more experienced wingman. Once that license comes off the printer with your name on it, training is over and you are expected to perform as a "licensed tech." These are some basic quick-centering tips for c-arm procedures in the O.R. Talk to me Goose!

Pacer insertion – center over sublcavian vein of affected side. In other words, if the doctor is working on the patient's right side, then he's going to be inserting a guidewire into the right subclavian and sending toward the SVC. What you don't want him to do is feed that guidewire in a long way and just hang out with your c-arm centered at the right ventricle. That guidewire can sometimes turn and go up the neck. You are controlling his eyes (the c-arm) for this part of the procedure. As we know, we don't want to push a guidewire into a small vessel because you run a risk of dissection if pushed hard enough. At the very least, it will give the doc something to get upset at you about. Try to find out which lead is being placed first (atrial or ventricular), and once the guidewire is in the SVC, keep the atrium or ventricle in center of field, including as much wire as possible.

Spine – center to the level of surgical procedure. If you are doing a cervical spine, try to include C1 or C2 as a point of reference for the surgeon. It's not that he can't tell what vertebral level he's at, but any confirmation that he is in the correct location with his instruments will be reassuring. He's probably under a bit of stress... If you're doing a lumbar spine, you may want to consider placing T-12 at the top of your field so he can see ribs and count from there. For the T-spine, doing this would be out of your field of view. Depending on the doctor, they might have you count at the beginning of the procedure while he marks the correct location with a sharpie or needle.

Hip – acetabulum should be in the center of the field in the AP projection. It should be in the lateral margin of the field of view for the lateral projection. This would be an excellent procedure to use a manual technique on depending on your patient and the type of procedure being performed. I'll write more on manual techniques in a post in the near future.

Angiogram – center at occluded area. If you've never seen an angiogram or don't think you can spot an occlusion, just look for the pinched area of the vessel. If you're c-arm is equipped with digital subtraction, you could be asked to perform a runoff. This is when you will be following a bolus injection down an extremity (we'll say leg for example. You should try to do a practice run with fluoro before any contrast is injected. You will need to make sure that your c-arm is positioned so that you can simply roll it sideways down the extremity. As you are rolling, it might be a good idea to unlock the lock that allows you to move the image intensifier away from you to allow for slight bends and curves in the vessels. Just remember to try to keep all vessels in the center. You want to visualize them full of contrast, so if they're not dilated and crisp, you might want to slow your c-arm motion down until they are, then procede moving it distally once you have good fill.

ERCP – endoscope should be placed at 6 o’clock in the field of view. If you can remember the anatomy, the common bile duct (CBD) is the most inferior portion of what we would like to image. If we follow that duct superiorly, we will have a branch of the cystic duct (CD) leading to the gallbladder (GB). Once that branches off, it's no longer the CBD, but is not wht common hepatic duct (CHD). This branches into right and left hepatic ducts (RHD, LHD), and then into smaller vasculature that you may never need to name. Sometimes we'll even see the pancreatic duct (PD) cutting transversely away from the GB. When and injection is being made, get as much of the biliary tree as possible without clipping the CBD.

Thanks...

To those of you who are visiting by way of the ASRT Scanner, I thank you for stopping by. I haven't been as active on this blog as I would like to be (or as I have been in the past) due to working 2 jobs, doubling up on classes for myself this semester, and a fairly new child in the home. I hope that you are finding this blog at least thought-provoking, and I encourage you all to participate by leaving commentary on practices that have worked for you. I will tell you right now that I don't claim to have "seen it all" but I know that with the wide range of experience possessed by everyone reading, we could most likely produce quite a collective set of best practices, tips, and tricks of the trade to further expand on our expertise in this profession.

So thanks again, and I look forward to continued discussion of more topics soon.

Angling to the Patient (for skull)

One of the most difficult things about performing any cranial work is those maticulous angles that must be acquired... 15 degrees caudal for the caldwell skull for example. Here's a simple suggestion to help you acquire the appropriate angulation when the patient cannot move:

First, place the patient in the desired position (or as close as they can manage). For the caldwell, the OML must be perpendicular to the image receptor. When the patient cannot do this, align the central ray to the OML by the side crosshair on the collimator housing or the laser light if you have one. If you don't have a light that is visible on the side of the patient's head, you can use your tape measure for a rough estimation. Once the tube is angled to the patient's OML, note the degree of angulation (10 degrees cephalic in this example).



Once you know how many degrees and in which direction the OML lies, you can angle accordingly. We know that a 15 degree caudal angle is applied to the OML if the patient were able to assume to position, so because it is a caudal angle, we subtract 15 degrees from the previously noted angulation of (+)10 degrees. 10 - 15 = -5 degrees, or 5 degrees caudal angulation.



Of course, with any degree of angulation, you may see some shape distortion on your radiographic image, but that is an acceptable sacrifice when you have all of the anatomy appropriately presented on film (or the monitor) for the Radiologist.

Thoughts on C-spine Obliques

I think most people are pretty happy during the student experience if they just get the whole c-spine on the film. You may position everything appropriately according to the x-ray atlas, but your films may not appear textbook depending on your patient's body habitus. Here are a couple of tricks for fine-tuning your c-spine obliques:

On obliques, the main goals are to visualize the intervertebral foramina, as well as the intervertebral joint spaces while including C1 - C7. Let's look at controlling factors for each, as well as a couple of films to refer to.





Intervertebral foramina - these are those round-looking things that you should be able to drive a truck through on the lateral side. You can visualize these if you have the appropriate amount of rotation. 45 degrees may not always work for everyone, depending on minor variances in bone structure, and definitely if there is any sort of lordisis or kyphosis. The first picture displays them beautifully, and the second gets a little bit closed off toward the T-spine. My guess at the error on #2 was that the shoulders were not rotated 45 degrees, while the head was turned completely lateral. This produces a different appearance in the foramina from proximal to distal, and this is probably why the newer versions of the atlas require no lateral rotation of the cranium. You know you're over-rotated if you are closing off the foramina and see spinous processes elongated laterally to them. You are under-rotated if you are closing off the foramina and don't see spinous processes.

Intervertebral joint spaces - this is not controlled by rotation, because you should see these in every view of the C-spine. Tube angulation is the key factor here. The second film above shows much better intervertebral joint spaces than the first. While the first excels in foramina demonstration, it would seem that the angle of the tube is too shallow to see a clear separation between the vertebral bodies. If you ever wondered why positioning atlases say "10-15 degrees, or 15-20 degrees," this is exactly why. No patient has exactly the same bone structure... this allows for the "majority" of patients. Someone with a normal curve on the c-spine might be able to employ a 12 degree angle on the oblique, while a kyhpotic patient may require 25 degrees. The key is in looking at your lateral view. I suggest performing your lateral first.





The patient in the first lateral will definitely need a steeper angle than the second. Difficult to see? Take a pen, or even your hand and do the following: Place the tip of your pen/finger at the dens of film #1. Angle your pen/finger so that the tip remains on the dens and the shaft of the pen runs through the vertebral body of C-7. Now maintain that same angle and slide the tip of your pen/finger to the dens of film #2. You should see a definite difference in position of the vertebral bodies here. Film #2 may require a 10-12 degree angle, and film #1 may take a 15 degree or more.