Top 10 Tips: For Radiographers New To Theatres

1.    Introduce yourself to as many people, especially surgeons, as possible. Doctors are often very          grateful and accepting when they learn you are new and are willing to guide you. Most doctors like things done a certain way and will be happy to teach you to get it right the next time. They generally don’t like it when you pretend you know what you’re doing and stuff it up!

2.     Familiarise yourself with the II. Know which buttons/levers move the machines in which directions so you know how to move the machine quickly and confidently.

3.     Be aware of where/how far you need to move the machine and clear all possible obstacles (e.g. cables, IV poles/lines, anything under the operating table) and ensure that the screens are visible to both yourself and the surgeon and won’t need to be moved during the case

4.     For urology/op chole/general abdo area cases – come in perpendicular to the patient. E.g. with an RGP, centre to the correct side of the patient and turn the wheels so the machine will move straight up and down the patient

5.     For orthopaedic cases such as hands, wrists, forearms, elbows – turn the machine so the II is on the bottom and the tube on top as surgeons will often rest the limb on the II

6.     For spinal cases (depending on doctor preference) – the machine may need to be flipped so that it can be swung over the top of the patient to get a shoot through lateral. Test this before you come into the theatre

7.     For hip cases – you may bring the machine in through the patient’s legs or the unaffected leg will be lowered and you’ll come in from the unaffected side. You’re not quite perpendicular to the patient but the angle depends on the patient set up and is usually guided by the surgeon. Centre over the hip for the AP and swing under the table for the lateral.

8.     Only screen when the surgeon asks and stop when they say or when they are no longer looking at the screen. Always ask before you screen if you want to check your position and make sure everyone in the room is wearing or is protected by lead.

9.     If the doctor doesn’t ask, save images at significant points (e.g. when contrast is seen, when screws/plates have been inserted)

10. Make use of both image screens i.e. save older images to the other screen as a reference. E.g. with hip cases, as you frequently change from AP to Lat, save the last image before you switch positions so the surgeon can compare from both angles

Tips for Writing Resumes (especially for newly qualified radiographers)

The most important thing you can do when applying for a job, especially your first radiography job out of university, is to have a strong resume. When you consider that everyone applying for a PDY/NPDP/New Grad/Level 1 (whatever you call it, wherever you are) Radiographer position has the same amount of clinical experience and effectively the same skills then what will set you apart is a great resume. Which is easier said than done. Here are some tips I have come across by reading a lot of resume of radiographers applying to my hospital as well as university resume courses I have attended. There is obviously no one correct way to write a resume, but there are certainly a lot of wrong ways.

Career Objective

Probably the hardest part of the resume to write. Don’t be afraid to tailor this to each job you apply for.

Examples:

•        I am a graduate of …..
•        I would like to obtain a position where I can continue to develop my skills in general   radiography, fluoroscopy, theatre and mobiles
•        I would like the opportunity to train in modalities such as CT and MRI so as that I can develop a well rounded skill base and be a valuable team member

Obviously if you are applying for a position  where they for example don’t have CT and MRI, it probably isn’t worth mentioning that you would like training there as it may make you look like you don’t really want the job there.

I also wouldn’t recommend writing something like “I hope to study medicine and become a doctor” because it makes you seem like you only have short term ambitions for the job, whereas most workplaces are looking for a more long term employee.

Education

How far back you go probably depends on how old you are. If you have been out of the work force for 20 years and have just recently completed a degree, you’re high school results are probably not necessary. Since most newly qualified radiographers completed high school reasonably recently, it is worth putting it in.

Mention any notable achievements such as awards or particular high marks (e.g. high GPA or high averages across subjects).

Clinical Experience

I have found the best way to set this out is to mention responsibilities you have had across all clinical placements. E.g.

-       use of CR/DR systems (Kodak, AGFA, Fugi etc)

-       performing examinations on wide range of patient presentations from ambulatory to non responsive

-       working independently and as part of a team

It is also good to mention where you have had clinical experience as this gives an indication of what skills you have developed. With each clinical setting, mention what specific skills you learned there. E.g.

•          final clinical placement at …. Hospital had extensive CT training and performed … procedures independently.

This gives you the opportunity to demonstrate all the training in different modalities you have gained.

Skills Summary

This is your chance to demonstrate all the key capabilities you possess which have been developed not only through clinical experiences but any other jobs you have had. A lot of job applications will mention certain skills you should have, so you should consider tailoring your resume to include these skills.

May include:

Clinical Reasoning Skills

•  questioning/assessing patients, identifying issues with requests, modifying examinations/techniques for patient presentation, evaluating radiographers

Practical Skills

•          experience in general, theatre, mobiles etc
•         trauma or paediatric experience
•         image interpretation

Professional Conduct

•           there is probably a guide or document to reference e.g. in Australia it is the Australian Institute of Radiography Guidelines for Professional Conduct for Radiographers, Radiation Therapists and Sonographers and The Code of Ethics       
•       awareness of patient confidentiality, OH&S, non discrimation etc

Communication and Teamwork

•          make mention of other jobs/activities where you have demonstrated this as well as clinical settings
•         communication and teamwork with radiographers, nurses, radiologists, referring doctors, other health care professionals

 Other Skills

•         CPR/First Aid
•         Other languages spoken
•         Possession of a driver’s license

Employment

Obviously where you can demonstrate other responsibilities you have had. It is especially important to demonstrate skills, which are transferrable to radiography (e.g. communication, teamwork, organisation etc.

Interests

Don’t have to go into too much detail but it is important to show that you have a life outside of work. Mention of couple of interests you have and don’t be surprised if they are mentioned in an interview.

Transcripts/Clinical Reports

This will be expected to be included so their absence will look like there is something you don’t want them to know!

General “Don’ts” For Resumes

Don’t:

•         Include a photo of yourself. I’m not sure why but employers generally don’t like this. They won’t hire you because you have a nice photo and it is generally unnecessary
•         Make spelling/grammatical mistakes. Have as many people as possible read and correct your resume. Constant spelling or grammatical mistakes will be a definite turn off
•         Talk yourself up to much. Find the line between demonstrating your skills and blatantly talking yourself up. You can’t be the best at everything, you can’t perform every possible examination and procedure perfectly so claiming it will only make you seem arrogant and complacent. I once read a resume which said exactly that but clinical reports said clearly the opposite!
•         Make it unnecessarily long. Use bullet points and get to the point quickly as most employers will skim it quickly for the main facts. If it takes too long to read they won’t read it.
•         Use a crazy font or colours. They won’t like it and it won’t help. Stick to the basics.

Hope this helps with the very difficult and long process of writing a resume. If you have any other tips or have seen something particularly terrible in a resume please share!

Interview Questions for Newly Graduated Radiographers

Here are some questions you might (hopefully) come across. Some questions I have had, others I've heard about or read about. I also have a few tips for answers which you may or may not agree with. Let me know your thoughts or if you have any other questions you have come across.

1. Why do you want to work at this hospital/ practice?

- if you've worked there before, you might mention the great teamwork/facilities/friendly staff/fact that you learnt a lot

- if you haven't worked there, mention that you have heard great things about the workplace or that they have a good reputation. Do some research so you can be specific about their facilities, which will make it more believable that you actually want to work there!

2. What are your best qualities? 
- try and think of something that is relevant to radiography

- e.g. Organization, communication, teamwork, friendly, hardworking etc

3. What are your worst qualities?

- whatever it is, you have already improved greatly on it. The trick is thinking of something that really isn't that bad. Dont say you can't communicate or you hate working with other people but also don't say things like "I'm a perfectionist" because no one really buys that. Try something like, "I used to have trouble with time management but I have greatly improved this at uni or in pracs"

4. What should you do to confirm you have the correct patient?

- time out - ask name, DOB, address if still unsure

- if inpatient also check name band

- ask the patient what exam they are having done

- ask questions about the history you are given to ensure it matches what the patient tells you

5. What should you do if the patient refuses an x-ray?

- Check that they understand the procedure and any risks involved

- Ask their concerns - helps to gauge if they are competent to make decision

- If you are satisfied they understand what they are refusing, do not go any further with the exam and notify the referring doctor - do not force or pressure patient

6. What should your film check post exam include?

- Check name, DOB, MRNA, study/accession number on film

- Check markers are correct

- Check anatomy is correctly demonstrated (e.g. Images haven't shifted in printing)

- Check contract/brightness

- Check you have all films

7. Talk about a situation where you have had to take charge

- Doesn't have to be a radiography situation, maybe another job or uni assignment but talk about your sensational communication and organizational skills

8. What is a trauma series and in what order would you perform the images?

- Unless protocols vary between states/countries - c-spine (lat), CXR and AP pelvis in that order (order of severity)

9. What would you do if you have calls for mobile X-rays, theatre and inpatients waiting all a the same time?

- Prioritise (good time to demonstrate organization/time management skills) cases in order of severity, ask for assistance from other staff where necessary (show that you are not afraid to ask for help), communicate with referring parties, keep them inforomed of your movements so they don't think you are ignoring them

10. What projection best shows a fracture of the greater tuberosity? 
- AP shoulder in external rotation

11. What additional imaging should you consider in a FOOSH injury?

- Scaphoid if pain in snuff box, radial head if elbow pain and decreased movement

12. What additional imaging should you consider with an inversion injury of the ankle?

- Oblique foot for base of 5th fracture

13. What would you do if a 16yr girl comes in with her mother for an AXR and says she may be pregnant?

- Ask pregnancy status away from mother - she has no legal right to information

- Contact referring doctor and check if they are aware and ask how they would like to continue

- If exam is not to be performed as per doctor (most likely) do not tell mother the reason, simply state if quested that the doctor has been spoken to and feels this may not be the right test and ask them to return to doctor

14. Where would you like to be in 5 yrs?

- Mention areas of interest (e.g. CT or MRI) but be careful when those areas are not available at the location you are applying for as it may appear as though you are only using them for short-term training.

- Consider mentioning having a well-rounded skills base, still working at their practice (may sound like a sucking up answer but may also be well received!)

15. Give an example where you demonstrated excellent communication/teamwork

- May be a patient who was very uneasy with having a procedure and you talked them through it

- Very difficult patient with extensive injuries requiring many Radiographers and nurses to work together

- Try to think of (or make up) a examples where you have worked with other team members, not just Radiographers, e.g nurses, doctors, radiologists, wardsmen - wide range of health professionals showing your ability to work in amultidimensional team

General Interview Tips:

- Be confident in your answers, speak clearly - don't be afraid to ask for clarification (e.g. Sorry, I don't quite understand, is this what you mean?)

- Gauge the tone of the interview, if it is serious, remain polite and professional, if it is more light hearted, don't be afraid to have a joke or laugh with the interviewers

- Ask questions - show you have an interest in the job/workplace - Research the workplace and be aware of their facilities to show you are interested in the job

- Turn up 10 minutes before the interview, any earlier/later runs the risk of inconveniencing the interviewers

- Don't try and draw the interview out too long - they may decide they like you in a short amount of time

- Take time to think about the questions, don't just rush out with the first answer you think of

- Relax and be yourself. The more natural you are the more comfortable the interview will feel and the interviewers will have a greater idea of your personality, which is often just as important as the questions.

Do you have any more questions you have come across? Please let us know!

Radiographer Performed Barium Swallow

Barium Swallow

• ·      Examination of the pharynx, oesophagus, stomach and duodenum
• ·      Used to disclose abnormalities that may be either structural or functional or both
• ·      Often used in conjunction with endoscopy when there is a suspected structural abnormality of the oesophagus as endoscopy can not assess functional abnormalities

Relevant Anatomy

Indications

• ·      Heartburn
• ·      Dysphagia (difficulty swallowing)
• ·      Odynophagia (painful swallowing)
• ·      Globus (feeling of something stuck in throat)
• ·      Hiatus hernia
• ·      Reflux
• ·      Unexplained vomiting
• ·      Assess gastric band position/tightness (limited study)

Patient Preparation

·      NBM from midnight of the night before examination

Imaging

·      Examinations on otherwise healthy patients can frequently be performed by the radiographer, with a supervising radiologist available to check the images – this will vary between practices however

·      If performing the study without direct radiologist supervision, the following projections provide a well rounded examination

Lateral and AP Upper Oesophagus

• ·      To show swallowing mechanism
• ·      May be rapid acquisition (2/3fps), fluoroscopy capture or single shot however need to demonstrate entire oesophagus filled with contrast
• ·      Stop examination if aspiration occurs

Lateral and AP Distal Oesophagus

• ·      Ensure overlap occurs with upper oesophagus images (arch of aorta as landmark)
• ·      Show entire oesophagus filled with contrast including gastroesophageal junction
• ·      May be rapid acquisition (1/2fps), fluoroscopy capture or single shot
• ·      Ensure oesophagus is shown to have emptied before performing supine images

Gas (Part 1, Part 2 solution) is administered to the patient before lying them down to distend stomach and oesophagus

Supine

• Centred to include only the distal oesophagus which should be empty

Left Lateral

• ·      Roll patient onto left side before RPO to move the barium to encourage reflux

RPO

• ·      If contrast is seen in the gastroesophageal junction or distal oesophagus then reflux has been demonstrated provided that it is proven that the barium has in fact emptied completely into the stomach initially
• ·      To demonstrate reflux it may be necessary to roll the patient slightly onto the left (to deposit gastric barium into the fundus) then slowly back into RPO position
• ·      Patient can also drink a small amount of water or dry swallow to help induce reflux

Prone

• ·      On full inspiration can better demonstrate a hernia and Schatzki’s ring

RAO

• ·      Have patient swallow barium continuously through a straw and image as it fills the cardioesophageal junction and passing into the fundus
• ·      Can also demonstrate a hiatus hernia

L-R Upper: R Lateral Erect, AP Erect Upper and Lower

L-R Lower: AP Erect Lower,

 R Lateral Erect Lower, RPO Supine demonstrating reflux

Variations

Modified Barium Swallow

• ·      Performed with presence of speech pathologist
• ·      Usually performed with patient erect with primarily oesophagus pictures (limited interest in stomach pictures other than to demonstrate hiatus hernia)
• ·      Patient swallows liquids of varying thickness and textures mixed with barium – prepared by speech pathologist
• ·      Checking swallowing mechanism, aspiration, reflux, hiatus hernia
• ·      Fluoroscopy store generally preferred with runs saved to video/DVD

Possible Pathology Demonstrated

• Hiatus Hernia
• Reflux
• Oesophageal Cancer
• Diverticulum
• Aspiration

Tips For Mobile Chest X-Rays

Mobile (or portable) chest x-rays can be particularly difficult to perform as there are often a lot of external factors to consider (e.g. difficult patient position, patient condition, patient size, artefacts etc). Plus, there is the added annoyance of (assuming you use a CR system) having to return to the department to process the image and return to the ward if it requires repeating.
Here are a few tips I have learned, which make mobile chest x-rays just a little easier!

  Patient Position

• Have the patient as erect as possible
• Always check with nursing staff before moving a patient as their condition may not allow them to move safely
• A supine x-ray is considered less diagnostics as the lung fields appear shortened, the heart is magnified and air fluid levels are not seen
• Watch for lines and tubing connected to the patient when you move them
• If the patient can’t pull themselves forward, have someone help you pull them forward using the sheet behind them and slide the cassette behind the sheet – this is less painful on the patient’s back

Cassette Position

• Place the top of the cassette at C7 (the notch on the back of the neck)
• Place your hand on top of the patient’s shoulder and ensure that your finger tips are not above the top of the cassette
• Consider also that the top of the cassette doesn’t need to be much above your fingers as the patient’s lungs can’t exceed their shoulders
• Put your hands on either side of the patient’s chest to feel that the cassette extends past your hands sideways – this will make sure you don’t cut off the side of the lungs

Landscape vs Portrait

• Generally, landscape will fit most patients and allows you more room to be off centre
• If the patient is particularly tall and skinny consider placing the cassette portrait
• Put your hand on the edge of the patient’s chest to ensure the cassette extents further sideways than your hand to ensure you don’t cut off the side of the lungs

Tube Angle

• The straighter the patient, the less you have to angle
• The best way to check for correct tube angle is to come to the side of the bed so the patient is on one side and the tub on the other
• If necessary, put your hand on the LBD to get the angle and follow it to the patient’s chest to see if they match up
• As a general rule, you will probably need to angle down slightly more than you think!

Centering and Collimation

• Don’t worry about which specific vertebrae to centre at – it’s too difficult to figure out – centre at what appears to be the centre of the chest!
• Open your collimators so you see them just above the shoulders but make sure you aren’t including too much abdomen, this will just throw off your exposure
• Include the shoulders. Additional pathology may be present or they may be used identify a patient if there is a confusion with patient identification (i.e. if you do 2 mobile x-rays and get the cassettes confused, one may have an identifying shoulder pathology which you can confirm with a previous film – not an ideal method but can come in handy!!)

Patient Directions

• Tell the patient that the cassette is cold and hard but that it won’t be there for long
• Ask them to try and hold still and not adjust their position even though the cassette is uncomfortable as the cassette will move and may need to be repositioned
• Tell the patient that you will call out for them to breathe in an hold their breath and to try not to raise their shoulders when they breathe in – when they raise their shoulders it often causes them to lean back, making the image more lordotic and may cause you to miss the apices
• If the patient is not conscious or is unresponsive, watch for their breathing and expose on inspiration – watch for a few breathes to gauge timing
• Ask the patient how they would like to be positioned after the x-ray is complete (sitting up, lying down etc)
• Return everything you have moved (side table, remotes, safety pins etc)
•  

Exposure

• Varies greatly depending on the machine, cassette and whether or not a grid is being used
• With a digital machine (no grid), I have used 80kVp, 4mAs for “regular” sized patients and 90kVp, 5mAs for large patients
• With an older CR machine, it was necessary to use 90kVp, 4mAs for even small patients
• Check the kind of machine you are using to determine exposure
• Increase exposure if you are looking for CVC placement, especially in larger patients as it is often difficult to visualize the tip

Markers

• Using a L/R marker (and Erect/Supine and Mobile where possible) will save you considerable time in post processing, especially if you have a whole ICU round to do!
• Try to use the same marker every time, where possible. This way, if you use a pillow case or slider you know you are putting the cassette in the right way every time

Organisation

• If you are doing multiple patients (assuming you are using a CR system) put the patient request or patient sticker on the cassette so as to not get them confused when it comes to post process
• This will also stop you from re using an already exposed cassette

When should it be repeated?

• If the apices are cut off --> may still be acceptable if you are only checking for NG tube placement
• If the bases are cut off  --> may still be acceptable if you are only checking for line placement (e.g. CVC, Swan Ganz catheter)
• Rotation (the clavicles are not equidistant from the spine) à may not be possible to correct due to patient condition, however try to adjust with aid of nurse
• Under exposure (too much noise)
• Insufficient inspiration à should see at least 7 ribs, however if the patient is not responsive a deeper breath may not be possible
• If any of these points occur, you should show the x-ray to the referring doctor to see if they require it to be repeated. They may, for example, only be looking for line placement and hence if a small amount of anatomy isn’t seen it may not matter
• In this case, an accurate request form is necessary so the reporting radiologist knows what is expected in the report

Lateral Knees - How to fix them when it all goes badly

For some reason, no one seems to like lateral knees, especially students. I remember hating them, though I can't quite remember why, I suspect it had something to do with the fact that it was so obvious when you got them wrong. That doesn't mean they are easy to get right however. I have a system for doing lateral knees that still only probably works 8 times out 10. You can think you have everything absolutely perfect and it will still look wrong.  I don't know whether I just wasn't paying attention one day at uni, but I can never remember being taught how to figure out how to fix your lateral knee. I don't think it was just me however because a lot of students I work with now don't seem to know either (or they are just humouring me and secretly thinking I'm stupid - all valid options)
In any case, here are a few tips I have picked up (or had forced upon me!) that will hopefully make lateral knees a little easier.

Standard Lateral Knee (patient rolled onto side)

• Ask the patient to roll right up onto their side/hip - not merely roll their leg out
• Keep the other leg behind the one you are x-raying - I find rolling it over the top will more often than not make you over rotated HOWEVER
• If the patient is struggling to roll onto their side (often the case with large patients) have the bring their other leg over the top
• Try and feel for the epicondyles to see if they feel superimposed (not always possible to determine)
• 2 finger  rule - I never really got this but people swear by it. I believe your 2nd and 3rd fingers should sit between the patella and the table when correctly positioned - can be difficult with large knees however
• Feel for the tibial spine, this should be running parallel to the table. If not, place a small sponge under the ankle to raise the lower leg and open the joint space.
• Angle up 5 degrees (again, seems to work most of the time but not fool proof)
• Slight bend in knee - should never be 45 degrees!

Assessing Rotation

• The best tip I have learned is to look at the fibula
• If you can see too much fibula - the knee is over rotated - try lifting the knee up off the cassette slightly or rolling the patients hips back towards the table slightly
• If most of the fibula is behind the tibia, you are under rotated - this is when rolling the other leg over the top may be useful  or simply rolling the patient slightly more onto their hip
• It is usually only a very small movement required to fix the rotation

Trauma or Horizontal Beam Lateral

• Should always be performed after trauma (regardless of whether the patient can roll for a lateral) to assess for fluid 
• Have a slight bend in the knee if tolerable to open the joint space
• Can feel for the epicondyles to assess rotation but again can be difficult with large knees or swelling
• Use ankle as an indicator however remember that some people's feet turn out/in so that may be misleading
• Again, I find feeling for the tibial spine to be most accurate. Run your hand down the spine to ensure it is running parallel to the table
• As the beam is now going lateral to medial (as opposed to medial to lateral in a standard AP) angle down 5 degrees 

Assessing Rotation

• If you see too much fibula, the leg is under rotated. Turn the whole leg slightly inwards
• If you don't seen enough fibular, the leg is over rotated. Turn the whole leg slightly outwards.

Again, these are general rules, however I find them to be successful most of the time. You will always find that one shonky knee which you just can't seem to get right. Don't be afraid to concede defeat after a few attempts. For some reason, a new set of eyes and hands will annoying get it right when you continue to fail. 

Remember to feel for landmarks to see if you are in the right position. These include the tibial spine, epicondyles and patella. For trauma or post surgical knees, try feeling the unaffected knee to get an idea of normal anatomy (patients also appreciate not poking their sore knee). This will also help get an idea of correct centring position as often swollen knees and be misleading. 

Finally, if you image a lot of knee replacements, remember that the joint is artificially made and therefore a lot easier to show perfect superimposition of condyles and a large joint space. With knees suffering from bad OA, the joint space is often tiny and the condyles may be uneven to start with, making superimposition very difficult. Don't necessarily expect a normal knee to look like a TKR replacement knee.

Please let us know if you have come across any other tips for lateral knees!

ERCP - Anatomy, Procedure and the role of the Radiographer

What does ERCP stand for?

Endoscopic Retrograde Cholangiopancreatography

What is an ERCP?

A technique utilizing endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal system.

When is an ERCP performed?

When the patient’s bile or pancreatic ducts may be narrowed or blocked due to:

• Gallstones, pancreatic stones, tumour or scar tissue
•  Inflammation due to trauma or illness (such as pancreatitis)
• Sphincters not opening properly

Who is involved in an ERCP?

• The gastroenterologist (doctor performing the procedure)
• A scrub nurse (who remains "sterile" for the procedure)
• A scout nurse (who finds and prepares necessary equipment)
• An anaesthetist 
• A radiographer

Review of Relevant Anatomy

ERCP Anatomy

Specific Vessels related to ERCP

Procedure

•  The patient is places in a LAO position under conscious sedation
•  The doctor will feed the endoscope into the mouth, down the oesophagus, through the stomach until the duodenum and ampulla is visualized
•  The ampulla is dilated using a catheter and guidewire
•  Fluoroscopy is now used to assist in proper placement of the guidewire (i.e. to ensure the guidewire has gone into the CBD not the pancreatic or common hepatic duct)
•  Contrast is injected to visualize the ducts and determine if there are any stones, strictures or other abnormalities
•  The CBD is often dilated using a small balloon, which is filled with air and dragged along the duct and out through the ampulla. This can also be used to remove stones or other material blocking the duct
•  Sometimes, a small cut is made in the ampulla (known as a sphincterotomy) to allow for better drainage of the duct and stone removal
•  Frequently, a stent is also inserted to improve drainage post procedure

Your Role as the Radiographer

• Depending on your department's equipment, you may have to stand in the room to x-ray or you may be able to stay out in the control panel. In the latter, it is important to pay close attention so as not to miss your cue to x-ray.
• Generally the doctor will ask you to x-ray when it is required. As a general rule, if they don't ask you stop, stop screening when they stop looking at the x-ray screen.
• Once you have found your initial position, it is unlikely you will have to move. This initial position is simply being centred over the common bile duct. It is difficult to know exactly where that is until contrast has been injected, but as a guide, have the tip of the endoscope at the bottom, centre of your screen. 
• The middle of the spine should be on the right edge of the screen. Depending on the size of your image plate/receptor, this should allow the entire duct to be visualised. 
• If the detector is quite large, you may be able to centre a little higher and cone down.  
• The doctor may also ask you to magnify the image as required.

Ideal Positioning for ERCP

Generally speaking, when contrast is being injected, you will be needed to x-ray, so pay attention to what is going on around you (e.g. has contrast been asked for?) so you are prepared to screen when required. The doctor will usually ask you to save/take a picture when the duct is full of contrast or when pathology (such as a stone) has been visualised. 

What preparation should you do before an exam?

Doctors are always a lot more pleasant to work with when everything goes smoothly. This frequently will have nothing to do with you, but there are a few simple tips you can do to help:

• Have the patient ID details ready before the procedure begins so you are ready to x-ray straight away
• If you use cassettes, have as many clean cassettes ready as possible and have them as close as possible so they can be changed quickly as multiple quick images are often desirable
• Change any imaging settings (e.g. horizontal or vertical flip, magnification) so the image is correct from the first point of screening
• Where possible, stand in a position out of the way of the doctor/nurses as they often move around a lot
• Ensure everyone in the room is wearing a lead gown - including the patient if they are young
• Bring the detector as close to the patient as possible to decrease magnification and reduce scatter
• Pay attention!! Try to anticipate when you will need to screen. Doctors don't like to ask twice!!