A Radiographic Examination: Justification Of Actions Taken

An introduction

Radiographers’ role is to identify the best imaging methods for each radiographic exam. Radiographers need to be able to assess the clinical data of patients, reason clinically and problem solve.

An radiographer will explain and justify the actions he took during an observation. The examination requested was that of a 50-year-old male, whose elbows were being x-rayed, in the A&E x-ray department.DiscussionJustification of why the examination was requested

A radiographic examination can be justified according to Vom and colleagues (2017). This is where a physician evaluates the medical notes to confirm that it is appropriate. According to the Ionising Radiation (Medical Exposures) Regulations (IR (ME)R2000), patient exposure must be justified. Before the exam, the radiograph checked that the request form was filled correctly (i.e. To ensure the proper filling of the request form, the radiographer double-checked that the correct name was used and that all clinical indications and requests for examinations were noted.

Also, the radiographer verified that the request had been authorized (signed by a registered doctor who is allowed to act as a referral e.g. A Radiologist, Doctor. The IR(ME),R Regulations (2000) require hospitals to list all medical and non-medical referrals in every department. This allows the radiographer to verify that authorization has been granted.

In this situation, the patient’s clinical notes state that he fell on his left side (FOOSH), had a tender bilateral radius head and required X-rays to show both the anterior-posterior elbows and the lateral projections. According to the International Commission on Radiological Protection(ICRP), the radiographer deemed this examination valid. It would allow doctors to identify any fractures and provide more benefit than harm. Knowing that there was a fracture would help to improve the patient’s treatment.

Referral forms must contain sufficient information to enable practitioners to evaluate the risks and benefits of radiation exposure. The IR(ME),R (2000) requires that referral forms contain sufficient clinical information to allow practitioners to properly assess whether radiation exposure has any effect on patient treatment.

Positive patient identification

When the patient entered the x-ray area, the operator called their name from the waiting area. To establish a friendly relationship, the operator introduced themselves to the patient and others in the room (Whitley and al 2016, After establishing the patient’s identity, the radiographer requested that they provide full names, addresses, and dates of birth according to Trust Ionising Radiation (Medical Exposures) Regulations (IR (ME)R2000) protocols. This states that the operator (individual who has undertaken the exposure) is responsible to identify the patient. The request form and the patient’s response are then cross-referenced so that they match.

The patient was also asked if they had ever been to an x-ray or if they have recently. This was done to verify that the referrer’s referrals and clinical indications correspond to what the patient said.

If the patient has had the same exam before, but images were not able to load on PACS, the practitioner can reexamine the patient without knowing that the previous examination was done. The best practice is to ask the patient which part of the body will be examined. Also, it is important to verify when the last Xray was taken. This helps to minimize the possibility of radiation dose to the patient.

CQC revealed in its 2013 annual report that incorrect examinations due to failed identification processes had been reduced through additional checks of medical information and previous imaging. Society of Radiographers (SOR, 2016), recommends that physicians confirm the patient’s date of birth and name with the patient.

The patient identification process was completed in the Xray rooms. In order to protect the patient’s confidentiality, we adhered to the 2017 Health and Social Care Council guidance.

Radiation protection considerations

After confirming the patient’s identity and checking the request, the radiographer checked PACS/RIS to see if there were any previous images. This was done in compliance of the Local Rules (2017). This allows the radiograph to decide in what projections and if it’s necessary. It reduces radiation exposure by preventing unnecessary examinations.

Whitley et.al (2016) stated that the Xray doors should be photographed. The radiographer should position the beam of X-ray away from the door so that there is less chance of someone getting in the way during exposure. The patient’s companion was asked outside to wait as only those who are necessary to perform the examination (Local Rules 2017) were allowed into the room.

Before exposure, the radiationographer checked that everyone was protected by the glass shield. Because the glass shield is made from lead, which can block radiation particles, practitioners are asked to make sure they are protected from radiation.

The radiographer ensured that the patient’s radiation dose was recorded accurately as required by (IRR, 1999) in order to allow dose monitoring and to evaluate patients for safety. The International Atomic Energy Agency (IAEA) (2016) states that medical radiation practice can improve and radiation doses can reduced without affecting diagnostic quality. This is done by continuously recording doses of patients, reporting any dose incidents, and analysing all data. The report also states that individual doses can be monitored and can be used to help prevent unnecessary exposures.

There are methods to reduce radiation dose and scattering radiation.

Holmes et.al (2013) defined scattered radiation as photons scattered in the body or detector. Radiation that has been deflected from an object (e.g. the detector, table or wall) can also be considered scattered radiation.

The contrast and definition of the radiograph or image resulting from scattering photons is reduced. The scatter radiation produced depends on the size of the area or field that was irradiated as well as the Source to Image Receptor Distance (SID). Image quality is affected by scatter radiation. To reduce the scatter radiation and avoid excessive irradiation of tissues, the radioographer reduced the field size by collimating x-ray beams to focus on the elbow. Holme (et.al. 2013, Collimation improves image clarity and radiation dose to patients, staff, and patients by minimizing scatter.

The patient was properly positioned so that the final image showed the area of interest. No repeats were necessary (Whitley and co. 2016). The radiographer checked that the patient was not lying below the imaging table. This was done in order to shield the patient’s lower limbs from scattered radiation (IR(ME),R 2000).

To minimize radiation exposure, the radiographer also performed other actions. These included setting up primarily exposure, preparing the area, and inviting the patient to enter. This decreases the chance of repeats and reduces patient dose.

Explanation of how exposure factors were chosen and the manipulations that were made

The exposure factors used by the radiographer were 60kvp in kilovoltage and two mAs in milliamperes to measure the antero-posterior projection and the lateral projection. Whitley and colleagues (2016). KVp stands for the penetrating power in x-rays and mAs denotes the radiation dose.

Low high kVp, low mAs were used as the patient is very small and the area of concern is small. The radiation is not going through much soft tissue. High energy radiation doses are not required for this patient. This would be against IRMER regulations, which require that the radiation dose to patients be kept as low as practicable (ALARP). Radiation is always harmful, and prolonged exposure can lead to further damage.

Whitley (2016) advises that the radiation energy used to penetrate a specific body part should exceed the kVp. A low contrast setting will allow radiation to penetrate the body at a reasonable rate to create maximum contrast. Structures with high density like bone absorb the low rays. Soft tissue and structures with lower density will absorb less of the radiation. The result is an image with high contrast.

Image quality could be affected by a decrease in contrast or decreased kVp. Additionally, bone trabeculae may not be visible. This indicates that abnormalities might not be obvious. The patient would then be exposed to more radiation, so a repeat procedure is necessary. It’s best to use a high dose of kVp to reduce skin exposure.

Explanation of Communication Strategies

To prevent patient intimidation, eye contact was established with the patient at eye level. According to…….establishing eye contact is very important because it shows interest in a conversation[AN2].

The patient was placed using non-technical terms, jargons and demonstrations. The patient will be able to understand the instructions and can position themselves correctly by being shown. An intern helps reduce the chances of the radiographer touching the patient or positioning them. This can cause discomfort for the patient. …….. [AN3] The simple use of speech helps the patient feel more in control and relax because they are able to understand what’s happening.

Every patient was asked if it was possible to perform certain positions. The radiographer would gently reassure the patient if he was unable or unwilling to perform a particular position. This was done to make sure the patient felt loved and to motivate him to follow the treatment AN4].

The patient and their doctor communicated throughout the procedure in order to reduce anxiety and to ensure that they didn’t feel disturbed or inconvenienced.

Discussion on clinical reasoning

Because the pain was too severe, the patient was unable turn his right elbow. Thus the radioographer was unable and unwilling to place him in the proper position for anterior/posterior elbow projection. The radiographer used the upright Bucky to project the elbow. The Bucky was placed in front of the patient. He was to be erect, his feet and hands alongside the body.

The radiographer encouraged the patient to face his palms forwards and took an x-ray. White (et.al 2016) did not recommend this modified method. However, the image showed the distal portion of the arm and the proximal end of the radius. Thus, it conformed with White’s essential image characteristics for an anterior/posterior knee.

Discussion on alternative or additional imaging options that might be available

Computed Tomography (CT), another technique that can be used for imaging the elbow, is also available. This creates a series in which the body is cut into slices. The images can then be used for constructing a 3-Dimensional view (Adam W.M. Mitchell 2015). This radiograph can be used to diagnose fractures and determine the extent of injury, if a normal radiograph is not able to do so. They can show bone and soft tissues, including cartilage, as well as visceral or internal organs. Dr. Hapugoda says that. S (ETAL 2017) CT scanning offers the best imaging modality for assessing the articular contours, and intra-articular pieces in joins.

CT examinations require higher radiation doses than regular x-rays, and they are also more costly. Jackson and Thomas (2005: p52) stated that most fractures can be diagnosed by plain x-rays except for complex areas like the ankle, wrist and hip joint. These complex areas make it more difficult to diagnose fractures. CT scans may only be used when radiographs alone fail to reveal any pathology. There are however reasons to believe otherwise.