The role of the radiographer in the multidisciplinary team

The progression of highlighting abnormalities through the use of a ‘red dot’ system ¹ has been well documented, and by 2004 a national survey showed that 81% of hospital trusts/boards were using this aspect of role development.² Alongside this, the development of the advanced trauma and life support (ATLS)³ approach to dealing with the patient with multiple injuries and the inception of the four-tier system⁴ of working in the UK have advanced the position of the radiographer within the accident and emergency (A&E) multidisciplinary team. Gradual development of service provision through advanced training, to create the reporting radiographer, has further ensured the value of this team member in the A&E department.

The role of the reporting radiographer has ensured that an invaluable service can now be provided instantly in the A&E department. Acting as report writer, advanced A&E imaging practitioner, advisor to junior radiographic staff or students and other professionals in the multidisciplinary team, the reporting radiographer keys in neatly with (at a minimum) the advanced practitioner or consultant practitioner level of the ‘four-tier’ system of work that has evolved during the first part of the 21st century. Moving forward with this, the current recommendations are for radiographers to give an initial interpretation of their image by issuing a comment;⁵ this aspect will be discussed later in this chapter.

Although the advanced practitioner may be seen as a key representative for imaging within the multidisciplinary team, it should be remembered that the radiographer has a developing responsibility to ensure they contribute fully to the trauma service. As a member of the ATLS team, the imaging practitioner must take command of their aspect of the service provided for the patient. A highly experienced team may not necessarily always provide this service and, in a stressful situation, the radiographer must control their contribution through being confident and assertive; this ensures that a good outcome is achieved while maintaining safety for patients and the wider ATLS team. In this way the radiographer becomes an advocate for all those who come into contact with ionising radiation in the resuscitation room.

It is not only in the ATLS situation that the radiographer will display the versatility to cope with the demands of the varied A&E patient presentations, across widely ranging age groups and varying requirements for adaptation of techniques. The radiographer also displays their value to the multidisciplinary team for all A&E cases in which they are involved. However, admitting a lack of knowledge or ability should not be seen as a suggestion of general inability; examples of this are most likely to lie in unusual circumstances, difficult patient presentations or difficulty with highlighting perceived abnormalities. Admission of lack of knowledge or ability, and acceptance that another more experienced or skilled member of the team may provide a better service, is the most responsible and appropriate action for this situation. This may be reflected in discussing A&E images, or requests for imaging, with the referrer or radiologist so that the best patient outcome may be achieved. Also, knowledge and its application in the form of advising alternative imaging, perhaps with a protocol-driven application of the Ionising Radiation (Medical Exposure) Regulations [IR(ME)R 2006],⁶ is further evidence of the extended service provision of the radiographer within the multidisciplinary team. Indeed, acting as a gatekeeper of ionising radiation exposure to the general public is one of the more demanding roles, expected even of the newly qualified radiographer.

It is necessary that the radiography professional understands the following:

• Trauma mechanisms

• Most common injury presentations associated with trauma mechanisms

• How trauma mechanism and presentation may influence projection or technique selection

• How trauma mechanism and presentation may influence technique adaptation, in varied situations

Being able to draw on a wide experience base that has been developed through reflection upon practice (be this formalised or in an intuitive way) is another expectation of the A&E radiographer. With this in mind, it is the professional and medicolegal responsibility of radiographers to ensure that they maintain and continually develop their skills. Ensuring participation in continuing professional development (CPD) is paramount for even the most experienced, and this is reinforced by Health Professions Council (HPC) requirements that radiographers must show evidence of ongoing CPD, in order to maintain registration with HPC.

The team role of the radiographer: image interpretation

The ‘red dot’⁷ system has become an accepted norm for the practising radiographer and features in many undergraduate radiography courses in the UK, along with a move towards providing initial comment on images.

The radiographer’s expertise in image appreciation begins with their ability to evaluate images for quality purposes, and one of the main purposes of this text is to promote a logical and systematic approach to this. During quality evaluation the radiographer will recognise pathologies or abnormalities, and so they are already effectively commenting to themselves or colleagues prior to the application of a red dot. The application of a number of basic pointers makes image review possible:

• Correct patient identifier

• Correct anatomical marker

• Correct area included (on all projections)

• Correct radiographic position

• Adequate exposure factors used (for contrast, density and sharpness)

These pointers apply to all radiographic images and relate to the structures used in this text, which are projection specific rather than broad in their application. As the image produced should be of a diagnostic standard, implementation of these checks is vital before the radiographer can comment on abnormal appearances adequately and with confidence. As for image quality assessment, there are some basic pointers to enable accurate assessment of the image for identification of any pathologies/abnormalities:

• Assess the whole area,⁸ avoiding the urge to focus on the ‘obvious’

• Examine the cortical outline and trabecular pattern ^8,⁹ (follow the outline of the bone, assess for disruption)

• Look at the soft tissue ^9,¹⁰ (any change may indicate a subtle fracture)

• Check radiographic lines, zones and arcs ¹⁰ (for this the radiographer needs to be aware of the basics and how to use them)

• Research any previous/recent imaging ¹⁰

Using these basic pointers will enable radiographers to expertly analyse images so as to be able to pass comment on them; when commenting systems are introduced this is likely to lead to the issue of training, so that the comments follow a standardised format. With the aid of reporting radiographers and radiologists this should prove to be a simple issue.

The introduction of a commenting system must be logically presented to all involved, from referral to image retrieval, so that practitioner and referrer are aware that this is not a final report but rather the opinion of a professional within their own field; it should be used as an aid by the referrer in deciding on a final diagnosis. A system where all radiographers are expected to participate will give the referrers more confidence in that system, especially compared to the ‘red dot’ scheme where radiographers may have opted out of making a decision, putting the onus on to the clinician/referrer. In addition to a suitable design, the success of such a system will require continued review and audit.

It may be difficult to ascertain the medicolegal position of a commenting system unless a test case were to be presented. Even if a radiographer is not held responsible in civil proceedings, there is no reason why disciplinary or professional conduct hearings would not find the radiographer guilty of negligent conduct in situations relating to comments on anatomical appearances, if the employer has implemented a suitable framework for a commenting scheme. Vicarious liability by the employing hospital trust expects reasonable standards of care to have been exercised when supporting its employees in the execution of their duties. This includes operating within recognised protocols, working to professional standards, and also, on the part of the employer, the provision of appropriate educational support and safe working practices agreed by all participants.¹¹

The team role of the radiographer: suitable equipment choice

Experience also plays a significant role in the activities of service provision, especially on the ancillary equipment selection front. Frequently, this type of equipment for support to the A&E imaging department is often selected without including the radiographer in the purchasing exercise. As an example, the choice of trolleys that are widely used across disciplines often results in difficulties not only for radiology staff but also for the patient and the wider team in the A&E department. In the end, a poor-quality service is often delivered because of a lack of foresight in operating as a cohesive team. Holistic care demands cooperation across boundaries seen as traditional divides; however, borders are created where they are inappropriate.⁴ This is a particular problem where professions that form the minority in an area of operation are perceived as lacking in appreciation for what is best for that department area or the patient. Advocacy for the patient and service can take many different forms that are frequently not recognised.

Mechanisms of injury

A range of reasons exists as to why patients present in A&E. Certain patterns of trauma present themselves time and again, i.e. the ‘common occurrences’, although some injuries present after apparently minor trauma or as a result of seemingly ridiculous circumstances. Probably the most famous of all causes of injury is the ‘fall onto outstretched hand’ or FOOSH. Another commonly encountered trauma involves twisting of the ankle, which generates injury patterns which are linked, as force is transmitted along the whole of the leg. Certain age groups, because of their involvement in specific activities, or alternatively as a result of pathological processes influencing bone integrity, display unexpectedly severe presentations of injury following apparently innocuous trauma forces. Table 25.1 attempts to draw together injuries linked to the mechanism so that potential plain film skeletal imaging projections can be determined and expected injury patterns anticipated.

Table 25.1 Mechanism of injury related to examination requirements

An awareness of the developmental anatomy of the skeleton is important, as injury patterns change with age. Young children may not yet possess the skeletal components that generate adult injury characteristics, and indeed the maturity of bone may be responsible for causing variations in presentation. With their understanding of this, the radiographer can act as a resource of information for the referrer, so that an appropriate examination is embarked upon with least detriment to the child radiologically.

It is with all the above in mind, and the need to deal with the psychological aspects of the traumatised patient and accompanying relatives or friends, that the role of the radiographer is a wide-ranging one, acting as the advocate for holistic imaging management. Following recognition of the above it is appropriate to consider the more esoteric projections or adaptations to plain X-ray imaging that may be considered useful adjuncts to the trauma radiographer’s range of skills.

Further projections and adapted techniques

Working around the patient in non-standard and trauma situations is one of the greater skills of the experienced A&E radiographer, and an understanding of how radiographic equipment or body parts may safely be moved to achieve the required positions is of major importance. As well as appreciating these subtleties, the radiographer has a further responsibility for ensuring that appropriate radiation protection methods can be achieved for the patient, staff or relatives who may have to be present in these situations. Good collimation, selection of appropriate imaging equipment and radiation protection techniques – all considered ‘run of the mill’ aspects of good practice – will require adaptation to ensure successful application. Clean technique approaches will also be required where open wounds present, with appropriate protection for the radiographer and supplementary considerations for equipment and the cleaning of this thereafter. Clingfilm is sometimes used in the A&E department to wrap equipment, as protection against contamination from blood and other body fluids. Alternatively, plastic sheaths may be made for foam immobilisation pads or cassettes; care must be taken to ensure that these covers are kept clean and do not cause problems through artefact generation on images.

The upper limb

Common mistakes made in obtaining projections of the hand and fingers frequently occur as a result of the mistaken belief that the radiographer is being kinder to the patient by not causing excessive pain. Another example is when the radiographer attempts to obtain several finger projections in a single exposure. In both these instances it becomes immediately apparent that a less than acceptable image might be obtained, resulting in an increased risk of inaccurate diagnosis from the projection provided for radiological opinion. This lack of foresight and poor practice serves no purpose except to place the patient at risk and to lay the practitioner open to claims of negligent practice. Although hand injuries may not appear severe, the actual effects of the injury may be quite significant. By understanding this, the radiographer should realise that the highest standard of imaging possible must be achieved. This requires assertiveness (with respect to encouragement of achieving an ideal position when the patient may resist) in order to gain the best result, or adaptation of a technique to allow an image to be obtained in less than ideal circumstances. Further up the upper limb, towards the elbow and shoulder, similar demands surface to ensure that unambiguous radiographic representation of the traumatised limb or joint is achieved. Of particular concern are the supracondylar and radial head regions of the elbow, and adequate evidence of the relatively rare, but easily missed, posteriorly dislocated shoulder is vital.

Adapted projections of the hand

Frequently the patient requiring hand radiography will present to the X-ray department on a trolley, as a result of shock after experiencing trauma and being able to see the effects of the damage inflicted upon the limb. It is possible that routine projections of the hand may be undertaken with the arm extended across onto a table or platform, but adaptation may be necessary if other injuries prevent this. At this point the radiographer must consider adapting technique to ensure a diagnostic image is produced, without the serious compromise of increased radiation dose to radiosensitive tissues. However, there are other methods of providing images of the hand, and this section identifies a range of these.

Lewis ¹³ identified a way to address the perceived problems of the inadequacy of hand projections by suggesting that the dorsipalmar (DP) projection is obtained with the forearm medially rotated at the elbow so that the ulnar border of the hand is lifted from the cassette surface. A 15° radiolucent foam pad is placed under this aspect of the hand to immobilise the limb and raise the medial portion of the hand (Fig. 25.1), with the remainder of the technique used following that of the DP hand described in Chapter 5.

Figure 25.1 Clear joint presentation in the injured hand. Placing a 15° pad under the fifth metacarpal enhances the joint visualisation of the injured hand.

As patients are often reluctant to flatten their hand and extend their fingers following trauma, or soft tissue swelling prevents this from happening, this small change to technique allows the interphalangeal, metacarpophalangeal and carpal joints to be displayed squarely so that a true representation of the bony relationships can be gathered. The elevation of the medial aspect of the hand also places the little finger and 5th metacarpal into a DP position, rather than the oblique position in which they lie in the routine DP hand position.

Lewis continues to make further suggestions about hand radiography that would improve visualisation of certain digits.¹⁴ Of the thumb he makes the point that, in the normal anteroposterior (AP) and lateral projections, the thenar eminence and other structures medial to the thumb are frequently superimposed over the first metacarpophalangeal joint, preventing clear visualisation owing to imperfect achievement of radiographic density. He suggests, for the AP projection, that the radiographer simply angles the central X-ray beam 10–15° along the long axis of the thumb, towards the wrist, so that the soft tissue structures are projected away from the area of interest. Using this technique helps reveal the proximal joint region without juggling with exposure factors that may overexpose the distal part of the thumb while attempting to reveal the proximal aspect (Fig. 25.2). Quite frankly, the supine AP thumb technique described in Chapter 5 is probably most suitable, especially for the patient who presents on a trolley.

Figure 25.2 Angulation to clear the thenar eminences of the thumb. Angulation 10° cranially along the long axis of the first metacarpal ensures the thenar eminences do not superimpose and a good view of the articular surface of the metacarpal base is achieved.

In a third suggestion about hand technique modifications Lewis describes another projection of the fifth metacarpal, a bone which is difficult to demonstrate owing to the anatomical relationship of the bones or soft tissues of the hand in the dorsipalmar oblique (DPO) or lateral projections.¹⁵ He recommends further external rotation of the hand from the lateral position by an extra 5–10° so that the overlying second to fourth metacarpals no longer superimpose. The central ray is directed towards the middle of the fifth metacarpal and angled so that the ray is parallel with the thumb, which has been extended and abducted such that it does not overlie the fifth metacarpal (Fig. 25.3). Although an elongated projection is generated, almost the whole of the fifth metacarpal becomes visible.

Figure 25.3 Fifth metacarpal neck projection. Slight over-rotation of the lateral hand allows visualisation of the neck of the fifth metacarpal. The thumb is further abducted before exposure.

Normally used for visualising the small joints of the fingers in the arthritic patient, the ballcatcher’s ¹⁶ projection may be used to show the extent of damage in the ‘fight bite’ situation (Fig. 25.4). Puncture of the assailant’s skin by the victim’s tooth may lead to the development of osteomyelitis. Other than the clinical signs of the puncture wound or soft tissue swelling, little evidence of such an injury may be noted. However, the tangential representation of the metacarpal heads generated by this projection allows the viewer to see the indentation caused when the tooth has impacted with the metacarpal during a punching injury. The technique is described in Chapter 5, but it is not necessary to expose both hands and centring must be altered to coincide with the head of the third metacarpal, collimating to the single hand.