Digital: Is the Technologist Ready?

OBJECTIVES:

Will copies of certificates or other documentation from the training provider suffice for the new mammographic modality training? Will accreditation continue to accept all mammography CME/CEU received? Will the mammography technologist require extra training to accredit within a digital site?

The new modalities are upon us. Are we ready? The ACR has some criteria on the subject. It usually follows that the CAR-MAP adopts most of the policies of American Accreditation so this becomes an interesting discussion.

What are examples of new mammographic modalities? What types of training would be acceptable as training in new mammographic modalities?

The term mammographic modality refers to a technology for radiography of the breast. Examples of long available mammographic modalities are screen-film mammography and Xeromammography. An example of a relatively new mammographic modality is full field digital mammography (FFDM). Personnel whose training pertained solely to screen-film mammography would be required to obtain 8 hours of training in FFDM, if they are to begin providing services or interpretations using this modality after April 28, 1999. However, if those personnel gained their experience using investigational FFDM units (units that were used for research purposes before being approved by FDA for commercial distribution), they are considered to have met the 8 hour requirement. New mammographic modality training can be in many forms, including, but not limited to, professional training, special training courses, continuing medical education, and training provided by the manufacturer.

Some personnel may receive some training in full-field digital mammography as part of their initial qualifications or have received specialized digital CME. In addition to counting toward their initial requirements, can this training also be applied to the eight hour mammographic modality training requirement?

Yes. They may use this training in digital mammography to count toward the eight hour mammographic modality training.

Can experience obtained using investigational Full Field Digital Mammography (FFDM) units count toward the 8 hour mammographic modality training requirement?

Yes; mammography technologists who began performing FFDM examinations on investigational FFDM units (units that were used for research purposes before being approved by FDA for commercial distribution), are considered to have met the requirement for 8 hours of training with that mammographic modality. However, these technologists must either attest to or document that they were providing such services. An example of acceptable documentation would be a letter from an appropriate official at the facility where the examinations were performed. Radiologic technologists who begin working with non-investigational FFDM units after April 28, 1999 must document that they had 8 hours of training in that mammographic modality before independently performing FFDM examinations. Radiologic technologists must document this training using the same methods as those used to document other training (certificates, letters from the training provider, etc.).

Are there any requirements for the content of the FFDM training and are they affected in any way by the changes in the field such as the publication of a new QA manual, FDA approval of soft copy interpretation, or the introduction of a new FFDM model by a manufacturer?

The 8 hours of initial training related to FFDM should include practical (hands-on) training in any aspects of the use of such systems such as the procedure for performing a FFDM examination and FFDM QC testing to be performed by the technologist. The remainder of the 8 hours, if any, can be didactic or practical training related to any aspect of FFDM. The instruction must be provided by a qualified instructor. Such training can also be counted towards the mammography technologist’s continuing education requirement.

FDA strongly recommends that Radiologic technologists whose 8 hours of FFDM training did not include any training in QC tests related to soft copy interpretation, obtain such practical training under a qualified instructor before beginning to independently perform such tests.

For other changes that can occur in the field, such as introduction of a new quality control manual by the manufacturer or the introduction of a new model of a FFDM unit, the same general principle as described above should be followed. If the new manual or model introduces new unique features to an FFDM system that fall into the technologist’s area of responsibility, practical training under a qualified instructor on those features should be included in the training of any technologist who has not already met the 8 hour requirement. Radiologic technologists who have previously met this requirement should also receive training in the new unique features under a qualified instructor before beginning to use them independently.

What qualifications have to be met by the individual providing the training?

The individual providing the training must be a qualified instructor. A qualified instructor is defined as an individual whose training and experience adequately prepares him or her to carry out specified training assignments. FDA recognizes Radiologic technologists who have previously met the 8 hour requirement for FFDM training as qualified to instruct other Radiologic technologists in this area.

If a mammography technologist has worked with stereotactic biopsy systems with digital image receptors before 1999. Are they considered to have met the 8 hours of training specific to FFDM?

No. Because these stereotactic biopsy systems are currently excluded from MQSA regulation, experience with these systems cannot be used to meet the requirement of 8 hours of training specific to FFDM.

I’m a Radiologic technologist and received training in current digital image receptors used for stereotactic biopsy. Can that training count toward the 8 hours of training specific to FFDM?

Training received in digital image receptors used for stereotactic biopsy after 1999 can count toward the 8 hours of training specific to FFDM if the training is essentially the same as that being given for FFDM. For example, if the technologist received training in the performance of a QC test for stereotactic digital image receptors, and the FFDM QC test is essentially the same as the stereotactic QC test; that training could count toward the 8 hours of training specific to FFDM.

What is the training requirement for a QC technologist working with digital units?

The QC technologist at a facility using a FFDM unit must be a qualified technologist who also meets the training requirement for performing FFDM examinations.

We do not have an FFDM unit at our facility; however, some of our personnel use an FFDM unit at another facility. Are we responsible for maintaining documentation showing that these people have received their initial training in the new mammographic modality?

No. Only the facility at which these personnel are actually using the FFDM unit is responsible for maintaining the documentation.

CONCLUSION:

Just because we don’t "have to" doesn’t mean we shouldn’t. It is logical to conclude that the working mammography technologist will benefit from some formal training regarding new technologies. These guidelines for preparation are sensible and within reason.

Gone are the days when our new modalities and tools are simple enough for us to master with a couple of hours applications. We will serve our patients better if we come to them well prepared. Seek the knowledge and share it.

Processing

Objectives:

Although digital imaging and CR PACS is becoming more popular and the common knowledge seems to be that the processor is growing to be extinct; we, the technologist on the floor where the action takes place still are responsible for the care and feeding of more processors than PACS systems. Until we are all basking in the cool light of the film-less Mammography suite here is some help.

Emulsion wet, streaky, milky, sticky or crinkled films; what to do? Who to call? It is so-o-o-o frustrating to start having processor problems in the middle of a busy day. If we know a little about what our chemistry is doing to our films it can help us identify the problem and eliminate the mess.

We may still need ‘the man’ but if we can direct him straight to the problem we can get him in and out of the department in record time.

We are not service engineers or photo chemists; it is not essential for us to know how to repair the processor or how to restore our chemistry. It is, however, our mandate to produce the best images in the most economical, efficient way possible. The more we know about how our images are produced and maintained the better we can accomplish our ultimate goal.

Development:

What is it?

Our developer turns the silver halide crystals in the emulsion that have been exposed to radiation to black metallic silver. The silver halide crystals that have not been exposed are not affected.

What are the most important factors affecting development?

1. immersion time
2. temperature
3. activity (type, concentration, replenishment, agitation)

What is in developer and what does it do?

CHEMICAL	COMPONENT	FUNCTION
Phenidone + Hydroquinone	The reducing agent	This chemical reduces (turns) the exposed silver halide crystals into back metallic silver.
Sodium Carbonate + Potassium Hydroxide	The activator or accelerator	This chemical swells and softens the emulsion and produces an alkaline environment.
Sodium Bromide or Potassium Bromide	The restrainer(starter)	This chemical restrains or stops the reduction of the unexposed silver halide crystals.
Sodium Carbonate/Bicarbonate or Sodium Hydroxide + Boric Acid	The buffer	This chemical maintains the base or alkaline nature of the solution. The pH of the developer should be maintained at 10.5.
Sodium Sulfate or Potassium Sulfate	The preservative	This chemical reduces oxidation and maintains the freshness of the chemicals.
Gluteraldehyde	The hardener	This chemical controls the softening and swelling of the emulsion.
Water	The solvent	Water holds the developer chemicals in solution.

Fixation:

What is it?

The effect of the fixer is twofold. First it stops or arrests the development action of the exposed silver halide crystals. Secondly it loosens and removes the remaining unexposed silver halide crystals leaving differing shades of gray on the film base.

What are the most important factors affecting fixation?

1. immersion time
2. temperature
3. activity(type, concentration, replenishment, agitation, exhaustion)

What is in fixer and what does it do?

CHEMICAL	COMPONENT	FUNCTION
Ammonium Thiosulphate	The clearing agent	This chemical clears the undeveloped silver halide crystals from film base.
Sulfuric acid	The activator	This chemical stops the development action and produces an acid environment.
Sodium sulfite	The preservative	This chemical reduces exhaustion and maintains the freshness of the solution.
Aluminum Chloride	The hardener	This chemical shrinks and hardens the emulsion.
Sodium Acetate + Acetic Sodium Bisulfate	The buffer	This chemical maintains a stable acid environment of pH 4.5.
Water	The solvent	The water holds the fixer chemicals in solution.

Wash Cycle:

What is it?

The wash cycle removes the chemical residue left behind by the process of development and fixation.

What are the most important factors affecting the wash?

1. The water temperature (must be significantly cooler than the development temperature)
2. The length of time the films are washed.
3. The circulation of the wash water (at least 2 to 3 gallons per minute)

Drying Cycle:

What is it?

The drying process squeegees the water from the film base and dries and hardens the gelatin base for storage.

What are the most important factors affecting the drying cycle?

1. The temperature of the air used to dry the films has to adequate to dry thoroughly but gentle enough not to burn the delicate emulsion.
2. The air used for film drying must be the correct humidity.
3. There must be adequate airflow over and around the films.

A Little Troubleshooting advice:

Ten Really Easy Things to Do at the First Sign of Trouble:

1. Check your water supply is: on, hot water OK, cold water OK, pressure OK, not contaminated.
2. Check the wash tank drain is closed.
3. Check the temperature of both the developer and fixer (by hand).
4. Check the levels of all the chemicals in your processor.
5. Check your replenishment rates.
6. Check the setting on your sensitometer.
7. Check the setting on your densitometer.
8. Check the pH level of the developer (10.5) and fixer (4.5) with litmus paper.
9. Run a second strip from the QC film box and recheck parameters.
10. Run a strip from a fresh box of film and recheck parameters.

What’s the Problem & Where to Look?

• Low-density films or poor penetration – MR/mAs, AEC, kVp.
• Decreased resolution — focal spot, phantom image, screen contact.
• Decreased contrast – kVp, HVL, mR/mAs, compression.
• Recurring artifact – screens, cassettes, film bin, processor rollers, compression.
• Grid lines – grid motion, defective grid mechanics.

Troubleshoot Your Phantom Image:

Resolution (clusters):

1. Is the contrast stable? If not, see #2.
2. Is the optical density stable? If not, check processor and place AEC on middle position, reverse your phantom so target is near film, if no improvement, check film/screen contact, screen speed and processor artifacts
3. If contact film improves resolution check focal spot.

Contrast (masses):

1. Check processor
2. Trend charts,
3. Optical density (processor, AEC)
4. Grid
5. kVp
6. HVL

Artifacts on image:

1. Retake image with same screen; feed film into processor OPPOSITE to the first film
2. If artifacts turn 90 degrees your problem is with a processing roller
3. If the marks remain the same they are either, on the screen (clean) or with the unit (service)

Troubleshoot Your Processor:

Temperature fluctuations

1. Check developer temperature with calibrated thermometer
2. Check rinse water temperature ( should be about 5 degrees lower than your developer temperature)
3. Check that hot air fans stop when no film is running
4. Check developer thermostat

Speed decrease (too light):

1. Chemistry? Too dilute, expired, ammonia smell
2. Replenishment? Not sufficient, blocked line
3. Developer? Agitating, still, temperature too low

Speed, contrast and/or base + fog increase (too dark):

1. over replenishment
2. Chemistry? Too concentrated, no starter, temperature too high

Contrast poor:

1. Chemistry? Brand change, environment change etc.
2. Temperature? Too low or too high
3. Extended processing? OK
4. Chemistry? Expired, diluted, contaminated

Conclusions:

Good, clean, sharp, high contrast images are consistently possible if we pay attention to a few details. This sometimes feels like a never ending, thankless job, however, our patients very lives might depend on it so I guess its just grit our teeth and get on with it. I hope the preceding charts will make the task a little faster, a little easier, a little more cost and time efficient.

Patient Assessment Vital Signs

Objectives:

In today’s highly integrated, intensely technical and increasingly invasive diagnostic imaging environment it becomes necessary for today’s technologist to understand and practice good patient assessment. There is no getting around it; we are professionals who are responsible for our patient’s welfare while they are in our care.

The skills we need are not controlled acts, they are not the private domain of others and they are easily within our scope of practice.

What are vital signs?

Vital signs are measurements of the body's most basic functions. Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.The four main vital signs routinely monitored by medical professionals and healthcare providers include the following:

• body temperature
• pulse rate
• respiration rate (rate of breathing)
• blood pressure (NB. blood pressure is not considered a vital sign, but is often measured along with the vital signs.)

What is body temperature?

The normal body temperature of a person varies depending on gender, recent activity, food and fluid consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature, according to the American Medical Association, can range from 97.8° F (or Fahrenheit, equivalent to 36.5° C, or Celsius) to 99° F (37.2° C).

What is fever?

Fever (also called pyrexia) is defined as body temperature that is higher than normal for each individual. It generally indicates that there is an abnormal process going on within the body. The severity of a condition is not necessarily reflected by the degree of fever. For example, influenza may cause a fever of 104° F, while pneumonia may cause a very low-grade fever or no fever at all. Body temperature may be abnormal due to fever (high temperature) or hypothermia (low temperature). A fever is indicated when body temperature rises above 98.6° F orally or 99.8° F rectally. Hypothermia is defined as a drop in body temperature below 95° F.

A person's body temperature can be taken in any of the following ways:

• Orally

Temperature can be taken by mouth using either the classic glass thermometer, or the more modern digital thermometers that use an electronic probe to measure body temperature.

• Rectally

Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7° F higher than when taken by mouth.

• Axillary

Temperatures can be taken under the arm using a glass or digital thermometer. Temperatures taken by this route tend to be 0.3 to 0.4° F lower than those temperatures taken by mouth.

• By ear

A special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature (the temperature of the internal organs).

NB. According to the Environmental Protection Agency (EPA), mercury is a toxic substance that poses a threat to the health of humans, as well as to the environment. Because of the risk of breaking, glass thermometers containing mercury should be removed from use and disposed of properly in accordance with local, state, and federal laws. Contact your local health department, waste disposal authority, or fire department for information on how to properly dispose of mercury thermometers.

What is the pulse rate?

The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate, but also can indicate the following:

• heart rhythm
• strength of the pulse

The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to have faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular conditioning, may have heart rates near 40 beats per minute and experience no problems.

Taking a Pulse: As the heart forces blood through the arteries, you feel the beats by firmly pressing on the arteries, which are located close to the surface of the skin at certain points of the body. The pulse can be found on the side of the lower neck, on the inside of the elbow, or at the wrist. When taking your pulse:

• Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.
• Begin counting the pulse when the clock's second hand is on the 12.
• Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute).
• When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.
• If unsure about your results, ask another person to count for you.

What is the respiration rate?

The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and with other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing.

Normal respiration rates for an adult person at rest range from 15 to 20 breaths per minute. Respiration rates over 25 breaths per minute or under 12 breaths per minute (when at rest) may be considered abnormal.

Conclusion

The skills of every profession change and evolve with the expanding of knowledge and the revising of best practice. If we want to continue to practice within this changing atmosphere then we must learn and carry out the skills to do so.

Technologist’s Breast Imaging Quiz (Entry level): Pathology

1. Which of the following are potential causes of breast edema?

a) Cancer

b) Lymph obstruction

c) Inflammatory disease

d) Hodgkin’s lymphoma

e) All of the above

2. Which of the following characteristics of calcification are usually benign?

a) Unilateral

b) Varied densities

c) Indian line

d) Dense

e) Tea-cup shaped

3. Which of the following characteristics of masses are usually malignant?

a) Irregular margin

b) Follow parenchymal lines

c) Radiopaque

d) Radiolucent

e) Palpable

4. Which of the following aspects of calcification usually require biopsy?

a) Decreased number

b) Lucent centers

c) Increased number

d) Decreased density

e) Rim

5. Which of these masses would probably be benign?

a) Stellate

b) Fixed

c) Smooth margin

d) Indistinct margin

e) Feels larger than it appears

6. Which of the following is a common cause of calcifications?

a) Necrosis

b) Atrophy

c) Fibrocystic change

d) Lipoma

e) Lymphedema

7. A lipoma is:

a) Radiopaque

b) Firm/fixed

c) Malignant

d) Never seen mammographically

e) Radiolucent

8. Which of the following is the most common neoplasm in the breast?

a) Cysts

b) DCIS

c) Internal mammary nodes

d) Fibroadenoma

e) Lipoma

9. Which of the following aspects of calcification probably would NOT required follow-up?

a) Increased density

b) Lucent centers

c) Increased number

d) Varied sizes

e) Irregular borders

10. Which of the following is a primary presentation of breast pathology?

a) Unilateral pain

b) Bilateral discharge

c) Asymmetry

d) Nipple inversion

e) Mass

11. Which of the following characteristics of a mass is considered benign?

a) Dense

b) Encapsulated

c) Fixed

d) Firm

e) Indistinct

12. Which characteristic of nipple discharge is clinically significant?

a) Creamy

b) Bilateral

c) Expressed

d) Spontaneous

e) Persistent

13. Architectural distortion is:

a) Disruption in the natural flow toward the nipple

b) Converging radial lines

c) Radial scarring

d) Diametrically opposing parenchyma

e) Patterns from surgical scarring

14. A malignant breast mass is usually

a) Occult

b) Mobile

c) Fixed

d) Oval

e) Smooth

15. What is the most common breast symptom?

a) Mastaglia

b) Cysts

c) Dysplasia

d) Lump

e) Nipple discharge

16. A simple cyst is:

a) Indefinite

b) Hallowed

c) Radiolucent

d) Ill-defined

e) Immobile

17. An infiltrating carcinoma:

a) Feels smaller than it looks

b) Moves easily within the breast

c) Has smooth borders

d) Is very uncommon

e) Has a stellate presentation

18. Paget’s Disease of the breast presents with:

a) A smooth mass

b) Low density calcifications

c) Morgagni’s tubercles

d) Eczema type rash

e) Stag-horn calcifications

19. Unilateral red, hard, hot, extremely tender breast tissue might indicate:

a) Fibrocystic condition

b) Mastitis

c) Sunburn

d) LCIS

e) Fibroadenoma

20. A tubular breast lesion is:

a) Benign

b) Common

c) Cystic

d) Bilateral

e) Malignant

SUMMARY:

I hope this little tech quiz has peaked your interest. If you had to guess at any of the answers all explanations are revealed in my manual “THE MAMMOGRAPHER’S COMPANION.” (If you think you or your department would benefit, you can order a copy directly from me. Send an email for details.). The simple answer key follows:

1. e)

2. d)

3. a)

4. c)

5. c)

6. a)

7. e)

8. d)

9. b)

10. e)

11. b)

12. d)

13. a)

14. c)

15. a)

16. b)

17. e)

18. d)

19. b)

20. e)

Technologist’s Breast Imaging Quiz (entry level): Anatomy

1. Where is the skin covering the breast normally the thickest?

a) Base

b) Areola

c) Nipple

d) Axillary tail

e) Equal thickness

2. Which quadrant of the breast usually includes most of the glandular tissue?

a) Lower outer

b) Upper outer

c) No particular quadrant

d) Lower inner

e) Upper inner

3. What term describes the fasciae bands that support the breast?

a) Cooper’s ligaments

b) Parenchyma

c) Superficial fascia

d) Pectoralis major

e) Deep fascia

4. How many lobes are normally found in each breast?

a) 2-3

b) 5-10

c) 15-20

d) 30-35

e) over 35

5. What term describes the cone shaped structure that lies just below the areola?

a) Ampulla

b) Inframammary fold

c) Retromammary space

d) Tail-of-Spence

e) Lactiferous duct

6. Which of the following describes the junction between the inferior border of the breast and the anterior chest wall?

a) Axillary tail

b) Inframammary fold

c) Deep fascia

d) Retromammary space

e) Tail-of-Spence

7. What term describes the area between the posterior aspect of the glandular tissue and the anterior aspect of the pectoralis muscle?

a) Axillary tail

b) Inframammary fold

c) Lactiferous ducts

d) Cooper’s ligaments

e) Retromammary space

8. Which of the following terms describe the embryologic origin of the female breast?

a) Mammalian

b) Hair follicle

c) Sweat gland

d) Skin pore

e) Sebaceous gland

9. Which of the following is an effect of estrogen?

a) Lobular proliferation

b) Lobular regression

c) Parenchymal fatty replacement

d) Ductal proliferation

e) Involution of the senescent breast

10. The physiologic function of the breast is performed by…

a) The glands

b) The tubercles

c) The lobes

d) The acini

e) The lobules

11. The distal portion of the ductal system + the acini make up…

a) The segments

b) The glands

c) The TDLU

d) The lobules

e) The ductules

12. The ductules are part of the…

a) Terminal duct lobular unit

b) Lymph system

c) Lobes

d) Cooper’s ligaments

e) Branching ducts

13. The functional mammary tissue is divided into 15-20…

a) Acini

b) Lobules

c) Ducts

d) Nodes

e) Lobes

14. The portion of the breast that extends laterally and superiorly from the centre is commonly termed…

a) Axillary nodes

b) The upper quadrant

c) The axilla

d) The tail

e) The Ampulla

15. Which borders of the breast are most mobile?

a) Superior/inferior

b) Medial/lateral

c) Inferior/lateral

d) Inferior/medial

e) Superior/lateral

SUMMARY:

I hope this little tech quiz has peaked your interest. If you had to guess at any of the answers all explanations are revealed in my manual “THE MAMMOGRAPHER’S COMPANION.” (If you think you or your department would benefit, you can order a copy directly from me. Send an email for details.). The simple answer key follows:

1. a)

2. b)

3. a)

4. c)

5. a)

6. b)

7. e)

8. c)

9. d)

10. d)

11. c)

12. a)

13. e)

14. d)

15. c)