COMMON POSITIONING PROBLEMS: The Solutions!

OBJECTIVES:
No matter which modality we are using, no matter whether we are practicing screening or diagnostic mammography, no matter what: We still have to position our patients so that all the breast tissue is demonstrated.

That is always a challenge and all the help that comes our way is useful. Here are some tips regarding positioning dilemmas with some handy remedies. I hope they are helpful.

I. THE CC PROJECTION: “IF”

A. The nipple is not in profile


If the nipple is not in perfect profile:

1. Elevate the IMF a little higher
2. Lift and pull the breast straight onto the bucky
3. Use both hands to handle the breast

(Hint): The nipple points toward the missing tissue

B. The medial Cleavage is not open and visualized


If the medial cleavage is not visualized properly:

1. Position from the medial side
2. Lift and drape opposite breast over the edge of the bucky
3. Do not press the patient’s face against the face protector
4. Place her head beside and beyond the tube

C. The lateral aspect or ‘Tail-of-Spence’ is not demonstrated


If the lateral aspect of the breast is not seen:

1. The Patient’s arm should be relaxed by side
2. Her palm should be supinated with her shoulder externally rotated
3. Control your patient’s posture with your hand around her back on her contra-lateral shoulder
4. She should be relaxed forward bent slightly at the waist
5. Release the breast to the compression with forward and medial orientation of your hand

D. The pectoral shadow is not visible at the chest wall and/or the PNL is not within 1cm of the PNL on the MLO

If the ½ moon of pectoral shadow is not seen at the chest wall of the CC view and/or the PNL is of an inadequate length:

1. Elevate the IMF until the tissue no longer moves easily along the chest wall
2. Identify the edge of the pectoral muscle visible just under the clavicle
3. Loosen the skin over the clavicle so the tissue moves easily
4. Compress parallel to the pectoral edge just under the clavicle
5. Release hand in a forward medial motion

II. THE MLO PROJECTION: “IF”

A. The pectoral muscle is not demonstrated to or below the level of the nipple


If the pectoral muscle is not seen to the level of the nipple or below:

1. Adjust your tube angle parallel to the obliquity of the patient’s pectoral muscle
2. Move the breast medially and anteriorly from the lateral border until the pectoral pouches out next to the sternum
3. Compress the projection parallel to the pectoral axis along the sternal edge

B. The pectoral muscle is not relaxed and convex in shape


If the pectoral shadow does not appear convexly shaped:

1. DO NOT rest your patient’s arm along the top edge of the bucky
2. Patient’s shoulder should be open, relaxed
3. The corner of the bucky high up and well back in the axilla
4. Patient’s arm should be slightly bent hanging loosely down the back of the bucky
5. Relaxed hand…NO gripping the handle

C. The breast is not 'up and out' and/or the retro mammary space is not visualized behind the parenchyma.


If the retro mammary space is obscured by parenchyma and the breast is not adequately ‘up & out’:

1. Move the breast from the lateral edge medially
2. Ensure the breast mound moves freely in your grip
3. Support the breast tissue from the inferior border using you entire hand
4. Immobilize the breast tissue on the bucky in the ‘up & out’ position using the edge of your hand to support the pectoral axis along the sternum
5. Release the breast to compression with a distinct out and away motion

D. The Infra-mammary Fold is not clearly seen curving to the abdomen un-obscured by wrinkles, folds or belly

If the IMF is not open and fold free:

1. Support the breast and always release with and up & out motion
2. Have the patient tilt her hips slightly backwards
3. Do not release your hold on the breast until the projection is immobilized by the compression
4. Gently run your thumb and finger down behind the breast along the IMF/belly border to clear folds, wrinkles and tummy

E. Nipple is not in profile


If the nipple shadow is not in perfect profile:

1. Make sure the patient’s feet are directly facing the bucky
2. Control the breast from the mobile lateral border only
3. Immobilize the breast parenchyma parallel to the pectoral muscle until the compression holds the projection

(Hint): The nipple points toward the missing tissue

SUMMARY
Mammography is a sensitive, complicated and difficult specialty. All our patients vary as to body habitus, temperament and compliance. It is essential we demonstrate all the tissue, see it clearly and know that all the borders of the breast are verified.

Breast Imaging is an area of DI where we work autonomously much of the time. We are responsible for checking and correcting our own work. I hope these tips will assist in the arduous task of perfecting your technique and knowledge.

ASSESSING THE QUALITY & REVIEWING OF OUR IMAGES: A New View

OBJECTIVES

With the onset of digital imaging the process of assessing our images has expanded from not only being able to produce excellent images but to being able to view them in high definition. Doing away with high contrast single emulsion film and high quality thin phosphorescent screens has simplified our QC lives in many ways eliminating many tedious tasks. However, now that our images are beamed through the stratosphere and displayed on a distant monitor, the display unit becomes crucial.

This article will be reviewing the image evaluation using the good old RMI which is still an indispensable standard in quality image production. It will also demonstrate method and rationale for careful monitor evaluation using the SMPTE test pattern.

RMI Phantom Evaluation Review:

Objective

The purpose of performing and evaluating the 'phantom test' is to identify weaknesses in our imaging chain and correct them.

Frequency

Weekly immediately after processor QC

Equipment

• RMI 156 or equivalent mammography testing phantom

• Designated QC cassette, tested and cleaned

• Mammography film from working film bin

• The acrylic OD difference disc

• Densitometer

• Magnifying glass

• Phantom worksheet or control chart

PROCEDURE

• Orient the phantom in the correct manner.

• Place your optical density acrylic disc on top of the phantom in the same manner every time. Mark the placement of the disc with an indelible marker.

• Do NOT glue the disc to the phantom.

• Lower the compression paddle onto the phantom and the disc.

• Position the photocell in the middle of the wax insert.

• Expose the phantom and acquire the image

PHANTOM IMAGE SCORING

Optical Density Difference of Phantom Image (for film/screen):

• Using your densitometer, take the OD of the phantom image in the middle of the wax insert and record the value.

• Take the OD in the center of the acrylic disc and record the value.

• Subtract the OD value of the acrylic disc from the background OD value.

• This represents your ' density difference'.

• The density difference MUST be above 0.4 to be acceptable.

Scoring of Phantom Image:

• RMI phantom images should be reviewed under optimal and identical viewing conditions by the same technologist each time.

• A minimum of the four largest fibers (4/6) should be seen in their entirety. To receive a score of 1 fiber the entire fiber must be seen. If the whole fiber cannot be seen the fiber may be given a score of .5. Score the individual fibers counting from the largest to smallest fiber adding the results together until you encounter a partial score (0.5). This is your total score; no more fibers may be counted.

• A minimum of the three largest speck groups (3/5) should be seen. Four to six specks in each group must be seen to result in a score of 1 speck group. If only two or three specks are seen in any group, that group may be given a score of .5. Score the speck groups from the largest to the smallest adding the results together until you encounter a partial score (0.5). This is your total score; no more specks may be counted.

• A minimum of the three largest masses (3/5) should be seen. Both a density difference and an entire circumscribed edge will result in a score of 1 mass. If only the density difference or part of the edge is seen the mass may be given a score of .5. Score the masses form the largest to the smallest adding the results together until you encounter a partial score (0.5). This is your total score; no more masses may be counted.

• Examine the image background for any artifacts that appear similar to a fiber, speck or mass. For a fiber-like artifact, subtract 1/2 a point for each artifact from your fiber score. For a mass-like artifact, subtract 1/2 a point for each artifact from your mass score. Subtract one speck for each speck-like artifact from the final group of specks scored.

• Record individual scores for fibers, specks and masses on you control chart weekly. The scores for any individual group should not decrease by more than 0.5.

Evaluating the Image on the Monitor: SMPTE Test Pattern Tutorial

Brightness and contrast:

The brightness and contrast of your monitor are adequately set if the 5% squares at both ends of gray scale are visible.

Using the pattern below: The gray scale is shown as a series of squares in the center of the image that range from black (0%) to white (100%) in a semi-rectangle. The 0% and 100% squares (see arrows on image) each contain smaller squares within them that represent signal level steps of 5% and 95%, respectively. You should be able to visually differentiate the inner square from the larger square that contains it.

Be aware that it may be impossible to adjust your monitor to show both of these inner squares perfectly and equally. Most video monitors do better in showing the 95% square than the 5% square. However, you might see if reducing ambient light improves the visibility of the 5% square.

BRIGHTNESS AND CONTRAST

:

Spatial Resolution and Distortion:

The spatial resolution (linearity) and aliasing (distortion) of your monitor are within acceptable limits if the high contrast bar patterns in the test image are distinct as simple patterns of black and white pairs.

Using the pattern below: In each corner of the image as well as in the very center (see arrows on image), inspect the 6 squares filled with varying widths of alternating black/white horizontal and vertical lines. You should be able to differentiate all the lines, from fat to narrow (6 pixels, 4 pixels, and 2 pixels) and both horizontally and vertically.

SPATIAL RESOLUTION AND DISTORTION:

SUMMARY:

A lot of things are changing in the wonderful world of breast imaging, but one of the things that remains is producing and displaying sharp detailed images. As our technologies expand and our expertise grows we are able to assure excellence in our images both out of the unit and on the display screen. One day the radiologist may be viewing these pictures on his Blackberry and we will be up to that challenge also.

Keep on growing, knowledge is power!

CARDIAC DISORDERS: Heart Problems in the Mammo Suite (Part 3)

SERIES OBJECTIVES:

Mammography is a specialty that requires us to be advocates to the public for all manner of health related issues. Breast imaging has a personal and emotional component to it. Our patients trust us, place their faith in us and rely on us to be knowledgeable in many areas of health care.

On the whole we deal with middle aged female patients. Recently it has been shown in clinical trials that this demographic is a dire risk of heart attack and other cardiac disorders simply by not knowing they are at risk. We have a responsibility, not to diagnose, not to treat, but to be able to give cogent, informed advice when asked because she may never ask anyone else.

This month begins a three part series on the hearts of our patients. Although this seems like a topic that does not relate to our specialty, all knowledge is power. Accept the knowledge and use it to edify your life.

PART THREE: ACUTE MYOCARDIAL INFARCTION - HEART ATTACK

OBJECTIVES
Acute myocardial infarction (AMI or MI), more commonly known as a heart attack, is a medical condition that occurs when the blood supply to a part of the heart is interrupted. The term myocardial infarction is derived from myocardium (the heart muscle) and infarction (tissue death due to oxygen starvation). The phrase "heart attack" is sometimes used incorrectly to describe sudden cardiac death, which may or may not be the result of acute myocardial infarction. A heart attack is different from, but can be the cause of cardiac arrest, which is the stopping of the heartbeat, and cardiac arrhythmia, an abnormal heartbeat. It is also distinct from heart failure, in which the pumping action of the heart is impaired; severe myocardial infarction may lead to heart failure, but not necessarily.

What is a Heart Attack?







Risk Factors:

• A history of vascular disease such as atherosclerotic coronary heart disease and/or angina
• A previous heart attack or stroke
• Any previous episodes of abnormal heart rhythms or syncope
• Older age—especially men over 40 and women over 50
• Smoking
• Excessive alcohol consumption
• The abuse of certain drugs
• High triglyceride levels, high LDL (low-density lipoprotein, "bad cholesterol")
• Low HDL (high density lipoprotein, "good cholesterol")
• Diabetes
• High blood pressure
• Obesity
• Chronically high levels of stress
• Chronic kidney disease

Classic symptoms of acute myocardial infarction include:

• Chest pain (typically radiating to the left arm or left side of the neck)
• Shortness of breath
• Nausea
• Vomiting
• Palpitations
• Sweating
• Anxiety (often described as a sense of impending doom)
• Feeling suddenly ill
• Women often experience different symptoms which can include shortness of breath, weakness, and fatigue
• One third of all myocardial infarctions are silent, without chest pain or other symptoms

Cardiopulmonary Resuscitation:
If a patient in your care loses consciousness, stops breathing and is pulse-less it will be necessary for you to begin life saving procedures until the EMS or the Code Blue teams arrive. For this type of emergency short term CPR only a few easy to remember steps are required. Blow here and Push there is all the drill you should need in a crisis.

CPR

1. CALL

• Check the victim for unresponsiveness
• No response
• Call a code and return to the patient

2. BLOW

• Tilt the head back and listen for breathing
• Pinch nose and cover the mouth with yours and blow until you see the chest rise
• Give 2 breaths
• Each breath should take 1 second

3. PUMP

• If the victim is still not breathing normally, coughing or moving, begin chest compressions
• Push down on the chest 11/2 to 2 inches 30 times right between the nipples

• Pump at the rate of 100/minute, faster than once per second.

CONTINUE WITH 2 BREATHS AND 30 PUMPS UNTIL HELP ARRIVES
NOTE: This ratio is the same for one-person & two-person CPR. In two-person CPR the person pumping the chest stops while the other gives mouth-to-mouth breathing.

SUMMARY
We, as mammographers, largely deal with female patients over the age of 50 years. It has been widely acknowledged that this group of patients is at risk of serious heart problems simply by not being aware they are at risk. Power is knowledge, pass it on!
Heart attack and/or cardiac death is the worst kind of patient distress that can enter our mammography suites. Fear and panic does not help. We must be able to recognize the distress, be ready to help assess the severity of the problem and, when necessary dive in with hands on assistance.

CARDIAC DISORDERS: Heart Problems in the Mammo Suite (Part 2)

SERIES OBJECTIVES:

Mammography is a specialty that requires us to be advocates to the public for all manner of health related issues. Breast imaging has a personal and emotional component to it. Our patients trust us, place their faith in us and rely on us to be knowledgeable in many areas of health care.

On the whole we deal with middle aged female patients. Recently it has been shown in clinical trials that this demographic is a dire risk of heart attack and other cardiac disorders simply by not knowing they are at risk. We have a responsibility, not to diagnose, not to treat, but to be able to give cogent, informed advice when asked because she may never ask anyone else.

This month begins a three part series on the hearts of our patients. Although this seems like a topic that does not relate to our specialty, all knowledge is power. Accept the knowledge and use it to edify your life.

PART TWO: HEART FAILURE

OBJECTIVES:

Heart failure sounds quite alarming. But it only means that the heart is not working as well as it used to, not that it has failed completely. Heart failure is usually a chronic (long-term) condition, with no complete cure. Treatment aims to reduce symptoms and prolong life.

People with heart failure are more prone to potentially dangerous conditions such as:

• abnormal heart rhythms (arrhythmias)

• stroke (damage to the brain caused by lack of blood supply)

• heart attack

• blood clots on the lung, in the leg veins and in the arteries of the arms and legs (called thromboembolism)

• liver problems

• depression (a third of people with heart failure develop severe depression)

What causes heart failure?

A number of conditions can cause heart failure to develop. Some examples are listed below.

• Coronary Heart Disease (Heart attack and/or Angina). The most common reason for heart failure. It causes damage to the heart muscle, preventing it from being able to pump enough blood around the body.

• High blood pressure (hypertension). This puts extra strain on the heart and can lead to heart failure over time.

• Heart valve abnormalities (either narrowed or weakened valves). These abnormalities can develop after rheumatic fever in childhood. They can be present at birth, or they may be caused by a heart attack. In developing countries this is the most common cause of heart failure.

• Heart rhythm abnormalities. A fast and/or irregular heartbeat does not allow the heart to fill with enough blood before it pumps it around the body.

• Congenital heart disease. This is a heart condition that is present at birth. For example, a hole in the heart's septum (the division between the left and right sides) can overload the heart with blood, causing heart failure to develop.

• Anemia or an overactive thyroid gland can also cause heart failure by making the heart beat too fast and work too hard.

Symptoms

One of the main symptoms of heart failure is tiredness and a lack of energy. This is because of poor blood supply to the muscles. Other symptoms depend on which side of your heart is most affected.

Left heart failure affects the side of your heart that pumps blood around your body. It commonly develops after a heart attack. Symptoms include breathlessness when exercising and/or when lying flat, severe breathlessness in the early hours, fatigue and a cough with frothy spit.

Right heart failure affects the side of the heart that pumps blood to the lungs. It often happens as a result of left heart failure, but it can also be caused certain chronic lung problems, such as chronic bronchitis. Right heart failure results in a build up of fluid in the legs that can extend over the lower back and inside the abdomen (where it is called ascites). The liver can become enlarged and there may be nausea and swollen veins in the neck. The extra fluid may cause weight gain, although severe chronic heart failure sometimes causes wasting.

Figure 1 CARDIAC/PULMARY CIRCULATION

Diagnosis

A physical examination and a review of the medical history will help the practitioner diagnose heart failure.

Diagnostic tests include:

A blood and urine test, to check things such as blood count, liver function and other markers of heart failure - B-type natriuretic peptide (BNP) is a common marker test which indicates left heart failure

An electrocardiogram (ECG), which traces the electrical activity in a heart

An echocardiogram (heart ultrasound scan), to show the pumping action of the heart and valves

A chest X-ray, to show the size of the heart and to check for fluid on the lungs

Medical treatment

A range of medicines can be used to relieve the symptoms of heart failure and slow down any worsening of the condition. Any underlying cause will be treated first (for example, drug treatment given to lower blood pressure).

The various types of drugs used to treat heart failure work in different ways.

ACE inhibitors

These drugs reduce the production of hormones which constrict blood vessels. This makes the walls of the blood vessels relax, which reduces pressure and makes it easier for blood to circulate. Overall, they improve the performance of the heart, reduce heart failure symptoms and prolong life. Side-effects can include a persistent dry cough, low blood pressure and faintness.

Angiotensin II antagonists

These act directly on the blood vessel wall to block the effects of the hormones which constrict them. Their action is therefore similar to those of the ACE inhibitors but they tend not to cause a dry cough. They are used if ACE inhibitors cause too many side-effects.

Beta-blockers

Beta-blockers are commonly used for treating high blood pressure. They also steady the heartbeat and make the heart more able to cope with exercise. In the past they were thought to be unsuitable for people with heart failure. However, studies have shown that specific beta blockers can actually help in some heart failure patients. They aren't suitable for people who have asthma.

Loop diuretics

These increase the production of urine, which helps to remove excess fluid from the body. This reduces leg swelling and removes fluid from the lungs, and can improve symptoms such as breathlessness. There are some side-effects. Diuretics can upset the balance of salts in the body (especially potassium), leading to muscle weakness, fatigue and abnormal heart rhythms. Other drugs or potassium supplements may help to counter this.

Spironolactone

This is a type of diuretic which works by interfering with the action of the hormone aldosterone. It is sometimes used if other medicines aren't helping to control the heart failure.

Digoxin

This works to slow the heartbeat and improve the heart muscle's pumping ability. It is used if symptoms aren't adequately controlled by ACE inhibitors and other drugs. Side-effects can include a loss of appetite and nausea.

Hydralazine and nitrates

ACE inhibitors or angiotensin II antagonists do not always help to control heart failure symptoms and are sometimes not tolerated. In these situations, hydralazine and nitrates, which relax the walls of blood vessels, have been shown to be useful.

Other treatments

Anticoagulants, e.g. warfarin

Blood clots are more likely to form in the heart chambers of people with heart failure and arrhythmias. These can be carried in the circulation and may block narrow vessels, preventing blood from reaching some tissue. If this happens in the brain it's called a stroke.

Anticoagulants are used to thin the blood, making blood clots less likely. Taking warfarin requires careful monitoring with regular blood tests. These drugs must be moderated before and after any interventional procedure. Thinning the blood too much, for example, can mean that an injury causes bleeding that is difficult to control.

Transplantation

For some people who have severe heart failure and a life expectancy of less than six months, a heart transplant may be an option. This can be a very successful procedure, although complications such as rejection of the donor heart can occur. It isn't suitable for all patients, and is limited by the amount of donor hearts available.

SUMMARY

The best method of controlling heart failure is of course head it off at the pass! To greatly reduce the incidence of heart failure it is vital to tackle the underlying causes. A heart-healthy lifestyle can reduce the risk of heart failure by reducing the risk of coronary artery disease and hypertension. This means not smoking, being physically active most days and eating a balanced diet. Sticking to moderate drinking and keeping a check on the blood pressure is also sensible. Most cardiac professionals also recommend you make these changes if you already have heart failure, to help prevent it getting worse.

We, as mammographers, largely deal with female patients over the age of 50 years. It has been widely acknowledged that this group of patients is at risk of serious heart problems simply by not being aware they are at risk. Power is knowledge, pass it on!

CARDIAC DISORDERS: Heart Problems in the Mammo Suite (Part 1)

SERIES OBJECTIVES:

Mammography is a specialty that requires us to be advocates to the public for all manner of health related issues. Breast imaging has a personal and emotional component to it. Our patients trust us, place their faith in us and rely on us to be knowledgeable in many areas of health care.

On the whole we deal with middle aged female patients. Recently it has been shown in clinical trials that this demographic is a dire risk of heart attack and other cardiac disorders simply by not knowing they are at risk. We have a responsibility, not to diagnose, not to treat, but to be able to give cogent, informed advice when asked because she may never ask anyone else.

This month begins a three part series on the hearts of our patients. Although this seems like a topic that does not relate to our specialty, all knowledge is power. Accept the knowledge and use it to edify your life.

PART ONE: HEART ARRHYTHMIAS

OBJECTIVES:

Heart rhythm problems (arrhythmias) occur when the electrical impulses in your heart that coordinate your heartbeats don't function properly, causing your heart to beat too fast, too slow or irregularly.

Arrhythmias are common and usually harmless. Most people have experienced these occasional, brief irregular heartbeats that feel like a skipped, fluttering or racing heartbeat. That's not surprising when you consider that your heart beats about 100,000 times a day, or more than 2.5 billion times during the average life span. However, some heart arrhythmias may cause bothersome — sometimes even life-threatening — signs and symptoms.

Signs and symptoms

Arrhythmias may not produce any signs or symptoms. In fact, your doctor might detect them before you do, during a routine examination. But often, abnormal heart rhythms cause noticeable signs and symptoms, which may include:

• A fluttering in your chest

• A racing heartbeat

• A slow heartbeat

• Chest pain

• Shortness of breath

• Lightheadedness

• Dizziness

• Fainting (syncope) or near fainting

Noticeable signs and symptoms don't always indicate a serious problem. Some people who feel arrhythmias often don't have a serious problem, while others who have life-threatening arrhythmias have no symptoms at all.

Causes

The heart is divided into four hollow chambers; divided top to bottom, the chambers on either half of your heart form two adjoining pumps with an upper chamber (atrium) and a lower chamber (ventricle). During a single heartbeat, the pumps operate in a two-phase cycle. First, the smaller, less muscular atria contract and fill the relaxed ventricles with blood. A split second later, the powerful ventricles contract and discharge blood as the atria relax and fill. Efficient blood circulation requires rhythmic coordination of this priming and pumping system. In addition, it requires proper heart rate control, which, in a normal heart, is 60 to 100 beats a minute when you're at rest. Orchestration of these two factors is performed by the heart's electrical system. Ideally, this system operates in the following three-step sequence:

• Initiation. Each heartbeat normally originates within a specialized group of cells called the sinus node. Located in the upper right atrium, the sinus node is your heart's natural pacemaker. It has the ability to spontaneously produce the electrical impulses that initiate heartbeats. Other cells within the heart have a similar ability, but they're normally inactive when the sinus node is doing its job of setting your heart's pace. Doctors refer to normal heart rhythm as normal sinus rhythm.

• Propagation. From the sinus node, electrical impulses travel through the heart. As an impulse travels, the heart muscle contracts. In a normal heartbeat, the impulse first spreads across the right, then the left atrium. After activating the atria from top to bottom, the impulse proceeds to the atrioventricular (AV) node, located at the center of the heart. The AV node normally is the only electrical path between the atria and ventricles. Within it, the impulse slows for a split second to allow the atria to fill the ventricles with blood. Exiting the AV node, the impulse is conducted along two electrical pathways (right and left bundles), which spread impulses throughout the right and left ventricles.

• Relaxation and recharging. Each cell in the heart that helps to conduct the heart's electrical impulses has two electrical states — a poised (polarized) state and a relaxed (refractory) state. In a polarized state, heart cells are ready and able to conduct the electrical impulse that will cause a heartbeat. After a heartbeat, the cells are momentarily in a refractory state before recharging to a polarized state for the next heartbeat. While it's in the refractory state, a heart cell is unable to conduct an impulse.

In a healthy person with a normal, healthy heart, it's unlikely for a sustained arrhythmia to develop without some outside trigger such as an electrical shock or the use of illicit drugs. That's primarily because a healthy person's heart is free from any abnormal elements such as an area of scarred tissue. Scarring can result from numerous problems — most commonly, from a previous heart attack — and may disrupt the initiation or conduction of electrical impulses. In addition, the inability of heart cells to conduct electrical impulses during the refractory period acts as a buffer, preventing the occasional offbeat electrical impulse from developing into an arrhythmia.

However, in a heart with some evidence of disease or deformity, the initiation or conduction of the heart's electrical impulses may be destabilized, making arrhythmias more likely to develop.

Conditions that may lead to arrhythmias Any pre-existing structural heart condition can lead to arrhythmia development due to:

• Inadequate blood supply. If blood supply to the heart is somehow reduced, it can alter the ability of heart tissue — including the cells that conduct electrical impulses — to function properly.

• Damage or death of heart tissue. When heart tissue becomes damaged or dies, it can affect the way electrical impulses spread in the heart.

These pre-existing heart conditions may include:

• Coronary artery disease. Although it has been linked to many arrhythmias, CAD is most closely associated with ventricular arrhythmias and sudden cardiac death. Narrowing of the arteries that occurs with CAD can progress until a portion of your heart dies from lack of blood flow (heart attack). An old heart attack leaves behind a scar. Electrical short circuits around the scar can prevent normal heart function by causing the heart to beat dangerously fast (ventricular tachycardia) or to quiver (ventricular fibrillation).

• Cardiomyopathy. This occurs primarily when the heart's ventricular walls stretch and enlarge (dilated cardiomyopathy) or when the left ventricle wall thickens and constricts (hypertrophic cardiomyopathy). In either case, cardiomyopathy decreases your heart's blood-pumping efficiency and often leads to heart tissue damage.

• Valvular heart diseases. Leaking or narrowing of your heart valves can lead to stretching and thickening of your muscle (myocardium). When the chambers become enlarged or weakened due to the added stress caused by the tight or leaking valve, there's an increased risk of developing arrhythmia.

Types of arrhythmias

Heart arrhythmias may occur when any phase in the heart's electrical system malfunctions. Doctors classify arrhythmias not only by where they originate (atria or ventricles) but also by the speed of heart rate they cause:

• Tachycardia (tak-ih-KAHR-de-uh). This refers to a fast heartbeat — a heart rate greater than 100 beats a minute.

• Bradycardia (brad-e-KAHR-de-uh). This refers to a slow heartbeat — a resting heart rate less than 60 beats a minute.

Not all tachycardias or bradycardias indicate disease. For example, during exercise it's normal to develop sinus tachycardia as the heart speeds up to provide your tissues with more oxygen-rich blood. Athletes at rest can have a heartbeat less than 60 beats a minute because their hearts are so efficient.

Tachycardias in the atria Tachycardias originating in the atria include:

• Atrial fibrillation. This fast and chaotic beating of the atrial chambers is a common arrhythmia. It affects mainly older people. Your risk of developing atrial fibrillation increases past age 60 mainly due to the wear and tear that may affect your heart's function as you age. During atrial fibrillation, the electrical activity of the atria becomes uncoordinated. The atria beat so rapidly — as fast as 300 to 400 beats a minute — that they quiver (fibrillate). The electrical waves have the same chaotic activity that you would see if you threw a handful of pebbles into a quiet pond. Fortunately, not all of these atrial impulses reach the ventricles. The AV node between the atria and ventricles acts as a gatekeeper, usually letting only a few the impulses through. Still, extra impulses often get through the AV node, which can greatly accelerate your pulse (ventricular contractions). In addition, the atrial impulses that reach the ventricles often arrive at irregular intervals. This may cause an irregular heart rhythm. Atrial fibrillation can be intermittent (paroxysmal), lasting a few minutes to an hour or more before returning to a regular heart rhythm. It can also be chronic, causing an ongoing problem. Atrial fibrillation is seldom a life-threatening arrhythmia, but over time it can be the cause of more serious conditions such as stroke.

• Atrial flutter. Atrial flutter is similar to atrial fibrillation. Both can coexist in your heart, coming and going in an alternating fashion. The key distinction is that more-organized and more-rhythmic electrical impulses cause atrial flutter. These occur because atrial flutter, unlike atrial fibrillation, arises from a short circuit. In typical atrial flutter, this short circuit exists in the right atrium. This is an important distinction because typical right atrial flutter is more amenable to some forms of treatment, such as catheter ablation.

• Supraventricular tachycardia (SVT). SVT is a broad term that includes many forms of arrhythmia originating above the ventricles (supraventricular). This type of arrhythmia may also be called paroxysmal supraventricular tachycardia (PSVT). SVTs usually cause a burst of rapid heartbeats that begin and end suddenly and can last from seconds to hours. These often start when the electrical impulse from a premature heartbeat begins to circle repeatedly through an extra pathway. SVT may cause your heart to beat 160 to 200 times a minute. Although generally not life-threatening in an otherwise normal heart, symptoms from the racing heart may feel quite strong. These arrhythmias are common in young people.

• Wolff-Parkinson-White syndrome (WPW). One type of SVT is known as Wolff-Parkinson-White syndrome (WPW). This arrhythmia is caused by an extra electrical pathway between the atria and the ventricles. This pathway may allow electrical current to pass between the atria and the ventricles without passing through the AV node, leading to short circuits and rapid heartbeats.

Tachycardias in the ventricles Tachycardias occurring in the ventricles include:

• Ventricular tachycardia (VT). This fast, regular beating of the heart is caused by abnormal electrical impulses originating in the ventricles. Often, these are due to a short circuit around a scar from an old heart attack and can cause the ventricles to contract more than 200 beats a minute. Most VT occurs in people with some form of heart-related problem, such as scars or damage within the ventricle muscle from coronary artery disease or a heart attack. Sometimes, VTs last for 30 seconds or less (unsustained) and are usually harmless, although they cause inefficient heartbeats. Still, an unsustained VT may be a predictor for more-serious ventricular arrhythmias, such as longer lasting (sustained) VT. An episode of sustained VT is a medical emergency. It may be associated with palpitations, dizziness, fainting, or possibly death. Without prompt medical treatment, sustained VT often degenerates into ventricular fibrillation. Rarely, VT occurs in an otherwise normal heart. In this setting, it's far less dangerous, but the condition still needs the attention of a doctor.

• Ventricular fibrillation. As many as 340,000 Americans die every year from sudden cardiac death believed to be caused by ventricular fibrillation. With ventricular fibrillation, rapid, chaotic electrical impulses cause your ventricles to quiver uselessly instead of pumping blood. Without an effective heartbeat, your blood pressure plummets, instantly cutting off blood supply to your vital organs — including your brain. Most people lose consciousness within seconds and require immediate medical assistance such as cardiopulmonary resuscitation (CPR). Your chances of survival may be prolonged if CPR is delivered until your heart can be shocked back into a normal rhythm with a device called a defibrillator. Without CPR or defibrillation, death results in minutes. As with VT, most cases of ventricular fibrillation are linked to some form of heart disease. Ventricular fibrillation is frequently triggered by a heart attack. However, ventricular fibrillation may also be your first indication of heart problems.

• Long QT syndrome. This syndrome may be either an acquired or an inherited condition. In older adults, this rare arrhythmia may be triggered by one — or a combination — of more than 50 drugs, many of them commonly used. These drugs affect the heart's electrical function. On an electrocardiogram, the letter Q marks the point where an electrical impulse signals the ventricles to contract. The letter T marks the point where the cells of your ventricles have electrically recharged for the next heartbeat. When the QT interval is prolonged, ventricle cells may not have recovered in time to properly conduct the next heartbeat. People with long QT syndrome are prone to palpitations and fainting spells, and may have an increased risk of sudden death.

Bradycardias

Although a heart rate below 60 beats a minute while at rest is considered a bradycardia, a low-resting heart rate doesn't always signal a problem. If you're physically fit, you may have an efficient heart capable of pumping an adequate supply of blood with fewer than 60 beats a minute at rest. However, if you have a slow heartbeat that isn't pumping enough blood, you may have one of several bradycardias including:

• Sick sinus. If your pacemaking sinus node isn't sending impulses properly, your heart rate may be too slow, or it may speed up and slow down intermittently. If your sinus node is functioning properly, sick sinus can be caused by an impulse block near the sinus node that's slowing, disrupting or completely blocking conduction.

• Conduction block. A block of your heart's electrical pathways can occur in or near the AV node or along the bundle branches that conduct impulses to each ventricle. Depending on the location and type of block, the impulses between your atria and ventricles may be slowed or partially or completely blocked. If the signal is completely blocked, certain cells in the AV node or ventricles are capable of initiating a steady, although usually slower, heartbeat. Some blocks may cause no signs or symptoms, and others may cause skipped beats or bradycardia. Even without signs or symptoms, a conduction block is usually detectable on an electrocardiogram (ECG). Since some blocks are caused by heart disease, an ECG showing a block may be an early sign of heart problems.

Premature heartbeats

Premature heartbeats can originate in either the atria or the ventricles. Although it often feels like a skipped heartbeat, a premature heartbeat is actually an extra beat between two normal heartbeats. Premature heartbeats occurring in the ventricles come before the ventricles have had time to fill with blood following a regular heartbeat. Thus, the beat feels weak if it's felt at all. This premature beat is usually followed by a pause, during which time the ventricles fill with more than the usual amount of blood. The ejection of more blood from the ventricle causes the next regular heartbeat to feel stronger than normal.

Although you may feel an occasional premature beat, they seldom indicate a more serious problem. Still, a premature beat can trigger a longer lasting arrhythmia — especially in people with heart disease. These types of arrhythmias are commonly caused by stimulants, such as caffeine from coffee, tea and soft drinks, over-the-counter cold remedies containing pseudoephedrine, and some asthma medications.

Risk factors

Certain factors may increase your risk of developing an arrhythmia. These include:

• Age. With age, your heart muscle naturally weakens and loses some of its suppleness. This may affect how electrical impulses are conducted.

• Genetics. Being born with a heart abnormality, such as the extra electrical pathway that occurs with Wolff-Parkinson-White syndrome, may affect your heart's electrical function.

• Coronary artery disease. Narrowed heart arteries, heart attack or other heart damage are risk factors for almost any kind of arrhythmia.

• Thyroid problems. Your metabolism speeds up when your thyroid gland releases excess hormones. This may cause fast or irregular heartbeats and is most commonly associated with atrial fibrillation. Your metabolism slows when your thyroid gland releases too few hormones, which may cause a bradycardia.

• Drugs and supplements. Over-the-counter cough and cold medicines containing pseudoephedrine and certain prescription drugs may contribute to arrhythmia development. The herbal supplement ephedra also increased the risk of arrhythmia, but in early 2004, the Food and Drug Administration banned ephedra from the marketplace because of such health concerns.

• High blood pressure. This increases your risk of developing coronary artery disease. It may also cause the walls of your left ventricle to thicken, possibly altering how your heart's electrical impulses are conducted.

• Obesity. Along with being a risk factor for coronary artery disease, obesity may increase your risk of developing an arrhythmia.

• Diabetes. Your risk of developing coronary artery disease and hypertension greatly increase with uncontrolled diabetes. In addition, episodes of low blood sugar (hypoglycemia) can trigger an arrhythmia.

• Obstructive sleep apnea. This disorder can cause bradycardia and bursts of atrial fibrillation.

• Electrolyte imbalance. Electrolytes, such as potassium, sodium, calcium and magnesium, help trigger and conduct the electrical impulses in your heart. Electrolyte levels that are too high or too low can affect your heart's electrical impulses and contribute to arrhythmia development.

• Alcohol consumption. Drinking too much alcohol can affect factors that alter the conduction of electrical impulses in your heart or increase the chance of developing atrial fibrillation. In fact, development of atrial fibrillation after an episode of heavy alcohol intake is sometimes called "holiday heart syndrome." Chronic alcohol abuse may depress the function of your heart and can lead to cardiomyopathy. Both are factors in arrhythmia development.

• Stimulant use. Stimulants, such as caffeine and nicotine, can cause premature heartbeats and may contribute to the development of more serious arrhythmias. Illicit drugs such as amphetamines and cocaine may profoundly affect the heart and lead to many types of arrhythmias or to sudden death due to ventricular fibrillation.

SUMMARY

Advances in medical technology have added new treatment methods to the procedures that doctors may use to try to control or eliminate arrhythmias. In addition, because troublesome arrhythmias are often made worse — or are even caused — by a weak or damaged heart, you may be able to reduce your arrhythmia risk by adopting a heart-healthy lifestyle.

We, as mammographers, largely deal with female patients over the age of 50 years. It has been widely acknowledged that this group of patients is at risk of serious heart problems simply by not being aware they are at risk. Power is knowledge, pass it on!

PREVENTIVE MASTECTOMY: “Is that an Elephant in the Room?”

OBJECTIVES:

In hopes of avoiding future disease, some women at very high risk of developing breast cancer elect to have both breasts surgically removed, a procedure called bilateral prophylactic mastectomy. The surgery aims to remove all breast tissue that potentially could develop breast cancer. Preventive breast cancer surgery also may be considered if a woman has already had breast cancer and is therefore at increased risk for developing the disease again in either breast.

Is Prophylactic Mastectomy Effective?

A recent study suggests that prophylactic mastectomy may reduce the risk of breast cancer by as much as 90%. However, results vary widely. In some studies, women had prophylactic mastectomies for a variety of reasons, such as pain, fibrocystic breast disease, dense breast tissue, cancer phobia or a family history of breast cancer. Some women still developed breast cancer even though they had their breast tissue removed. But in most studies, patients did not develop breast cancer after prophylactic mastectomy. However, many of these patients would not have been considered high-risk for developing cancer.

Being identified as high risk doesn't mean the patient will get cancer, but it does mean that she'll have important decisions to make. One of which may be whether to have prophylactic (preventive) mastectomy — surgery to remove one or both breasts in hopes of preventing or reducing the risk of breast cancer. Some experts argue that even for high-risk women, prophylactic mastectomy is inappropriate because not all breast tissue can be removed during a surgical procedure. To understand why, we need to know what comprises breast tissue and where cancer originates.

Where Does Cancer Come From?

Breast cancers may develop in the glandular tissue of the breast, specifically in the milk ducts and the milk lobules. These ducts and lobules are located in all parts of the breast tissue, including tissue just under the skin. The breast tissue extends from the collarbone to the lower rib margin, and from the middle of the chest, around the side and under the arm.

In a breast skin-conserving mastectomy, it is necessary to remove tissue from just beneath the skin down to the chest wall and around the borders of the chest. However, even with very thorough and delicate surgical techniques, it is impossible to remove every milk duct and lobule, given the extent of the breast tissue and the location of these glands just beneath the skin.

Who Should Have a Prophylactic Mastectomy?

Does this mean that every patient should consider breast cancer prevention surgery? The answer is clearly no. The decision to proceed with prophylactic mastectomy is an individual decision. Such factors as an estimation of individual breast cancer risk, the ability to monitor the patient for early breast cancer and, most importantly, the patient's concerns and feelings need to be considered in making this decision.

According to the American Cancer Society, only those women who are at very high risk of breast cancer should even consider surgery.

This includes women with one or more of the following risk factors:

• Mutated BRCA genes.

• Previous cancer in one breast and a strong family history of breast cancer.

• History of lobular carcinoma in situ (LCIS).

• Prophylactic mastectomy should only be considered after the patient has received the appropriate genetic and psychological counseling to discuss the psychosocial impacts of the procedure.

Emotional effects of mastectomy

The decision to have a prophylactic mastectomy is a difficult one, but it isn't an urgent decision. Taking six months to a year to decide to pursue this type of surgery is appropriate. The patient should discuss her concerns and feelings with a psychologist even if she feels she is not struggling with the decision.

If the patient has a high risk of breast cancer, a prophylactic mastectomy might make her feel better about her future because it can significantly reduce the risk. She might spend less time worrying about her health after the procedure and continue with a productive life.

The majority of women who undergo prophylactic mastectomy are satisfied with their choice. Those who regret their decision may feel this way because of complications with their breast implants or dissatisfaction with their appearance after the procedure. In addition, women who choose surgery primarily because their doctors recommended it may be more likely to regret their decision.

Other options

If you're at high risk of breast cancer and you decide against prophylactic mastectomy, you do have other options:

Surveillance:

The goal of surveillance is to detect any possible cancer at its earliest stage.

• Breast self-exam every month beginning at age 20

• Clinical breast exams once or twice a year

• Annual mammograms may be recommended when you're 25 to 35.

• If you have a family history of breast cancer that doesn't seem to be related to a mutation in BRCA1 or BRCA2, annual mammograms about five to 10 years before the age at which your youngest affected first-degree relative was diagnosed with breast cancer or by age 40 whichever comes first

Chemo-preventive drug therapy:

This prevention method uses drugs to prevent cancer.

Tamoxifen, a drug used to prevent recurrence in women who have already had cancer, can also be used as a preventive or risk-reducing measure for high-risk women. Side effects include hot flashes, vaginal discharge, an increased chance of endometrial cancer and blood clots

Raloxifene is a similar drug to tamoxifen with has side some similar effects, but raloxifene isn't linked to endometrial cancer.

What Are My Options for Surgery?

For women who choose prophylactic mastectomy, several new and important surgical options have become available.

It is now possible to remove breast tissue using skin-sparing techniques in which the underlying breast tissue is removed from just under the skin and down to the chest wall. This technique removes the vast majority of the glands where breast cancer may be more likely to develop. The nipple and surrounding tissue, the areola, are also removed because the ducts converge toward the nipple, creating a concentrated area of duct tissue. However, the skin of the breast is spared, preserving the breast skin envelope.

When skin-sparing mastectomy is combined with immediate breast reconstruction, the results can be excellent. Women who choose prophylactic mastectomy, often combined with immediate reconstruction, are very pleased not only with their choice but also the reconstruction.

The doctor may recommend a simple (total) mastectomy, which removes the breast tissue, nipple, the areola and some of the overlying skin. Removing the entire breast is preferred because it allows the surgeon to cut out as much breast tissue as possible.

Breast reconstruction surgery:

Reconstruction surgery won't restore normal sensation to the breasts. And although breast reconstruction has advanced in many ways, chances are the reconstruction won't look exactly like the natural breast tissue. However, the contour of the new breasts can usually be restored so that the silhouette looks similar to the natural breasts.

Breast reconstruction isn't for everyone. The patient may prefer artificial (prosthetic) breast mounds that can be worn externally. This helps the figure look more natural after mastectomy.

Different approaches to breast reconstruction include:

• Using breast expanders or implants

• Using your body's own tissue (Tramflap)

• Using a combination of tissue reconstruction and implants

SUMMARY:

Only women with a high risk of developing breast cancer are candidates for prophylactic mastectomy, and the decision can be difficult to make. Researching the options and talking with professionals can give the patient information needed to decide whether prophylactic mastectomy is right for her. While surgery is not an approach that should be advocated for all high-risk individuals, it can be very important for appropriately selected women.

Prophylactic mastectomy is a controversial and awkward issue. It is a difficult decision for both patient and care-giver. If we ignore the subject and do not arm ourselves with the proper information and the whole truth we can leave our patient alone and uneducated with a complicated and difficult dilemma.

“Is My Patient is Fainting?”: VASOVAGAL SYNCOPE

Breast Imaging has become a complicated and often invasive process. These procedures are stressful and taxing on the body systems of our patients. We must be able recognize and accurately monitor the signs of moderate and acute patient distress. We must know how to intervene with a distressed patient and have a mollifying effect on her symptoms. 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.

What is Vasovagal Syncope?

Vasovagal syncope is the most common type of fainting. There are a number of different syncope syndromes which all fall under the umbrella of vasovagal syncope. The common element among these conditions is the central mechanism leading to loss of consciousness.

Pathophysiology and Mechanism:

The mechanism of syncope is similar in the various vasovagal syncope syndromes. In it, the nucleus tractus solitarius of the brainstem is activated directly or indirectly by the triggering stimulus, resulting in simultaneous enhancement of parasympathetic nervous system (vagal) tone and withdrawal of sympathetic nervous system tone. This results in a spectrum of hemodynamic responses. On one end of the spectrum is the cardioinhibitory response, characterized by a drop in heart rate. The drop in heart rate leads to a drop in blood pressure that is significant enough to result in a loss of consciousness. It is thought that this response results primarily from enhancement in parasympathic tone. On the other end of the spectrum is the vasodepressor response, caused by a drop in blood pressure without much change in heart rate. This phenomenon occurs due to vasodialtion, probably as a result of withdrawal of sympathetic nervous system tone. The majority of people with vasovagal syncope have a mixed response somewhere between these two ends of the spectrum.

One account for these physiological responses is the Bezold-Jarisch Reflex. This reflex involves a variety of cardiovascular and neurological processes, which can be summarized as follows:

• Prolonged upright posture results in some degree of pooling of blood in the lower extremities that can lead to diminished intracardiac volume
• This phenomenon is accentuated if the individual is dehydrated
• The resultant arterial hypotension is sensed in the carotid body baroreceptors, and afferent fibers from these receptors trigger autonomic signals that increase cardiac rate and contractility
• Pressure receptors in the wall and trabeculae of the underfilled left ventricle may then sense stimuli, indicating high-pressure C-fiber afferent nerves from these receptors
• They respond by sending signals that trigger paradoxical bradycardia and decreased contractility, resulting in additional and relatively sudden arterial hypotension

Vasovagal syncope is rarely life-threatening in itself, but may be associated with injury from falling. The core of the diagnosis of vasovagal syncope rests upon a clear description by the patient of a typical pattern of triggers, symptoms, and time course. Also is pertinent to differentiate lightheadedness, vertigo and hypoglycemia as other causes. In patients with syncope, diagnostic accuracy can often be improved with one of the following diagnostic tests:

• A tilt table
• Implantation of an insertable loop recorder
• A Holter monitor or event monitor
• An echocardiogram
• An electrophysiology study

Triggers For Vasovagal Syncope:

The differences among patients apparently suffering syncope are in the factors which trigger this mechanism. People with vasovagal syncope typically have recurrent episodes, usually when exposed to a specific trigger. The initial episode often occurs when the person is a teenager, then recurs in clusters throughout his or her life. Prior to losing consciousness, the individual frequently experiences a prodrome of symptoms such as lightheadedness, nausea, sweating, ringing in the ears, and visual disturbances. These last for at least a few seconds before consciousness is lost, which typically happens when the person is sitting up or standing. When they pass out, they fall down; and when in this position, effective blood flow to the brain is immediately restored, allowing the person to wake up.The autonomic nervous system's physiologic state (see below) leading to loss of consciousness may persist for several minutes, so: If the person tries to sit or stand when they wake up, they may pass out again; and, the person may be nauseated, pale, and sweaty for several minutes after they wake up.

Typical Triggers for Vasovagal Syncope Include:

• Prolonged standing or upright sitting
• Stress
• Any painful or unpleasant stimuli, such as:

• Giving a blood donation or watching someone give one
• Having an unpleasant or uncomfortable procedure
• Watching someone experience pain
• Hyperthermia, a prolonged exposure to heat
• Sudden onset of extreme emotions
• Hunger
• Nausea or vomiting
• Dehydration
• Urination ('micturition syncope') or defecation ('defecation syncope')
• Swallowing ('swallowing syncope')
• Coughing ('cough syncope')
• Abdominal straining or 'bearing down' (as in defecation)
• Random onsets due to nerve malfunctions
• Pressing upon certain places on the throat, sinuses, and eyes.
• High altitude

Treatment:

Treatment for vasovagal syncope focuses on avoidance of triggers, restoring blood flow to the brain during an impending episode, and measures which interrupt or prevent the pathophysiologic mechanism described above.

• The cornerstone of treatment is avoidance of triggers known to cause syncope in that person. Before known triggering events, the patient may increase consumption of salt and fluids to increase blood volume. Sports and energy drinks may be particularly helpful.
• Discontinuation of medications known to lower blood pressure may be helpful, but stopping antihypertensive drugs can also be dangerous. This process should be managed by an expert.
• Patients should be educated on how to respond to further episodes of syncope, especially if they experience prodromal warning signs: They should lie down and raise their legs; or at least lower their head to increase blood flow to the brain. If the individual has lost consciousness, he or she should be laid down with his or her head turned to the side. Tight clothing should be loosened. If the inciting factor is known, it should be removed if possible (for instance, the cause of pain).
• Wearing graded compression stockings may be helpful.
• There are certain orthostatic training, exercises which have been proven to improve symptoms in people with recurrent vasovagal syncope.
• Certain medications may be helpful, but are rarely effective by themselves:
• Beta blockers (ß-adrenergic antagonists) are the most common medication given

Other medications which may be effective include:

• Fludrocortisone
• Midodrine
• SSRIs such as paroxetine or sertraline
• Disopyramide
• Where a syncope is anticipated, atropine
• For people with the cardioinhibitory form of vasovagal syncope, implantation of a permanent pacemaker may be beneficial or even curative.

SUMMARY

When we are aware of the cause, process and cure for the physical distress our patients find themselves in, it is easier for us to cope with the realities of our new expanded roles. Physiological mechanisms are important for us to understand so we can adequately assist our medical team when any emergency arises. Do not be afraid of change. Understand, adapt and embrace.

Coping with the Handicapped Patient: The Short and Sweet To-Do List

OBJECTIVES
Mammography of high quality depends a great deal on the cooperation of our clients. When our 'clients' become 'patients' who are ill, frail, incapacitated, helpless, unbalanced, delayed or otherwise handicapped, the assignment of obtaining excellence becomes gargantuan. Without writing a thesis on the subject, I have assembled a concise list of helpful hints under some short universal topics related to imaging disabled patients.

THE FACILITY

• Accessible parking close to entrances
• Accessible front entrance
• Doors that are wide and easy to open
• Accessible route through facility
• Sign language information
• Braille information
• Large print documentation
• Space in waiting area for wheelchairs
• Space in change area for wheelchairs
• Adjustable height examination tables
• Mammography units that will adjust to wheelchairs or gurneys
• Mammography rooms large enough to allow stretcher access

COMMUNICATION

General Communication

• Treat every person with respect
• Do not use patient's first name useless prompted by the patient to do so
• Offer assistance but WAIT until the patient accepts your help
• Allow the patient to give you instructions on the best way to help
• Always speak to the patient rather than to the companion
• Let the patient set the pace for the procedure
• Relax, do not feel discomfort on the patient's behalf
• Assistive devices are part of the patient's personal space. Do not move them without permission
• When conversing with a chair or bed bound person, always put yourself at eye level
• Always ask before moving a patient who is immobilized in any way

Communication with the Visually Impaired

• Allow the person to take your arm when assisting
• You are acting as a guide NOT a leader
• Speak in a normal tone of voice
• Identify yourself and all others with you
• Always indicate when you are moving from one place to another during the test

Communication with the Hearing Impaired

• Tap the person softly on the shoulder or gently wave your hand to get their attention
• Look directly at the person and speak clearly, directly and expressively
• Written notes or illustrations may be of great assistance
• Do not eat, chew gum or place you hands near your face

Communication with Persons with Speech Impairment

• Give whole and unhurried attention to people who have difficulty speaking
• Be encouraging, patient and allow the person to complete their thoughts
• Ask short questions that require only very short answers
• Never pretend to understand, take your time and understand in a different way

Communication with the Cognitively Deficient

• Take the time to achieve clear understanding
• Use body language
• Use simpler words
• Use pictures, cartoons or diagrams
• Provide the patient with the same information in different ways (be creative)

POSITIONING

Positioning of the disabled patient is the most important and most difficult aspect of dealing with the handicapped. There are innumerable problems involved in safely and efficiently controlling the examination of the disabled. I hope these concise tips dealing with actual manipulation and acquisition of the required views will facilitate the technologist in obtaining quality images.

Common Concerns with Positioning the Handicapped Patient

• Inadequate amount of retroglandular tissue imaged
• Inability to position C-arm parallel to chest wall
• Inability of patient to cooperate with exam
• Exam room of inadequate size to accommodate stretcher, wheelchairs or immobilization devices
• Extra views may be necessary to view tissue adequately
• Two mammographers may be necessary to safely handle the patient and obtain satisfactory views
• Enough time assigned to the procedure to allow it to be carried out with care, safety and precision

The Basic Positions Required for Handicapped Patients

• From Below(stretcher)/CC(Chairbound)
• Mediolateral Oblique
• 90 degree Lateromedial

OBTAINING THE REQUIRED PROJECTIONS

• From Below (Stretcher)
• Stretcher patients must lie on their unaffected side
• Tube is placed in the 90 degree position and moved under the affected breast
• The compression is applied from beneath
• Mammographer should stand behind the image receptor for better control

CC (Chairbound)

• Wheelchair patients must be able to lean into receptor
• Wheelchair patients may have to be moved to a wheeled armless positioning chair or moveable bench
• Remove face plate if needed and turn the patient’s head away from the tube
• Have the patient grip the underside of the bucky
• Tilt the tube 5° if needed

Mediolateral Oblique

• A proper MLO view cannot be acquired on a stretcher bound patient without the patient being able to tolerate the head of the gurney being elevated at least 60 degrees
• Raise the head of the stretcher as far as will be permitted
• The image receptor should be placed against the stretcher, parallel to the patient's pectoralis
• Move the patient over to side of gurney and raise her arm up out of the field of vision
• Have her lean into the receptor and compress the tissue adequately
• Patients confined to wheelchairs must be able to lean into the image receptor or they must be transferred to an armless wheeled positioning chair or moveable bench

Lateromedial

• This may be the most valuable and easiest view to accomplish dealing with the stretcher bound patient
• The patient should lie flat on their side with the affected side up
• Rotate the tube so that it is parallel to the gurney
• Place the bucky along the patient's sternum
• Roll the patient slightly forward and raise her top arm out of the way
• Move the breast superior and laterally
• Bring the compression down as far laterally as possible without including the latissimus dorsa

SUMMARY

Most people will experience some form of disability as they age. Physicians often have difficulty prescribing preventative services for their disabled patients because of lack of adequate facilities. For women with disabilities access to mammography greatly diminishes with age and increase of functional limitation. By age 65, 57% of healthy women have had a mammogram, as compared with 43% of women who are functionally challenged. Encourage your facility to be part of the solution - NOT part of the problem.