STANDARD PRACTICE GUIDELINES FOR DIAGNOSTIC RADIOLOGY

Radiographer Responsibilities
By Prof. Dr. Omar Hussein Prof. of Diagnostic Radiology

Preface
It is my honor to be on the head of a such a successful project as ESRP (Egyptian Swiss Radiology Project) A project that made a huge leap in the management of radiology services in the MOH, not only in Site Rehabilitation & Equipment Procurement, but also in making use of the most advanced technology solutions as Tele-radiology to improve peoples health & medical education. The idea of having a project that is concerned with improving the services of the radiology departments at the different MOH hospitals all over Egypt; The ESRP in 2002 was established with a mixed Swiss/Egyptian fund. The project made a very huge leap in the radiology services. In the first phase 80, and in the second phase109 radiology departments have been developed, starting from rebuilding infrastructure according to specific international requirements ended by supplying the hospitals by the latest technology in the radiology field. Owing to the great importance of having guidelines for the different operational steps at radiology departments, we had developed these 6 books of guidelines to help each one in the radiology department to make a change & difference in his domain to the best. These guidelines are the fruit of efforts exerted by many experts from different backgrounds related to radiology field to ensure that all points have been tackled, & by going through these books it will help each one seeking for the best performance & latest updates in this field.

Egyptian Swiss Radiology Project

I would like here to thank the different parties that helped us to reach this stage top on the list his Excellency Dr. Hatem AlGabally Minister of Health whom without his support & guidance this project wouldnt have seen the light. I would also like to thank the Swiss tropical institute for believing that together we can achieve the improvement required in the radiology service. Finally I would like to thank all the coordinators working at the ESRP as well as the experts from different fields collaborating to achieve our fruitful desired targets.

Prof. of Radiology Cairo University Advisor of HE Minister of Health ESRP Manager

Dr. Dorria Salem

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Table of Contents
1 1.1 1.2 1.2.1 1.2.2 1.2.3 1.2.4 1.2.5 1.2.6 1.2.7 1.2.8 1.3 1.3.1 1.3.2 1.4 1.4.1 1.4.2 1.5 1.5.1 1.5.2 1.6 1.6.1

Radiographer Responsibilities Handling the patient Radiological procedures in Emergency cases and Patient Needing Special Care in Radiology Department Accident victims Head Injuries Spinal Injuries Extremity fractures Multiple Emergencies Pediatric, Geriatric and Diabetic patients Bedside Radiography Neonatal Nursery Patient preparation Procedure for Preparation for conventional radiological studies Preparation for contrast studies Computed Radiography (CR) and Digital Radiography (DR) Computed Radiography (CR) Digital Radiography (DR) Computed Tomography and Magnetic Resonance Imaging Computed Tomography (CT) Magnetic Resonance Imaging (MRI) The Darkroom Processing

1 1 2 2 2 3 3 3 4 4 5 5 6 6 7 7 8 9 9 11 15 17

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1.6.2 1.7 1.8 1.9 1.9.1 1.9.2 1.9.3

Responsibility Quality Assurance Documentation Supplies and Consumable Storage and Handling Handling and Storage of X-ray Films Handling and Storage of Chemicals Handling and Storage of Contrast Media

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Standard practice guidelines for Diagnostic Radiology 1. Radiographer Responsibilities 1.1 Handling the patient:
Procedure: - Before starting any radiological technique 1. Avoid undue delay and do not leave the patient unattended in the waiting area, take into consideration his anxiety and fear, unconscious or irritable patient may fall from the stretcher if left unattended. 2. Careful identification of the patient`s name to know exactly what procedure will be done. 3. Talk to the patient in a friendly way , call him by his name and introduce yourself, explain in a simple language what is going to happen, what he will feel, what is expected from him to undergo successful procedures and how long the examination will take. This will lead to his cooperation. 4. Ask if the instructions given for the preparation were correctly carried out or not. 5. Enquire about any premedication given before starting the examination. 6. Careful transfer of the patient from wheel chair or stretcher to x-ray table. 7. Beware of urinary catheters, collection bags or drainage tubes. Responsibility and Documentation: Radiographer should write in patient request form any observation concerning patient preparation, premedication, presence of catheters or collection bags. - After the examination: Procedure: 1. Check that the patient is feeling well and everything went right and that the vital signs are back to normal. 2. Check film quality is satisfying and refer to radiologist for confirmation 3. Avoid undue delay in sending patient back to his room if hospitalized.

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Responsibility and Documentation: 1. Adverse reactions to contrast media must be promptly treated and carefully reported on patient`s chart, including details of treatment. 2. Report any patient discomfort, pain , bleeding especially after invasive procedures to the radiologist in charge.

1.2 Radiological procedures in emergency cases and patient needing special care in radiology department: 1.2.1 Accident victims:
Procedure: 1.The most common emergencies in the radiology department are traumatology cases. 2. By the time the patient arrives to department, airway should be secured with iv infusion line in place. 3. Avoid cutting or tearing clothes before radiographic examination if patient is still dressed. 4. Patient manipulation should be minimal to avoid exacerbation of trauma. Responsibility: 1.When radiographs are taken and reviewed, they are sent with accompanying nurse ( make sure patient identification clearly written on films). Documentation: Any observation regarding limited movement or positioning, patient`s consciousness, distress should be:

1.2.2 Head Injuries:

1. Watch for deterioration in the level of consciousness and signs of increased intracranial pressure (irritability, lethargy, slowing pulse and respiration). 2. The most important consideration in dealing with unconscious patients is to maintain a free airway. The airway is commonly compromised by accumulated saliva, blood or vomits, which can be aspirated in the lungs.

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3. The safest posture that will avoid these complications is the lateral decubitus position. However, if the patient must be positioned for radiography careful monitoring is necessary and the patient should be returned to lateral decubitus position as quickly as possible. 4. Patients with head trauma may not show external signs of trauma. CT examination when available is the first choice to evaluate both skull and brain and should be done as fast as possible.

1.2.3 Spinal Injuries:

1. Suspected fracture spine are transported prone. Never attempt to put them supine since any movement can increase the risk of cord injury. 2. Where possible exposures are made without moving the patient. A lateral shoot through radiograph with a horizontal beam is taken and evaluated before positioning the patient for additional views.

1.2.4 Extremity fractures:

1. When it is necessary to position a fractured limb without splint, avoid rough handling and minimize movement of fractured segments. This can cause a closed fracture to develop into a compound one or may injury a near by vessel, plus the considerable patient pain. 2. The extremity must be supported at sites proximal and distal to the fracture at least by two persons. Responsibility: 1. Splinting devices should not be removed except after permission from physician. 2. Evaluate the taken films before positioning the patient for additional views.

1.2.5 Multiple Emergencies:

Patients are usually admitted to the radiology department on a scheduled or on a first to come first served basis. When more than one patient

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requires examination at the same time, highest priority should be assigned to patients who: - Have unstable vital signs. - Have severe respiratory distress. - Need immediate care, depending on the result of the examination. Responsibility and Documentation: In cases of major accidents, some of the victims may be with unknown names. To avoid incorrect identification of the victims, these are usually assigned numbers which are written on tags and attached to their wrists or ankles. These numbers are recorded on the x-ray requests and are used to identify the radiographs of each patient. This may prove to be very important from the medicolegal point of view later on.

1.2.6 Pediatric, Geriatric and Diabetic patients:

Radiology departments always make it a practice to begin the daily routine with patients who must fast in preparation of their examination, so that they will not have to go without food for too long. Procedure: After the emergency patients have been examined, the next priority should be on pediatric and geriatric patients where fasting is difficult for long periods for them. Also diabetics who postpone their insulin shot after their breakfast and come fasting for a barium study are considered of high priority for examination .

1.2.7 Bedside Radiography:

Bedside radiography by mobile or portable x-ray unit is requested when patient condition makes it difficult or hazardous to transport the patient. It is usually requested for: 1. Patients in I.C.U who are critically ill, or those injured who require constant monitoring or ventilator dependent.

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2. Patients on orthopedic traction . 3. Fractured long bones with traction to maintain the alignment of the fragments as they heal . 4. Patients with major surgery in the immediate postoperative period, having nasogastric tube, intercostals drainage tube, Procedure : 1. Sterilization and special precautions are mandatory in I.C.U. 2. Gentle care in handling critical patients. 3. Take more than one film before leaving to film processing to avoid errors of dosage or positioning of patient .

1.2.8 Neonatal Nursery:

Premature babies nursed in incubators, newborns with incomplete lung expansion are all high risk patients. Some infants may be safely removed from the incubator for brief periods of time and can be examined radiographically on an open table. The neonate at risk must be radiographed within the incubator. Procedure: Whether radiographed in x-ray department or in incubator, proper immobilization and choosing the proper technical factors are important to avoid re-exposure. Responsibility: It is the physician responsibility to decide the neonate to be radiographed outside or inside the incubator according to his clinical condition and not the radiographer.

1.3 Patient preparation:

Many requested X-ray studies need no special preparation and can be done immediately according to the workload of the department or the acuteness of the patient`s condition, e.g. patients with pneumothorax or suspected fractures.
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Any investigation in the abdomen and pelvis needs a clear colon and empty stomach practically in techniques using contrast media. Patients with suspected volvulus or ileus do not need colonic cleansing before the study.

1.3.1 Procedure for Preparation for conventional radiological studies:

Radiography of the skull, axial and peripheral skeleton , chest and heart X-rays do not need any preparation. Infants, babies and irritable , uncooperative patients may require mild sedation and additional help to restrain their movement in order to obtain optimal radiographs. Responsibility: Sedation should be given by a nurse. 1 or 2 teaspoonful of chloral hydrate will be sufficient to sedate infants and children. 10 mg Diazepam (1 ampoule Valium) for adults i.m or i.v. Uncooperative patients or babies should be attended by a member of their family or a nurse to minimize their movement. Documentation: Any sedative agent and dosage should be reported in patient`s sheet.

1.3.2 Preparation for contrast studies:

Procedure for upper GI Baruim series: No smoking as this increases gastric secretions. Fasting for 6 hours at least. Procedure For lower GI Barium enema: A meticulous cleansing of the colon is mandatory. The day before the study give fluid diet aiming at reducing faecal residue in the colon, e.g juice, tea, broth. Dairy products are to be avoided. The night before the examination give light supper , eg a piece of bread and cheese and a cup of tea or one fruit or one cup of juice.

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A laxative should be given to clean bowel, either castor oil 60cc flavoured with mint extract, or tablets (alphalaxine or boldolaxine) 2 tablets at 6 pm In the morning (day of study) , if patient still passes stools, make a low enema (either ready made enemax or prepare one by mixing 1.5 l warm water with 2 tablespoons sodium chloride) . Enema should be done 12hours before the study to give time to water in the colon to be absorbed or otherwise it will dilute the barium enema.

Patient preparation for any radiographic examination of the abdomen, urinary tract and pelvis (particularly contrast study) is similar to the preparation for barium enema. In urographic studies, no need for fluid restriction, on the contrary encourage the patient to drink as much as possible. Newer contrast media render excellent visualization of the urinary tract and well hydrated patient is desirable Responsibility: If preliminary films taken before contrast administration revealed poor patient preparation, the radiographer should report this to radiologist before further continuation or postponing of procedure.

1.4Computed Radiography (CR) and Digital Radiography (DR) 1.4.1 Computed Radiography (CR):
Procedure: Rather than utilizing conventional x-ray film to capture an image, computed radiography uses an imaging plate contained inside the cassette. This plate contains photo sensitive storage phosphors which retain the latent image. When the imaging plate is scanned with a laser beam in the digitizer, the latent image information is released as visible light. This light is captured and converted into a digital stream to compute the digital image. The CR systems require the purchase of a reader/ eraser workstation with computer and software.

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Dry printer camera is needed for printing the films (no chemicals are used in the procedure).

1.4.2 Digital Radiography (DR):

Procedure: Utilizing this process, the image is captured directly on the flat panel detector and the image is transmitted directly to the computer. No intermediate steps or additional processes are required to capture the image. Process provides a direct feed from panel to imaging workstation. DR systems require the purchase of an imaging panel, cable, computer and software. Dry printer camera is needed for printing the films (no chemicals are used in the procedure). Advantages of Computed Radiography CR and Digital Radiography DR: The storage phosphors on the Digital Imaging Plate have an extremely wide dynamic range. This gives a high tolerance for varying exposure conditions and a greater freedom in the selection of the exposure dose. As a consequence, the need for retakes is drastically reduced Digital radiographic image:Ability to copy and duplicate without loss of image quality, E-mail image which can be read on any PC, Software image enhancement and analysis tools, Ability to zoom, compare multiple images and perform a variety of analytical functions while viewing the images, No image degradation over time, Rapid storage and retrieval. CR can be placed inside or close to X-ray room. No requirement for darkroom or chemical processing; environmentally friendly. Exposure time reduction from 5 to 20 times less than film. Safe operation with minimum Small Controlled Area. Up to 10,000 times re-usable phosphor flexible plates. Less physical storage space required.

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The wide dynamic range makes it possible to investigate and evaluate more complex shaped parts with a wider thickness range than possible with film in only one exposure i.e. Reduces numbers of exposures for multi-thickness sections. Reduction in radiation exposure thus causing increases personal and environmental safety. Imaging Plate effectively substitutes for film using same basic set-up, settings and using existing film holders.

Disadvantage of CR and DR: Initial cost of equipment is high as compared to conventional radiography. Responsibility and Documentation: Patient identification is written through the workstation and printed on each film. Proper training and computer knowledge is mandatory for good film processing and archiving data for follow up cases.

1.5 Computed Tomography and Magnetic Resonance Imaging 1.5.1 Computed Tomography (CT):
CT produces a volume of data which can be manipulated, through a process known as "windowing", in order to demonstrate various bodily structures based on their ability to block the X-ray beam. Although historically the images generated were in the axial or transverse plane, orthogonal to the long axis of the body, modern scanners allow this volume of data to be reformatted in various planes or even as volumetric (3D) representations of structures.

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Process: X-ray slice data is generated using an X-ray source that rotates around the object; X-ray sensors are positioned on the opposite side of the circle from the X-ray source. The sensors are scintillation detectors based on photo diodes instead of photomultipliers with more desirable characteristics. Many data scans are progressively taken as the object is gradually passed through the gantry. They are combined together by the mathematical procedures known as tomographic reconstruction. The data are arranged in a matrix in memory, and each data point is convolved with its neighbours according with a seed algorithm using Fast Fourier Transform techniques. This dramatically increases the resolution of each Voxel (volume element). Then a process known as Back Projection essentially reverses the acquisition geometry and stores the result in another memory array. This data can then be displayed, photographed, or used as input for further processing, such as multi-planar reconstruction. Newer machines with faster computer systems and newer software strategies can process not only individual cross sections but continuously changing cross sections as the gantry, with the object to be imaged, is slowly and smoothly slid through the X-ray circle. These are called helical or spiral CT machines. Their computer systems integrate the data of the moving individual slices to generate three dimensional volumetric information (3DCT scan), in turn viewable from multiple different perspectives on attached CT workstation monitors. This type of data acquisition requires enormous processing power, as the data are arriving in a continuous stream and must be processed in real-time. CT is used in medicine as a diagnostic tool and as a guide for interventional procedures. Sometimes contrast materials such as intravenous iodinated contrast are used. This is useful to highlight structures such as

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blood vessels that otherwise would be difficult to delineate from their surroundings. Using contrast material can also help to obtain functional information about tissues. Pixels in an image obtained by CT scanning are displayed in terms of relative radiodensity. The pixel itself is displayed according to the mean attenuation of the tissue(s) that it corresponds to on a scale from +3071 (most attenuating) to -1024 (least attenuating) on the Hounsfield scale. Pixel is a two dimensional unit based on the matrix size and the field of view. When the CT slice thickness is also factored in, the unit is known as a Voxel, which is a three dimensional unit. The phenomenon that one part of the detector cannot differentiate between different tissues is called the "Partial Volume Effect". That means that a big amount of cartilage and a thin layer of compact bone can cause the same attenuation in a voxel as hyperdense cartilage alone. Water has an attenuation of 0 Hounsfield units (HU) while air is -1000 HU, cancellous bone is typically +400 HU, cranial bone can reach 2000 HU or more (os temporale) and can cause artifacts. The attenuation of metallic implants depends on atomic number of the element used: Titanium usually has an amount of +1000 HU, iron steel can completely extinguish the X-ray and is therefore responsible for well-known line-artifacts in computed tomograms. Artifacts are caused by abrupt transitions between low- and high-density materials, which results in data values that exceed the dynamic range of the processing electronics.

1.5.2 Magnetic Resonance Imaging (MRI):

Magnetic resonance imaging (MRI), is primarily a medical imaging technique most commonly used in radiology to visualize detailed internal structure and limited function of the body. MRI provides much greater contrast between the different soft tissues of the body than computed tomography (CT) does, making it especially useful in neurological , musculoskeletal, cardiovascular, , cancer imaging. Unlike CT, it uses no ionizing radiation, but uses a powerful magnetic
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field to align the nuclear magnetization of (usually) hydrogen atoms in water in the body. Radio frequency (RF) fields are used to systematically alter the alignment of this magnetization, causing the hydrogen nuclei to produce a rotating magnetic field detectable by the scanner. This signal can be manipulated by additional magnetic fields to build up enough information to construct an image of the body. MRI, on the other hand, uses non-ionizing radio frequency (RF) signals to acquire its images and is best suited for non-calcified tissue, though MR images can also be acquired from bones and teeth . Contrast agents for MRI are those which have paramagnetic properties, e.g. gadolinium and manganese. Both CT and MRI scanners can generate multiple two-dimensional cross-sections (slices) of tissue and three-dimensional reconstructions. MRI has a long list of properties that may be used to generate image contrast. By variation of scanning parameters, tissue contrast can be altered and enhanced in various ways to detect different features. MRI can generate cross-sectional images in any plane (including oblique planes). MRI is also best suited for cases when a patient is to undergo the exam several times successively in the short term, because, unlike CT, it does not expose the patient to the hazards of ionizing radiation. Pacemakers and implants: Pacemakers are generally considered an absolute contraindication towards MRI scanning, though highly specialized protocols have been developed to permit scanning of select pacing devices. Several cases of arrhythmia or death have been reported in patients with pacemakers who have undergone MRI scanning without appropriate precautions. Other electronic implants have varying contraindications, depending upon scanner technology, and implant properties, scanning protocols and anatomy being imaged.

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Many other forms of medical or biostimulation implants may be contraindicated for MRI scans. These may include vagus nerve stimulators, implantable cardioverter-defibrillators, loop recorders, insulin pumps, cochlear implants, deep brain stimulators, and many others. Medical device patients should always present complete information (manufacturer, model, serial number and date of implantation) about all implants to both the referring physician and to the radiologist or technologist before entering the room for the MRI scan. While these implants pose a current problem, scientists and manufacturers are working on improved designs which will further minimize the risks that MRI scans pose to medical device operations. One such development in the works is a nano-coating for implants intended to screen them from the radio frequency waves, helping to make MRI exams available to patients currently prohibited from receiving them. The current article for this is from New Scientist. Ferromagnetic foreign bodies (e.g. shell fragments), or metallic implants (e.g. surgical prostheses, aneurysm clips) are also potential risks, and safety aspects need to be considered on an individual basis. Interaction of the magnetic and radio frequency fields with such objects can lead to trauma due to movement of the object in the magnetic field, thermal injury from radio-frequency induction heating of the object, or failure of an implanted device. These issues are especially problematic when dealing with the eye. Most MRI centers require an orbital x-ray to be performed on anyone suspected of having metal fragments in their eyes, something not uncommon in metalworking. Because of its non-ferromagnetic nature and poor electrical conductivity, titanium and its alloys are useful for long term implants and surgical instruments intended for use in image-guided surgery. In particular, not only is titanium safe from movement from the magnetic field, but artifacts around the implant are less frequent and less severe than with more ferromagnetic materials e.g. stainless steel. Artifacts from metal frequently appear as regions of empty space around the implant- frequently called 'black-hole artifact'. e.g. a 3 mm titanium alloy
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coronary stent may appear as a 5 mm diameter region of empty space on MRI, whereas around a stainless steel stent, the artifact may extend for 1020 mm or more. In 2006, a new classification system for implants and ancillary clinical devices has been developed by ASTM International and is now the standard supported by the US Food and Drug Administration:

MR Safe sign MR-Safe - The device or implant is completely non-magnetic, non-electrically conductive, and non-RF reactive, eliminating all of the primary potential threats during an MRI procedure.

MR Conditional sign MR-Conditional - A device or implant that may contain magnetic, electrically conductive or RF-reactive components that is safe for operations in proximity to the MRI, provided the conditions for safe operation are defined and observed (such as 'tested safe to 1.5 teslas' or 'safe in magnetic fields below 500 gauss in strength').

MR Unsafe sign MR-Unsafe - Nearly self-explanatory, this category is reserved for objects that are significantly ferromagnetic and pose a clear and direct threat to persons and equipment within the magnet room.

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Though the current classification system was originally developed for regulatoryapproved medical devices, it is being applied to all manner of items, appliances and equipment intended for use in the MR environment. In the case of pacemakers, the risk is thought to be primarily RF induction in the pacing electrodes/wires causing inappropriate pacing of the heart, rather than the magnetic field affecting the pacemaker itself. Much research and development is being undertaken, and many tools are being developed in order to predict the effects of the RF fields inside the body.

1.6 The Darkroom

Many of the errors in X-ray diagnosis arise because of faults in processing. In terms of patient care, a poor quality radiograph may be more harmful than the patient not having an X-ray examination at all. An adherence to routine process described in this book is extremely important in providing radiographs of high quality and ensuring optimum health care. The following recommendations should be taken into consideration whenever a new darkroom is built or old places rearranged. 1. Location of darkroom: The darkroom should be centrally placed next to the X-ray rooms. 2. Darkroom size and shape: A long darkroom is more convenient than a square one because: More wall space is available for equipment. Less movement of personnel is required. No wasted floor space in the center of the room. A surface area of 6 square meters with a separate entrance is the minimal requirement for a darkroom serving one X-ray examination room. 3. Light tightness: There must not be any light coming into the darkroom. All potential openings to the outside are light tight (doors, ventilation, windows). Entrances to darkrooms are usually single doors which must be well fitted with stripped
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edges and have bottom seals. For most situations, simple devices such as warning lamps on the door to indicate that film is being processed and clear warning signs are appropriate. 4.Safelights: All safe lights should be at least 1.3 m above the working bench and should preferably be pointing upwards. The bulbs used in the safelights should never exceed 25 Watts. 5. Ventilation: The darkroom must be adequately ventilated and should have an adequate extraction fan, which functions whenever the darkroom is in use. Air conditioning should be considered if the temperature cannot be kept in the range of 16o c to 24o c. 6. Finishing and wall color: The color of the darkroom walls should not be black or dark. Maximal reflection under safelight illumination is achieved if the wall color is white, ivory, cream or a light posted shade. Darkroom wall finishes should be resistant to splashes from processing solutions; ceramic tiles are installed covering two meters above the floor. 7. Dry and Wet areas: The darkroom contains dry and wet areas.It must always be kept clean and tidy. The dry area contains a bench for the films, clean film hangers, film boxes and cassettes. Your hands must be dry when you work at this bench. The wet area consists of the processing tank holds the chemicals and washing water for processing the X- ray films. The fixer must always be kept separate in their own tanks, which usually inside the processing tank. 8. Continuous warm and cold water supply: An extra water outlet for automatic processor has to be provided. A pump is installed to increase water pressure if automatic processing unit shall be used. 9. Cleaning facilities: Large sink for cleaning rollers and efficient water disposal system.

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1.6.1 Processing:
A-Manual Processing: Processing is a series of actions by which exposed X- ray film yields an image. In processing a film, the subsequence of actions should be as follows: 1. Mark the patients name on the film. 2. Develop the film. 3. Rinse developer from the film. 4. Fix the film. 5. Wash the fixer from the film. 6. Dry the film. 7. Check the name, date and patient number on the film, and check the right and left marks. The manual processing steps are: 1. Using separate paddles, stir the developer and the fixer thoroughly to equalize the temperature and chemical activity of the solution. Adjust the temperature at 20o c. 2. In safelight condition remove the film from the cassette and load it on a processing hanger of an appropriate size (attach the lower corners first to ensure correct tension of the film in hanger). 3. Keep fingers to edge of film only immerse the film smoothly in the developing solution and set the timer for correct developing time, ensure that the film does not touch the side of the tank or adjacent films. Agitate the film several times and repeat this once every minute during development to remove air bubbles and distribute developer all over the film. On the completion of development, remove the film from the developer. Development time: a film is completely developed as soon as the development time has been seven times as much as has been required for appearance of the first image tracers. 4. Rinse the film in the running water or in the acid stop bath for at least 30 seconds. Lift from rinse bath and drain the hanger well before moving to the fixer.
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5. Immerse the film in the fixer solution and agitate it until it becomes clear, and the milky look has disappeared. Do next expose the film to while light until the emulsion has cleared. Fixation time is double the clearing time, at least 5 minutes. 6. Lift the film from the fixer and transfer directly to the washing tank and leave the film in running water for 30 minutes. 7. Drain. 8. Dry in dust free atmosphere preferably by circulating warm air in a drying cabinet or on an air-drying rack. Keep the films well separated during drying. 9. Do not remove films from hangers until they are fully dry and trim corners to remove clip marks, insert films in identified envelopes with the X-ray request; they are now ready for reporting. Important Recommendations for Manual Processing: 1. Measure the liquid capacity of solution tank (Width x length x total depth) in inches divided by 277 (cubic inches per gallon) will indicate true capacity of a tank. This to assure the use of correct amount of concentrate solution when mixing chemicals. 2. Mix solutions carefully and completely according to manufactures directions. 3. Stir solutions thoroughly at least once a day or after they have stood idle for a period of time, to prevent precipitation of chemicals. 4. Use a thermometer to check the temperature of solutions. 5. Keep the solution tanks, particularly the developer, covered when not in use, to reduce evaporation and air oxidation. 6. Maintain scrupulous cleanliness around the tanks and wipe up any accidental spillage of chemicals before some permanent damage results in accident. A dirty darkroom produces dirty films. 7. Clean the processing tanks periodically. Even stainless steel will stain if not cared for properly. 8. Maintain order in the darkroom. It should not be used as a storehouse; however, it is a place for everything but everything is in place.

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9. Agitate film periodically during development and for the first few seconds after placement in the fixing solution. This will prevent streaking of the film or formation of air bubbles. 10. Remove film carefully from the various chemicals to avoid splashing into the other tanks. Please Remember 1. Dont compound an error in exposure by sight developing the film. Sight development does not work e.g. on over exposure a film is not corrected by under development. 2. Dont handle film or cassettes and dont go near the workbench with wet hands. 3. Dont place on hangers more films than can be accommodated in the developer tank at one time. The extra- film is completely protected against safelight fogging until put in the developer. 4. Dont crowd films in the solution tanks leave about one inch space between hangers in the tank to prevent scratching or adhesions of films. 5. Dont forget to cover all unexposed films before turning on any white light to avoid fogging. 6. Dont allow cassettes to stand open on the working bench. 7. Dont store films with the boxes lying on a flat side. Stand them on edge. 8. Dont over fix films, to avoid fading of silver image on the film. 9. Dont fail to have an adequate supply of developer replenisher mixed and ready for use at all times to top up the tank level or prolong the life of the developer. Never top up developer by adding water. 10. Mix solutions carefully and completely according to manufactures directions. 11. Stir solutions thoroughly at least once a day or after they have stood idle for a period of time, to prevent precipitation of chemicals. 12. Keep the solution tanks, particularly the developer, covered when not in use, to reduce evaporation and air oxidation.
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Automatic Processing: The increase in films volume used, plus the ever present desire to see radiography at the instant an exposure terminates, brought about and expanded the use of the automatic X- ray film processing system. The treatment of the film in the automatic processor is not a new method of working, when compared to the manual development, as in the machine also, the films have to undergo developing, fixing, washing and finally drying. The only difference remains in the fact that every film is treated exactly in the same way and there is no rinse between the developer and fixer. The main components of an automatic processor: 1. Transport system for passing the films through the processing solution and dryer. 2. A series of thermostats for maintaining correct temperature in the different phases. 3. A system for replenishment of the processing solution according to the surface area of the films processed. 4. Circulation devices for chemicals and wash water which allow one to carry out consistent processing. 5. Hot air ventilation system for film drying in the roller processor, the machine consists of a feed table, three vertical tanks (for development, fixing and washing respectively a dryer and a collector. Chemicals and films used in automatic processing units: Automated processing is not just mechanization of the hand processing, but a process depending on the interrelation of mechanics, chemicals and films. Special chemicals and films were developed to meet the particular needs and conditions of automated processing (films and chemicals used in manual processing cannot be used in the automatic processing machine). Advantages of automatic processing: The introduction of automatic processing has made a major impact in the radiology departments and has benefited many other departments in the

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hospital as well e.g. outpatient clinics, causalities and emergency unit , to the extent that the duties and routine steps in such departments have to be reorganized according to the rapid rate of services offered by the radiology department. Technical advantages: Constant processing parameters and stability of radiolographic quality. Shortening of both processing and access time. Economic advantage: Small floor space occupied by the processor. Film hangers and drying cabinet are not required. Saving in personnel, one trained technician can run the room efficiently and produce large number of films. Reduction in the patients waiting time. Longer life of the X-ray tubes because of lower load on them as the repeat exposures are kept to minimum.

1.6.2 Responsibility:
The working principles of the automatic processor : Operating the processor is extremely simple, and does not need special trained staff. The main point is to carefully observe the following instructions, and to check at regular intervals that the machine is processing the film satisfactorily. Daily maintenance and periodical servicing: Experience has shown that an automatic processor will stay mechanically and photographically completely reliable in operation as long as regular maintenance is carried out exactly as described in the instruction manual of the processor (weekly, monthly, quarterly and yearly). The working routine should include the following operation for the automatic processor:

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1.6.2. a) Before startup the days work:

Remove the crossover and the tank lid, using water moisten cleaning pad, wipe over the rollers and guide plates in the wet section of the processor which are above the liquid level. Switch on the heater elements for the processing solution (which requires about 15 -20 minutes to reach the working temperature). Open the water valves, in the case of a processor with hot water supply, check the temperature and delivery rate of the water and adjust if necessary. Check whether the solutions in the processing and replenisher tanks are at the proper level, color and smell, check replenishment hoses for binds or leaks. Start the dryer a few minutes before the solutions reach the required temperature. In the case of the processor provided with a energy saving device, the dryer is automatically switched on as soon as the first film is fed into the processor. Replace crossovers and tank lids. When the machine is ready for processing, feed up four large waste (clean) films into the processor in order to remove possible residual chemicals from the rollers and guide plates or feed in one unprocessed 14X17 inch film instead of the processed film as these are harder and contain fixer. Inspect the processed clean up film. Feed a second film if feel necessary do not proceed with the daily workload until you are satisfied that the rollers are clean.

1.6.2.b) Procedure while the automatic processor is in operation:

Place the film on the feed table and hold it between thumb and forefinger to avoid kinks. Without exerting any pressure and without bending the film, push it into the feed slot until it is gripped between the first pair of rollers. It is advisable to load films alternatively at the right and left hand side of the feed table, so as to use the full length of the roller evenly. After a film has been fed into the processor, wait for the visual or audio signal before inserting the next one.

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 Always feed the long side of the films into the processor, narrow films can be fed two sides by side, provided that a space of about 4 cm is left between them. Films should be allowed to freely drop into the receiving tray as they leave the dryer. Films must never be pulled from the dryer, as this may damage the film and or the transport system. The processor is immediately and automatically switched off by a build in a safety micro switch when the lid cover is removed. In case of any abnormal noise or vibration; stop the processor by removing the lid cover, check for the reason to prevent further damage. Documentation: Record in a separate document dates of regular cleaning of tanks, chemicals renewal, expiry dates of chemicals .

1.7 Quality Assurance

A- The general principles associated with good imaging performance are: 1. Film identification or imaging annotation . Documentation: Patents name, sex, age. Date. The hospital name. The part examined and timing if sequential films are taken. Positional marker R, L. Technician ID. These should not obscure the diagnostically relevant region of the radiograph. 2. Proper technical factor - The proper K.V. & mAS and screen film combination The F.F.D. and the focal spot size (large focal spot sizes are employed with large F.F.D. and smaller foci are employed with faster screen film combination). - Bucky or no bucky. - Size of the film to be used and central ray.

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3. Patient positioning Correct patient positioning plays a major role in the production of a diagnostic radiogram. Suitable immobilization and compression devices have an important role to play in the production of satisfactory images. A handling book of patient positioning should be available in the department for learning and reference in special unusual positions 4. X-ray beam limitation Image quality is improved and the radiation dose to the patient is reduced by limiting the X- ray beam to the smaller field giving required diagnostic information. Radiosensitive organs should be excluded from the field of irradiation whenever possible. On no occasion should the x-ray beam fall outside the image receptor area. Evidence of beam limitation on the film is desirable e.g. edge of the diaphragm limiting he lumbar spine. An automated beam limitation device would be helpful. 5. Protective Shielding Lead shielding of the testis and ovaries particularly in young patient and in repeated examination as in congenital hip dislocation is essential. 6. Diagnostic radiograph The three properties of a diagnostic radiography are:a. Proper density or blacking. b. Good contrast. c. Clear definition. Film density is the most important and in its absence the other properties lose their significance. For the diagnostically relevant part of the film the overall range of optical densities should be between 0.5 and 2.2, however film blacking is subject to personal preference of the radiologist. When a film has been found to be too dark it should be viewed with a bright spotlight before a decision is made to repeat the examination. A dark film is usually associated with a relatively higher patient dose.

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7. Radiographic exposure per examination The number of radiographic exposure with one examination must be kept to a minimum, consistent with obtaining the necessary diagnostic information. 8. Film processing Optimal processing of the radiographic film has important implication on the diagnostic quality of the image. Proper darkroom technique should be followed. Regular maintenance of the processing equipment. 9. Image viewing conditions Proper assessment of the image quality and accurate film reporting can be best achieved by proper viewing condition, means to restrict the area to the radiography to avoid dazzling. - Additional spotlight with iris diaphragm for viewing exceptionally dark areas in the radiographic image - The reporting room should be of a relatively low level of light. 10. Reject analysis Rejected films should be collected, the reason for rejection should be analyzes and corrective action should be taken. A checklist for number of rejected films, cause, name of technician should be revised every month. A- Quality assessment of the radiographs: The aim of the quality criteria is to characterize a level of acceptability of normal basic radiogram. Quality and safety is the hall works for efficient and successful medical service using ionizing radiation. The quality criteria are designed to be carefully applied in any X-ray department without the need for special equipment apart from a means of measuring or estimating the dose to the patient. There are indented to provide a standard of good practice both in terms of a satisfactory level of image quality and acceptably low radiation dose to the patient.
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1.8 Documentation:

The factors affect the radiographic quality: Proper patient positing. Proper imaging devices. The selection of the proper technical factors. These factors are very much interrelated and for any given radiographic examination, a proper interpretation and application of each of these factors must be made. A smaller change in one may require a compensating change in another.

Every patient data (Name, age, sex, date and type of examination) should be registered and archived in a separate notebook or in a computer file. Number and sizes of used and wasted films should be recorded (by using CR or DR technology this record of wasted films is cancelled). Any recorded allergy to contrast media, its nature and treatment should be also recorded. A copy of technician name and radiological report for any further follow up or enquiry by clinician or patient. A separate file concerning used radiologic tools ( cannulas, catheters, guide wire, biopsy needles.) and contrast vials should be available with chief nurse. These should be checked and reduced from storage stock every month.

1.9 Supplies and Consumable Storage and Handling: 1.9.1 Handling and Storage of X-ray Films:

1) X-ray Films a) Films sizes commonly used in medical radiography Film sizes in inches Film sizes in centimeters 8x10 18x24 10x12 24x30 12x15 30x40 14x14 14x17

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Less commonly used films 4x10 inches 6.5x8.5 inches 6x12 inches 11x14 inches

13x18 Cm.

b)Packing of X-ray films Some x-ray films are supplied in bulk with no interleaving; others are supplied interleaved (folder wrapped).The films are packed sealed in special waterproof polythene composite foils, which are packed in special cardboard boxes. Each box contains 25, 50, 75 or 100 films and they should not be opened except under the recommended safelight condition. c) Storage of x-ray films All photographic materials deteriorate very gradually from the date of manufacture, the rate deterioration depending on the storage conditions. Under the recommended storage condition, the deterioration doesnt become significant until after the expiratory date printed on the box. Under poor storage conditions, the rate of deterioration may increase, and in fact the film may become unsatisfactory before expiratory date. The principle effects of deterioration are a gradual increase in the basic fog, a fall in contrast and a change in speed (some films may gain speed and others may lose speed). Heat, light, humidity, x-rays, radioactive substances, chemical fumes, pressure, rolling, bending, etc., are all capable of adversely affecting the x-ray emulsion and consequently, care must be taken when storing x-ray films to avoid these conditions.

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Procedure of Ideal storage conditions of x-ray films: 1. A temperature not exceeding 20oc and a relative humidity of not less than 50% and not more than 65% i.e. cool and dry. Sealed package of films are affected by heat and opened package by humidity as well as heat. Normal aging of photographic products occur four times quicker if these products are stored at 30oc instead of 20oc. 2. Dont store films near heat sources such as radiators steam pipes, or where gases such as vapours of formalin, hydrogen sulphide, or ammonia can leak into the air and fog the films. 3. Fog due to ionizing radiations is not easily avoided since sensitivity to these wavelengths is one of the essential characteristics of an x-ray film. This problem can only be overcome by protecting the films from such radiation, while they are in the storage area, in the darkroom or even in the exposure rooms. 4. The x-ray films should be ordered in quantities to provide reasonably rapid turnover and ensure freshness. In departments where large number of film boxes is stored, the boxes should be placed vertically on their edge, one close to the other as books in such a way that narrow side on which expiry date is printed is visible. They should never be stacked flat one on top of the other as this would cause the lower box to bear the pressure of all the other and, in time, would damage the coats of emulsion which are also sensitive to mechanical injuries. The way the boxes are arranged should permit easy access to the boxes, which have been in stock for the longest time, this method avoids excessive aging of some films. Consequently, newly requested boxes should be placed at the back of those which have been in storage for some time, or placed at their side and clearly marked with easily readable numbers. If the boxes are used in numerical order the material will always be fresh and upon, give good uniform result (first in, first out).

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5. Special fire precautions are not required because the x-ray films are made of safely base with low inflammability. If the films are kept in refrigerator, to ensure that the cooled films do not become clouded when their packing is opened, it is essential that the boxes or film should be left unopened for 12 hours after they have been removed from the refrigerator.

1.9.2 Handling and Storage of Chemicals:

In manual processing: The chemicals whether the developer or the fixer are supplied either in powder form or as concentrated liquids preparation. In automatic processing: - The chemicals are supplied only as concentrated liquid preparation. - They are stored in the darkroom if there is enough space, if not they can be kept anywhere in the department. - In preparing the solution follow the instruction of the manufacture. A) Preparation of Developer Solution in Manual Processing: Preparation procedure of developer from powdered chemical: Preparation of powdered chemical should be done in a separate room to avoid contamination of sensitized material from chemical dust rising in the air during processing. If this is not practical, wipe the loading bench with a damp cloth to remove any trace of chemical dust after the solution is mixed. The chemicals are supplied in two bags: - Bag 1 (the bigger one) contains the developing agents. - Bag 2 contains the accelerator, the preservative and the restrainer. 1) Pour water in clean tanks first. Add the contents of bag 1, till it is completely dissolved, then the contents of bag 2 are gradually added with continuous stirring till all the contents are dissolved.
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Proper stirring is particularly important to prevent caking or the formation of lumps of chemicals. Keep dusting to a minimum by slow careful pouring of the powder avoid dust inhalation or eye contact. 2) Add cool water to top up the solution to the correct volume of the tank and to the proper temperature. - The developer shouldnt be used except on the next day or at least left to stand for 12 hours before it is ready for use. - The tank containing the developer should always be covered to reduce evaporation, contamination and surface oxidation. B) Preparation procedure of developer from liquid solution: 1) Dilute the concentrated solution with water with quantities indicated and at the recommended temperature, so that all the ingredients will go into solution properly. 2) Stir thoroughly so as to obtain perfect homogeneity of the liquid. Preparation of Fixer Solution in Manual Processing: The water used in preparing fixer solutions should not exceed 27.5O c, otherwise the destruction of the fixing agents will be speeded up and the possibility of forming sludge of aluminum hydroxide is increased. Preparation of Chemicals in Automatic Processing: The chemicals are always supplied in liquid form. The developer is supplied in three parts: Part A: containing the developing agent (hydroquinone), the alkali and the preservative. Part B: containing the developing agent (phenidone) and the fungicide. Part C: the hardener. The solution is made up by dissolving the contents of A in 15 liters of water at 40.5f c with continuous stirring, then add the contents of B. After dissolving of A and B, add C with continuous stirring and top up with cold water until the final volume of 20 liters is obtained. Higher temperature during preparation results in irreversible damage, and consequently in decomposition of the developer.

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A starter is added to the tank before it can be used (20-25 ml starter for each one liter of the prepared solution). The fixer is supplied in 2 parts: Part A: contains fixing agent, preservatives, buffer and antisludge agent. Part B: contains the hardener and an acid The content of A is added to the water tank then the content of B and thoroughly mixed. These chemicals when prepared must be allowed to stand not less than 12 hours before use. Non-observance of this rule may cause poor image quality. In automatic processing the prepared developer and fixer are used as a replenisher, while in manual processing for the developer there is a special replenisher, but the fixer doesnt have special replenisher, the fixer itself is used. The replenisher of the developer in manual processing cannot be used as original developer.

1.9.3 Handling and Storage of Contrast Media:

After the final quality control made by the manufacturer, months or even years may pass before the CM are actually used. During that period, the products are transported and stored under varying conditions, which may impair the quality of the CM solution. 1. The stability of CM is satisfactory at normal room temperature (15-25 degree Celsius). There is no need to store the product in a cool place unless this is clearly expressed on the label. 2. X-ray contrast media are sensitive to light and to some extent to irradiation. They should be stored in a dark place (e.g. in a cupboard) and not near X-ray equipment. Although brown glass ampoules protect the solution from light, they have the disadvantage that any fragment may go unnoticed in the solution (eg fragments from the stopper, or crystals) or that changes in colour of the solution are not easy to recognize. That is why colourless glass containers are preferable. The outer pack is not removed until shortly before use. Avoid direct sunlight exposure.
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3. Observe the expiry date storage under normal conditions is possible (shelflife of up to 5 years) Prolonged storage at a high temperature (eg 30oc) should be avoided as it accelerates degradation reactions . 4. Examination of the contrast media solution for clarity before use ( discoloration, turbidity, cloudiness and precipitations are an indication of imperfect quality and the solution should not be given to the patient). Some compounds can crystallize at low temperature (in winter).These crystals are easily seen and can be dissolved again in unopened container by warming up to 30oc. Contrast media generally tolerate heating to this temperature without problem since they are heated after manufacture to 120oc for 20 minutes for purpose of sterilization. Warming of contrast media to body temperature (37oc) before use reduces the viscosity of the contrast media to about a half, thus improving their tolerance. Risks of bacterial contamination: Tri-iodinated urographic contrast media are originally developed from antibacterial substances and conventional ionic contrast media display distinct antimicrobial activity especially at high concentrations (300 mg/ ml and upward). Non-ionic contrast media are a good culture media for fungi and bacteria, because of their chemical composition and tolerance. To avoid the risk of microbial contamination : 1. Do not pour the contrast medium over non sterile lip of the original container. 2. Do not keep open vials longer than 4 hours after first use. 3. Discard all remains at the end of the day . 4. Under no circumstances should unused solutions be returned to the original vial . 5. Re-sterilization of solutions in opened containers is not permitted. Bacterial contamination can , of course be recognized only macroscopically at a very late stage. The typical finding of fungal infection is a cloud of the suspensed particles resembling a discolored cotton swab.

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References
1. "American College of Radiology guideline on MRI, 2005" 2. American College of Radiology. Appropriateness Criteria for Imaging and Treatment Decisions/ ACR, Reston VA/USA 1995 3. American College of Radiology.Standards. ACR, Reston VA/USA 1994 4. European guidelines on quality criteria for diagnostic radiographic images, Luxembor office for official publications of European communities 1996 5. Filler AG (2009). "The history, development, and impact of computed imaging in neurological diagnosis and neurosurgery: CT, MRI, DTI". 6. Frederick A. Morro, Computed Radiography: The Future of Radiographic Inspection 15th WCNDT,2000 7. Hay Ward Ivan, Substandard radiology: Endemic in Third world, Diagnostic Imaging.Nov.: 1992:189 8. Khattar,N.: The principles of the dark room techniques 1987 9. Khattar , N.: A practical guide to special techniques in diagnostic radiology, 2nd Edition 2003 10. Khattar ,N.: Basic principle in Radiology Practice 2003 11. Le Bihan D, Breton E, Lallemand D, Grenier P, Cabanis E, Laval-Jeantet M. (November 1986). "MR imaging of intravoxel incoherent motions: Application to diffusion and perfusion in neurologic disorders.". Radiology. 161 (2): 4017. 12. Liyold,R.J.: Quality assurance workbook for radiographers and radiological techniques.WHO publications, 2001 13. Murphy KJ, Brunberg JA, Cohan RH (1 October 1996). "Adverse reactions to gadolinium contrast media: A review of 36 cases". AJR Am J Roentgenol 167 (4): 8479. 14. Nelson F, Poonawalla A, Hou P, Wolinsky JS, Narayana PA (November 2008). "3D MPRAGE improves classification of cortical lesions in multiple sclerosis". Mult Scler. 14 (9): 1214 - 9.

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15. Palmer, P.E.S.: Radiology and primary care scientific publication No 367, WHO publication, 2001 16. Palmer,P.E.S.: Appropriate technology for diagnostic imaging in small hospitals.Br Med J 288: 1430 -1437 , 1984 17. Price DL, de Wilde JP, Papadaki AM, Curran JS, Kitney RI (January 2001). "Investigation of acoustic noise on 15 MRI scanners from 0.2 T to 3 T.". Journal of Magnetic Resonance Imaging 13 (2): 288 -293. doi:10.1002-1522/ 288<13:2(200102)2586::AID-JMRI1041>3.0.CO;2-P. PMID 11169836 18. Thulborn KR, Waterton JC, Matthews PM, Radda GK (February 1982). "Oxygenation dependence of the transverse relaxation time of water protons in whole blood at high field". Biochim. Biophys. Acta 714 (2): 265 -70. 19. Squire LF, Novelline RA (1997). Squire's fundamentals of radiology (5th ed.). Harvard University Press . 20. WHO Primers on darkroom technique, positioning and image interpretation c9 ( WHO publication dept)

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