- Kevin M. Rice, MD
Dr. Rice’s Radiography Top Ten
Radiologic technologists have an opportunity to greatly assist the radiologists by performing high quality exams. Unfortunately there is variable quality seen in radiology. (Fig. 1). I explain how these top ten quality tips will greatly reduce errors in the radiology department and improve the ability for radiologists to make an accurate diagnosis.
Figure 1. The good, the bad, and the ugly. Unfortunately there is variable quality seen in radiology.
Dr. Rice’s Radiography Top Ten:
1. Verify that all images and notes are in PACS for the radiologist. 2. Use a lead side marker with your initials. 3. Remove all clothing, jewelry, and other foreign objects from the field. 4. Use a metal pointer on the area of maximal bone or joint pain. 5. Abdomen x-ray must show both sides of diaphragm and lesser trochanters. 6. Shoulder x-ray must collimate to the shoulder and have 3 views. 7. Wrist X-ray must include a scaphoid view if patient is age 10 or older. 8. CXR must include both lung apices and both lung bases. 9. Accession #, order, and study description for the exam must match the images in PACS. 10. Indication must be available to the radiologist.
1. Verify that all images and notes are in PACS for the radiologist.
No sense going to all the trouble to get great images if the radiologist can't see them. If your system does not send an electronic receipt message to the modality, the tech should check the PACS after each case to be sure all the images went through.
2. Use a lead side marker with your initials.
The initials are essential so if there is a problem, the radiologist can discuss it with the appropriate person. Technologists should always use physical anatomic side markers placed on the image receptor. Putting on the side marker after taking the image may lead to errors. (Figs. 2-4). This is well documented in the standard textbook for radiographers here:
Figure 2. Electronic side marker, placed on the image with software AFTER it was obtained. The "L" has actually been incorrectly pasted on the patient's right side.
Figure 3. Same patient as in Fig. 2 above done the next day, with physical lead side marker placed on the image receptor BEFORE the image was obtained. Technologist has correctly used lead side marker.
Figure 4. Example of ambiguous side markers. The radiologist is unable to determine if this is left or right. Study description is LEFT ankle; Marker is RIGHT. If the order is for the wrong side, it is crucial to get the order corrected BEFORE obtaining the radiograph. Also the technologist improperly added the "R" with the imaging software after the image was taken.
3. Remove all clothing, jewelry, and other foreign objects from the field.
Extraneous items such as clothing, EKG leads, and jewelry can obscure pathology. (Figs. 5-6) Technologists should be sure to remove it all before taking the image. If the patient refuses or the items can not be removed, the technologist should make a note of it so the radiologist is aware. (Fig. 7. B)
Figure 5. Hair extensions on xray. All foreign objects need to be removed prior to taking the radiograph.
Figure 6. Jewelry needs to be removed prior to taking the radiograph.
Figure 7. A. If there is a reason the images are not following protocol, the tech should make a note of it.
Figure 7. B. If the patient refuses or the items can not be removed, the tech should make a note of it.
4. Use a metal pointer on the area of maximal bone or joint pain.
The referring physicians have an advantage when they look at the radiographs as they know the exact spot where the patient is having pain. Technologists can give the radiologist the same benefit by placing a metal pointer at the site of pain prior to taking the image. (Figs. 8-10). The technologist should not use the software to insert an electronic pointer after taking the image since this has the same drawbacks as inserting the "L" or "R" after taking the image. (Fig. 10). Using an electronic pointer may result in pointing to the wrong place, or the technologist may be tempted to point to a suspected radiographic abnormality rather than the region of clinical concern.
Figure 8. Tech has correctly put a lead marker on the site of maximal tenderness.
Figure 9. Same patient as above Fig. 8. Subtle fracture visualized, with help from the tech. Blue arrows are the author's, showing the fracture.
Figure 10. A: The tech has put an electronic arrow on the image after it was done. Figure 10. B: The tech has put a physical marker on the site of maximal tenderness.
5. Abdomen x-ray must show both sides of diaphragm and lesser trochanters.
Radiologists can miss pathology such as free air or urinary tract calculi if all the anatomy is not included on the images (Fig. 11).
Figure 11. A: The upper abdomen is not included on this abdomen radiograph.
Figure 11. B: The subsequent chest xray demonstrates free air under the diaphragm (red arrow).
Figure 11. C: This is confirmed on the CT scan which shows free air in the abdomen outlining the falciform ligament (blue arrow).
6. Shoulder x-ray must collimate to the shoulder and have 3 views.
The central beam should be on the shoulder to avoid geometric distortion. The tech should always shoot a scapular Y view, axillary view, or Grashey view to evaluate for dislocation (Fig. 12).
Figure 12. A: The frontal radiograph of the left shoulder demonstrates internal rotation which may give the radiologist a clue to the diagnosis.
Figure 12. B: The axillary radiograph of the same patient's left shoulder demonstrates the posterior dislocation and reverse Hill Sachs lesion (also known as a McLaughlin lesion).
7. Wrist X-ray must include a scaphoid view if patient is age 10 or older.
Missing a scaphoid fracture may result in non-union and avascular necrosis. Adding the scaphoid view will help the radiologist to make this important diagnosis (Fig. 13).
Figure 13: A subtle scaphoid fracture (white arrow) seen on scaphoid view.
8. CXR must include both lung apices and both lung bases.
Radiologists can miss pathology such as pneumothorax (Fig. 14), a small pleural effusion, or free air in the abdomen (Fig. 11) if all the anatomy is not included on the images.
Figure 14. A: The lower chest is not included on this supine chest radiograph.
Figure 14. B: With the lower chest now visible, bilateral pneumothoraces are visualized with a deep sulcus sign on the right (red arrow) and a large lucency on the left (blue arrow).
9. Accession #, order, and study description for the exam must match the images in PACS.
All the demographic information has to be correct before sending images to PACS. Trying to fix something after it is in PACS is a nightmare for PACS administrators!
10. Indication must be available to the radiologist.
Technologists need to make sure the relevant clinical information is available to the person reading the images. Not only is it important from a patient care perspective, but it is a compliance matter to have a relevant indication on the final report.
Through the use of excellent technique, radiographers can greatly assist the radiologists in making an accurate diagnosis, which in turn is a major benefit for our patients. By using the tips in this article you will be on the journey to high quality and safety in the radiology department.
Kevin M. Rice, MD serves as the Chair of the Radiology Department and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice together with Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.
Follow Dr. Rice on Twitter @KevinRiceMD
