ApplicatioRadiographic Licensing

Remote Operators Radiographic Licensing
Radiographic Procedures Manual

Page 1 of 95
Department of Health is a Smoke Free Workplace
D EPART M E NT O F H EALTH
TABLE OF CONTENTS
Section 1 Introduction
1.A 1.B 1.C General Introduction Legislation and Imaging Requirements Contacts
Section 2 - General Radiation Physics

2.A 2.B 2.C 2.D 2.E 2.F Introduction to Physics Production of X-rays The X-ray Tube Properties & Interactions of X-rays Biological Effects and Hazards Basic Radiation Protection
Section 3 - Radiographic Equipment

3.A 3.B 3.C 3.D 3.E Overall Description Basic Exposure Controls X-ray Installations in the Northern Territory Ancillary Equipment Film/Screen Radiography
Section 4 - Computed Radiography (CR)

4.A 4.B 4.C 4.D 4.E 4.F 4.G Introduction Cassettes Phosphor Plates Digitizer/ Scanner Post Processing Image storage & Transfer for Radiologist Review Image File Types
2011 Radiographic Procedures Manual.doc
Page 2 of 95
Version 2: 29-June-2011 Revision Date: June 2014
Section 5 - Working Procedures and Instructions

5.A 5.B 5.C Initial Preparation Positioning and Exposure Determination Patient Identification
Section 6 - Radiographic Critique & Positioning

6.A 6.B 6.C Radiographic Critique Chest Upper Extremity I. II. III. IV. V. VI. 6.D Hand & Fingers Thumb Wrist Forearm Elbow Shoulder
Lower Extremity I. II. III. IV. V. Foot & Toes Ankle Calcaneus Tibia/Fibula Knee & Patella
6.E
Exposure Chart
Page 3 of 95
Page 4 of 95
Section 1 Introduction
Page 5 of 95
SECTION 1 - INTRODUCTION
Section 1.A General introduction
The Remote Operators (ROs) X-ray Program has been in operation within the Northern Territory since 1981. With the recent change from conventional radiography to computed radiography and the increase of satellite health facilities with radiographic equipment it was thought that the entire program needed to be reviewed. Initially licences were granted by the Radiographers Board of the Northern Territory, however, with recent legislative changes the Radiation Protection Section within Environmental Health now grants the licenses. The practical training of ROs is undertaken at Royal Darwin Hospital and this document is aimed to be used to compliment that practical training and also as a reference for the RO in the future. The purpose of the program is to train GPs and Nurses from remote locations in basic radiographic position of Extremities and Chest imaging to decrease the need for patient transfer to larger regional centres for imaging and therefore treatment.
Section 1.B - Legislation and Imaging Requirements

Currently Radiographers and ROs performing radiography within the NT are bound by the following legislation and regulatory requirements: Northern Territory Radiation Protection Act Radiation Protection Regulations Health Practitioners Act NT Remote Health Atlas - http://remotehealthatlas.nt.gov.au/xray_equipment.pdf
Commonwealth Radiation Protection Regulations (RPR) o The aforementioned provide a framework for the regulation of radiation related activities and include taking x-rays.
And any relevant future legislation, Federal or Territory
Page 6 of 95
Further References Radiation Protection Series - published by the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) Radiation Protection in Diagnostic and Interventional Radiology Safety Guide The Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation establishes regulatory requirements for using x-ray apparatus in medicine. National recommended dose limits for medical workers apply.
RADIATION PROTECTION PLAN (RPP)
All sites with Xray equipment require a Radiation Protection Plan. This is the name for an application for a principal licence. It forms a generalised plan for radiation protection. This plan is formulated for the purpose of ensuring that all diagnostic radiography sites operate as safely as possible and in compliance with Northern Territory legislation, in particularly the Radiation Protection Act, and Radiation Protection Regulations of the Northern Territory. A copy of the plan must be easily accessible and is provided by the procession licensee of the premises, which is the principal licence holder, who controls x-ray apparatus and all licence holders at a practice. The plan applies to all of the X-ray equipment and premises and is in the possession of the principal licensee. Compliance with this RPP (Radiation Protection Plan) will ensure that the radiation doses to users and patients are below the prescribed limits and are as low as reasonably achievable (ALARA Principle). It will also ensure that the number of people exposed to radiation and the likelihood of unexpected exposure to radiation are minimised. Royal Darwin Hospital have an internal document called a Radiation Safety and Protection Plan. It is an additional document to a RPP.
A person dealing with radiation apparatus will have to: Apply for and maintain concurrency of all permit, license and/or registration certificates; Pay prescribed fees (NTG employees are exempt from all fees under the Radiation Protection Act); Keep records; Disseminate information to employees and radiation workers; Post appropriate signs and notices; Comply with certain directions in routine and emergency situations; Monitor levels of radiation exposure and doses; Write and submit reports;
Page 7 of 95
ALARA Principle While undertaking any radiographic imaging it is important to adhere to the ALARA (As Low As Reasonably Achievable) Principle, when dealing with radiation. ALARA should be considered when determining the initial need for the radiographic procedure and also the necessity for repeat exposures or any extra views, always weighing up exposure and radiation risks vs. diagnostic benefit. Mandatory Image Identification All images must include the following details: 1. Patient Identifier number 2. Patient Name 3. Date of Birth 4. Sex of Patient 5. Date of Exposure 6. Exposure Number (if applicable, this may not be required for remote locations) 7. Location exposure was taken ( e.g. which health facility) 8. Appropriate side marking 9. Identifier of person taking the x-ray (either on image or legibly on request form) When images are transferred to the NT PACS for storage and/or to Royal Darwin Hospital for formal image reporting, a formal imaging request with the same above details as well as all relevant clinical information should be faxed to RDH as soon as possible to allow for the appropriate efficiency in reporting and storage. Along with the request form a Medicare form signed by the patient should also be faxed to RDH. The process of image transfer and accompanying documentation will be discussed in more detail in Section 4 Computed Radiography of this manual. Training Medical practitioners or registered nurses may conduct chest and extremity X-rays after passing a remote operators course, which is available at Royal Darwin Hospital. You must complete: at least 40 hours experience working with a registered radiographer at Royal Darwin Hospital and successfully complete a 3 hour examination with a certain level of correct answers .
Some registered nurses may take x-rays at Katherine, Tennant Creek and Gove Hospitals under the direct supervision of a radiographer. A remote area operators course may become available at Alice Springs Hospital at some stage in the future.
Page 8 of 95
Licensing RPA includes the following radiation related activity: Licence to manufacture, sell, acquire, possess, use, store, transport, dispose of or otherwise deal with x-ray apparatus and radioactive material. Some non-ionising radiation apparatus are defined as radiation source in the RPR
These legislation, regulatory requirements and references can be viewed electronically through any web search. Conditions of your license The licensee must operate in accordance with the Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation (2008). If the licensees professional registration is repealed by the licensees professional registration board, this license expires at the same time. Except in an emergency, the licensee must limit taking radiographic views to those for which the licensee is trained, chest and extremity X-rays only. A record of each radiographic view and number of repeats must be maintained and made available when requested. Examinations are to be reported by a Radiologist unless advised otherwise. A request for advice by email is sufficient. The licensee must operate according to the current radiation protection plan and must not use a radiation source unless a current certificate of compliance for a radiation place is on display in the radiation place. Certificate of Compliance One protection strategy is the certificate of compliance. This is issued by service providers who will be accredited to do this. Certificate of compliance is to ensure that a particular source is safe to use. The radiation place must have a certificate of compliance and this must be prominently displayed. This certificate means that it is safe to take x-rays.
Page 9 of 95
Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation (2008)
You must comply with this code because it is a condition of your licence. Please be aware that there is a safety guide, with the same name, that helps you understand this code. You can obtain this code and this guide from here: www.arpansa.gov.au.
Of particular importance to Remote Operators are the following sections... Section 3.1.3 (a) No x-ray image is to be taken unless it is justified and approved for each individual by you or a written guideline. Section 3.1.3 (c) A licence condition limits you to chest and extremities and therefore you must ensure that the field of view is set so that embryos and unborn babies cannot receive a radiation dose in excess of 1 mSv.
Page 10 of 95
Section 3.1.7 (a) You must use radiographic factors as described during your training. This can be used to determine the radiation dose received by the patient. It is important never to increase mAs or kVp significantly because an acceptable image will be produced but the patient will receive a radiation dose that is significantly greater than that produced from using the stipulated radiographic factors. Section 3.1.9 You must wear your personal monitoring device if you could exceed a radiation dose of 1 mSv in a year. If there is a change in the shielding design or this is a new practice, it is recommended that personal monitoring devices are used.
There are other responsibilities that the clinic manager or the Director Remote Health must meet. These are available to view the web page for the Radiation Protection Section www.nt.gov.au/health/radiationprotection
The following statement was taken from the Queensland Governments 2005 Licensed Operators Manual For Chest and Extremities (Rural & Remote Extended). It highlights the severity and seriousness of following correct protocol and procedures when conducting radiographic examinations and highlights the fact that these issues are prosecuted in states and territories across Australia.
Remember: The law is the law. There are no special conditions provided by the Radiation Safety Act that say we can ignore the rules in emergencies. If you do not have a use licence and you decide to use a radiation source, or if you do have a use licence and you decide to use a radiation source in a way that is not covered by your licence, you are responsible for that action. You will be held liable for a breach of the legislation. The Department cannot indemnify a person who chooses to ignore the legislation.
Page 11 of 95
Section 1.C Contacts

Radiographic: Clinical Director of Radiology Services Royal Darwin Hospital Glenn Drogemuller ph: 08 8922 8080 Superintendant Radiographer Royal Darwin Hospital Roger Weckert ph: 08 8922 8732 Email: roger.weckert@nt.gov.au Tutor Radiographer Royal Darwin Hospital: Andrew Loughman ph: 08 8922 8951 Email: andrew.loughman@nt.gov.au Radiation Protection Officer Royal Darwin Hospital: Mark Palmer ph: 08 8922 8784 Email: mark.palmer@nt.gov.au Fax for Request Forms and Signed Medicare Forms: 08 8922 8908 PACS: PACS Administrator Royal Darwin Hospital: Grant Buckley ph: 08 8922 8951 Email: grant.buckley@nt.gov.au
Page 12 of 95
Licensing: Department of Environmental Health: Manager Radiation Protection ph: 08 8922 7489 Email: russell.robinson@nt.gov.au
Radiation Protection Section 2nd Floor, Casuarina Plaza 258 Trower Road Casuarina NT PO Box 40596 Casuarina NT 0811 ph: (08) 8922 7152 Fax: (08) 8922 7334 Email : envirohealth@nt.gov.au
Equipment Faults & Servicing: Contact your closest Base radiographic provider for advice first. Secondly refer to your service contracts and manuals for assistance with any equipment faults. Most locations have Fuji CR systems and Shimadzu mobile X-ray units. However some locations use AGFA CR Systems and will have different service contacts and help lines.
Page 13 of 95
Page 14 of 95
Section 2 General Radiation Physics
Page 15 of 95
SECTION 2 GENERAL RADIATION PHYSICS

Section 2.A - Introduction
Wilhelm Roentgen discovered X-rays in 1895 during his experiments on the passage of electricity through partially evacuated glass tubes. Roentgen realised he had found a previously unknown type of radiation and because very little was understood about its properties, the emissions were given the name of X-rays. Since those early days, much work has been done on X-ray radiation with the result that the properties of X-rays are now well understood. X-rays are electromagnetic radiation and form part of the electromagnetic spectrum along with visible light, microwaves, radio-waves etc. They have a wavelength of less than 1 x 10-10 metres.
Wavelength in metres
Wave type
10-14 10-12 10-10 10-8 10

-6
Cosmic rays Gamma rays X-rays Ultraviolet Visible light Non Ionising Ionising
Figure 2.1: Wavelength of Different Radiation
Page 16 of 95
Section 2.B Production of X-rays

X-rays are produced within part of the X-ray unit called the tube. This is an evacuated glass tube inside which is fitted two electrodes. One electrode is called the Cathode (negatively charged) while the other is called the Anode (positively charged). X-rays are produced whenever very energetic electrons are rapidly decelerated. When electrons are suddenly stopped by a metal object, some of their Kinetic (motion) energy is converted into electromagnetic radiation. An x-ray tube uses this principle to produce radiation. If we evacuate the air out of an X-ray tube, heat the cathode filament with an electric current and apply a very high voltage (greater than 40,000 volts [40kVp]) between the anode and the cathode, electrons will escape from the cathode and be accelerated towards the anode. When these fast moving electrons rapidly decelerate as they approach the anode (also called the target), heat and X-ray photons are produced in all directions. This is referred to as Bremsstrahlung (braking) Radiation. If the voltage between the anode and the cathode is increased, the electrons are accelerated faster and therefore have more energy when they reach the anode. This results in the production of X-rays having a higher energy level. If the number of electrons passing from the cathode to the anode is increased then the number of X-rays (photons) increases with a resultant increase in the intensity of the X-ray beam. Heat is produced when the fast moving electrons strike the target. In fact, up to 99% of the kinetic (motion) energy of the electrons is converted into heat, whilst only 1% is available for the production of X-radiation. To cope with this large production of heat, the X-ray tube must be constructed so that the heat can be conducted away from the anode as rapidly as possible before it melts the anode. Copper and tungsten are the most common materials used for the anode as both are very good heat conductors. The actual target area is usually tungsten while the backing and support material is copper. Tungsten has a melting point of 3380C while copper has a melting point of 1070C. During X-ray exposures the target area may reach temperatures of approximately 2000C.
Page 17 of 95
Section 2.C The X-ray Tube

Two types of X-ray tube are used in diagnostic medicine, Stationary anode tubes and rotating anode tubes. In the stationary anode tube, the target area is a section of tungsten embedded in a copper anode. In the rotating anode tube, the target is a rotating tungsten disc. The rotating anode allows the electron beam to interact with a much larger target area. The result is that the heating of the anode track is not concentrated in such a small area as it is in that of a stationary anode tube. See figure 2.1 for comparison of these two tube types. As stated earlier, when the anode stops fast moving electrons, X-rays are produced in all directions. The tube is constructed so that only the useful beam of X-rays is able to escape from the tube through a specially designed window. The anode design also determines a preferred direction. The anode is always tilted at an angle to the direction of the accelerated electrons. The glass tube and lead lined tube housing restricts X-rays from escaping from the tube in other directions. Any radiation that does get through is termed leakage radiation. This radiation does not contribute anything useful to the image on the film; instead it presents a hazard to the patient and the operator.
Stationary Anode Figure 2.2: Comparison of Standard X-ray Tubes Focal spot
Rotating Anode
The target area of the anode from which the X-rays are emitted is called the focal spot. (4) The approximate location of the focal spot is usually indicated on the tube housing by a dot or a cross.
Page 18 of 95
Section 2.D Properties & Interactions of X-rays

Voltage (kVp) applied across the X-ray tube
The Energy of the X-rays emitted from the X-ray tube depends upon the Energy of the electrons, which bombard the target of the X-ray tube. The peak kilovoltage (kVp) used across the X-ray tube between the cathode and the target determines the Energy of the electrons. Therefore the kVp determines the maximum energy of the X-rays produced. The higher the Energy level, the more penetrating the X-ray beam. THE GREATER THE VOLTAGE APPLIED ACROSS THE X-RAY TUBE, THE GREATER THE PENETRATING POWER OF THE X-RAY BEAM.
X-ray tube current (mA)

The unit of measurement for electric current is the Ampere (A). One thousandth of an Ampere is a milliampere (mA). The number of X-rays produced depends on the number of electrons that strike the target of the X-ray tube. The cathode filament produces electrons and the number of electrons depends directly on the heating current applied to the cathode filament. The greater the number of electrons, the greater is the current flow (mA) across the tube and the greater the number of X-rays produced. The size of the current passing across the X-ray tube is in the milliampere range (50mA to 1200mA). However, changing the X-ray tube current does not affect the penetrating power of the X-ray beam. Since the current flow across the tube is directly related to the heating current supplied to the cathode filament, it is possible and in fact easier, to set the controls to provide a given current across the tube. THE GREATER THE X-RAY TUBE CURRENT, THE GREATER THE INTENSITY OF THE XRAY BEAM. There is a linear relationship between mA and the amount of X-rays produced. If the mA is doubled, the amount of X-rays produced is also doubled. For example: If 100 mA produces 500 X-ray photons in one second, 200 mA will produce 1000 X-ray photons in one second (an X-ray photon is a bundle of X-ray energy).
Exposure time (s)

The number of X-ray photons produced depends on the number of electrons that strike the target of the X-ray tube. There is another way of increasing the number of electrons. Instead of increasing the tube current, we can increase the time of the exposure and therefore the time that the filament is energised. For example: If 100 mA produces 500 photons in one second, 100 mA will produce 1000 photons in 2 seconds.
Page 19 of 95
Milliamp second (mAs)

Tube current in milliamperes (mA) and exposure time in seconds(s) are often linked and become milliamp seconds (mAs). This figure is a product of the tube current and the exposure time. (mA x seconds = mAs)
Filtration
The diagnostic X-ray beam is composed of X-rays that have a whole range of energies. The production of a radiograph depends on the different rates of absorption of X-rays by different tissues. Bone absorbs more radiation than soft tissue, which absorbs more radiation than gas. As the X-rays pass through a patient, most of the lower energy X-rays are absorbed in the first few centimetres of tissue, and only the higher energy X-rays penetrate the patient to form the radiographic image. Since the patients radiation dose depends on the number of X-rays absorbed, it can be seen that the low energy radiation adds to the radiation dose to the patient without contributing anything to the radiograph. The low energy X-rays can be removed from the beam by the use of an aluminium filter interposed between the X-ray tube and the patient. THE ONLY FUNCTION OF THIS FILTER IS TO REDUCE THE RADIATION DOSE TO THE PATIENT.
Scatter
When X-rays strike matter, three things happen: some x-rays pass through with or without any interaction. some are absorbed, and some are scattered in a variety of directions.
In the process of scattering, the X-rays lose energy so that scattered radiation is always of lower average energy than the primary beam. X-rays may be scattered several times before finally being absorbed. The relative amounts of absorption and scattering, which occur, depend on the energy of the Xrays and the material that they encounter. Lead is a very efficient absorber of X-rays in the diagnostic energy range. Other materials such as soft tissue, water and bone, scatter some of the radiation and also absorb some of the radiation. The production of a radiograph depends on the different absorption in different materials (e.g. bone and soft tissue). Scattered radiation is of no value in the production of a radiograph. In fact it not only reduces the quality of the radiograph but it is a major source of unwanted absorbed radiation dose for both the patient and the operator.
Page 20 of 95
Figure 2.3: Scatter Radiation
Figure 2.4: Inverse Square Law
The Inverse square law

The Inverse Square Law states: THE INTENSITY OF THE X-RAY BEAM VARIES INVERSELY WITH THE SQUARE OF THE DISTANCE FROM THE SOURCE OF THE BEAM X-rays, like light, diverge along straight paths and cover an increasingly larger area with diminishing intensity as they travel from their source. The relationship between distance and intensity of radiation is called the INVERSE SQUARE LAW, because the intensity of the radiation varies inversely as the square of the distance from the source. This effect is demonstrated in Fig 2.4 in which the same radiation that covers a given area at a distance of 10cms disperses itself over four times as great an area at 20cms or twice the distance (4 is the square of 2). This means that the intensity of the radiation at a point in the area at 20cms is one fourth (or one quarter) of the intensity at 10cms. If the distance is increased to 40cms or four times the distance at 10cms then the intensity would be one sixteenth of the original (the square of 4 is 16). At 80 cm the intensity would be one sixty-fourth of the original.
Page 21 of 95
The inverse square law impacts on radiography in the following ways: Radiation safety: The further you are away from the source of radiation, be it the primary beam or scattered radiation, the less radiation dose you will receive. Exposure: The intensity of the beam varies considerably as the distance from the source (X-ray tube) varies, therefore an exposure for use at a focal film distance of 100 cms will be unsuitable if the focal film distance is varied one way or the other.
EXPOSURE FACTOR kV (kilovoltage) mA (milliamps) s (seconds) mAs FFD (Focus to Film Distance)
RELATIONSHIP TO X-RAYS Controls Penetrating power of the x-rays Controls Quantity of the x-rays Controls Duration of the Exposure Product of mA multiplied by s Intensity of x-rays at the target. See inverse square law
Figure 2.5:
Relationship of exposure factors and X-rays
Section 2.E Biological Effects & Hazards of Radiation lonising radiations are dangerous
The effects on the human body of exposure to ionising radiations are complex and depend upon the radiation dose received, the volume of tissue irradiated, and the sensitivity of the organs irradiated. These effects are termed SOMATIC and may appear within a few days of exposure although some may not be apparent for many years. Somatic effects include reddening of the skin, loss of hair, necrosis of tissues, a pre-disposition to neoplasms or, with extreme doses, death of the individual. In addition, the GENETIC effects of radiation received by the gonads must be considered. A definite link has been established between irradiation of these organs and an increase in the natural mutation rate of offspring. The genetic effect represents a potential hazard to future generations Ionising radiations are beneficial to medicine when used under controlled conditions. They provide a valuable diagnostic aid for speedy and accurate assessment of a wide variety of conditions and may be used to check the efficacy of a particular treatment. They are a valuable therapeutic tool in the treatment of a great number of conditions, including the relief from symptoms of inoperable neoplasms
2011 Radiographic Procedures Manual.doc Page 22 of 95 Version 2: 29-June-2011 Revision Date: June 2014
The benefits to be had from the medical uses of ionising radiations greatly outweigh the dangers inherent in their use. The aim of radiation protection is to keep radiation doses as low as reasonably achievable, economic and social factors taken into account (ALARA Principle). For X-Ray exposure: 1sievert (sv) = 1joule/kg of energy.
Occupational Exposure
Note: The doses received from any exposure to radiation as a patient, from exposure to normal natural background radiation, or from other exposures received by the individual as a member of the public are not to be taken into account when working out their dose equivalent received while at work. The Australian Radiation Protection and Nuclear Safety Agency, Safety Guide, Radiation Protection in Diagnostic and Interventional Radiology, Annex C, prescribes the following annual radiation dose limits:
20mSv as effective dose for persons involved in carrying out a radiation practice (occupationally exposed) 1mSv as effective dose for other staff and members of the public 150 mSv equivalent dose to lens of the eye. 500 mSv equivalent dose to the skin. 500 mSv equivalent dose to hands and feet. 1mSv equivalent dose to the conceptus, after declaration of pregnancy for the remainder of the pregnancy All radiation exposure should be kept to as low as reasonably achievable values.
Pregnancy
An employee who becomes pregnant and works in an area where they may be exposed to ionising radiation must advise the employer as soon as practicable, so that appropriate measures may be taken to control her exposure and to provide adequate levels of protection. In light of the normal occupational levels of exposure evidenced by historical measurements made in diagnostic radiography practices, pregnant staff members involved in plain film/CR diagnostic radiography do not need to alter their duties. However, how their duties performed will be evaluated to ensure that the doses remain as low as reasonably achievable, and less than 1mSv per annum. Pregnant staff should avoid work that may result in higher radiation doses (e.g. involvement in fluoroscopic procedures).
Public Exposure
The radiation dose limits applying to the public exposure of a person while the radiation practice is carried out are as follows: The effective dose received by a member of the public must not exceed 1mSv in a year. That is, with the exception of a member of the public who assists a use licensee to carry out a diagnostic or therapeutic procedure involving the use of ionising radiation. o For example a parent who assists a use licensee by holding their childs arm in the correct position so that it maybe radiographed Under these circumstances, the effective dose must not exceed 5 mSv in a year. The equivalent dose limit to the lens of the eye must not exceed 15 mSv annually. The equivalent dose limit to the skin must not exceed 50 mSv annually. o The annual equivalent dose limit to the skin applies to the average dose received by any 1 square cm of skin, regardless of the total area exposed.
Sources of radiation exposure

Radiation is either of natural origin or it is artificially produced. Everybody is exposed to natural radiation to some extent, depending on where they live. Radiation reaches us from outer space in the form of cosmic rays, the emissions from radioactive elements in the earths crust irradiate us as the elements decay, and there are natural radioactive elements in the air and in our diet. People are exposed to radiation from artificial radiation sources in medical procedures, as fall out from nuclear weapons testing and sometimes as a result of occupational exposure in the course of their work e.g. medical workers, and industrial radiographers. There is also some contribution to a populations radiation exposure from miscellaneous sources such as increased cosmic ray exposure from air travel and by-products from the nuclear fuel cycle. For example, the (UK) Health Protection Agency in its publication Living with Radiation gives the following breakdown for the average annual dose to the population of the U.K.
Source exposure
of % contribution to Average Annual Dose to the population
Natural:
cosmic Terrestrial gamma

13.0 16.0
Page 24 of 95 Version 2: 29-June-2011 Revision Date: June 2014
internal radiation 16.0 sources Radon 33.0
Artificial:
medical fallout Occupational Miscellaneous
20.7 0.4 0.4 0.5
Figure 2.6: Radiation Source Vs % of Contribution to Annual Dose The overall effective dose equivalent from radiation of natural and artificial origin in the UK averages about 2.4mSv per year. There are considerable variations about this value with some individuals receiving doses several times higher than the average.
Effects of radiation exposure

The potential biological effects of ionising radiation can be divided into four groups: Acute short term effects which appear in hours, days or a few weeks Delayed later effects seen after months or years Genetic __ effects seen only in descendants Foetal effects developing in irradiated embryos/foetuses
Since 1895 the effects of high doses of X-rays have been catalogued. The effects of high radiation exposures are obvious. For example, 60 Sv delivered to a malignant tumour may kill it, while a whole body dose of 5sv is likely to prove fatal within a few weeks. An instantaneous dose of 5 Sv to the skin only would probably cause it to redden in a few days. If, however, 5 Sv is delivered to a person over a long period of time, there may be no obvious signs of injury in the short term. This does not mean that damage has not occurred since it may be that the damage will only become apparent in the individual later in their life or even in their offspring.
Page 25 of 95
Approximate whole body Acute clinical symptoms dose
100Sv and above
central nervous syndrome, death after several minutes(> 1000Sv) to 48 hours.
10 100Sv
gastro-intestinal syndrome predominant, death after 10 to 30 days
2 10Sv
bone marrow syndrome, death after 10 to 30 days
1 2Sv
mild symptoms
1Sv and below Figure 2.7: Acute Effects
few symptoms
Section 2.F Basic Radiation Protection & Safety

A Radiation Safety and Protection Plan, is the comprehensive plan for the practice which the possession licensee must maintain and contains details of the radiation source which the possession licensee is allowed to possess under that licence. Radiation Safety and Protection Plans must state the following: particulars, and an assessment, of all the radiation hazards specific to the practice and source the licensee knows, or ought reasonably to know, exist or might arise; the radiation safety and protection measures to deal with the hazards; any other measures necessary to deal with the hazards; how the licensee proposes to monitor and review the implementation and effectiveness of the measures; An RSO is not specifically required but a holder of a Certificate of Accreditation to test only a radiation source is now called Radiation Protection Adviser; particulars of the training program for persons carrying out the practice.
If a person, other than the patient being irradiated as part of a diagnostic, may receive from the carrying out of the practice, a radiation dose higher than the radiation dose limit prescribed under a regulation, the plan must provide for (a) the supply of a personal monitoring device to the person; and (b) the assessment of the device.
The licensees radiation safety and protection plan for the practice must state the functions of the radiation safety officer appointed by the licensee for the practice. Please note a copy of RDH Radiation Safety Plan can be found on any NT Government computer at: F:\RadiationSafety\RadiationSafetyOfficer\RDH SafetyPlan
Operator protection
The diagnostic operator works with X-rays to exploit their benefits for medical diagnosis. Throughout his work, the operator must remember the dangerous nature of the X-rays he uses. Before any radiographic exposure, they must ensure that all persons present are being protected as fully as possible, from unnecessary radiation. The protective measures to be taken follow the recommendations of the Radiation Safety and Protection Plan formulated for each individual department. Persons to be considered for protection may be grouped under three headings the OPERATOR, the PATIENT and OTHER PERSONS. The more important considerations are given below: The OPERATOR must never support patients during radiographic exposure; should make all exposures from behind a protective screen; must wear protective clothing when it is necessary to remain outside the protected area; should always be the maximum distance possible from the X-ray tube: must always wear a suitable monitoring device.
The PATIENT is best protected by a good radiograph first time; positive identification; careful use of limiting diaphragms and collimation; clear and concise instructions before exposure: the use of immobilisation aids; the correct use of gonad protectors:
OTHER PERSONS are best protected by exclusion from the room if their presence is not essential: standing behind the protective screen during exposure; wearing protective apron and gloves when assisting; keeping outside the path of the main beam; not assisting too frequently;
Personnel in the X-ray room: Only persons who are directly involved in the radiographic procedures should be in the X-ray room. Mobile X-ray equipment: When a mobile X-ray machine is used, the operator and other persons involved in the X-ray examination should stand away from the primary beam and at least 2 metres from the X-ray tube and patient when the exposures are made. If it is not possible for them to stand at this distance they must wear a protective apron of at least 0.25mm lead equivalent. If an operator protection screen is available, it should be used. When a fixed X-ray machine is used, the operator and other persons present should stand behind the protective screen which, under the legislation, must be provided. Primary Beam: The primary beam must not be directed towards any person other than the patient and must always be collimated to the anatomical area of interest. Holding a Patient: If it is absolutely necessary for a person to hold a patient, their hands should never be in the primary beam. If the hands are in close proximity to the primary radiation beam, protective gloves with a lead equivalent of 0.5mm should be worn. Doors: All doors to the X-ray room should be closed before making an exposure.
Patient protection
An X-ray examination should only be carried out if it is of benefit to the patient, particularly if pregnancy is an issue. Avoid retakes as they increase the radiation dose to the patient and the operator. Patient doses are reduced by: correct patient positioning avoid irradiating a pregnant patient if possible reducing the irradiated area by primary beam collimation correct processing procedures using the correct exposure for the area under examination use of correct focus to film distance using non-grid techniques regular servicing of the X-ray equipment gonad protection should always be used for an X-ray examination unless direct irradiation of the organ is unavoidable for the purposes of the investigation. Lead rubber of at least 1mm lead equivalent should be used as gonad protection.
Page 28 of 95
Section 3 Radiographic Equipment
Page 29 of 95
SECTION 3 RADIOGRAPHIC EQUIPMENT

Section 3.A Overall Description
The equipment you will be using will be either fixed or mobile. In any event, all units are made up of similar components: Control Panel used to set kVp and mA and time (mAs). An X-ray tube shown in figure 2.2 and the tube housing X-ray Tube Support or Stand Light Beam Diaphragm (LBD) An exposure switch incorporating a PREP and EXPOSE button, usually in the form of a dead-man switch.
There are also many ancillary pieces of equipment that may be accessible to you in order to improve the quality of your image.
Section 3.B Basic Exposure Controls

All x-ray units have a means to control your exposure settings. kVp can be manipulated independently mA and s are either manipulated individually or on one control setting as mAs.
Exact specifics of this will be determined by the equipment at your facility however the fundamentals can be applied across any general radiographic equipment.
Figure 3.1: Control Console at RDH
Control Console of Shimadzu Mobile X-ray Unit
Page 30 of 95
Section 3.C X-Ray Installations in the NT

Radiographic services are provided at many locations across the Northern Territory. Remote Operators are trained primarily at Royal Darwin Hospital. The following is a list of fixed x-ray tubes across the NT: Royal Darwin Hospital o o MRI, CT, US & Fluoroscopy also provided. Onsite Radiologists CT, US & Fluoroscopy provided Onsite Radiologists US provided US provided
Alice Springs Hospital o o
Gove District Hospital o Katherine District Hospital o Tennant Creek District Hospital Nguiu Health Clinic Send paperwork to RDH
These locations also have mobile x-ray units, which are also located in the following satellite locations: Wadeye Health Clinic Send paperwork to RDH Jabiru Health Centre Send paperwork to RDH Maningrida Health Clinic Send paperwork top GDH Alyangula Health Clinic - Send paperwork top GDH Borroloola Health Centre Send paperwork to KH Papunya Health Clinic Send paperwork top ASH Yuendumu Health Clinic Send paperwork top ASH
The Centre for Disease Control (CDC) Darwin has a portable X-ray unit with a Bench-top Processor. This system uses Film/Screen Radiography technology and is used for community screening in locations where there isnt an available x-ray service
Page 31 of 95
Section 3.D Ancillary Equipment

Grids
Grids are used to reduce the amount of scatter radiation that reaches the cassette this allows for a more detailed and sharper image with increased contrast. Scatter radiation is produced when x-rays pass through and interact with human tissue. The amount of scatter radiation is increased as the thickness of the body part being imaged is increased, e.g. more scatter is produced when imaging a shoulder than with a wrist. Grids consist of alternating strips of lead interspaced with a radiolucent material, usually aluminium. These strips of lead can either be parallel or angled. When the lead strips are angled the grid is called a focused grid. With a focused grid it is important that the recommended focal distance is observed. This is shown in figure 3.2 below. By having the Lead angled to the primary beam, all radiation that is not travelling in the same direction as the primary beam is then absorbed by the lead strip. The radiolucent interspace material allows almost all radiation to pass. When using a grid your exposure factor needs to be doubled from the standard non-grid exposure. As a remote operator you will only need to use grids when imaging shoulders and adult chest.
Parallel Grid
Focused (angled Pb strips) Grid
Figure 3.2: Radiographic Grids Construction

Bucky
A Bucky is a device that consists of an inbuilt grid along with a tray that is used to hold a cassette securely in position. The tray ensures correct alignment between the cassette and the x-ray tube.
Figure 3.3: Bucky Tray
Light Beam Diaphragm (LBD)

The LBD is attached directly to the underneath of the x-ray tube. It contain: 2 sets of multi-planar internal lead shutters that are adjusted with external knobs. The combination of knobs and shutters are known as collimators and the process of adjusting them is collimation. A light globe and mirror that reflects the light through the shutters in order to illuminate the collimated field.
The purpose of an LBD is to allow the radiographer to select the most appropriate field size for radiation to ensure that the smallest exposure field size is used for all imaging.
Internal Diagram Figure 3.4: Light Beam Diaphragm
External Picture
Page 33 of 95
Section 3.E Film/Screen Radiography

While it is unlikely that as Remote Operator in the Northern Territory you will experience film/screen radiography, it was thought necessary to include a very brief overview. The exposure equipment (tube, console, bucky etc.), remains the same as used with computed radiography. The image capture devices (Cassettes) while superficially the same are internally different. Image Capture is significantly different. Processing Procedures are vastly different
The workflow comparison for CR vs. Film Screen is included in figure 4.1. It outlines the similarity and differences for the two. The patient positioning remains unchanged, exposure factors may vary slightly from CR if using film and the need for accurate exposure factors are more important as you have no ability to manipulate images after processing.
X-ray film
X-ray film consists of a base coated on both sides with a light sensitive emulsion and comes in various sizes. The sizes most commonly used by X-ray Operators are 24 x 30cm and 35 x 43cm.
The film base

The film base or support is made from a transparent plastic that meets the fire retardant and other safety requirements of the American National Standards Institute. It is usually blue tinted, provides the right degree of strength, stiffness and flatness for handling, has good dimensional stability, and absorbs very little water, which is important in processing.
Light sensitive emulsion

The light sensitive emulsion is made up of innumerable tiny micro-crystals of photographic grains of silver halide suspended in gelatine. Silver halide is a compound of silver and bromine, chlorine or iodine, which are members of the halogen family of elements. Silver bromide microcrystals containing small amounts of iodide are commonly used in emulsions of X-ray films. The light sensitive emulsion has a low sensitivity to X-rays and an increased sensitivity to light. Some emulsions are sensitive to blue light whilst some are sensitive to green light. In addition film emulsions are made with different sized micro-crystals and it is the size of these microcrystals that determine the speed and definition of the X-ray film. Small micro-crystals give better definition but are less sensitive to light and therefore have slow speed i.e. they require more radiation to produce a diagnostic image. Larger crystals do not give as good a definition as the smaller crystals but are more sensitive to light and have a faster speed i.e. they require less radiation to produce a diagnostic film.
The latent image. (Gurney -Mott theory)

When the micro-crystals in the light sensitive emulsion absorb energy from light, a physical change takes place in them. This change the formation of a latent or hidden image cannot be detected by ordinary physical methods. However, when the exposed film is processed in a solution called a developer, a chemical reaction takes place, which changes the exposed microcrystals of silver compound to tiny masses of black metallic silver and leaving the unexposed crystals unaffected. This black metallic silver, suspended in the gelatine, constitutes the visible image on the radiograph.
Film handling, storage and rotation

X-ray film can be subject to damage and deterioration due to incorrect handling and storage. Observation of the following will reduce and possibly eliminate film artefacts: ensure hands are clean and dry when handling films. Use of hand cream can cause a problem. handle films only on edges and ideally at a corner. do not eat, drink or smoke in the darkroom. do not draw film across the screen as this can cause static discharge. check film boxes on delivery to ensure that they have not been damaged in transit. store film boxes upright; never stack them flat. check the expiry date on each box as you add or remove from stock, avoid using outdated film by making sure stock is rotated i.e. use oldest film first. store films away from light, heat, chemicals, radioactive materials and sources, radiation sources, e.g. X-ray machines and room heaters.
Fluorescent intensifying screens

X-rays have the ability to cause certain substances (phosphors) to fluoresce (that is to emit light). An intensifying screen consists of a layer of tiny phosphor crystals bonded together in a suitable binder and coated in a smooth uniform layer on a plastic or cardboard support. A protective coating is applied over the external surface of these layers to guard against abrasion, absorption of moisture and staining. In use, intensifying screens are placed either side of the Xray film so that the light produced by the interaction between the phosphor and the X-rays produces a latent image on the film. Intensifying screens are attached to the back and front of the cassette. See fig 3.4 Just as the speed of the film is governed by the size of the micro-crystals, so the speed of the intensifying screen depends on the size of the phosphor crystals. Small crystals emit less light, give finer definition but are less sensitive to X-rays, while larger crystals emit more light, give slightly less definition but are more sensitive to X-rays. Intensifying screens are classed according to their speed and are referred to as slow (detail or fine), medium (regular) and fast. The choice of which intensifying screens to use depends on the type of examination to be performed.
Page 35 of 95
Cassette front Front padding Support layer Phosphor layer Protective coating Double coated film Protective coating Phosphor layer Support layer Back padding Lead foil Cassette back Back Intensifying Screen Front Intensifying Screen
Fig 3.5: Cross section of a loaded cassette (not to scale) Fig 3.4 shows the screen/film configuration most commonly used in medical radiography enclosed in a light proof container called a cassette. A double-coated film (one with emulsion on both sides of the support) is sandwiched between two intensifying screens and enclosed in a cassette which provides good screen/film contact and protection from light and damage. The back of many cassettes is covered on the inside with a sheet of lead foil to prevent backscattered X-radiation from reaching the screen/film combination.
Screen cleaning
It is important that intensifying screens be inspected and cleaned regularly to keep them free from dust and foreign material. In order to achieve this, screens should be cleaned with a compatible screen cleaning solution. If a screen cleaning solution is not available use warm dilute soapy water: dampen a clean soft, lint free cloth with the cleaning solution and using a circular motion clean one of the screens. after cleaning, wipe the surface dry using straight, even, overlapping strokes with a soft, dry, lint free cloth. repeat this procedure on the remaining screen. on completion of cleaning, turn cassette on end and leave open to dry for approximately 20 minutes.
Page 36 of 95
Darkroom
Darkroom safety precautions Exposure to processing chemicals and their fumes can be hazardous to ones health, so ensure the following: processing solutions should not come into contact with skin; wear protective clothing as necessary. when handling chemistry always follow manufacturers instructions and precautions. splashes of processing solutions on skin should be washed off immediately. spillage should not remain to contaminate the environment. all materials contaminated by processing solutions either due to spillage or cleanup must be either thoroughly washed or disposed of in a sealed container. check processing equipment plumbing for leaks, cracks or blockages. ensure processing chemicals are sealed and stored safely. do not eat, drink or smoke in the darkroom. do not loiter next to the processor or use it as a source of heat. it is recommended that adequate ventilation be provided to ensure a minimum of 15 changes of air volume per hour, with exhaust ducted to the external atmosphere. faults and problems should be reported immediately so adequate remedial steps can be taken.
General darkroom design and basic equipment

A properly designed darkroom will have the facility of automatic film processing. It should be shielded from all external light sources, illuminated by red tinted safelights and have adequate film and chemical storage. An adequate ventilation system providing at least 15 changes of air volume per hour is required to protect the operator and safeguard the equipment. Basic design and equipment should include: light tight darkroom seals on all openings that exclude the entry of all white light. automatic film processor. Red tinted safe lights as recommended by the film manufacturer. Check that globe is 25 watts for indirect light and 15 watts for direct light. Ensure light is at least 120cm above the bench. thermometer alcohol or electronic. adequate plumbing hot and cold running water. adequate drainage. chemicals developer and fixer. Mix according to the manufacturers instructions. workbench flat smooth surface for film and cassette handling. adequate film storage away from radiation, constant temperature and dry. Store on edge. protective clothing aprons, gloves, goggles, respirator, etc.
Automatic processing
With automatic processing of radiographic film, the results are accurate and reproducible, providing the chemicals are regularly changed and the temperature is consistent . Once a film has been exposed it is passed to the darkroom for processing. Make sure that the processor has been switched on for sufficient time for the chemicals to reach their correct operating temperature. Under safelight conditions, the cassette is opened and the film carefully removed. Handle the film by the corners and/or edges and take care not to allow the film to the flex and crease. Imprint the patients details onto the film by the use of the identification printer (I D Printer) then feed the film into the processor. Reload the cassette carefully. If there is not a light proof door on the feed tray of the processor, make sure that all of the film has passed into the processor before opening the darkroom door. Wait for the film to completely emerge from the drier. Principle of operation The essence of automated processing is the controlled interaction of film, chemicals and processor. See figure 3.5 below.
Figure 3.6: A Modern Bench Top Processor (similar to the one owned by CDC) To develop, fix, wash and dry a radiograph in the short time available in an automatic processor requires several things: specially formulated chemicals. rigid control of solution temperatures. agitation. replenishment. means of transporting the film at a controlled speed.
film with special characteristics that are compatible with processing conditions, shortened processing times and the mechanical transport system.
Processing Operations
Film processing consists of four operations: development, fixation, washing and drying. Developer A developer is a chemical solution that changes the latent image on a film to a visible image. The developer causes the gelatine of the film emulsion to swell so that the developing agents can penetrate to reach the silver halide crystals. The developing agent is a chemical compound capable of converting exposed grains of silver halide into black metallic silver. At the same time it has no appreciable effect on the unexposed grains in the emulsion. Fixer In a properly developed X-ray film, those silver halide crystals that were exposed to light from the intensifying screens are converted to black metallic silver. The unexposed crystals are unaffected by the developer. To complete the processing, the developed film must be cleared of all the undeveloped crystals before washing so that the film will not discolour or darken with age or exposure to light. Also the gelatine in the film emulsion must be hardened so that the film will resist abrasion and can be dried in warm air. This process is called fixation and it is important to the retention qualities of a radiograph. The fixing agent is a chemical compound capable of clearing all undeveloped silver halide crystals and hardening the surface of the film. Wash If a finished radiograph is to remain inert to light or chemical activity, it must contain only developed silver masses suspended in the gelatine. This means that it must be properly washed to remove processing chemicals and any residual undeveloped silver crystals. If it is not washed long enough with proper agitation in an adequate volume of water, the image may eventually discolour and fade. In an automatic processor the squeegee action of the rollers removes most of the chemicals and the water dilutes and removes the rest. Dryer In the dryer section of the automatic processor, warm air is directed onto the film. In a properly functioning processor the film is dry by the time it exits from the processor. Daily and weekly maintenance of automatic desktop processors with gravity feed replenishment systems All processors have service and operation manuals provided when installed and these should be followed for all starting up, closing down and maintenance procedures.
DAILY MAINTENANCE ensure adequate ventilation of the darkroom for the escape of fumes.
check correct operation of processor by the processing of a clearing film. turn the processor off if it is not to be used for a considerable period of time. Always check temperature before use. check the fixer and developer tank levels before start-up and replenisher reserves daily. Report any faults to supervisor or service personnel if replenishing rate is unusually high or low. check and replace filters on incoming water supply if applicable. lift the lid of the processor when not in use and leave ajar. Leave the door of the darkroom open to ensure adequate ventilation for escape of fumes when not in use.
WEEKLY MAINTENANCE drain all tanks. Thoroughly clean and rinse all tanks, roller racks, crossovers, splashguards, etc. Leave the lid of the machine ajar and allow drying. Wait until the machine is required before mixing developer replenisher and filling water bottle. Put bottles onto machine, wait until the tanks have filled up then re-start the machine. Wait until the processor and chemicals have reached correct operating temperature before processing films. Process at least 2 cleaning films (old film) before developing any new work. Freshly cleaned rollers may leave marks.
Page 40 of 95
Section 4 Computer Radiography (CR)
Page 41 of 95
SECTION 4 Computed Radiography

Section 4.A Introduction
Computed Radiography has been developed over the last 20 years and is becoming the most common system used in radiography. The workflow remains predominantly the same with CR as with film/screen radiography (see figure 4.1 below). Much of the equipment looks the same at first glance, and basic workflow is the same, however there are some major functional differences between the two systems.
The main difference between film/screen and CR is how the final image is generated. With CR the optical signals are processed based on a phenomenon called photo-stimulated luminescence rather than phosphorescence as in the case of film/screen radiography.
In CR, the imaging plate containing storage phosphor is inserted in a cassette similar to a film in a film/screen system. When exposed to x-rays the latent image is trapped by the plate. Reading the image is done by the scanning of a laser beam within the digitizer. A photomultiplier tube then enhances the signal coming from the IP (Imaging Plate) and the final image is displayed on the computer screen. The digital images can then be printed by laser printer, stored electronically or even printed to a paper printer.
Some major advantages of CR are its large dynamic range of image processing, digital format, portability, and post-processing capability. (Practical guidelines for radiographers to improve
computed radiography image quality, N Pongnapang*, PhD Faculty of Medical Technology, Mahidol University, Bangkok, Thailand).
Figure 4.1: Workflow Comparison: CR Vs Film/Screen

View image on computer screen for review. Post Process if required. Repeat if necessary.
Place cassette in the Digitizer
CR
Position Patient and expose cassette Put Patient details on cassette Take cassette to processing area
Film/Screen
Process in Darkroom or place cassette in daylight processor
View film on lightbox for review. Repeat if necessary
Page 42 of 95
Section 4.B Cassettes

CR cassettes are visually similar to film/screen cassettes and are available in all the same sizes. CR cassettes do not contain intensifying screens, nor film. A phosphor plate (often called the Imaging Plate or IP) is inserted and it is this that stores the latent image. Each cassette contains backscatter protection and as a result it is important to place the cassette the correct way. They also have some form of method for linking the images to the study, wether it is via internal memory or a barcode system. Care should be taken in situations where blood or body fluids may enter the cassette, as this can be hard or impossible to clean and may result in the equipment needing replacing.
Section 4.C Imaging Plates and Phosphor layer

The IP (Imaging Plate) is the insert within the cassette that is responsible for capturing the latent image. It serves the same purpose as film does in film/screen radiography. During exposure the x-ray photons pass through the anatomy of interest, the beam then strikes the phosphor layer within the IP and store the radiation level received at each point in local electron energies. The latent image has a half life and should be processed as soon as possible. However in the case of equipment failure it is possible to store the cassette in a radiation free environment for up to 24hrs before image quality is sufficiently compromised. The IP is then read by a digitizer where the latent image, which consists of valence electrons stored in high energy traps, is transformed into a format that is displayed on the screen. Imaging Plates are very sensitive to scatter and background radiation. In order to ensure the highest quality of imaging, they should be erased after a long period if un-used. At RDH we erase the plates that are not used over the weekend each Monday morning. A more practical approach for ROs could be to perform a secondary erase of each cassette prior to performing the examination. Imaging plates can theoretically be re-used thousands of times if they are handled carefully. Cleaning of cassettes must be done with great care, water must NEVER be used please refer to the manufacturers guide Fig 4.2:Layers of a Phosphor Plate EBC = Electron Beam Coated
Image from AGFA.com
Page 43 of 95
Section 4.D Digitizer/Reader

This device is used to convert the latent image on the phosphor plate into a format that can be displayed on a computer screen. When the plate is put through the scanner, the scanning laser beam causes the electrons to relax to lower energy levels (i.e. return to the valence band), emitting blue light that is detected by an ultra-sensitive photo-multiplier tube, which is then converted to an electronic signal. The electronic signal is then converted to discrete (digital) values and placed into the image processor pixel map and thus displayed on the computer screen. Due to the sensitivity of the photomultiplier, Digitizers should NEVER be opened.
Digitizers come in many different shapes and sizes. Below, figure 4.3, is some example that were found on the AGFA website. Figure 4.3: Different Agfa Digitizers
Benchtop Digitizer
Portable Digitizer
High Throughput
Page 44 of 95
Note: There are many different manufacturers that distribute CR related products. While most will be similar there will be differences. For maintenance protocols and procedures please refer to your manufacturers website, helpdesk or manuals.
Page 45 of 95
Section 4.E Post Processing

Post processing is all image manipulation that occurs after the acquired image has been displayed on the computer screen and before the image is sent. It is here that you can add annotation and comments to your film (such as side of interest, weight bearing, erect, supine, prone etc). You can also crop, rotate and magnify your image through this software. Another feature of post processing is the ability to alter the window width and window levels (commonly referred to as windowing). This is the control of the displayed images contrast, density and brightness. You can use these features to change the appearance of the image to assist with diagnosis and interpretation.
Note: Post processing does not compensate for poor radiographic technique. While it may be possible to make a poor quality image look respectable through the use of post processing tools it, in actual fact does not, and poor radiographic technique can lead to misdiagnosis and misinterpretation.
As with digitizers, different vendors have different computer programs and tools and you should contact your vendor or refer to their website, helpdesk or manuals for specific assistance with post processing.
Section 4.F Image Storage and Transfer for Radiologist Review

Most digitizers have a limited inbuilt memory which after a certain number of examinations will become full. This is one of the reasons why all images must be transferred onto a Picture Archival & Communications System (PACS). Under NT legislation all Xray examinations must be documented and stored for future reference. Transferring the images allows for Radiologist review and reporting in a timely manner. A Picture Archival & Communications System (PACS) is the preferred method of archiving images. While this is the optimal way to store images, it is expensive and not financially viable for most satellite locations. Alternative archive storing options include CDs/DVDs or transferring images to an off-site PACS. Sites with permanent digital imaging facilities will electronically transfer images into the Northern Territory Government PACS. Images saved onto CD/DVD can be imported to NTG PACS. When images are acquired at sites without digital equipment, images will be scanned into NTG PACS at Royal Darwin Hospital and Alice Springs Hospital.
Northern Territory Medical Imaging (NTMI) provides reporting services at Royal Darwin Hospital for the Top End. Jones and Partners provide reporting services at Alice Springs Hospital for Central Australia.
Page 46 of 95
Section 4.G Image File Types

DICOM (Digital Imaging and Communications in Medicine) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. DICOM is the preferred format for reporting and viewing purposes, as this file format allows manipulation of the image by the Radiologist/Clinicians. DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving and communication system (PACS). The different devices come with DICOM conformance statements which clearly state the DICOM classes they support.
This file format also provides the highest quality image. The file size is quite large and often takes considerable time to load and save. A DICOM image cannot be emailed.
BITMAP (map of bits) is the best format for displaying grayscale images besides DICOM. BITMAP is the preferred format for emailing images where a direct connection to NTG PACS is unavailable. JPEG (Joint Photographic Experts Group). This is the same file system that you would use to store your colour digital photos. The file size is much smaller than DICOM, however there is image degradation and leads to poorer quality images and as a result, Radiologists are reluctant to report this file type. In cases where images might need to be emailed, converting the Xray image from DICOM to Bitmap (.bmp) or JPEG (.jpg) are good options.
Page 47 of 95
Page 48 of 95
Section 5 Working Procedures & Instructions
Page 49 of 95
Section 5 - Working Procedures and Instructions

Section 5.A - Initial Preparation
A radiograph of top quality can only be obtained with the cooperation of the patient. Movement, or failure to maintain the correct position, will seriously impair the quality of the resulting radiograph. The operator must bear in mind that a patient will frequently be in pain and may be very nervous. The nature of the examination should be explained, and assurance given that what is required of the patient will be within his capabilities. A calm and confident manner will put the patient at ease. All radiographic investigations should follow a planned sequence, somewhat along the following lines: Fill out or Authenticate patients request. Identify patient and check pregnancy status where applicable. Confirm required examination. Check previous examination o images and exposure factors used the tube-head is directed according to the first projection and the correct focal-film distance is set. Any ancillary equipment (grid, sponge, lead rubber etc.) is easily accessible the correct number, size and type of cassettes are made available, the first film is placed in position and the radiographic factors are set Room prepared in advance o o
Exposure selection o
Patient preparation The patient is correctly positioned for the first exposure o Full use must be made of positioning aids for complete immobilisation e.g. sandbags, radiolucent pads, compression bands. The tube is accurately centred and the primary beam limited to the area in question.
Protective devices should also be applied if relevant. Ensure that patient side markers are affixed to cassette. Advise patient of respiratory state o the procedure is explained to the patient and, if necessary, respiratory movements are rehearsed. A patient who has held his breath must be instructed to recommence breathing.
Take exposure Process image. o Apply any post-processing techniques that may be needed to make the image more aesthetically appealing and easier to report.
Complete documentation.
o Operator to sign request form and ensure that it is faxed to Royal Darwin Hospital to be scanned onto PACS and to ensure the radiologist has sufficient clinical information available at time of reporting. A Medicare form signed by the Patient must also accompany the Request Form. Fax Number: RDH 08 8922 8908
o o
Evaluation of examination.
Section 5.B - Positioning and Exposure Determination

In order to take a diagnostic radiograph, both the patient positioning and exposure factors must be considered. Patient positioning will be explained in much greater depth in section 6 of this manual. You should ensure you are aware of which images you plan to take before the patient enters the room and have any ancillary equipment available before you start. The golden rules for positioning of a patient are: 1. Anatomy examined should be in centre of film 2. The body part should be immobilised, where practical and required. 3. The Anatomy being imaged should be free from radio-opaque objects and clothing which may produce artefacts on the final image. 4. Only the anatomy of interest should be exposed. 5. Collimated field should be large enough to image anatomy but smaller than the cassette. 6. Where possible the gonads should be shielded. 7. Respiration should be explained to patient prior to exposure, where relevant. Optimal exposure of a radiograph revolves around penetrating power and duration of the primary x-ray beam. Penetration is controlled by the selection of the kVp and the duration of the exposure is determined by adjusting the mAs control. Your facility should have an exposure chart that is suitable for your machine and the thicker the anatomy to be examined the higher exposure required. For example: Lower Limb exposures at RDH for an average size adult with FFD = 100cm Foot: 55 kVp / 2.8 mAs
Ankle: 56 kVp / 3.2 mAs Tib/Fib: 58 kVp / 3.2 mAs Knee: 60 kVp / 5 mAs
Page 51 of 95
While the exposures at your facility may vary slightly from those above, this example gives you a trend to follow.
Section 5.C - Patient Identification

The first steps when imaging a patient are to: Fill out or Authenticate patients request. Identify patient. Confirm required examination. Check pregnancy status where appropriate.
Patient details are entered onto the CR system prior to image acquisition, this is dependant on your operating system. At the major centres the CR system is connected to the Hospital RIS (Radiology Information System) and patient identification is automatically transferred from the RIS. This means pre-registration of patient details isnt required at places like RDH, ASH, GDH KH and TCH. All images must include the following details: 1. Patient Identifier number (HRN, UR etc.) 2. Patient Name 3. Date of Birth 4. Sex of Patient 5. Date of Exposure 6. Exposure Number (if applicable, this may not be required for remote locations) 7. Location exposure was taken ( e.g. which health facility) 8. Appropriate side marking. a. Ensure that the side marker will not obscure any anatomy of interest. b. Markers are best placed anteriorly or laterally of the anatomy of interest c. At the time of image acquisition, not on the post processing software. 9. Identifier of Operator (either on image or legibly on request form)
Page 52 of 95
Section 6 Radiographic Positioning
Page 53 of 95
Section 6 Radiographic Positioning

Section 6.A Radiographic Critique
When critiquing your radiograph it is useful to look at the aspects that make up a good image. One way to ensure you cover all areas is to use an acronym such as: Positioning Anatomy of Interest Collimation Exposure Factors Markers Abnormality/Anomaly Name Below is a summary of the qualities that are needed for each letter of PACEMAN (P) - Positioning: Is the patient in the correct position? Is the patient rotated? Does the image correctly show any needed joint spaces? (A) Anatomy of Interest: Has the entire anatomy of interest been included within the collimated field? (C) - Collimation: Is the image properly collimated? E.g. is four way collimation seen on an extremities film? N.B: The collimated field should be the smallest possible, in order to adequately image the area of interest, and never larger than the cassette in order to help reduce scatter and patient dose. (E) Exposure Factors: Were the exposure factors set correctly? Does the image show the correct contrast and density? Are there any factors that need to be changed to produce a better image? (M) - Markers: Have markers been placed on the image? (Markers are traditionally placed either laterally or anteriorly to the imaged anatomy) Are they correctly identifying left and right?
(A) Abnormality/Anomaly: Is there any abnormal pathology? Is there any anatomical anomalies? (N) - Name: 1. Does the image correctly identify the patient? 2. Does it have any other relevant identification details? 3. Patient Identifier number 4. Patient Name 5. Date of Birth 6. Sex of Patient 7. Date of Exposure 8. Exposure Number, (if applicable, this may not be required for remote locations) 9. Location exposure was taken (e.g. which health facility) By looking at each image with the aforementioned in mind you ensure that you take a radiograph that is the most diagnostic possible as well as aesthetically pleasing. This helps ensure correct diagnosis and therefore treatment of your patient. Viewing Radiographs All radiographs are viewed in a standard manner. With a few exceptions, this is as though one were facing the patient who stands in the correct anatomical position. This viewing position is maintained whether AP. or PA positioning was used to produce the radiograph. Lateral projections are viewed from the aspect of the X-ray tube during exposure. Exceptions to the standard viewing routine are: Hands and wrists are viewed from the posterior aspect with fingers uppermost Toes and feet are viewed from the dorsal aspect with toes uppermost. Lateral chest films are viewed from the film aspect.
Page 55 of 95
Section 6.B CHEST PA CHEST
PA CHEST Preferred Projection

Cassette Size: 35x43 cm Cassette Orientation: Landscape (unless pt is extremely tall then orientate cassette portrait) FFD: 180cm Central Ray: Perpendicular to Bucky Centring Point: Entering Pt at level of T6/T7 Collimation: To include apices and costophrenic angles, lateral margins of chest and last rib (laterally) Positioning: Pt should have there chest against the bucky and chin placed on the top of the bucky/cassette holder. Pts arms should either be wrapped around the bucky for support or placed on the iliac crest with palms facing backwards. Rotate the pts shoulders forward so that the scapulae rotate laterally and not superimposed over the lung field. Respiration: Inspiration +/- Expiration for Pneumothorax
Section 6.B CHEST LATERAL CHEST
LATERAL CHEST Should only be performed if something is seen on AP/PA that needs further investigation
Cassette Size: 35x43 cm, must use grid. Cassette Orientation: Portrait FFD: 180cm Central Ray: Perpendicular to Cassette Centring Point: Entering Pt in 5cm anterior the MCP at level of T6/T7 Collimation: To include apices and costophrenic angles, Anterior and Posterior margins of lungs Positioning: Left side of patient against the bucky. Pts hands on head with their elbows together. If pt is unsteady they can place their hands together on a drip stand at eye level. Rotate the pt slightly so that the costophrenic angles will be superimposed on the resultant image Respiration: Inspiration
Section 6.B CHEST AP CHEST
AP CHEST
Cassette Size: 35x43cm Cassette Orientation: Landscape (unless pt is extremely tall then orientate cassette portrait) FFD: 180cm Central Ray: Perpendicular to cassette Centring Point: Entering pt at the midpoint between xiphoid process and sternal notch Collimation: To include apices and costophrenic angles, lateral margins of chest and last rib (laterally) Positioning: Patient seated in wheelchair or upright in bed with back against cassette Arms by side Respiration: Inspiration +/- Expiration for Pneumothorax
Section 6.C UPPER EXTREMITY I. HAND & FINGERS
PA HAND
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Entering hand at 3rd MCP Jt Collimation: To include entire hand and carpal bones. For finger include distal tip of affected finger to proximal end of Metacarpal bone. Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Place affected hand/finger palmar side down on cassette
Page 59 of 95
OBLIQUE HAND
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Entering hand at 3rd MCP Jt Collimation: To include entire hand and carpal bones. For finger include distal tip of affected finger to proximal end of Metacarpal bone. Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Place affected hand/finger palmar side down on a 450 sponge/angle thumb side raised.
LATERAL HAND
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: To enter at the MCP Jt Collimation: To include entire hand and carpal bones For finger include distal tip of affected finger to proximal end of Metacarpal bone. Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Place affected hand with thumb raised, down on cassette. To properly visualise the phalanges the fingers should be positioned in a fan like arrangement as per picture above. This is not required if area of interest is the metacarpal bones.
Page 61 of 95
Section 6.C UPPER EXTREMITY II. THUMB
PA THUMB
Cassette Size: 24x30cm Cassette Orientation: Landscape. All three thumb images can fit on one film. PA Image should be to the medial side of the film FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: MCP Collimation: To include distal tip of thumb and distal carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Place hand in lateral position with little finger on cassette. Lay thumb so that it is parallel with the cassette, A sponge can be used to steady the thumb if required
OBLIQUE THUMB
Cassette Size: 24x30cm Cassette Orientation: Landscape. All three thumb images can fit on one film. Oblique Image should be in the middle of the film FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: MCP Collimation: To include distal tip of thumb and distal carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Place hand flat with the palmar surface down. This orientate the thumb to an oblique position
Page 63 of 95
LATERAL THUMB
Cassette Size: 24x30cm Cassette Orientation: Landscape. All three thumb images can fit on one film. Lateral Image should be to the lateral side of the film FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: MCP Jt Collimation: To include distal tip of thumb and distal carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Lateral aspect of thumb resting on the cassette with
Page 64 of 95
Section 6.C UPPER EXTREMITY III. WRIST
PA WRIST
Cassette Size: 24x30cm Cassette Orientation: Landscape. All three Wrist images can usually fit on one film. PA Image should be to the medial side of the film FFD: 100cm Central Ray: Perpendicular to the cassette. Centring Point: Midway between the radial and ulnar styloid processes Collimation: To include the distal 1/3 of the forearm and metacarpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Forearm resting with anterior aspect on the table, with cassette under wrist.
Page 65 of 95
OBLIQUE WRIST
Cassette Size: 24x30cm Cassette Orientation: Landscape. All three Wrist images can usually fit on one film. Oblique Image should be in the middle of the film FFD: 100cm Central Ray: Perpendicular to the cassette. Centring Point: Radial Styloid Process Collimation: To include the distal 1/3 of the forearm and metacarpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Forearm resting with anterior aspect on the table, with cassette under wrist. Rotate wrist 450 with thumb side raised and rest on sponge if required.
Page 66 of 95
LATERAL WRIST
Cassette Size: 24x30cm Cassette Orientation: Landscape. All three Wrist images can usually fit on one film. Lateral Image should be in the lateral side of the film FFD: 100cm Central Ray: Perpendicular to the cassette Centring Point: At carpal bones Collimation: To include the distal 1/3 of the forearm and metacarpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Forearm resting with ulnar side on the table, with cassette under wrist.
Page 67 of 95
Section 6.C UPPER EXTREMITY III. WRIST ADDITIONAL VIEW SCAPHOID ULNAR DEVIATION
SCAPHOID ULNAR DEVIATION

Cassette Size: 24x30cm Cassette Orientation: Portrait Both Images will fit on one cassette Use top half straight tube and bottom half for angled tube FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Anatomical Snuff Box Collimation: To include carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: As for PA wrist but with the wrist in ulnar deviation
Page 68 of 95
Section 6.C UPPER EXTREMITY III. WRIST ADDITIONAL VIEW SCAPHIOD CRANIAL ANGLE
SCAPHIOD CRANIAL ANGLE

Cassette Size: 24x30cm Cassette Orientation: Portrait Both Images will fit on one cassette Use top half straight tube and bottom half for angled tube FFD: 100cm Central Ray: 200 Cranial Angulation Centring Point: Anatomical Snuff Box Collimation: To include carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: As for PA wrist but with the wrist in ulnar deviation
Page 69 of 95
Section 6.C UPPER EXTREMITY IV. FOREARM
AP FOREARM
Cassette Size: 35x43cm or 24x30cm depending on Patient size Cassette Orientation: Portrait or Diagonal if required FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Midshaft of forearm Collimation: To include both wrist and elbow within field Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Ideally you should have: Posterior aspect of Forearm on cassette with both wrist and elbow in AP position. Elbow straight. When this isnt possible due to trauma/injury try: Elbow straight Posterior aspect of elbow on cassette with wrist lateral and elbow AP.
Section 6.C UPPER EXTREMITY IV. FOREARM
LATERAL FOREARM
Cassette Size: 35x43cm or 24x30cm depending on Patient size Cassette Orientation: Portrait or Diagonal if required FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Midshaft of forearm Collimation: To include both wrist and elbow within field Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Ideally you should have: Medial side of Forearm on cassette with both wrist and elbow in lateral position. Elbow flexed at 900. When this isnt possible due to trauma/injury try: Elbow flexed at 900 Anterior side of forearm on cassette with wrist PA and elbow lateral.
Section 6.C UPPER EXTREMITY V. ELBOW
AP ELBOW
Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: Elbow Joint Collimation: To include Distal third of humerus and proximal third of forearm Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Elbow as close to straight as the pt is able, with posterior aspect on cassette. Humerus and forearm should both be in contact with the cassette in order to ensure a open joint space
Page 72 of 95
OBLIQUE ELBOW
Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: Elbow Joint Collimation: To include Distal third of humerus and proximal third of forearm Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Elbow as close to straight as the pt is able, with posterior aspect on cassette Rotate entire arm laterally as far as pt will tolerate This should display the radial head clear of any superimposition from other bones. Humerus and forearm should both be in contact with the cassette in order to ensure an open joint space.
LATERAL ELBOW
Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: Elbow Joint Collimation: To include Distal third of humerus and proximal third of forearm Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Elbow flexed at 900, with wrist in lateral orientation. Forearm, Humerus and cassette all parallel. You may need to raise the wrist slightly with a sponge in order for this to occur. This ensures an open joint space as well as superimposition of the humeral epicondyles.
Page 74 of 95
Section 6.C UPPER EXTREMITY V. ELBOW ADDITIONAL VIEW RADIAL HEAD
ELBOW RADIAL HEAD

Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Angled at 200 Cranially (Towards Shoulder) Centring Point: Radial Head Collimation: To include Distal third of humerus and proximal third of forearm Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table, gonads shielding is advisable. Positioning: Elbow flexed at 900, with wrist in lateral orientation. Forearm, Humerus and cassette all parallel. You may need to raise the wrist slightly with a sponge in order for this to occur. This ensures an open joint space as well as superimposition of the humeral epicondyles.
Page 75 of 95
Section 6.C UPPER EXTREMITY VI. SHOULDER
AP SHOULDER
Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to cassette/bucky Centring Point: Coracoid Fossa Collimation: To include the lateral skin edge and medial aspect of the clavicle Skin edge superiorly to inferior angle of scapula Positioning: Patient standing Arm hanging by side in neutral position Back against the bucky
Section 6.C UPPER EXTREMITY VI. SHOULDER
LATERAL SHOULDER
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to cassette/bucky Centring Point: At level of scapulohumeral joint Collimation: To include the proximal third of the humerus and AC Jt Lateral skin edge and medial border of the scapula. Positioning: Patient standing Place pt with the point of their shoulder against the bucky. Hand should be resting on waist Rotate the patient so the central ray will through the medial border of the scapula and the AC Jt.
Section 6.C UPPER EXTREMITY VI. SHOULDER - CLAVICLE
CLAVICLE
Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to cassette/bucky Centring Point: Midshaft of the Clavicle Collimation: T o include the medial end of clavicle and the lateral skin edge Positioning: Patient standing Arm hanging by side in neutral position Back against the bucky
Section 6.C UPPER EXTREMITY VI. SHOULDER - CLAVICLE
CRANIAL ANGLE CLAVICLE Should only be used for initial diagnosis

Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: 200 Cranial Angulation Centring Point: Midshaft of the Clavicle Collimation: To include the medial end of clavicle and the lateral skin edge Positioning: Patient standing Arm hanging by side in neutral position Back against the bucky Central Ray angulation clears the clavicle of superimposition with the ribs
Section 6.D LOWER EXTREMITY I. FOOT & TOES
DP FOOT
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: 50 Cranial Angulation Centring Point: Foot: Mid Foot Toes: MTP Jt of affected toe Collimation: Foot: To include entire foot Toes: To include distal tip of toe and distal end of metatarsal. Positioning: Patient supine or seated on table, with knee bent and plantar aspect of foot placed on cassette
OBLIQUE FOOT
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: 50 Cranial Angulation Centring Point: Foot: Mid Foot Toes: MTP Jt of affected toe Collimation: Foot: To include entire foot Toes: To include distal tip of toe and distal end of metatarsal. Positioning: Patient supine or seated on table, with knee bent and plantar aspect of foot placed on cassette and rotated internally 450.
LATERAL FOOT
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to the cassette Centring Point: Foot: Mid Foot Toes: MTP Jt of affected toe Collimation: Foot: To include entire foot and tibiotalar Jt Toes: To include distal tip of toe and distal end of metatarsal. Separate toes using a tongue depressor or foam pad if required Positioning: Patient supine or seated on table with leg externally rotated so that the lateral aspect of the foot is resting on the cassette. Foot should be flexed at 900. Raise knee from bed until the plantar surface of the foot is perpendicular to the cassette.
Section 6.D LOWER EXTREMITY II. ANKLE
AP ANKLE
Cassette Size: 24X30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: perpendicular to Cassette Centring Point: Midway between Malleolus Collimation: To include distal third of tib/fib and skin edge Positioning: Patient supine or sitting on bed with leg straight. Foot Dorsi-flexed to 900. Toes pointing straight to roof.
Page 83 of 95
MORTISE ANKLE
Cassette Size: 24X30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: perpendicular to Cassette Centring Point: Midway between Malleolus Collimation: To include distal third of tib/fib and skin edge Positioning: Patient supine or sitting on bed with leg straight. Foot Dorsi-flexed to 900. Toes pointing straight to roof and leg internally rotated so that a line from the little toe to the middle of the Calcaneus is perpendicular to the cassette, as per diagram above.
Page 84 of 95
LATERAL ANKLE
Cassette Size: 24X30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: perpendicular to Cassette Centring Point: Medial Malleolus Collimation: To include distal third of tib/fib, Posterior skin edge and head of 5th metatarsal Positioning: Patient supine or seated on table with leg externally rotated so that the lateral aspect of the foot is resting on the cassette. Foot should be flexed at 900. Raise knee from bed until the plantar surface of the foot is perpendicular to the cassette. A line from the little toe to the middle of the Calcaneus is parallel to the cassette, as per diagram above, will ensure superimposition of the talar dome. This tip can help when anatomy isnt standard and you are having difficulty with positioning.
Section 6.D LOWER EXTREMITY III. CALCANEUS
AXIAL CALCANEUS
Cassette Size: 24x30xm Cassette Orientation: Landscape FFD: 100cm Central Ray: 300-500 Cranial Angulation, depending on tolerated foot flexion. Centring Point: At level of base of 5th Metatarsal in the midpoint of the foot Collimation: Lateral and Posterior skin edge and to include baser of 5th Metatarsal Positioning: Patient Supine with leg straight and toes pointed to the roof. Flex foot as far past 900 as pt will tolerate. You may need to use a belt or something similar in order to achieve this. Cassette underneath leg.
Page 86 of 95
Section 6.D LOWER EXTREMITY III. CALCANEUS
LATERAL CALCANEUS
Cassette Size: 24X30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: Mid Calcaneus Collimation: Posterior skin edge to base of 5th Metatarsal and Inferior skin edge to medial Malleolus Positioning: Patient supine or seated on table with leg externally rotated so that the lateral aspect of the foot is resting on the cassette. Foot should be flexed at 900. Raise knee from bed until the plantar surface of the foot is perpendicular to the cassette.
Page 87 of 95
Section 6.D LOWER EXTREMITY IV. TIBIA/FIBULA
AP TIB/FIB
Cassette Size: 35x43cm or 24x30cm depending on Patient size Cassette Orientation: Portrait or Diagonal if required FFD: 100 150 cm depending on length of leg. Remember to adjust exposure according if you increase the FFD. Central Ray: Perpendicular to cassette Centring Point: Midshaft of tibia Collimation: To include both knee and ankle within field Positioning: Pt supine or seated with leg straight. Foot flexed to 900. Cassette placed under leg.
Page 88 of 95
Section 6.D LOWER EXTREMITY IV. TIBIA/FIBULA
LATERAL TIB/FIB
Cassette Size: 35x43cm or 24x30cm depending on Patient size Cassette Orientation: Portrait or Diagonal if required FFD: 100 150 cm depending on length of leg. Remember to adjust exposure according if you increase the FFD. Central Ray: Perpendicular to cassette Centring Point: Midshaft of tibia Collimation: To include both knee and ankle within field Positioning: Patient to lay on side with lateral aspect of affected leg on cassette. Knee should be flexed at approx 450 Foot should be flexed at 900
Page 89 of 95
Section 6.D LOWER EXTREMITY V. KNEE & PATELLA
AP KNEE
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: 50-100 Cranial Angulation Centring Point: Apex of Patella Collimation: To include distal third of femur and proximal third of tibia and Lateral and medial skin edge Positioning: Pt supine or seated with leg straight. Cassette placed under knee.
Page 90 of 95
LATERAL KNEE
Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: 50-100 Cranial Angulation Centring Point: Medial Femoral Condyle Collimation: To include distal third of femur and proximal third of tibia and Anterior and Posterior skin edge Positioning: Patient to lay on affected side, cassette under knee. Knee flexed at 450. Sponge under foot to ensure that tibia is parallel with cassette and table.
Page 91 of 95
SKYLINE (AXIAL PATELLA)

Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Angled so that it is perpendicular to the Patellofemoral Jt space Centring Point: Apex of Patella Collimation: To include medial, lateral and anterior skin edge and fibula head. Collimation needs to be as tight as possible as primary beam is directed at the pts body. Positioning: Pt seated with knee flexed approx 450. Pt to hold the cassette perpendicular to table resting on the anterior aspect of the femur.
Page 93 of 95
D EPART M E NT O F H EALTH Section 6.E Exposure Chart

Please use the RDH Exposures for an average sized adult as a starting point and guide. Different factors can affect the exposure required, such as FFD, body habitus and patient size, POP, equipment etc. Please alter your exposure factors to suit your situation and equipment.
Area of Anatomy
Projection PA Grid (No Grid)
RDH Exposure kVp/mAs 105/4 (86/3.2) 86/3.2 110/8 52/2 54/2 56/3.2 52/2.5 54/2.5 56/3.2 58/3.2 58/3.2 58/3.2 58/3.2 58/3.2 60/3.6 70/10 75/16 68/10 70/12
Remote Exposure
Chest
AP Lateral Grid
Hand, Fingers & Thumb
PA Oblique Lateral PA
Wrist
Oblique Lateral AP
Forearm Lateral AP Oblique Elbow Lateral Radial Head AP (Grid) Shoulder Lateral (Grid) AP (Grid) Clavicle Cranial Angle (Grid)
2011 Radiographic Procedures Manual.doc Page 94 of 95
AP Foot & Toes Oblique Lateral AP Ankle Mortise Lateral Axial Calcaneus Lateral AP Tib-Fib Lateral AP Knee Lateral Skyline
55/2.8 55/2.8 56/3.2 56/2.8 56/2.8 56/3.2 66/6 56/3.2 58/2.8 58/2.8 60/5 60/5 66/8
Page 95 of 95

ApplicatioRadiographic Licensing

Загружено:

Сведения о документе

Исходное описание:

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

ApplicatioRadiographic Licensing

Загружено:

Авторское право:

Доступные форматы

Remote Operators Radiographic Licensing

Radiographic Procedures Manual

Department of Health is a Smoke Free Workplace

Section 2 - General Radiation Physics

Section 3 - Radiographic Equipment

Section 4 - Computed Radiography (CR)

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

Section 5 - Working Procedures and Instructions

Section 6 - Radiographic Critique & Positioning

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

Section 1.B - Legislation and Imaging Requirements

And any relevant future legislation, Federal or Territory

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

RADIATION PROTECTION PLAN (RPP)

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

Section 1.C Contacts

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

Section 2 General Radiation Physics

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

SECTION 2 GENERAL RADIATION PHYSICS

10-14 10-12 10-10 10-8 10

Figure 2.1: Wavelength of Different Radiation

2011 Radiographic Procedures Manual.doc

Version 2: 29-June-2011 Revision Date: June 2014

Department of Health is a Smoke Free Workplace

Section 2.B Production of X-rays