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 you facility to part of the solution NOT part of the problem.

COMMON POSITIONING PROBLEMS - The Solutions!

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.

THE CC PROJECTION: “IF”

A) The nipple is not in profile

If the nipple is not in perfect profile: Elevate the IMF a little higher Lift and pull the breast straight onto the bucky 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: Position from the medial side Lift and drape opposite breast over the edge of the bucky Do not press the patient’s face against the face protector 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: The Patient’s arm should be relaxed by side Her palm should be supinated with her shoulder externally rotated Control your patient’s posture with your hand around her back on her contra-lateral shoulder She should be relaxed forward bent slightly at the waist 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: Elevate the IMF until the tissue no longer moves easily along the chest wall Identify the edge of the pectoral muscle visible just under the clavicle Loosen the skin over the clavicle so the tissue moves easily Compress parallel to the pectoral edge just under the clavicle Release hand in a forward medial motion

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: Adjust your tube angle parallel to the obliquity of the patient’s pectoral muscle Move the breast medially and anteriorly from the lateral border until the pectoral pouches out next to the sternum 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: DO NOT rest your patient’s arm along the top edge of the bucky Patient’s shoulder should be open, relaxed  The corner of the bucky high up and well back in the axilla Patient’s arm should be slightly bent hanging loosely down the back of the bucky Relaxed hand…NO gripping the handle

C) The breast is not ‘up & 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’: Move the breast from the lateral edge medially  Ensure the breast mound moves freely in your grip Support the breast tissue from the inferior border using you entire hand 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 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: Support the breast and always release with and up & out motion Have the patient tilt her hips slightly backwards Do not release your hold on the breast until the projection is immobilized by the compression 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: Make sure the patient’s feet are directly facing the bucky Control the breast from the mobile lateral border only 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. 

STANDARDIZATION OF MAMMOGRAPHY POSITIONING

Standardization of modern mammographic positioning techniques helps to improve image quality. We can improve the quality assurance of our departments and ensure versatile, consistent examinations. Each technologist can produce intelligent, comprehensive breast images if we all practice from the same base. Correction rather than repetition is the key.

Many certification processes involve positioning competency testing. This ensures that all certified mammographers will be practicing from a uniform standard. If part of your responsibility is department stability and unvarying excellence of mammograms then a ‘POSITIONING COMPETENCY CHECKLIST’ may be of assistance in your department. 

This type of checklist helps students to check their positioning case by case. It helps all of us check our positioning on those days when NOTHING is working. It can help clinical instructors offer helpful constructive suggestions. Positioning checklists are used to great advantage in many departments to regulate the quality of their positioning. 

Using a standard checklist lets both staff and reviewer know exactly what is required thereby making any necessary routine staff evaluations easier and way less stressful for everyone involved. 

I have a couple of really simple ‘clip and post’ checklists that can help any mammographer ‘check and correct’ her cases on the fly. I use mine all the time I hope you find them helpful too.

POSITIONING COMPETENCY CHECKLIST ‘CC’ PROJECTION

In order to include the maximum amount of breast tissue on the CRANIOCAUDAL projection, the technologist should be able to perform the following steps: 

PERFORMED STEPS	YES	NO
1. Have your patient stand facing the unit with her feet perpendicular to the bucky
2. Externally rotate the patient’s arm on the side being imaged and make sure it is relaxed at her side.
3. Determine the proper film receptor size and photocell position.
4. Stand on the medial side of the imaged breast.
5. Elevate IMF to its maximum height and adjust bucky appropriately.
6. Use both hands to lift and pull breast onto receptor.
7. Center breast over photocell with nipple in profile (if possible).
8. Anchor breast solidly with one hand and never let go!
9. Lift and drape the opposite breast over the corner of the bucky.
10. Place your arm across the patient’s back and rest it on her shoulder to relax it and keep her tilted toward the bucky.
11. Rotate the patient’s head away from the breast being imaged.
12. Have the patient incline towards the unit with her head forward and beyond faceplate.
13. With your hand still on the patient’s shoulder, loosen the skin over clavicle.
14. Pull the lateral tissue anteriorly and medially as the compression takes over.

POSITIONING COMPETENCY CHECKLIST ‘MLO’ PROJECTION

In order to include the maximum amount of breast tissue on the MEDIOLATERAL projection, the technologist should be able to perform the following steps:

PERFORMED STEPS	YES	NO
1. Have your patient stand facing the unit with her feet perpendicular to the bucky
2. Determine proper film receptor size and photocell position.
3. Determine degree of obliquity (parallel to pectoral muscle).
4. Rotate C-arm so that the long axis is parallel to the pectoral muscle.
5. Adjust height of bucky tray so that the top corner is level with the highest point of the axilla.
6. Lift arm of the side being imaged and place shoulder up and over the corner of the bucky.
7. Place corner of the bucky as high up and as far back in the axilla as possible but still anterior to the lattissimus dorsi.
8. Place the patient’s hand of the side being imaged on the C-arm, with her elbow flexed and her shoulder relaxed over the corner of the bucky.
9. Pull the breast and the pectoral as far anteriorly and medially as possible with the flat front surface of your hand.
10. Scoop breast tissue up, your hand grasping the lateral border of the breast with fingers and the medial border with thumb.
11. Hold breast up and out with the thumb supporting the base of the breast and the fingers are holding the medial aspect pointing up and out.
12. NEVER LET GO!
13. Center breast with nipple in profile if possible and apply compression starting with corner of paddle just under the clavicle.
14. With thumb and first two fingers smooth down abdominal tissue to open IMF.