Evolve and Elsevier

Now that I have had a chance to see how many students vs. licensed technologists view my blog, I feel like it's pretty evident that I can post a lot of things here that students will appreciate. I also know that those of you who are into technology will appreciate this:

Yesterday at a faculty meeting, a sales representative from Elsevier publishing marketed a service to us called "Evolve." Basically, the service focuses on healthcare related textbooks and offers resources for students and instructors. There are some resources that are free, which I am currently researching for the instructor portion, and there are some that are free for students that you can register online to take possession of.

The thing that caught my eye most was the ability to load your textbooks onto your personal computer or laptop. I hate carrying books, and if your institution allows you to have a laptop in class, then all of your books can be contained in them. The sales rep provided a demonstration for all of us, showing us some of the available tools. The PC version has correlating page numbers synonymous with the hard copy of the book that you receive, and it has all of the same images in digital format that you find in the pages of your textbook as well. You can highlight sections of the textbook with a click-and-drag of the mouse, and there is a "notes" column that automatically saves everything you highlight for reference at any time. I also liked that you can pull up more than one textbook at a time in multiple windows. There are some more advanced features that we did not have a chance to discuss due to time constraints, but overall, this seemed like a handy dandy tool to have.

For instructors reading, there is a way to link the test banks with blackboard (they currently use the angel platform, but the rep stated he would assist in transferring between platforms). There are nice features for online/hybrid courses from resources all the way up to pre-designed powerpoints and lesson plans. Upon registration in the "instructor site" they do a strict screening process including verification of instructor status to ensure that students are not attempting to obtain instructor material.

The cons:

Currently, the publisher is requiring a minimum purchase of three books in order to make this feature available. In addition to the price of the books, there is an additional charge. If you're not interested in an example of the cost/numbers, then please scroll down to the next paragraph. Say you have three textbooks that cost $100 each. All 3 must be purchased and a 20% charge is added, then 10% is taken off the whole thing. So, $300 + 20% = $360...... -10% = $324. Of course, this example is without tax included. The sales rep did say that you could buy one high-priced item (Merrill's for instance), and two low-priced items to still receive the deal.

Once the three (or more) books are ordered, they will custom-create a dvd disc for you that includes the books on your order. You go online to https://evolve.elsevier.com and register as student or instructor to receive your access.

I tried to ask how much memory each book would approximately take, and the rep did not know if the files were compressed on the dvd copy. Also, the digital version is good for updates once you download it onto your computer, but if a new edition of the book comes out (like Bushong in a few months), then you have to purchase the new book (along with 2 other books) in order to receive the digital version from the publisher.

Another con is that you can only download the digital resources twice. Let's say your computer crashes, or your child spills orange juice all over it and it short-circuits, then you've only got one more shot at a download before it will not let you retrieve the product you purchased.

All in all, there are some very heavy pros and for me, some fairly heavy cons, but at least we know that it is available. Until yesterday, I hadn't even heard of this resource. If you can afford it, and if you are a tech-geek like me, then it might be worth looking into. If anything, you can check out the free resources on the website before you make a purchase in order to help you decide yay or nay.

In the News

I just received the ARRT Educator Update for September, 2007 and there are some very interesting topics that relate to us Roentgenographers.

No Cheating!

One of the big changes being made on the application for ARRT certification is a section which asks "has a student ever been subjected to a sanction as a result of violating an academic honor code?" Basically, as of 2008, if a student has ever been caught cheating on an exam, forging a clinical record, or violating the academic honesty policy at his or her institution, it could lead to a hearing by the ARRT Ethics Review Committee. The application itself will consist of questions like, "Have you ever..." With a "yes" answer, you may find yourself before a panel of ARRT folks for additional questions. A similar situation occurs currently if students have a misdemeanor or felony on their record and report it on the ARRT application. As with any review committee, this does NOT mean that you are automatically unable to obtain your ARRT registration, but the process will require additional steps and review by the people administering the exam to decide eligibility. The idea is to uphold the ARRT Rules of Ethics as early as possible.

It is increasingly important that Program Directors inform students who have had a history of such an occurrence, and have been permitted to remain in their programs, that they should be contacting the ARRT with any questions about registration as soon as possible to begin the ethics review process to ensure eligibility. The article states that there is now a pre-application that can be submitted by students who are more than 6 months away from graduating to expedite the process. You can find more info at the ARRT website, and if you can't find the answers online, you may call the Ethics Department at (651) 687-0048 ext. 580.

"I finished my ARRT exam and I probably passed, mom!"

You will find starting on the January, 2008 ARRT exam that you will receive on-site preliminary results for the Radiography and Radiation Therapy exams. Preliminary results have been tested on Sonography and Nuclear Medicine exams for a while now, and have proven to be extremely accurate, and now it's time to give it a try with therapy and gen rad. What an excellent improvement... I remember waiting about 5 weeks for my results. Of course, it is not an official score, and you will not technically be registered until you receive your copy of official results in the mail, but at least you may be able to sleep better at night... you'll probably need that sleep once your program is over!

Looking way into the future

Starting in 2011 (I suppose it's not that far away), the ARRT will be increasing the number of digital radiography questions on the exam pretty dramatically, while decreasing the number of film/screen questions by the same amount. For those of you taking the ARRT exam before 2011, expect to see some pilot questions (that do not affect your score).

Reminder

If any students are looking for scholarship opportunities, don't forget to check out the ARRT Grants and Scholarships page, and look into student membership. There are also scholarships for schooling related to the profession beyond your associate degree in the field of Radiology.

Riddle Me This...

To everyone who voted on my poll posted about the reason you entered the field of Radiography, thank you! You have all made my assignment much easier by allowing me to follow up here.

Anatomy of a Histogram

We've all seen a histogram before if we've used CR or DR imaging systems, but it is important that we all know how to interpret them. Take a look at this histogram:



The horizontal axis in my histogram represents the quantity of information in my image, or the optical density values. In this particular instance, I have densities ranging from a value of 0 (absolute white) on the left to 256 (absolute black) on the right side of my image.

*Note: Keep in mind that this histogram was taken using "Image J" so the bit depth is limited. On a traditional CR system, and depending on the bit depth your system utilizes, you may see up to 16,000 plus shades of gray. This histogram is simply for demonstration.

The vertical axis represents the number of pixels that are assigned within each density value.

In the following image, one of the great aspects of the Image J software is displayed. Depending on where my cursor is placed on the histogram, you can tell on each image what the density value is for each column, as well as how many pixels were assigned that density value. In the image on the left, the value (or degree of density on a scale of 0-256) is 73. The count (or the number of pixels exposed with this density level) is 456. In the image on the right, my cursor was moved over a higher density value of 188, and a higher count of 5883. So in this image, the crosshair placement represents a darker density assigned to a greater number of pixels.



Just as a point of reference, this is the image represented by the histogram:



The CR system has a pre-programmed algorithm for each type of exam you do... this is what you are selecting when you input "chest lateral" before image plate scanning. This tells the computer that a histogram similar to the pre-programmed shape will be scanned. This is where the CR system can produce errors. Depending on the raw data that is scanned, the computer will assign a range on your histogram termed "values of interest" or VOI. Unfortunately, the Image J software did not include this, but I have represented the VOI with red lines in the following image:



The VOI on the histogram helps to determine your Exposure Index (Kodak) or S Number (Fuji), as well as how your image will be rescaled. In first generation CR systems, the operator could slide the VOI to the left or to the right in order to visualize recorded anatomy better, but most current applications do not allow the radiographer to do so. It may be possible, however, to apply a different LUT (lookup table) to the image to make adjustments. So when the computer applies automatic rescaling (the computer's attempt to adjust the image due to over/under exposure) to your image, the process may fail if the original histogram analysis is incorrect. Believe it or not, it is STILL very important to utilize the proper exposure factors.

This brings us to an important role of the software, histogram equalization. Equalization is performed by the computer in attempt to produce a more uniform histogram to increase the level of contrast in your image. After the original histogram is derived, an "inverse" histogram can be calculated and a spreading (or commonly termed flattening) of histogram values can be applied. Compare this image before histogram equalization and after:





This is a very basic explanation of a histogram and how it is utilized in a CR system. It would be easy to go onto many tangents from here (which I have a bad habit of doing in-person). A number of processing and post-processing errors can occur that I hope to dive into in the near future, but a basic understanding of histogram analysis is required. In the meantime, I would like to encourage everyone reading this to familiarize yourselves with the histograms utilized in your own imaging departments, and maniplulate them if you have the capability on your CR system and/or PACS terminals. There's not a lot of information about this in current textbooks, but I can imagine that we will all be responsible for knowing more about these things as we continue to replace conventional automatic processor technology with digital equipment.

Image J

I recently became aware of some free downloadable software that I found incredibly useful both as a student and an educator. Thanks to the Radiography faculty at UNC, I'm in love with Image J!

It's an online PACS toolset that allows you to manipulate any image you can view on your computer in multiple formats. Now, this isn't a database of images, but you can do pretty much anything that a PACS system can to any picture that you already have stored on your computer. Here's what you'll see at their home page:



To download, go to the "download" option at the very top of the page and click... then select the operating system you are utilizing on your PC. I happen to be using Windows at home, but notice one thing before you download - you can download with or without JAVA software included. I know I have JAVA on my computer, so I saved some room and chose the "without JAVA" option. You'll notice the file size is much smaller (1.7 MB compared to 21 MB). If you noticed already, I used Image J to create these images with a screen capture tool.



If you're familiar with PACS systems, you'll have lots of fun bringing up any image (particularly radiographic images) and playing around with the software, but there are many user-friendly features similar to what you might accomplish on photoshop with this software. If you go to the "documentation" hyperlink, there are tutorials available for you.



Once downloaded, you can open an image by going to file, open



Then select a picture from a file on your computer (or download something online first). Disclaimer - you must be aware of copyright infringement laws depending on the use of the picture you are downloading. Make sure to reference where you obtained the picture and/or obtain permission to use it :-)



Once you have selected a picture, you can begin utilizing the software to your heart's delight. This is a quick-start to get you going, but I encourage you to check out the "documentation" link listed above to learn about all of Image J's features. If you are planning on using this software for a school project or a lesson plan, it's worth investing a few minutes. I hope you like it as much as I do!

Lumbar Spine Obliques

Even on a patient with normal anatomy, lumbar spine obliques can be quite a challenge no matter how many years of experience you have. If you've memorized the "scotty dog" anatomy, that's great and it will come into play during the critique of your images, but a basic understanding of how the anatomy is laid out in planes is good to know before you begin your positioning.

On most patients, the cervical spine is in the same plane as the lumbar spine, and this can prove to be a valuable positioning tool if utilized properly. In other words, if a patient is lying on their back and you had do take a tomo slice of the c-spine, the same exact tomo slice, centered over the lumbar spine would work as well. Additionally, if you look at a (normal) spine in the anatomical position, then rotate that spine 90 degrees, you could draw a straight line extending from the cervical spine down to the lumbar spine and it will be in the same plane.



So if you can go from AP to lateral with the C and L-spines in the same plane, then you should be able to go half-way (into an oblique position) and still have them in the same plane.



Of course, it's easy to demonstrate this with elaborate stick-man drawings, but it requires a bit of forethought when doing this on a patient. I like to use a radiolucent pad on the table for a couple of reasons... one, it's just mean not to when you have one available, and two, it is a valuable positioning tool when there is a sheet underneath it. It can easily be slid with a patient on it to better align or even help rotate the patient.

So, with the patient on a pad, position and shoot your AP film. I like to perform the RPO next, so I would inform the patient that I am going to roll them. If it is a small enough patient, it's easy to roll them instead of giving them instructions to roll. When they roll, they usually slide their hips over before rolling one way or the other. You can simply grab your 45 degree sponge and be ready to lift. Grab the pad by the patient's shoulders with one hand and hips with another. Slide them away from the center of the table if necessary so you don't roll them on the floor. Roll them up placing the sponge underneath the pad to the desired position. The sponge shouldn't slip if it's directly on the table.

If your patient is too heavy to do this with, some simple instructions will prevent them from shifting their hips, misaligning your C and L-spines. For RPO, have them bend their left knee. Then have them reach their left arm across their chest. Standing on their right side, place one hand on the left shoulder and the other on their left knee and just assist them while they roll. Wedge your sponge underneath and you're all set.

Once obliqued, align the L-spine and center your tube like you normally do. Now you have another way to check your positioning... go to the head of the table and see whether or not your central ray is in the same plane as your cervical spine. This only works when the patient does not slide their hips. Make minor adjustments as needed and check your results.

For conventional centering, it's always a good review to know the "finger-width" measurements that work for you. Look at an L-spine oblique film on an average sized patient that's centered well (print one out if you need to in order to get "actual size).



On the printed image, check to see how many fingers it takes you to place the horizontal crosshair at the center of L-3's vertebral body. Then see how many finger-widths it takes from the ASIS to the center of L-3. This should be a film that you performed, and it should be positioned exactly the same with each patient. If the patient is not obliqued the same amount, then the distance from the ASIS to L-3 will change. This is the most accurate way to know what works for you. You may have learned this in school, but I would bet that the person teaching you this had different sized fingers than you, and you have to measure this for yourself. The same thing goes with your spot film.

For laterals and spot films, you still need to keep the C and L-spine in the same plane, but the most common errors are in over/under-rotation - not the whole body, but in the shoulders and hips not being in the same plane. But that's another post...

On a Personal Note...

A couple of weeks ago, I sustained a knee injury which was a freak occurrence, random happenstance, and still, a very confusing injury to me. I am well aware of proper body mechanics and posture, and was practicing them to the best of my ability when this occurred (I know this because there were three students in the room - one helping me with the patient's legs - and I made a mental note to demonstrate proper lifting technique).

I was performing a two-man lift moving a patient from wheelchair to stretcher (or gurney as I learned on the left coast), lifted the patient off the chair, placed his hips on the stretcher, and while I was lowering his shoulders onto the stretcher, felt a "pop" in my knee accompanied by instant pain and an inability to bear weight. I thought for sure I had torn a ligament, and thankfully, this occurred after the patient was safely on the gurney.

I had an initial set of x-rays that day that showed lateral joint effusion (my opinion) which the doctor called normal. After protesting and noting a few other discrepancies, I decided to obtain a second opinion at the local Emergency Room the following morning. A second set of x-rays showed no fracture that I could see, or that the Radiologist's report could identify. Still, I was referred to an orthopedic surgeon for a follow-up visit. We did the range-of-motion tests, which were accomplished easily by the time I got in to see her as it was healing nicely I thought. And then she pushed down on the lateral part of my knee right at the joint, and I felt like I was going to pass out it hurt so bad. Needless to say, an MRI was ordered "just in case."

So I had my MRI yesterday, and showed my films to a Radiologist that I work with... it seems I have a tibial plateau fracture, nondisplaced, but rather large that didn't show up on the x-rays at all. He said it was definitely there, but the angle of the fracture made it appear to be a part of the cortex on the tibial plateau. I found myself looking at the x-rays in vain trying to see the original fracture, and I've been walking on it pain-free for about a week now.

What I've learned:

I already knew that some fractures might not be seen on plain films, but now have first-hand credibility to that claim.

Also, no matter how good your body mechanics and posture are, we still perform a job with lots of lifting that wears on your body over time. I wonder how bad my injuries could have been without proper body mechanics?

Finally, document everything - and document well. Seek second opinions if necessary and write as much detail as possible, not only for yourself, but for patients that you encounter when you are performing your daily examinations. You never know how much it will help them.