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!!

Top 10 - Worst Reasons For Ordering a Mobile Chest X-Ray (and what your response should be)

10. The Doctor said it should be mobile
(Ok, but did they say why?)

9. The patient is tired
(Not going to make them run down here)

8. The patient is having lunch
(Can't be super urgent then)

7. The patient is about to go home
(Then do they actually need an x-ray? If yes, surely they are now well enough to visit our fine department?)

6. The patient doesn't feel like coming down to the department
(Did you tell them we have heated blankets down here?)

5. We lost the pre-op films
(Thank goodness for online storage)

4. The patient is on oxygen
(They have recently invented portable oxygen bottles)

3. We forgot to order it last night
(Then we'll do it this morning??)

2. The patient has pain
(They are in hospital - par for the course - we promise not to make them do yoga while they're down here)

1. Well, you are already x-raying the patient next door so while you're here….

(What if we stand them side by side and do it at the same time?)

Top 10 Tips - Students Going On Practical Placement

10. Research your location
Workplaces like to know you have an interest in what they do so try and find out what modalities are available, what kind of procedures are performed, whether they work in conjunction with other hospitals or private practices etc. This will also allow you to figure out what you can best get out of the placement.

9. Review what should already know
It's often a long time between pracs for student and you are bound to forget things so try and brush up on your anatomy, positioning and common protocols for examinations you have learnt on previous placements. Make sure you are also confident with the theory of examinations you have just learnt and will be performing for the first time on placement. Workplaces often become frustrated when students are in their 2nd and 3rd year and can't do the basics right, so make sure you know your anatomy, positioning and protocols for simple examinations like chests, abdomens and extremities.

8. Ask questions…at a good time
Qualified radiographers are usually only too happy to answer your questions and make sure you understand what your doing, but there is nothing worse than a student tailing you with thousands of questions when you are run off your feet. Try to ask questions away from the patient so they don't feel as though they are a test subject. Also, if the department is busy or the radiographer you are working with is involved in a difficult case, wait until you have finished and the madness has calmed down so they have time to think and answer you properly.

7. Don't just work with other students
It can be great having other students around to help each other out, but you will learn more working with qualified radiographers. Also, have 2 or 3 students all helping can be overwhelming for the patient and often leads to examinations taking longer with more mistakes (too many cooks in the kitchen). Furthermore, it can be off putting for a student having other students watching them. Try and spread out and working one on one with other radiographers.

6. It's not all about the competency
If you have to get "signed off" or marked as "competent" for particular examinations, advise staff of what they are at the beginning of your placements so they can offer you the chance to perform these examinations as they come up. Remember however that it is not always convenient to have a student complete an examination as a competency (e.g. when the department is very busy) so try and consider if it a good time before you ask. Make sure you are confident with performing the examination by yourself and don't try and claim one when you haven't really performed it properly. There is nothing worse than students continuously bugging you to sign something off that really aren't competent in doing.

5. Work as part of the team
Try and get involved in all aspects of the workplace, not just x-raying. If there is a complicated patient, ask how you can help get the job done faster. If there isn't much work and people are cleaning, restocking, doing paperwork etc, ask if you can help out with anything. Workplaces really appreciate having students pitch in without having to ask them and tend to remember this when they want a job!
It's also fun to get to know staff outside of work so if you get invited along to something, try to go, it will make working there a much more sociable and enjoyable experience.

4. Take on advice, don't give it
This might sound really arrogant but it is rarely appreciated when a student tells a qualified radiographer what to do. If you think they are doing something wrong, ask them (away from the patient) "is there a reason you do this that way?" or "can this also be performed like this?" Furthermore, if you are told to do something a particular way, there is probably a reason - generally its protocol. If you are really doubtful that what you are being told is correct, ask another radiographer in private. If you are given advice on areas to improve on, take the advice on board, nothing looks worse than a student who appears to know everything and can't be taught.

3. Practice makes perfect
One thing I often see with students, especially in their final year, is they get sick of doing "easy" examinations like chests, hands and feet, however you are never too good to do another x-ray. Just because you may be "competent" at something, doesn't mean you shouldn't keep practicing. So if a radiographer asks if you'd like to perform a certain examination, always say yes! If there is a different procedure you'd rather try to get more practice, explain this to them, but don't ever say "I can already do that" or "I don't need to do any more of those." That's a pretty quick way to get disliked!

2. Be punctual and don't clock watch
It can often be difficult getting to placements which are far from home or require a lot of public transport, but try to arrive 10-15 minutes before your shift starts. This shows staff that you are professional and enthusiastic and makes a good impression if you want a job. Also, don't stand around all day complaining about how much longer before lunch/going home etc - we're all probably thinking it, but try not to say it, it's not a good look! We also appreciate you may have to leave at a certain time for transport or other commitments and people will forget what time you are supposed to leave but it's nice to ask "would it be ok if I head off now, so I can the train?" etc rather than just leaving. If the department is busy and you can stay, offer to stay and help, it will always be greatly appreciated! One last thing, don't expect an early mark, a lot of places will do it, especially if you're not busy but asking for it makes you look kind of lazy!

1. Be polite, friendly and have fun!
Most workplaces want you to enjoy working there so the more friendly you are with staff the more enjoyable your placement will be. Don't just sit and socialise with other students, meet the other staff and get to know them and you'll make some great relationships. When it comes time to hire radiographers, workplaces often look for someone who will "fit in" with their staff, so the more you socialise and are friendly with the staff, the better impression you will leave!