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RADIOLOGIC
®
Journal of the American Society of Radiologic Technologists
Vol. 82, No. 2
November/December 2010
Factors Influencing Success in RA Programs: A Survey
The Role of Mobile Electronic Devices in Radiographer Education
Domestic Violence
Diagnosis and Treatment of Scaphoid Fractures
American Society of
Radiologic Technologists
The ASRT Education
and Research Foundation
Jump 2011 Scholarship Programs
Into
Action!
Professional Scholarships
Elekta Radiation Therapy Educators Scholarship
Four $5,000 scholarships
Awarded to radiation therapy educators pursuing an undergraduate
or graduate degree. Funding support provided by Elekta Inc.
Medical Imaging Educators Scholarship
Four $5,000 scholarships
Awarded to medical imaging educators who are pursuing their bachelor’s,
master’s or doctoral degree to enhance their position as a program
director, faculty member, clinical coordinator or clinical instructor.
Special thanks to our scholarship patrons for their financial support
of this program.
Siemens Clinical Advancement Scholarship
Four $5,000 scholarships
Awarded to medical imaging and radiation therapy professionals seeking
to enhance their clinical practice skills and ability to provide excellent care.
Funding support provided by Siemens Medical Solutions USA Inc.
Professional Advancement Scholarship
Several $1,500 scholarships
Awarded to professionals who are obtaining an additional degree
to advance their careers. Funding support provided by HEALTHeCAREERS
and our scholarship patrons.
Don’t Be Afraid.
Get the Facts.
MYTH There is no scholarship money for education
in the radiologic sciences.
FACT
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$200,000 in professional and entry-level
student scholarships during 2011.
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specific needs.
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The Foundation offers almost 50 awards
in a variety of scholarships for managers,
educators, clinical professionals and
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Entry-level Student Scholarships
Jerman-Cahoon Student Scholarship
Five $2,500 scholarships
Awarded to outstanding students attending entry-level radiologic
sciences programs. Special thanks to our scholarship patrons for their
financial support of this program.
Royce Osborn Minority Student Scholarship
Five $4,000 scholarships
Awarded to outstanding minority students attending entry-level
radiologic sciences programs. Special thanks to the American Registry
of Radiologic Technologists for its major funding commitment to this
scholarship program.
Varian Radiation Therapy Student Scholarship
Nineteen $5,000 scholarships
Awarded to outstanding students attending entry-level radiation
therapy programs. Funding support provided by Varian Medical Systems.
Applications are available online.
Contact the ASRT Education and Research
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[email protected] for more information.
ASRT
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1,2
Introducing ABLAVAR®: the first and only blood-pool
contrast agent for MRA1,2
A low-dose MRA contrast agent with the unique benefits of albumin binding3
• Time to acquire high-resolution first-pass and steady-state images3
• Imaging window up to 1 hour with a single, low-dose (0.12 mL/kg body
weight [0.03 mmol/kg]) IV bolus1,3
• Diagnostic accuracy comparable to conventional X-ray angiography4,5
• Documented safety and tolerability with no reported cases of NSF* 6
*No reported cases of nephrogenic systemic fibrosis (NSF) to date in clinical use with nearly 90,000 patients.
INDICATIONS: ABLAVAR® is indicated for use as a contrast agent in magnetic resonance
angiography (MRA) to evaluate aortoiliac occlusive disease (AIOD) in adults with known or
suspected peripheral vascular disease.
CONTRAINDICATIONS: History of a prior allergic reaction to a gadolinium-based
contrast agent.
IMPORTANT SAFETY INFORMATION:
WARNING: NEPHROGENIC SYSTEMIC FIBROSIS (NSF) Gadoliniumbased contrast agents increase the risk of nephrogenic systemic
fibrosis (NSF) in patients with:
• acute or chronic severe renal insufficiency (glomerular filtration
rate <30 mL/min/1.73m2), or
• acute renal insufficiency of any severity due to the hepato-renal
syndrome or in the perioperative liver transplantation period.
In these patients, avoid use of gadolinium-based contrast agents
unless the diagnostic information is essential and not available
with non-contrast enhanced magnetic resonance imaging (MRI).
NSF may result in fatal or debilitating systemic fibrosis affecting
the skin, muscle, and internal organs. Screen all patients for
renal dysfunction by obtaining a history and/or laboratory tests.
When administering a gadolinium-based contrast agent, do not
exceed the recommended dose and allow a sufficient period of
time for elimination of the agent from the body prior to any
re-administration.
To order, call 1-800-299-3431
www.ABLAVAR.com
ABLAVAR® Injection: As with other contrast media: the possibility of serious or life-threatening
anaphylactic or anaphylactoid reactions, including cardiovascular, respiratory and/or cutaneous
manifestations, should always be considered. As with other paramagnetic contrast agents,
caution should be exercised in patients with renal insufficiency due to the possibility of further
deterioration in renal function.
In clinical trials, a small increase (2.8 msec) in the average change from baseline in QTc was observed
at 45 minutes. These QTc prolongations were not associated with arrhythmias or symptoms. Caution
should be used in patients at high risk for arrhythmias due to baseline QTc prolongation.
Have emergency resuscitative equipment available prior to and during ABLAVAR® administration.
Please see brief summary, including boxed WARNING regarding Nephrogenic Systemic Fibrosis
(NSF), on the following page.
References: 1. ABLAVAR® [package insert]. North Billerica, MA: Lantheus Medical Imaging, Inc.; 2009. 2. U.S. Food
and Drug Administration Web site. http://www.fda.gov/drugs. Accessed February 1, 2010. 3. Goyen M. Gadofosvesetenhanced magnetic resonance angiography. Vasc Health Risk Manag. 2008;4(1):1-9. 4. Goyen M, Edelman M,
Perreault P, et al. MR angiography of aortoiliac occlusive disease: a phase III study of the safety and effectiveness
of the blood-pool contrast agent MS-325. Radiology. 2005;236(3):825-833. 5. Rapp JH, Wolff SD, Quinn SF, et al.
Aortoiliac occlusive disease in patients with known or suspected peripheral vascular disease: safety and efficacy of
gadofosveset-enhanced MR angiography–multicenter comparative phase III study. Radiology. 2005;236(1):71-78.
6. Data on file, Lantheus Medical Imaging, Inc.
ABLAVAR is a registered trademark
of Lantheus Medical Imaging, Inc.
© 2010 Lantheus Medical Imaging, Inc.
All rights reserved. Printed in USA.
AB-JA-Aug 2010
BRIEF SUMMARY
WARNING: NEPHROGENIC SYSTEMIC FIBROSIS (NSF)
Gadolinium-based contrast agents increase the risk of nephrogenic
systemic fibrosis (NSF) in patients with:
• acute or chronic severe renal insufficiency (glomerular filtration
rate <30 mL/min/1.73m2), or
• acute renal insufficiency of any severity due to the hepato-renal
syndrome or in the perioperative liver transplantation period.
In these patients, avoid use of gadolinium-based contrast agents unless
the diagnostic information is essential and not available with noncontrast enhanced magnetic resonance imaging (MRI). NSF may result
in fatal or debilitating systemic fibrosis affecting the skin, muscle, and
internal organs. Screen all patients for renal dysfunction by obtaining
a history and/or laboratory tests. When administering a gadoliniumbased contrast agent, do not exceed the recommended dose and allow
a sufficient period of time for elimination of the agent from the body
prior to any re-administration [see Warnings and Precautions]
INDICATIONS AND USAGE
Ablavar is indicated for use as a contrast agent in magnetic resonance
angiography (MRA) to evaluate aortoiliac occlusive disease (AIOD) in
adults with known or suspected peripheral vascular disease.
DOSAGE AND ADMINISTRATION
agents. These reports have not always identified a specific agent. Prior
to marketing of Ablavar, where a specific agent was identified, the most
commonly reported agent was gadodiamide (Omniscan™), followed
by gadopentetate dimeglumine (Magnevist®) and gadoversetamide
(OptiMARK®). NSF has also developed following sequential administrations of gadodiamide with gadobenate dimeglumine (MultiHance®)
or gadoteridol (ProHance®). The number of post-marketing reports is
subject to change over time and may not reflect the true proportion of
cases associated with any specific gadolinium-based contrast agent.
The extent of risk for NSF following exposure to any specific gadoliniumbased contrast agent is unknown and may vary among the agents.
Published reports are limited and predominantly estimate NSF risks with
gadodiamide. In one retrospective study of 370 patients with severe
renal insufficiency who received gadodiamide, the estimated risk for
development of NSF was 4% (J Am Soc Nephrol 2006; 17:2359). The
risk, if any, for the development of NSF among patients with mild to
moderate renal insufficiency or normal renal function is unknown.
Screen all patients for renal dysfunction by obtaining a history and/
or laboratory tests. When administering a gadolinium-based contrast
agent, do not exceed the recommended dose and allow a sufficient
period of time for elimination of the agent prior to any re-administration.
NSF was not reported in clinical trials of Ablavar [see Clinical
Pharmacology and Dosage and Administration].
Hypersensitivity Reactions
Ablavar may cause anaphylactoid and/or anaphylactic reactions, including
life-threatening or fatal reactions. In clinical trials, anaphylactoid and/or
anaphylactic reactions occurred in two of 1676 subjects. If anaphylactic
or anaphylactoid reactions occur, stop Ablavar Injection and immediately
begin appropriate therapy. Observe patients closely, particularly those
with a history of drug reactions, asthma, allergy or other hypersensitivity
disorders, during and up to several hours after Ablavar administration.
Have emergency resuscitative equipment available prior to and during
Ablavar administration.
Pounds (lb)
Milliliters (mL)
40
88
4.8
50
110
6.0
60
132
7.2
70
154
8.4
80
176
9.6
90
198
10.8
100
220
12.0
110
242
13.2
120
264
14.4
130
286
15.6
Acute Renal Failure
In patients with renal insufficiency, acute renal failure requiring dialysis
or worsening renal function have occurred with the use of other
gadolinium agents. The risk of renal failure may increase with increasing
dose of gadolinium contrast. Screen all patients for renal dysfunction
by obtaining a history and/or laboratory tests. Consider follow-up renal
function assessments for patients with a history of renal dysfunction. No
reports of acute renal failure were observed in clinical trials of Ablavar
[see Clinical Pharmacology].
QTc Prolongation and Risk for Arrhythmias
In clinical trials, a small increase (2.8 msec) in the average change
from baseline in QTc was observed at 45 minutes following Ablavar
administration; no increase was observed at 24 and 72 hours. A QTc
change of 30 to 60 msec from baseline was observed in 39/702 (6%)
patients at 45 min following Ablavar administration. At this time point,
3/702 (0.4%) patients experienced a QTc increase of > 60 msec. These
QTc prolongations were not associated with arrhythmias or symptoms.
In patients at high risk for arrhythmias due to QTc prolongation (e.g.,
concomitant medications, underlying cardiac conditions) consider
obtaining baseline electrocardiograms to help assess the risks for
Ablavar administration. If Ablavar is administered to these patients,
consider follow-up electrocardiograms and risk reduction measures
(e.g., patient counseling or intensive electrocardiography monitoring)
until most Ablavar has been eliminated from the blood. In patients with
normal renal function, most Ablavar was eliminated from the blood by
72 hours following injection [see Clinical Pharmacology].
140
308
16.8
ADVERSE REACTIONS
150
330
18.0
160
352
19.2
Dosing Guidelines
Administer Ablavar as an intravenous bolus injection, manually or by
power injection, at a dose of 0.12 mL/kg body weight (0.03 mmol/kg)
over a period of time up to 30 seconds followed by a 25-30 mL normal
saline flush. (See Table 1 for weight-adjusted dose volumes).
TABLE 1. Weight-Adjusted Volumes for the 0.03 mmol/kg Dose
Body Weight
Kilograms (kg)
Volume
Inspect the Ablavar vial visually for particulate matter and discoloration
prior to administration. Do not use the solution if it is discolored or
particulate matter is present.
Ablavar is intended for single use only and should be used immediately
upon opening. Discard any unused portion of the Ablavar vial.
Do not mix intravenous medications or parenteral nutrition solutions
with Ablavar. Do not administer any other medications in the same
intravenous line simultaneously with Ablavar.
Imaging Guidelines
Ablavar imaging is completed in two stages: the dynamic imaging
stage and the steady-state imaging stage. Both stages are essential for
adequate evaluation of the arterial system, and dynamic imaging always
precedes steady-state imaging. During interpretation of the steady-state
images, Ablavar within the venous system may limit or confound the
detection of arterial lesions.
To assess the initial distribution of Ablavar within the arterial system, begin
dynamic imaging immediately upon injection. Begin steady state imaging
after dynamic imaging has been completed, generally 5 to 7 minutes
following Ablavar administration. At this time point, Ablavar is generally
distributed throughout the blood. In clinical trials, steady-state imaging
was completed within approximately one hour following Ablavar injection.
DOSAGE FORMS AND STRENGTHS
Ablavar is a sterile solution for intravenous injection containing 244 mg/
mL (0.25 mmol/mL) gadofosveset trisodium [see How Supplied/Storage
and Handling]
CONTRAINDICATIONS
History of a prior allergic reaction to a gadolinium-based contrast agent.
WARNINGS AND PRECAUTIONS
Nephrogenic Systemic Fibrosis
Gadolinium-based contrast agents increase the risk for nephrogenic
systemic fibrosis (NSF) in patients with acute or chronic severe renal
insufficiency (glomerular filtration rate <30 mL/min/1.73m2) and
in patients with acute renal insufficiency of any severity due to the
hepato-renal syndrome or in the perioperative liver transplantation
period. In these patients, avoid use of gadolinium-based contrast
agents unless the diagnostic information is essential and not available
with non-contrast enhanced MRA. For patients receiving hemodialysis,
physicians may consider the prompt initiation of hemodialysis following
the administration of a gadolinium-based contrast agent in order to
enhance the contrast agent’s elimination. Ablavar binds to blood albumin
and use of a high-flux dialysis procedure is essential to optimize Ablavar
elimination in patients receiving chronic hemodialysis. The usefulness of
hemodialysis in the prevention of NSF is unknown [see Boxed Warning
and Clinical Pharmacology].
Among the factors that may increase the risk for NSF are repeated or
higher than recommended doses of a gadolinium-based contrast agent
and the degree of renal function impairment at the time of exposure.
Post-marketing reports have identified the development of NSF following
single and multiple administrations of gadolinium-based contrast
Because clinical studies are conducted under widely varying conditions,
adverse reaction rates observed in the clinical studies of a drug cannot
be directly compared to rates in the clinical studies of another drug and
may not reflect the rates observed in practice.
Clinical Studies Experience
Anaphylaxis and anaphylactoid reactions were the most common
serious reactions observed following Ablavar injection administration
[see Warnings and Precautions].
In all clinical trials evaluating Ablavar with MRA, a total of 1,676 (1379
patients and 297 healthy subjects) were exposed to various doses Ablavar.
The mean age of the 1379 patients who received Ablavar was 63 years
(range 18 to 91 years); 66% (903) were men and 34% (476) were women.
In this population, there were 80% (1100) Caucasian, 8% (107) Black,
12% (159) Hispanic, 1% (7) Asian, and < 1% (6) patients of other racial or
ethnic groups. Table 2 shows the most common adverse reactions (≥1%)
experienced by subjects receiving Ablavar at a dose of 0.03 mmol/kg.
Table 2 Common Adverse Reactions in 802 Subjects
Receiving Ablavar at 0.03 mmol/kg
Preferred Term
n (%)
Pruritis
Headache
Nausea
Vasodilatation
Paresthesia
Injection site bruising
Dysgeusia
Burning sensation
Venipuncture site bruise
Hypertension
Dizziness (excluding vertigo)
Feeling cold
42 (5)
33 (4)
33 (4)
26 (3)
25 (3)
19 (2)
18 (2)
17 (2)
17 (2)
11 (1)
8 (1)
7 (1)
Post-marketing Experience
Because post-marketing reactions are reported voluntarily from a
population of uncertain size, it is not always possible to reliably estimate
their frequency or establish a causal relationship to drug exposure.
The profile of adverse reactions identified during the post-marketing
experience outside the United States was similar to that observed during
the clinical studies experience.
DRUG INTERACTIONS
Following injection, Ablavar binds to blood albumin and has the
potential to alter the binding of other drugs that also bind to albumin.
No drug interaction reactions were observed in clinical trials. Consider
the possibility of Ablavar interaction with concomitantly administered
medications that bind to albumin. An interaction may enhance or decrease
the activity of the concomitant medication [see Clinical Pharmacology].
Warfarin
In a clinical trial of 10 patients receiving a stable dose of warfarin, a single
dose of Ablavar (0.05 mmol/kg) did not alter the anticoagulant activity of
warfarin as measured by the International Normalized Ratio (INR).
USE IN SPECIFIC POPULATIONS
Pregnancy
Pregnancy Category C
There are no adequate and well-controlled studies of Ablavar in pregnant
women. In animal studies, pregnant rabbits treated with gadofosveset
trisodium at doses 3 times the human dose (based on body surface
area) experienced higher rates of fetal loss and resorptions. Because
animal reproduction studies are not always predictive of human
response, only use Ablavar during pregnancy if the diagnostic benefit
justifies the potential risks to the fetus.
In reproductive studies, pregnant rats and rabbits received gadofosveset
trisodium at various doses up to approximately 11 (rats) and 21.5
(rabbits) times the human dose (based on body surface area). The
highest dose resulted in maternal toxicity in both species. In rabbits that
received gadofosveset trisodium at 3 times the human dose (based on
body surface area), increased post-implantation loss, resorptions, and
dead fetuses were observed. Fetal anomalies were not observed in the
rat or rabbit offspring. Because pregnant animals received repeated daily
doses of Ablavar, their overall exposure was significantly higher than that
achieved with a single dose administered to humans.
Nursing Mothers
It is not known whether gadofosveset is secreted in human milk.
Because many drugs are excreted in human milk, caution should be
exercised when Ablavar is administered to a woman who is breastfeeding. The risks associated with exposure of infants to gadoliniumbased contrast agents in breast milk are unknown. Limited case reports
indicate that 0.01 to 0.04% of the maternal gadolinium dose is excreted
in human breast milk. Studies of other gadolinium products have shown
limited gastrointestinal absorption. These studies were conducted with
gadolinium products with shorter half-lives than Ablavar. Avoid Ablavar
administration to women who are breastfeeding unless the diagnostic
information is essential and not obtainable with non-contrast MRA.
In animal studies, less than 1% of gadofosveset at doses up to 0.3 mmol/kg
was secreted in the milk of lactating rats.
Pediatric Use
The safety and effectiveness of Ablavar in patients under 18 years
of age have not been established. The risks associated with Ablavar
administration to pediatric patients are unknown and insufficient
data are available to establish a dose. Because Ablavar is eliminated
predominantly by the kidneys, pediatric patients with immature renal
function may be at particular risk for adverse reactions.
Geriatric Use
In clinical trials, no overall differences in safety and efficacy were
observed between subjects 65 years and older and younger subjects.
Whereas current clinical experience has not identified differences in
responses between elderly and younger patients, greater susceptibility to
adverse experiences of some older individuals cannot be ruled out.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Long-term animal studies have not been performed to evaluate the
carcinogenic potential of gadofosveset. Gadofosveset was negative in the
in vitro bacterial reverse mutation assay, CHO chromosome aberration
assay, and the in vivo mouse micronucleus assay. Administration of up
to 1.5 mmol/kg (8.3 times the human dose) to female rats for 2 weeks
and to male rats for 4 weeks did not impair fertility [see Use in Specific
Populations].
HOW SUPPLIED/STORAGE AND HANDLING
Ablavar Injection is a sterile, clear, colorless to pale yellow solution
containing 244 mg/mL (0.25 mmol/mL) of gadofosveset trisodium in
rubber-stoppered glass vials with an aluminum seal. Ablavar Injection is
supplied as follows:
NDC 11994-012-01 - 10 mL fills in 10 mL single use vials packages of
10 vials
NDC 11994-012-02 - 15 mL fills in 20 mL single use vials in packages
of 10 vials
Store Ablavar Injection up to 25°C (77°F: excursions permitted to 15 to
30°C [59 to 86°F]). Protect from light and freezing.
PATIENT COUNSELING INFORMATION
Instruct patients receiving Ablavar Injection to inform their physician or
healthcare provider if they:
• are pregnant or breast feeding
• have a history of allergic reaction to contrast media, a history of
bronchial asthma or allergic respiratory disorder
• have a history of kidney and/or liver disease
• have recently received a gadolinium-based contrast agent
• have a history of heart rhythm disturbances, or cardiac disease
• are taking any prescription or over-the counter medications
Gadolinium-based contrast agents, including Ablavar, increase the
risk for NSF in patients with severe renal insufficiency or acute renal
insufficiency of any severity due to the hepato-renal syndrome or in the
perioperative setting of liver transplantation. Patients with less severe
renal insufficiency who receive repetitive administrations of a gadoliniumbased contrast agent may have an increased risk for the development
of NSF, especially if the time interval between the administrations
precludes clearance of the previously administered contrast agent from
the body. If Ablavar is administered in these situations, instruct patients
to contact their physician or healthcare provider if they develop signs or
symptoms of NSF, such as burning, itching, swelling, scaling, hardening
and tightening of the skin, red or dark patches on the skin, stiffness in
joints with trouble moving, bending or straightening of the arms, hands,
legs, or feet, pain deep in the hip bones or ribs, or muscle weakness [see
Warnings and Precautions (5.1)].
Inform patients that they may experience:
• reactions at the injection site, such as: redness, mild and transient
burning or pain or feeling of warmth or coldness
• side effects of itching or nausea
To report SUSPECTED ADVERSE REACTIONS, contact Lantheus
Medical Imaging, Inc. at 1-978-667-9531/1-800-362-2668 or FDA at
1-800-FDA-1088 or www.fda.gov/medwatch
Distributed by Lantheus Medical Imaging, Inc., 331 Treble Cove Road,
North Billerica, MA 01862, United States
US Patents: 7,060,250; 7,229,606; and 5,919,967
515903-1009
October 2009
An Official Journal
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Tricia Leggett, DHEd, R.T.(R)(QM)
Zane State College
Zanesville, Ohio
Michael E Madden, PhD, R.T.(R)(CT)(MR)
Fort Hays State University
Hays, Kansas
Kimberly Metcalf, EdD, R.T.(R)(T)(MR)
Massachusetts General Hospital
Institute of Health Professions
Boston, Massachusetts
Dwayne Richardson, MSN, R.T.(R), RN
Hahnemann University Hospital
Philadelphia, Pennsylvania
Diane Scutt, PhD
University of Liverpool
Liverpool, United Kingdom
Joan E Siederer, MPH, R.T.(R)
SureWay Marketing Services
Princeton, New Jersey
Christina A Truluck, PhD, R.T.(N),
CNMT
Thomas Jefferson University
Philadelphia, Pennsylvania
Bettye G Wilson, MEd, R.T.(R)(CT),
RDMS, FASRT
University of Alabama at Birmingham
Birmingham, Alabama
Ben D Wood, MSRS, R.T.(R)
Northwestern State University
Shreveport, Louisiana
ASRT Journal Staff
Arlene Sheir-Allen, editor
Kathryn Faguy, ELS, publications manager
Ellen Lipman, director of professional development
Julie James-Griego, art director
Marge Montreuil, graphic designer
Laura Reed, graphic designer
Loren Stacks, graphic designer
JoAnne Quirindongo, advertising and
sponsorship manager
ASRT Office
15000 Central Ave SE
Albuquerque, NM 87123-3909
Phone: 800-444-2778; Fax: 505-298-5063
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sponsorship manager, at Ext. 1317, or
e-mail [email protected].
For questions regarding subscriptions or
missing issues, phone Member Services at
800-444-2778 or e-mail [email protected].
110
For questions about submitting an article,
e-mail [email protected].
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
.................................................................................. . . . . . . . . . . . . . . . . . . .
CONTENTS
November/December 2010
Volume 82/Number 2
P EE R- RE VIE WE D ARTICL E S
Factors Influencing Success in RA Programs: A Survey
Rebecca Ludwig, Joanne Huck, Jeffrey S Legg. . . . . . . . . . . . . . . . . . . . . . . . . 113
On the Cover: “Bare
Bones” is the second in a
series of cover images created
by Dr Kai-hung Fung, a
radiologist from Hong Kong.
This artistic rendering of a
3-D computed tomography
scan shows bone stripped to
its matrix at the distal end
of the femur. The marrow
is shown in blue; the yellow
structure at the bottom is
the patella.
The Role of Mobile Electronic Devices in
Radiographer Education
Jason S Applegate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
D I R E CTE D RE ADIN G ARTICL E S
Domestic Violence
Bryant Furlow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Diagnosis and Treatment of Scaphoid Fractures
Cynthia N Patrick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
C OL U MN S & DE PARTME N TS
Open Forum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Teaching Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
My Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Writing & Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Technical Query . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Literature Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
RE: Registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Student Scope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Patient Page. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
111
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open forum
CT Dose: Medical Residents Take Note
Open Forum is open to all
individuals interested in commenting on matters of concern
to the radiologic sciences.
Writers should e-mail their
letters to communications@
asrt.org. Letters may be edited
to conform with the Journal’s
space or style requirements.
Views expressed in this column
do not necessarily reflect the
views of the ASRT.
Editor:
In the March/April 2010 issue of
Radiologic Technology, Gudjonsdottir,
Ween and Olsen methodically outlined how newly developed automatic
exposure controls(AECs) in computed
tomography (CT) scanners can effectively keep patient dose to mutually
agreed upon accepted limits, if they
are used properly and according to the
manufacturer’s recommendations.
If the scientific community agrees
that CT scanning dose limits can be set
and standardized, and the latest AEC
technology can be employed, patient
dose should be as low as reasonable. In
other words, the technology is in place
to do its job. Radiographers will use the
AEC equipment as instructed, and all
will be just fine.
Not so fast. Walk around a radiology
department these days and hear what
technologists have to say about CT scanning and freshly minted doctors ordering
CT scans for a study that just a few years
ago could be handled with an anteroposterior and a lateral plain image. For
instance, why would a doctor order a CT
scan for a thumb? Yes, that’s right — a
thumb. How we got to this point is not
the issue. How new physicians can be
taught to correctly request a radiologic
examination is the question.
Robert J Slothus, R.T.(R)
(via e-mail)
112
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............................................................................. . . . . . . . . . . . . . . . . . . . . . .
peer review
Factors Influencing Success
In RA Programs: A Survey
Rebecca Ludwig, PhD, R.T.(R)(QM), FAEIRS
Joanne Huck, RRA, R.T.(R), RDMS
Jeffrey S Legg, PhD, R.T.(R)(CT)(QM)
Purpose To assess the factors registered radiologist assistants and radiologist assistant (RA) students perceive to be most significant for
success in an RA educational program.
Methods An electronic survey was sent to graduates of and students currently enrolled in RA programs (N = 99) via their program
directors. The response rate was 60.6% and represented 8 RA programs. Factor analysis was used to examine the relationships among the
variables.
Results Four factors accounted for nearly 93% of the variance, with 3 of the 4 related to the role of the radiologist preceptor. Although
the quality of the program itself seemed to be somewhat important, personal characteristics were perceived as contributing little to student
success.
Conclusion This study supports the importance of developing strategies to engage radiologist preceptors in the RA educational process.
S
ince inception of the radiologist assistant
(RA) model for advanced practice in medical imaging, educators anticipated that
instruction for RAs would be markedly different from the teaching techniques used
in traditional radiography programs. All RA programs
would require extensive preceptorships with a radiologist
or radiologists. Some programs would deliver courses
using new distance education formats, either as a supplement to conventional classroom courses, or entirely as
distance learning programs via online courses. Many RA
students would be the only such students at their clinical
affiliate site, rather than part of a cohort rotating
through the same facility. The RA students themselves
also would be distinctly different from other radiologic
science students; all would be experienced radiographers with diverse workplace backgrounds and highly
motivated to advance their imaging careers. Because of
the novelty of this advanced-practice model, educators
could only guess which factors would likely determine
the success of RA students and graduates.
This project focuses on the perceptions of students and graduates in identifying the major factors
enabling them to successfully complete an RA program. The researchers assumed that a combination
of factors related to the educational program, the
clinical preceptorship experience, the clinical affiliate site and the student himself or herself likely affect
academic success for any given individual. Identifying
specific factors that are perceived to enhance the success of many students would significantly assist educators in developing ways to maximize this benefit.
Literature Review
Research on the education of RAs is limited because
the profession is so new. The RA program at Loma
Linda University in California, which celebrated its
seventh anniversary in the fall of 2010, was the first
of only 9 RA programs recognized by the American
Registry of Radiologic Technologists (ARRT) at the
time of this study.1 A tenth program recently received
recognition from the ARRT. Graduates of ARRTrecognized programs are eligible to become registered
radiologist assistants (RRAs) through an examination
process. Until more data become available regarding
the education and clinical practice of RRAs, studies
of other physician-extender professions and medical
students or residents provide the closest parallel for
comparison. The literature search included MEDLINE
using PubMed, CINAHL Plus, HealthSource Nursing/
Academics, PsychINFO and Web of Science (SCI &
SSCI), all limited to Human and 2003-2009.
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
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SUCCESS IN RA PROGRAMS
Expanding the
Table 1
topic of factors for
Rank of Top 10 Factors for Student Success2
student success to all
Rank Category
Item
Important
Important
health professions
to Learning to Learning
yielded one study of
(N = 1642)
(%)
1642 medical students
and residents in 5
1
Site
Effective teachers
1569
98.4
Canadian medical
2
Site
Opportunity to see patients independently
1592
97.3
schools that closely
3
Preceptor Is open to questions
1540
96.7
matched this study’s
subject and became
4
Preceptor Gives constructive feedback
1522
95.6
the foundation for
5
Preceptor Demonstrates enthusiasm for teaching
1515
95.1
this project.2 The
6
Site
Opportunity to see large variety of patients
1511
94.8
investigators surveyed
the medical students
7
Preceptor Reviews differential diagnosis
1507
94.6
and residents on 24
8
Site
Opportunity to see adequate number of
1496
93.9
site characteristics
patients
and 38 preceptor
9
Preceptor Delegates appropriate responsibility for
1491
93.7
behaviors. Findings
patient care
suggested that the top
10 most important
10
Site
Preceptors readily available
1490
93.5
factors for student suc- Adapted with permission from Schultz K, Kirby J, Delva D, et al. Medical students’ and residents’
cess clustered around
preferred site characteristics and preceptor behaviours for learning in the ambulatory setting; a crossthe themes of opporsectional survey. BMC Med Educ. 2004;4:12.
tunity to perform
procedures and engage in communication with the
released in 2009 by the U.S. Department of Education.3
preceptor (see Table 1).
Controlled studies comparing the different versions of
Preceptor behaviors were items such as gives cononline learning were evaluated for students in college,
structive feedback, demonstrates enthusiasm for teachgraduate studies and professional training. This metaing, delegates appropriate responsibility for patient
analysis supported the inclusion of online opportunities
care and makes student feel like a valued member
to provide extra time for learning, additional resources,
of the practice. Site characteristics included items
or opportunities for collaboration and reflection. The
such as opportunity to see an adequate number of
findings indicated that distance learning, alone or in
patients, large variety of patients, seeing patients
combination with conventional classroom instruction,
independently, performing procedures, observing
resulted in stronger learning outcomes than exclusively
preceptors and interacting with referring physicians.
face-to-face classroom teaching. Rather than having
Site characteristics also encompassed items related to
information simply provided and explained by an
the characteristics of the respective programs such as
instructor, distance learning requires more studenteffective teachers, teaching of time management skills,
directed and independent learning. Distance or
clearly defined objectives for the site rotation and close
blended learning appears to yield better outcomes than
proximity of the clinic to the program’s campus. The
strictly traditional classroom learning because to some
inability to separate program characteristics from site
degree the students assume more responsibility for the
characteristics may somewhat limit the generalizability
learning process.
of the study findings to other situations. Also, the stuAssuming that the academic outcomes are essendent’s individual characteristics were not considered,
tially the same for learning completely online, or for
and these might also potentially influence the student’s
online learning blended with classroom instruction,
ability to succeed academically.
the importance of one delivery format over the other
Considering the type of educational format, the most
likely relates to issues of convenience for the individual
comprehensive study comparing online learning to
student. With few RA programs in the U.S., students
conventional classroom performance is a meta-analysis
with employment or preceptors and potential clinical
114
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LUDWIG, HUCK, LEGG
affiliate sites located far away from academic programs
would logically choose online course offerings. If
distance is not a consideration, then students would
seem more likely to prefer the nearest program as a
matter of convenience. The personal experience of the
investigators supports this notion. Program applicants
frequently cite the convenience of an online learning
format, or conversely the convenience of close proximity, as primary reasons for interest in a particular RA
program. At least informally, whichever educational
environment is most convenient for the student appears
to be his or her preference.
A growing body of medical literature validates the
importance of the preceptor to the clinical learning
experience. A 5-year study of 6527 medical students
and 16 583 physician residents at U.S. Department of
Veterans Affairs facilities reported that factors influencing satisfaction were similar for the 2 groups. Four
domains were evaluated: learning environment, clinical
faculty, working environment and physical environment. Clinical faculty members’ enthusiasm, willingness to delegate responsibility and providing feedback
were highly valued by the medical students, whereas
medical residents indicated that the variety of patients
and evaluating patients independently were important.4
All 5 of these factors also were associated with the earlier study by Schultz et al, as listed in Table 1.2
Similar themes regarding effective preceptors
emerged in a review of 110 reflective journals written
by medical students at a private midwestern medical
school. The 5 attributes ranked highest by the students
were demonstration of professional expertise, actively
engaging the students in learning, creating a positive
environment, demonstrating collegiality and professionalism and discussing discipline-specific topics and
issues. Interestingly, the characteristics associated with
ineffective preceptors included too much time spent
shadowing, comments discouraging students to ask
questions and a lack of interest in getting the student
involved in performing procedures. The factors identified in the study for success in medical education
reinforce the critical role of preceptors in involving
students in learning, encouraging autonomy and
providing feedback.5
Another study of medical students’ opinions found
that the students associated their preceptors’ effectiveness with enthusiasm, availability, inspiring confidence,
explaining decisions and giving feedback. The analysis
was based on 276 evaluation forms submitted by all
third-year medical students completing 12-week rotations
at an outpatient facility. Based on the student responses,
the investigators recommended that preceptors actively
involve students in developing clinical skills.6 Although
this study was restricted to a limited practice situation,
the strength of the data further validates themes found
in the other studies.
Methods
Dr Karen Schultz gave permission for the investigators to adapt a survey instrument she designed
for her study of medical students and residents,2 and
the proposed project was approved by the Internal
Review Board at the University of Arkansas for Medical
Sciences. The formatting was changed to facilitate
online delivery of a 68-item survey using Survey
Monkey with a similar Likert scale plus the choice of
“not applicable.” The demographic items specific to
medical students or residents were replaced with items
related to RA students or graduates. Nineteen of the
31 items related to preceptor behaviors were drawn
directly from the original survey. The remaining 12
items for preceptor behaviors were suggested via panel
discussions with faculty and current RA students. Eight
of the 21 items for affiliate site characteristics came
from the original survey. The other 13 items for the
affiliate site also were suggested by panel discussion.
Ten additional items were created to specifically target characteristics of the academic program, such as
instructional methods, access to library resources and
effectiveness of instructors. Six items were added about
the respondents’ personal characteristics, including
separating clinical activities from paid employment,
distance from the program and clinical site, and being
married or having family obligations. Finally, participants were given the opportunity to add comments at
the end of the survey.
Only 9 RA programs with limited numbers of
graduates and enrolled students existed when this
project was undertaken. In an effort to capture as
large a sample as possible, all 9 RA program directors
were e-mailed a link to the survey with a request to
forward the link to their currently enrolled students
and program graduates. The program directors also
were asked to reply to the e-mail with the numbers of
students and graduates receiving the forwarded message so that a return rate could be calculated. Eight
programs participated, with 52 students and 47 graduates receiving the link to the survey, yielding a study
sample of 99 people. Individual respondents were
completely anonymous to the investigators.
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SUCCESS IN RA PROGRAMS
Data were analyzed using
Table 2
SPSS for Windows, version 16.0.
Demographic Characteristics of Survey Respondents
Descriptive statistics were comN (%)
piled for the respondents’ demographic characteristics, clinical
Sex
site characteristics, preceptor
Female
31 (51.7)
behaviors, RA program characMale
29
(48.3)
teristics and personal characteristics. An exploratory factor analyAge (y)
sis was conducted using the scores
7 (11.7)
from the Likert scale for the clini- 20-25
26-30
15 (25.0)
cal site characteristics, preceptor behaviors and RA program
31-35
15 (25.0)
characteristics. Factor analysis is
> 35
23 (38.3)
a multivariate statistical approach
RA Program
used to analyze the interrelationships among large numbers of
Bloomsburg University (Bloomsburg, PA)
3 (5.1)
variables and to explain the variLoma
Linda
University
(Loma
Linda,
CA)
8 (13.6)
ables by their common underlyMidwestern State University (Wichita Falls, TX)
13 (22.0)
ing dimensions (ie, factors). The
technique allows reduction of a
Quinnipiac University (Hamden, CT)
1 (1.7)
large number of variables into a
University of Arkansas for Medical Sciences (Little Rock)
14 (23.7)
smaller set of dimensions/factors
6 (10.2)
with minimum information loss.7,8 University of Medicine and Dentistry of New Jersey (Newark)
The dimensions/factors are interUniversity of North Carolina at Chapel Hill
10 (16.9)
preted to identify the underlying
Virginia Commonwealth University (Richmond)
4 (6.8)
(ie, hidden) constructs that may
Prior Experience as R.T. (y)
be responsible for the observed
variables and correlations. For
<4
14 (23.3)
this study, varimax rotation was
4-6
12 (20.0)
used to create a factor structure
in which each variable loads high- 7-10
15 (25.0)
ly on one and only one factor.
11-15
7 (11.7)
According to Sharma, varimax
16-20
11
(18.3)
rotation results in each factor
8
representing a distinct construct.
> 20
1 (1.7)
Because this is a first-of-its-kind
study for RAs, all study variables were used in the factor
largest group of respondents was older than 35 years
analysis; no subanalysis was conducted.
old, with nearly 90% of respondents being 26 years
or older. Nearly one-quarter of survey respondents
Results
had less than 4 years of experience as a radiologic
A total of 99 surveys were e-mailed to current
technologist (RT), and approximately 32% reported
students (n = 52) and graduates (n = 47) of 8 RA pro11 years or more of experience in the profession.
grams in the United States in 2008. Sixty surveys were
Experience as an RA was low, as expected, considerreturned, for a response rate of 60.6%. One responing that this is a relatively new advanced practice area
dent provided only some demographic informain radiologic technology. The majority of respondents
tion; 6 others responded to some, but not all, items.
(66.7%) described their primary clinical affiliate as
Demographic characteristics of the survey responlarge; only 10% reported a small clinical affiliate. The
dents are listed in Table 2. Men and women were repmajority of clinical affiliates were public teaching hosresented relatively equally among respondents. The
pitals (54.2%). Private hospitals, both teaching and
116
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
...........................................................................................................
LUDWIG, HUCK, LEGG
were all ranked high. The effect
of the preceptors’ monitoring of
the quality of the clinical rotaN (%)
tion (3.98) and teaching the use
of community resources (3.76)
were ranked as only sometimes
34 (56.7)
enhancing the respondent’s
18 (30.0)
clinical experience.
Respondents’ perceptions
5 (8.3)
regarding the effect of clini3 (5.0)
cal site characteristics on their
clinical experience are ranked
in Table 4. Opportunities to
6 (10.0)
observe and perform a vari14 (23.3)
ety of procedures as well as
40 (66.7)
interact with radiologists were
consistently ranked as the most
important issues. For example,
32 (54.2)
the site characteristics with
10 (17.0)
the highest mean scores were
the opportunity to observe
12 (20.3)
both radiologists/preceptors
5 (8.5)
(4.76) and specialty procedures
(4.68). Also highly valued were
opportunities to interact with
27 (45.0)
physicians (4.61) and perform a
23 (38.3)
variety of radiologic procedures
(4.53). The existence of a site
coordinator (3.85) and the pres8 (13.3)
ence of other students in the
clinical site (3.60) were ranked
lower in terms of their perceived
effects on the quality of the clinical experience.
Table 5 displays respondents’ perceptions of the
RA program characteristics on their clinical experience. Again, respondents reported that program
characteristics had an important, positive effect on
their clinical experiences. Effective instructional
methods (4.71), helpful course instructors (4.63)
and online courses (4.61) were identified as the most
important characteristics of the RA program pertaining to respondents’ clinical experiences. Interestingly,
offering traditional classroom courses was ranked
lowest, although with a mean rating of 4.21 traditional
courses still “sometimes enhanced” the respondents’
clinical experience.
Last, the effects of the respondents’ personal characteristics were assessed to determine their impact on
clinical experiences (see Table 6). Unlike the previous
categories discussed, personal characteristics were
Table 2 (continued)
Demographic Characteristics of Survey Respondents
Experience as RRA (y)
0
1
2
3
Primary Clinical Affiliate Size
Small
Medium
Large
Primary Clinical Affiliate Type
Public teaching
Public nonteaching
Private teaching
Private nonteaching
No. of Clinical Sites Used in Program
1
2-3
4-5
>5
2 (3.4)
nonteaching, composed only 28.8% of clinical facilities. The largest percentage of respondents (45.0%)
reported using only 1 clinical facility. Approximately
84% of respondents reported using between 1 and 3
clinical sites.
Table 3 summarizes the perceived effect of preceptor
behaviors on respondents’ clinical experience, ranked
from highest to lowest: 5 = greatly enhanced internship,
4 = sometimes enhanced internship, 3 = no effect on
internship, 2 = sometimes adverse effect on internship
and 1 = adverse effect on internship. Overall, the mean
scores for the Likert-scaled responses were very high,
indicating the positive impact of the various preceptor behaviors on clinical experiences. For example, the
preceptors’ demonstration of a caring attitude toward
patients (4.65), discussion of their clinical reasoning
(4.63), responsiveness to questions from the student
(4.62) and provision of constructive feedback (4.62)
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
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SUCCESS IN RA PROGRAMS
Table 3
Perceived Effect of Preceptor Behaviors on RA Clinical Experience
Preceptor Behaviors
Demonstrates a caring attitude toward patients
N
Mean
(SD)
Range
54
4.65
(.55)
2-5
Discusses own clinical reasoning processes
54
4.63
(.62)
2-5
Open to questions
55
4.62
(.73)
2-5
Gives constructive feedback
55
4.62
(.68)
2-5
Asks students challenging questions
53
4.60
(.72)
2-5
Reviews differential diagnoses
53
4.58
(.69)
2-5
Observes clinical interactions directly
53
4.55
(.70)
1-5
Tries to help student meet clinical objectives
55
4.51
(.86)
1-5
Provides a role model of professional behavior
55
4.49
(.79)
2-5
Demonstrates effective interactions with other health care providers
53
4.47
(.64)
3-5
Outlines specific task(s) to be done during a clinical encounter
52
4.46
(.70)
3-5
Suggests relevant reading
53
4.43
(.80)
2-5
Demonstrates a caring attitude toward students
55
4.42
(.71)
2-5
Demonstrates enthusiasm for teaching
55
4.40
(.91)
2-5
Gives timely feedback
54
4.39
(.90)
1-5
Provides a role model of balance between personal and professional life
54
4.39
(.79)
2-5
Teaches patient assessment skills
52
4.37
(.69)
2-5
Identifies and responds to student’s specific learning needs
55
4.36
(.85)
2-5
Defines student’s roles in the specific clinical setting
50
4.36
(.66)
3-5
Connects new concepts to existing knowledge
53
4.34
(.68)
2-5
Asks for student’s ideas before giving own
53
4.32
(.75)
2-5
Teaches appropriate use of health care resources
50
4.26
(.83)
2-5
Sets time aside to discuss topics that could not be discussed during busy
clinical periods
51
4.22
(.86)
2-5
Provides background on patient before students sees patient
50
4.22
(.82)
2-5
Seeks to understand student’s ideas
53
4.19
(.79)
2-5
Facilitates student’s participation in follow-up care
52
4.17
(.79)
2-5
Teaches communication skills
49
4.14
(.87)
1-5
Practice group provides tuition assistance
29
4.10
(1.57)
1-5
Practice group provides income during clinical internships
28
4.07
(1.41)
1-5
Discusses limitations of his or her own knowledge
49
4.06
(.80)
2-5
Monitors quality of the rotation
48
3.98
(1.0)
1-5
Teaches use of community resources
42
3.76
(.98)
1-5
Abbreviation: SD, standard deviation.
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LUDWIG, HUCK, LEGG
Table 4
Perceived Effect of Clinical Site Characteristics on RA Clinical Experience
Site Characteristic
N
Mean
(SD)
Range
Opportunity to observe radiologists/preceptors if desired
51
4.76
(.55)
2-5
Opportunity to observe specialty procedures
50
4.68
(.71)
2-5
Opportunity to interact with physicians
51
4.61
(.72)
2-5
Radiologists readily available when needed by student
51
4.57
(.67)
2-5
Opportunity to do a variety of procedures
51
4.53
(.99)
1-5
Appropriate use of protocols during program
51
4.53
(.70)
2-5
Readily available equipment
50
4.52
(.76)
2-5
Adequate volume of procedures performed
51
4.49
(.92)
2-5
Adequate variety of procedures performed
51
4.49
(.99)
1-5
Availability of computer resources
51
4.43
(.81)
2-5
Opportunity to do a large number of procedures
51
4.43
(1.04)
1-5
Availability of library resources
50
4.38
(.78)
2-5
Supportive administrators/supervisors
52
4.38
(.91)
1-5
Opportunity to observe new technology in clinical operation
48
4.33
(.86)
2-5
Orientation to the radiology department
46
4.30
(.87)
2-5
Radiologic technologists demonstrate positive attitudes toward students
51
4.29
(1.06)
2-5
Orientation to the patient care areas
46
4.20
(.91)
1-5
Affiliate site provides income during clinical internships
26
4.19
(1.39)
1-5
Affiliate site provides tuition assistance
25
4.12
(1.56)
1-5
Existence of a site coordinator for students
34
3.85
(1.02)
1-5
Presence of other students in clinical site at the same time
40
3.60
(1.24)
1-5
Abbreviation: SD, standard deviation.
rated as having a lesser effect, with means ranging
from 2.50 to 3.72. For example, the 2 highest ranked
personal characteristics were financial support from
family (3.72) and distance from the clinical site most
often used for meeting clinical requirements (3.51).
However, the mean scores for the items separating
employment from clinical activities (2.94), distance
from the RA program location (2.84) and having children (2.50) tended to be more neutral or have a “sometimes adverse” effect on clinical education. Overall,
respondents’ personal characteristics appear to have a
more neutral or even less positive effect on RA clinical
experiences.
For the factor analysis, factor loadings of +.700 or
greater were interpreted for the dimensions/factors.
Four factors, accounting for 92.76% of the variance
for all the study variables, were identified. Table 7
displays the interpretation of the factors along with
the variables and their corresponding factor loadings.
Factor 1, representing 41.24% of the variance, pertains
to the teaching skills and methods of the supervising
radiologist based on variables such as the preceptors’
teaching of patient assessment skills and use of community resources, connecting new concepts to existing
knowledge, and so forth. Factor 2 explains an additional 24.00% of the variance (cumulative variance =
65.24%) and appears to represent a sense of “buy in”
and commitment on the part of the physicians and
practice. Key variables for this factor include the preceptor asking students challenging questions and openness to teaching. Factor 3, representing 14.38% of the
variance (cumulative variance = 79.62%), is interpreted
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SUCCESS IN RA PROGRAMS
influence on their
success in the RA
educational process.
RA Program Characteristic
N
Mean (SD)
Range
Interactions with
radiologists regarding
Effective instructional methods
51
4.71
(.54)
3-5
patient care and medHelpful course instructors
51
4.63
(.66)
2-5
ical decision making,
Online courses offered
51
4.61
(.90)
2-5
as well as involvement in procedures,
Library resources through program
51
4.57
(.67)
3-5
appear critical for
Expectations for professional development and growth
51
4.57
(.61)
3-5
enhancing RA cliniTimely response to inquiries
51
4.53
(.78)
2-5
cal education. Based
on our findings, we
Meaningful and relevant assignments
51
4.47
(.78)
2-5
suggest that RA proAssistance with addressing clinical issues
51
4.45
(.78)
2-5
gram faculty increase
efforts to establish
Communication of emerging professional issues and events 51
4.39
(.83)
1-5
positive relationships
Traditional classroom courses offered
32
4.21
(.98)
1-5
and rapport between
Abbreviation: SD, standard deviation.
radiologist preceptors
and students. In addition, respondents
Table 6
cited the imporPerceived Effect of Personal Characteristics on RA Clinical Experience
tance of radiology
Personal Characteristic
N
Mean
(SD)
Range
practices and cliniFinancial support from family
32
3.72
(1.25)
2-5
cal site staff to the
educational process.
Distance from clinical site used to meet most requirements 49
3.51
(1.29)
1-5
These factors should
Being married
39
3.03
(1.16)
1-5
be emphasized when
Separating employment from clinical activities
47
2.94
(1.28)
1-5
establishing clinical
preceptor agreeDistance from RA program location
49
2.84
(1.20)
1-5
ments. Nonetheless,
Having children
32
2.50
(1.02)
1-5
in the experience of
Abbreviation: SD, standard deviation.
the authors, involving radiologists in
the educational process has proved challenging. This
as representing the quality of the educational program.
is especially true when the preceptors are located off
Last, the fourth factor explains 13.14% of the variance
campus, which is common among RA programs. Not
(cumulative variance = 92.76%) and appears to focus
only is further study warranted on the educational proprimarily on the clinical reasoning/meaningfulness of
cess for radiologist-extenders, but perhaps even more
the clinical education and experiences dimension.
importantly, more effort is needed to develop mechanisms for involving preceptors in RA education in a
Discussion
meaningful way.
The clinical training and supervision of RAs is
Support from a variety of levels (clinical site, program
unique among radiologic technology educational
faculty and educational institution) also is perceived to
programs because it requires an increased level of
be an important influence on RAs’ clinical success. As
radiologist involvement. As midlevel health care provida new element in radiologic technology, RAs have little
ers, RAs have a higher level of responsibility and must
precedent on which to build. RA students may feel wary
incorporate activities and skills into their practice that
and concerned about the newness of the profession as
were formerly conducted by radiologists. Not surpriswell as their enhanced roles and opportunities while
ingly, the responses of RA students and graduates
forging ahead as midlevel radiologist-extenders. Thus, it
strongly suggest that the preceptor has the greatest
Table 5
Perceived Effect of RA Program Characteristics on RA Clinical Experience
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Table 7
Factor Analysis Results for Study Variables
Factor
% of Variance Explained
Cumulative Variance
Explained (%)
41.24
41.24
Teaching skills of MD & resources
Items Making up Factor
Factor
Loading
Teach use of community resources
.906
Discuss limitations of his or her own knowledge
.879
Demonstrates a caring attitude toward students
.875
Adequate volume of procedures performed
.875
Opportunity to observe radiologist/preceptor if desired
.875
Communication of emerging professional issues and events
.871
Appropriate use of protocols during program
.871
Presence of other students in clinical site at the same time
.841
Define student’s roles in the specific clinical setting
.840
Readily available equipment
.840
Adequate variety of procedures performed
.828
Opportunity to do a variety of procedures
.828
Observes clinical interactions directly
.828
Teaches communication skills
.827
Demonstrates effective interaction with other health care providers
.827
Teaches patient assessment skills
.827
Teaches appropriate use of health care resources
.820
Seeks to understand student’s ideas
.820
Connects new concepts to existing knowledge
.820
Helps students meet clinical objectives
.808
Existence of site coordinator for the student
.803
Orientation to the radiology department
.798
Orientation to the patient care areas
.798
Assistance with clinical issues
.788
Expectations for professional development and growth
.782
Library resources through program
.782
Sets time aside to discuss topics unable to be discussed during
busy clinical periods
.728
Facilitates student’s participation in follow-up care
.723
Provides background on patient before student sees patient
.723
Outlines specific tasks to be done during a clinical encounter
.712
Continued
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SUCCESS IN RA PROGRAMS
Table 7 continued
Factor Analysis Results for Study Variables
Factor
% of Variance
Explained
Buy-in and commitment of physician or practice
24.00
Items Making up Factor
65.24
Factor
Loading
Open to questions
.959
Demonstrates enthusiasm for teaching
.959
Asks students challenging questions
.959
Practice group provides income during clinical internships
.959
Practice group provides tuition assistance
.959
Affiliate site provides income during clinical internships
.959
Affiliate site provides tuition assistance
.959
Gives constructive feedback
.780
Suggests relevant reading
.744
Provides a role model of balance between personal and
professional life
.711
Quality of educational program
14.38
79.62
Demonstrates a caring attitude toward patients
.807
Online courses offered
.788
Availability of library resources
.749
Opportunity to interact with other MDs
.749
Effective instructional methods used
.749
Clinical reasoning & meaningfulness of clinical education
13.14
92.76
MD discusses own clinical reasoning
.756
Distance from RA program
.754
Meaningful and relevant assignments
-.877
is important for RA programs and other organizations
involved in developing the RA role (ie, the American
College of Radiology, American Society of Radiologic
Technologists and American Registry of Radiologic
Technologists) to continue to communicate regarding
issues facing RAs and the radiologists and health care
institutions involved in educating them.
This study has several limitations. The data collected
are based on a survey created for a different health
care profession with revisions made to reflect RAs.
Laboratory learning experiences and specific preceptor
behaviors were not addressed. Furthermore, there are
122
Cumulative Variance
Explained (%)
no reliability or validity data for the initial or current
survey, although the original study encompassed a large
sample. Because of the relative newness of the profession
and the small study population, an attempt was made
to capture as many RRAs and student RAs as possible.
However, it is possible that some RAs were not included
in the survey, so the findings should be interpreted with
caution. Last, factor analysis requires interpreting data
to determine hidden factors, and as with any interpretive activity, results may vary by researcher. Based on our
review and the findings of other investigators, we believe
the factor analysis interpretation is strong.
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LUDWIG, HUCK, LEGG
Conclusion
The emergence of the RA’s role as a midlevel practitioner can both advance the radiologic technology
profession and increase opportunities for technologists.
Benefits to radiologists, radiology groups and radiology
departments are predicted, but have not been empirically
studied yet. Considering the novelty of the profession and
the opportunities for a variety of stakeholders, continued
examination and review of the RA educational process,
clinical role and impact on the clinical environment are
crucial for the success of this profession. The findings of
this study provide insight into the factors and attributes
critical to the success of RA students.
References
1. American Registry of Radiologic Technologists.
Frequently asked questions about the ARRT registered
radiologist assistant certification program. www.arrt.org.
Accessed October 5, 2009.
2. Schultz K, Kirby J, Delva D, et al. Medical students’ and
residents’ preferred site characteristics and preceptor
behaviours for learning in the ambulatory setting; a crosssectional survey. BMC Med Educ. 2004;4:12.
3. Means B, Toyama Y, Murphy R, Bakia M, Jones K. U.S.
Department of Education, Office of Planning, Evaluation,
and Policy Development. Evaluation of evidence-based
practices in online learning; a meta-analysis and review of
online learning studies, 2009. www2.ed.gov/rschstat/eval
/tech/evidence-based-practices/finalreport.pdf. Accessed
August 25, 2010.
4. Cannon GW, Keitz SA, Holland GJ, et al. Factors determining medical students’ and residents’ satisfaction during
VA-based training: findings from the VA learner’s perceptions survey. Acad Med. 2008;83(6):611-620.
5. Huggett K, Warrier R, Maio A. Early learner perceptions
of the attributes of effective preceptors. Adv Health Sci Educ
Theory Pract. 2008;13(5):649-658.
6. Elnicki DM, Kolarik R, Bardella I. Third-year medical
students’ perceptions of effective teaching behaviors
in a multidisciplinary ambulatory clerkship. Acad Med.
2003;78(8):815-819.
7. Hair J, Black B, Babin B, Anderson R, Tatham R.
Multivariate Data Analysis. 6th ed. Upper Saddle River, NJ:
Prentice Hall; 2005.
8. Sharma S. Applied Multivariate Techniques. New York, NY:
John Wiley & Sons; 1996.
Rebecca Ludwig, PhD, R.T.(R)(QM), FAEIRS, is an
associate professor, chairman and director of the Radiologist
Assistant Program at the University of Arkansas for Medical
Sciences in Little Rock.
Joanne Huck, RRA, R.T.(R), RDMS, works at Associated
Radiologists, Ltd, in Jonesboro, Arkansas.
Jeffrey S Legg, PhD, R.T.(R)(CT)(QM), is associate professor and chairman of the Department of Radiation Sciences
at Virginia Commonwealth University in Richmond. He is
also a member of the Radiologic Technology Editorial
Review Board.
The authors thank Dr Michael Anders from the
Department of Respiratory Care of the College of Health
Related Professions at the University of Arkansas for Medical
Sciences for his inspiration and willingness to share ideas
related to this project. Permission from Dr Schultz to adapt her
survey instrument for this study was also greatly appreciated.
Reprint requests may be sent to the American Society of
Radiologic Technologists, Communications Department,
15000 Central Ave SE, Albuquerque, NM 87123-3909, or
e-mail [email protected].
©2010 by the American Society of Radiologic Technologists.
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. . . . . . . . . . . . . . . . . . . . . . . . ...........................................................................
peer review
The Role of Mobile Electronic
Devices in Radiographer Education
Jason S Applegate, MSRS, R.T.(R)(CT), CNMT
Background Students commonly use mobile electronic devices (MEDs) for everyday activities such as e-mailing, texting, talking and
playing. Students’ familiarity with these devices may make it beneficial for educators to use MEDs to enhance classroom teaching and
clinical learning.
Methods This literature review examines the use of MEDs in radiography educational programs.
Results Various potential uses for MEDs are discussed, such as clinical logs, archiving data, accessing reference material and evaluation tools and providing course materials. The author also addresses factors for selecting an MED, advantages and disadvantages of
MEDs, their limitations and suggestions for future research.
Conclusion Research suggests that there are several areas in the classroom and clinical situations where MEDs could benefit students
and faculty. In particular, MEDs may improve efficiency in data collection and clinical evaluation and prove valuable as an information delivery tool.
M
obile electronic devices (MEDs) are
popular tools that are similar to computers, but with more limited capabilities.1,2 In this article, MED refers to personal digital assistants (PDAs), Palm
Pilots, I-pods, I-phones, Blackberrys, pocket PCs, handheld computers and smartphones. Students of all ages
are regular users of MEDs such as cell phones and digital music players.3,4 Because students tend to be very
comfortable using these devices and MEDs can conveniently store and process data, educators are interested
in incorporating them in learning environments.5,6
Software companies have developed programs
that help an individual customize a data collection
and storage system unique to his or her needs.7,8
This allows collection of specific data tailored to the
individual’s interest and can be used for various academic fields. For example, MEDs may be valuable in
instruction and information gathering in the field of
radiography.
It is important to research the use of these devices
as an instructional aid and clinical assessment tool to
determine whether they could be used effectively in
the educational setting. This article reviews research
focused on either classroom use or clinical uses of
MEDs. To determine uses for these devices in radiography education, it is necessary to explore both of
these avenues.
124
Methods
This article is a review of the peer-reviewed literature on the use of MEDs as an academic and data collection tool in radiography. Databases were accessed
using the search terms “electronic devices in learning,”
“handheld devices in learning,” “personal digital assistant,” “use of pdas,” “pda and education” and “PDA.”
The Academic Search Complete database was accessed
using the term “electronic devices in learning,” and 115
articles were retrieved. Narrowing the search by using
“handheld devices in learning” produced 24 articles.
Abstracts were reviewed to determine whether they
directly related to the research topic. The MEDLINE
database was then accessed using the term “PDA.” This
searched yielded 35 results that also were reviewed for
content relevance. The search terms “PDA” and “PDA
and education” were used to search Academic Search
Complete, and 127 articles were located.
The Cumulative Index to Nursing and Allied
Health Literature database was accessed using the
search terms “personal digital assistant” and “handheld devices.” The Boolean term “or” was used, and
the articles were limited to those in 2004 or later. This
narrowed the results to 192 articles. MEDLINE was
also accessed, and identical parameters were used to
perform the search. The search results included 278
articles. Finally, Google Scholar was used to locate
more articles of interest using the phrase “PDAs for
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education” and “use of PDAs” to search for articles
unavailable through the other database searches. Each
search was limited to articles published between 2004
and 2009, as well as selecting full-text articles that were
peer reviewed. After review of the abstracts, articles
were selected based on their relationship to the subject
matter and quality of content. References cited by each
article reviewed were researched to acquire additional
information related to the research topic.
Selecting an MED
Taylor et al determined that cost and ease of use
were critical factors in determining which MED to
use.7 They specifically mentioned the use of disposable batteries, which reduced the need for recharging
equipment or a docking station where an MED can
be placed to charge batteries or transfer information
to a host computer. The host computer is usually a
laptop or a personal computer. Conversely, Anderson
and Blackwood believed that rechargeable batteries
were better because of their reusability.3 The Taylor
study focused on the use of PDAs for a family medicine
clerkship and included 85 medical students, whereas
Anderson and Blackwood focused on higher education
in general.
The authors of another study selected devices based
on recommendations provided by the software company that was used.9 This research focused on the use
of PDAs to access pertinent information at the patient
bedside and included clinical and library staff.
White and associates used the expertise of the
Center for Information Technology and Distance
Learning (CITDL) to select an appropriate device.5
This use benefited the study because the CITDL staff
could match the physical requirements of the devices
to the specifications of the needed software. This
approach also allowed the staff to become familiar with
the devices before implementation so that their expertise could be used for technical support.
Savill-Smith and Kent published a landmark literature review that focused on the use of MEDs in education.10 Their research suggested that the most common
approach to selecting the devices was to find something
users are comfortable with and stick with that choice for
as long as feasible. The article also mentioned the use of
specialized Web sites to help determine the type of device
that would be suited to individual needs. Unfortunately,
most articles reviewed did not give specific reasoning
for the selection or mention whether the devices were
already available to the research participants because
of prior purchase. It appears that no one factor can be
used to select a device best suited for a project; however,
selection based on individual need is the most common
approach.
Introducing MEDs to Faculty and
Students
Any new device can create apprehension that may
result in a lack of use. Successful implementation of
MEDs requires that individuals feel comfortable using
these devices. One of the articles reviewed discussed
the implementation of PDAs in an undergraduate nursing program.11 Because of a lack of funding, only the
students received PDAs; faculty were excluded. The
researchers believed this led to a decrease in student
use because faculty did not promote the value of the
device. Several articles discussed the use of training sessions of an hour or more before implementation.5,8,12-14
Participants believed that the training sessions were
helpful and likely would reduce their anxiety when
actual implementation began.
Other researchers used volunteers only.9,12,15-17 This
likely would yield higher acceptance of the devices, but
would bias any qualitative data collected on perceptions
of usefulness and ease of use. Unfortunately, using a
random sampling of participants may yield subjects who
are unwilling to participate, which also biases the data.
Even though participants in the research conducted by
Lee17 were voluntary, there were some negative comments about using the device in the early stages. Later
in the study, participants adapted to the devices and
were more comfortable using them. Lee focused on
Lewin’s change theory, which suggests that individuals go through stages when change is introduced. The
first stage is “unfreezing.” According to the theory, in
the unfreezing stage individuals resist change until
a certain level of comfort has been reached. Lewin’s
theory suggests that training and initial acclimation to
the devices before use seems to be the logical method
of introduction. This was also a suggestion in research
conducted by Farrell and Rose.12
MEDs in the Classroom
Literature that focuses on the use of MEDs in radiography education is very limited. Most relevant literature focused on the education of medical and nursing
students, as well as uses in information technology
(IT) courses. Rawlinson and Bartel introduced PDAs
into an IT course at Central Washington University
(CWU).1 Their research included a qualitative study
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MOBILE ELECTRONIC DEVICES IN RADIOGRAPHER EDUCATION
of students using their devices for daily learning activities. The goal of the research was to introduce new
technology to students who were entering the IT and
administrative management program at CWU to determine whether use of PDAs could benefit the students
educationally. The sample size of the survey was limited
to 2 small groups of students enrolled in IT courses.
The total number of students involved in the research
was 74. This small sample size, as well as the lack of
diversity in the research groups, unfortunately reduces
the ability to generalize the results to a wider population and reduces reliability. Students were likely already
interested in technology and therefore may have had
interest in using new technology. This makes it difficult
to determine whether the results can be generalized to
radiography students.
Students participating in the research study were
required to purchase the devices for class and were
asked to assess the PDA as a useful tool for learning by
means of a survey instrument.1 Students evaluated the
PDAs at the end of the semester. Results were based on
their satisfaction with the device as a possible educational aid, what applications were most often used by
the students and what future uses the students would
find beneficial. According to the survey, the greatest response regarding usage (97%) was to access the
Internet. Other commonly used applications were
e-mail, games, file sharing and scheduling. Responses
to future uses of the device were similar.
Accessing the Internet could be both a beneficial and
distracting function of MEDs. The students would gain
access to useful information that is available on Web
sites. Assignments could be developed that require the
students to perform small amounts of research during
class time. This may help to develop research skills and
promote learning beyond the classroom. The downside
would include surfing the Web while a lecture is in progress or checking e-mail during class sessions.
A related obstacle is the need for a wireless Internet
infrastructure, which is an important building block
to implementation.1,18,19 The absence of this technical
component would severely diminish the usability of the
MEDs. Anderson and Blackwood’s article stated that
educational institutions will need to move toward a
better wireless infrastructure to accommodate the everincreasing growth in wireless devices such as MEDs.3
Song focused on the use of MEDs specifically as
an educational tool, breaking down the uses into the
following 6 categories: educational, managing, information seeking and handling, games and simulations,
126
data collection, and context awareness.18 Many of these
categories have been broken down into subcategories.
The most intensely discussed category is educational
communication. Song discussed the use of PDAs for
different types of communication in the educational
setting, including several applications that were considered most frequently used by Rawlinson and Bartel.1
Sharing/exchanging ranked high in the research conducted by Rawlinson and Bartel, and Song mentioned
it as one of the subcategories of educational communication. Wu and Lai also believed that sharing/
exchanging was a benefit of using MEDs.19 PDAs could
be used as an effective way of transferring data to students in the classroom. Instead of using paper-based
literature, a file exchange could be used to reduce costs
for materials and services such as copying.1 Using this
application to transfer course documents to students
also could assure the instructor that students have the
information they need for class rather than expecting
students to purchase resources.
Smordal and Gregory used this process to transfer
an e-book to medical students.20 The process itself was
a success but, according to the researchers, the students did not use the resource as much as anticipated.
However, no data were provided to back up this claim.
It would seem reasonable that radiography instructors could consider giving quizzes or assignments via
MEDs to students in lieu of traditional paper-based
formats. This use of MEDs is mentioned as an option
for educators to consider.1,18,21
Other uses for MEDs in the classroom include podcasts, videocasts and polling devices.1,4,15,18,22 Using audio
or video formats, lectures can be recorded before or
during class to allow students the opportunity to study
the material at a later time. Podcasts are audio or video
recordings that are stored as a media file. These files
can be accessed by students or faculty and downloaded
to computing devices. This allows the student to focus
on the lecture itself rather than taking notes during the
lecture.22 The use of MEDs as a polling device enables
the instructor to create an interactive class and deliver
quizzes and assessments.1,22 Data can be quickly collected
and organized by the instructor’s receiving device.
MEDs in Clinical Settings
Most research on the use of palmtops as a clinical
assessment tool has focused on nursing and medical
students. Radiographers increasingly use technology
every day; therefore, it seems reasonable to suggest that
integrating technology into the training of radiography
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students would be useful. The use of MEDs in the clinical setting may be valuable considering their small size
and portability, and the ability to communicate with
other computers via multiple channels.10,18 Farrell and
Rose found that students thought the devices were easy
to use and helpful in several aspects of clinical education.12 McKenney’s research at The Ohio State University
Medical Center focused on the use of PDAs to create
a mobile delivery option for learning materials used
by medical students in clinical rotations.21 Learning
modules were loaded onto the devices’ memory either
by accessing the modules on an Internet site or using a
data CD that was produced in-house. The modules consisted of Microsoft PowerPoint presentations (Microsoft
Corporation, Redmond, Washington) and text documents.
Other research has suggested that the MED is effective as a teaching tool because of its ability to provide
information to students at the point of care.12,16,23 The
use of a small MED for reference vs a cumbersome textbook seemed to be appealing to students.16,24 An adaptation of this to radiography students could include
having anatomy and positioning information stored
on the device for reference during clinical rotations.
Martino and Odle pointed out that one facility stores
imaging protocols on the devices for easy access at the
point of care.4 This could foster a greater sense of independence and self-reliance in students.
Fisher and Koren researched perceptions on the use
of PDAs by undergraduate nursing students.16 Their
study was based on qualitative data for a relatively small
sample size (28), which raises concerns regarding the
reliability of their results. They used focus groups with
impartial facilitators to collect responses to open-ended
questions about personal perceptions of MED use
during clinical rotations. The answers were analyzed
and grouped according to predetermined categories.
Results indicated that students perceived the devices as
a useful resource, but opinions were mixed regarding
the devices’ usefulness for developing critical thinking
and improving quality of care.
Another aspect of research that has potential for
cross-over into radiography education is the use of
MEDs to capture images or video for use in the classroom or on discussion boards.20,21 The use of video
has both advantages and disadvantages, considering
patient privacy, but if the proper channels are followed,
it could be used for numerous learning activities.
One possibility would be to create videos of students
performing a procedure during a clinical rotation
and later use this to evaluate their performance. The
image capture application may be used to store images
of unusual pathology or anomalies for discussion in
class or on an online discussion board. Covington
and Claudepierre suggested this as an option in their
research on use of PDAs in a dental hygiene educational program.15
White et al studied the use of student-written clinical journals in educating nursing students at Duke
University.5 Student journals included descriptions of
procedures performed or skills used, pertinent patient
history and a reflective learning section. The journals
were submitted to the faculty weekly. The researchers
stated that this improved students’ organizational skills
and accountability. The journals also forced students
to recall their clinical experiences and reflect on what
they had learned. Faculty benefited from the journals
because they enabled tracking of students’ progress
and aided in planning assignments or lectures.
Using the devices to evaluate student performance in
a clinical setting is another potential benefit of MEDs.
Martino and Odle mentioned that some radiography
programs are currently using MEDs to evaluate students’
clinical performance; however, there is no literature
describing the successfulness of the devices in such a
setting.4 Data collection with MEDs could be useful to
faculty in the radiologic sciences. Teaching institutions
are responsible for ensuring that students are exposed to
the variety of examinations mandated by the American
Registry of Radiologic Technologists’ competency
requirements. By using MEDs to collect data on the
number of examinations performed by each student,
faculty can determine areas in which a student is weak or
which types of examinations are lacking at a clinical site.
This information could be used as documentation in
accreditation reviews, for making clinical assignments,
or as feedback to individual students.
Approaches to Data Collection
Many of the articles reviewed described approaches
taken by researchers in the medical field. Research pertaining to the education of nurses and physicians was
considered most relevant to the education of radiographers. Data collected from the field of nursing focused
on patient care issues such as input/output data or
medication-related data.17
Hardwick, Pulido and Adelson discussed the use of
MEDs to collect data for nursing.25 The article mentions uses in specialty areas such as home health and
orthopedics. The researchers also discussed the use of
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voice recording abilities to record patient observations
when a link to the hospital’s medical records was not
available. This would decrease the likelihood of lost or
skewed data due to the time interval between observation and recording. This feature also could be useful to
technologists who are observing students performing
competencies during busy times. If the technologist
does not have time to complete an evaluation form
when the examination is completed, the recollection
of events may become obscure, and an accurate evaluation may not occur.
Treadwell investigated the use of PDAs as a replacement for paper-based clinical examinations.8 Treadwell
mentioned several consistent problems with the paperbased form, including illegible handwriting and lost
documents. The researchers used data collection software that was personalized to their needs. Luo and Ton
also found the database software to be user-friendly
with minimal training.26 The ability to tailor data collection software to the needs of the researcher appeared
to be a significant strength of the devices. Treadwell
focused on medical students, who are evaluated on specific competencies in a manner similar to the way radiography students are evaluated on performing competencies. The research was performed over a 3-year
period on medical and dental students, and focused on
increasing evaluation efficiency and user satisfaction.
The research occurred in 2003, 2004 and 2005 with
309, 314 and 270 research subjects, respectively.
The most notable finding of the study was the
amount of time spent on preparing evaluations. Paperbased assessments required preparing checklists, photocopying and calculating evaluation results. Paper-based
evaluations were used in the first year of the research,
and the amount of time spent on preparation totaled
525 minutes. The amount of time spent using the PDAbased assessment initially totaled 120 minutes because of
training in 2004, and only 35 minutes in 2005.
The main reliability issue with this study was that
the paper-based procedures were studied for only 1
year, whereas the use of PDAs was studied for 2 years.
The results cannot be considered significantly reliable
until research has been conducted for multiple years
on each of the evaluation types. The data could be
skewed because of internal or external factors. In addition, although the sample sizes were significant, the use
of medical and dental students limits the study’s generalizability to radiography students. However, similar
improvements in efficiency as a result of switching from
paper-based evaluations to evaluations completed on
128
MEDs were detailed in other research studies.6,27 This
may be a significant finding that could reduce instructors’ workload in evaluating radiography students.
Data Collection Outcomes
Data collection with MEDs can have many benefits
over paper-based collection.25 Paper-based collection
systems have several inherent problems. Falsification
of data, failure to accurately recall data and illegible
handwriting were noted in several studies.6,8,25,26-28
Software can be installed on MEDs to collect, process
and display data. Collecting, entering and processing
the data can be performed with one device rather
than using a system of forms, clerical staff and a network of computer systems.7,8,26 Stengel et al found that
the use of MEDs to assign International Classification
of Diseases-9 codes to hospital patients resulted in
fewer coding errors (P < .001).27 Although this appears
to be the most significant research conducted on data
collection using MEDs, the study was performed over
a short period of time. If this data is indicative of
efficiency improvements in data collection, the study
should be replicated for a longer period of time to
improve the reliability.
Treadwell’s research results did not necessarily agree
with those of Stengel and associates.27 Treadwell noted
a nonsignificant difference between the paper-based
evaluations vs the MED-based evaluations. Regardless of
the difference in the 2 results, there does not appear to
be a negative outcome when using MEDs to collect data.
This seems to suggest that MEDs are at least comparable
to paper-based methods. It may be that researchers will
need to evaluate which method is most suited to their
needs when selecting a data collection process.
Guadagno and associates discovered a downside to
using PDAs to collect data at the point of care.13 Their
research focused on using PDAs to assess neglect of
elderly patients who were brought to the emergency
department. Participants in the study found it difficult to
enter data while focusing their attention on the patient
and his or her needs. This eventually led to participants
collecting data with pen and paper first, then entering it
on the MED. Participants reported that the MED interface made it challenging to focus on patient responses
while entering text. In this case, the benefit of increased
efficiency is countered by the redundancy in data logging. The researchers suggested creating a more userfriendly interface for the PDAs in which a drop-down
box could be used to select certain variables. Other
research also suggested this modification to simplify the
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data collection process. In the study by Guadagno et al,
a poorly designed data collection process might have
biased the research outcome.13 This underscores the
need for a user-friendly device and interface to successfully implement the use of PDAs.
In addition to reducing the time spent collecting
data, MEDs could reduce the number of errors during
calculation of evaluation scores, thereby making data
collection and processing more accurate. Calculating
midterm and final clinical grades from data input
would be an area where this feature would be useful. The data processing could be performed by the
MED, allowing clinical instructors to spend more time
instructing students.
Data collection with MEDs also may allow educators to increase the amount and type of data collected
without increasing the time spent on collection.28
Ducut and Fontelo stated that some schools have shifted away from paper-based evaluations to PDA-based
evaluations to cut costs.22 The ability to tailor data
collection software allows the faculty or department
leaders to collect data relevant to a program’s performance. Information on the number of examinations
completed, diversity of examinations and individual
workload could prove useful.
Limitations of MEDs
Although MEDs have many benefits over paperbased data collection processes, there are also limitations and undesirable characteristics. Data loss due to
equipment failure is one issue discussed by Kho et al.28
However, data loss also was a problem with paper-based
data collection.8,26 One specific reason cited for data
loss with MEDs was the loss of power due to run-down
batteries.26 Treadwell selected devices with a long battery life, which suited his research design.8 Luo and
Ton mentioned the use of the MED alarm function
to remind the user to synchronize the MED to a host
computer.26 This function also could be used to alert
the user that the batteries need to be recharged. This
should alleviate the issue with data loss due to dead
batteries. The user can transfer data stored on the
MED to a host computer, thereby reducing the risk of
a significant amount of data being lost as a result of
equipment failure.3
Several articles suggested the use of memory expansion cards to ensure that data remain on the device
without loss.7,9 The lack of available memory also is seen
as an obstacle to widespread use of MEDs in educational
and clinical settings.1,21,29 However, the expandability
of the device’s memory by use of a secure digital (SD)
card is an easy fix. McKenney gave the example that
1 megabyte (MB) of memory is equal to the contents
of a 600-page book.21 The devices used in the research
conducted by McKenney consisted of a 64-MB SD card,
which was reported to be sufficient for the applications
and data used in the research project.21 Considering that
McKenney’s findings were documented in 2004, recent
advances in technology have likely increased the amount
of memory available for MEDs.
Another issue with MEDs is confidentiality of
patient and student information. When data are collected for any reason, the information must remain
secure. MEDs can be used to store sensitive information that should not be seen by unauthorized individuals. This leads to a security issue with the MED.
Hardwick et al addressed this issue in their research.25
The team discussed the use of password protection for
the device against unauthorized use. If the device were
to be left unattended or stolen, the information would
remain secure because it could not be accessed without
the proper password.13,17,25 Likewise, those researchers
mentioned that when sensitive data are transferred
to another computer for processing, the information
should be encrypted to ensure security.
The small screen on an MED also was found to be a
significant limitation.1,29 Research suggested that screen
size may create significant problems for individuals who have certain disabilities; however, Treadwell
found no such problem.8 The limited screen size also
forces the need for special programs and applications
designed to fit the screen.21 The authors of several
articles mentioned the size of the screen as a possible
barrier to widespread use.1,20,21 The small screen makes
viewing larger documents and Web pages difficult.8,20
In Treadwell’s research, a technique called “branching”
was used to simplify large checklists used to evaluate
medical students. Branch design is described as creating “steps” or “branches” to different items rather than
having a large global view of a checklist. This process
was made possible by a software system installed on the
palmtop called HaPerT. (HaPerT was developed privately.) Treadwell’s study had a small sample size (42)
and was not large enough to generalize to larger and
more diverse groups.8 Treadwell researched practical
performance assessment of medical students. Faculty
members used MEDs to administer objective structured clinical examinations to medical students. The
focus of the research was whether an MED could produce similar assessments as paper-based formats while
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MOBILE ELECTRONIC DEVICES IN RADIOGRAPHER EDUCATION
maintaining or exceeding user satisfaction.8 Guadagno
et al found that entering data on the small screens was
cumbersome, and research participants found that a
drop-down box with choices that could be selected by
tapping on them was easier to use.13
The need for training users on the device was
a common challenge for many of the research
groups.1,8,16,21 Most of the researchers trained users
before implementation and offered support by information technology personnel during the research.1,16,21
Research that focused on student use in the clinical
setting mainly let the students explore the devices
themselves, with technical support available to them.
Considering the amount of time that might be spent
learning the devices, it may be wise to offer training on
the devices before their use in educational settings.
Suggestions for Further Research
The small size of MEDs allows them to be taken virtually anywhere with little effort. Despite their portability,
little attention has been focused on the use of MEDs in
educating radiography students. Small pilot programs
should be started to assess the effectiveness of the devices
as instructional aids in the classroom or clinical setting.
Research should focus on the effectiveness of transferring course material electronically vs by traditional
paper-based systems. Is this method as effective, or even
more effective? Will students use the device more readily
than books and paper resources? How much infrastructure would be required to facilitate wireless communication for classroom use of these devices? Research also
should focus heavily on the use of the devices in clinical
settings. It would be wise to assess the effectiveness of
the devices as reference tools for radiography students in
clinical settings.
Research using MEDs to collect data also should be
considered by all branches of health sciences including nursing, radiography and physical therapy. Use of
MEDs as an evaluation tool or clinical data collection
device has not been sufficiently researched. Research
should focus on these areas, as well as the usefulness
of MED data-collecting abilities in determining a program’s progress or effectiveness. There is also room for
research into whether MEDs should be in the hands
of students or with clinical evaluators. Both of these
groups likely can benefit from the devices.
Can these devices provide redundancy with other
resources to facilitate student learning? Can faculty use
the devices to collect useful data about the procedure
trends occurring in their clinical facilities? Is it possible
130
for students to use the devices for time management during clinical rotations? Considering the lack of research
on MEDs in the education of radiography students, it is
difficult to suggest one area of focus. The door appears
wide open for research in this area.
Conclusion
MEDs — small electronic devices with functions
similar to computers — have been used for several
years by students and faculty alike. Use of these devices
in educating medical and nursing students has been
documented in several articles with mixed results. It
is likely that these devices hold some value as educational tools if used appropriately by student and faculty members in a radiography program. The devices
can be used for making assignments and supplying
course materials, administering quizzes and tests, and
conducting research in the classroom. However, care
should be taken to avoid the distractions that also come
with these devices.
Integrating MEDs into clinical settings could
provide additional educational opportunities. For
example, they could be used as a resource for anatomy
and positioning information for radiography students.
Instead of carrying around textbooks that can take up
enormous amounts of space, students could have the
reference material in their pockets. The devices also
may be valuable for documenting student progress or
interesting cases during clinical rotations. A joint effort
will be required by the faculty and information technology professionals to develop and maintain curricula
that include MEDs.
Research on the use of these devices in the field of
radiography is extremely limited. However, research
on their use in the nursing and medical professions
can help guide development of MED uses in the field
of radiography, improving educational processes and
methods of collecting and processing important data.
Although there are limitations to the devices, the
benefits may outweigh the limitations. Only through
persistent research can we determine whether MEDs
can effectively enhance the education of radiography
students.
References
1. Rawlinson D, Bartel K. Implementing wireless PDA
technology in the IT curriculum. Educause Quarterly.
2006;1:41-47.
2. Whitsed N. Learning and teaching. Health Info Libr J.
2006;23(1):73-75.
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3. Anderson P, Blackwood A. Mobile and PDA technologies:
their future use in education. Joint Information Systems
Committee Technology Watch. Joint Information Systems
Committee website. http://citeseerx.ist.psu.edu/viewdoc
/download?doi=10.1.1.105.6184&rep=rep1&type=pdf.
Published November 2004. Accessed August 20, 2009.
4. Martino S, Odle T. New models, new tools: the role of
instructional technology in radiologic sciences education.
Radiol Technol. 2008;80(1):67-74.
5. White A, Allen P, Goodwin L, Breckenridge D, Dowell J,
Garvy R. Infusing PDA technology into nursing education.
Nurse Educ. 2005;30(4):150-154.
6. Ranson SL, Boothby J, Mazmanian PE, Alvanzo A. Use of
personal digital assistants (PDAs) in reflection on learning
and practice. J Contin Educ Health Prof. 2007;27(4):227-233.
7. Taylor J, Anthony D, Lavalee L, Taylor N. A manageable
approach to integrating personal digital assistants into a
family medicine clerkship. Med Teach. 2006;28(3):283-287.
8. Treadwell I. The usability of personal digital assistants
(PDAs) for assessment of practical performance. Med Educ.
2006;40(9):855-861.
9. Honeybourne C, Sutton S, Ward L. Knowledge in the
palm of your hands: PDAs in the clinical setting. Health
Info Libr J. 2006;23(1):51-59.
10. Savill-Smith C, Kent P. The use of palmtop computers
for learning: a review of the literature. British Journal of
Educational Technology. 2005;36(3):567-568.
11. Miller J, Shaw-Kobot J, Arnold M, et al. A study of personal
digital assistants to enhance undergraduate clinical nursing education. J Nurs Educ. 2005;44(1):19-26.
12.Farrell M, Rose L. Use of mobile handheld computers in
clinical nursing education. J Nurs Educ. 2008;47(1):13-19.
13. Guadagno L, VandeWeerd C, Stevens D, Abraham I,
Paveza GJ, Fulmer T. Using PDAs for data collection. Appl
Nurs Res. 2004;17(4):283-291.
14. Scollin P, Callahan J, Mehta A, Garcia E. The PDA as a
reference tool: libraries’ role in enhancing nursing education. Comput Inform Nurs. 2006;24(4):208-213.
15. Covington P, Claudepierre K. Personal digital assistants:
exploration of their use in dental hygiene education and
practice (evidence for practice). Canadian Journal of Dental
Hygiene. 2006;40(2):80-83.
16. Fisher K, Koren A. Palm perspectives: the use of personal
digital assistants in nursing clinical education. A qualitative
study. Online Journal of Nursing Informatics. 2007;11(2). http
://ojni.org/11_2/fisher.htm. Accessed September 30, 2010.
17. Lee T. Adopting a personal digital assistant system:
application of Lewin’s change theory. J Adv Nurs.
2006;55(4):487-496.
18. Song Y. Educational uses of handheld devices: What are
the consequences? Tech Trends. 2007;51(5):38-45.
19. Wu CC, Lai CY. Wireless handhelds to support clinical
nursing practicum. Educational Technology and Society.
2009;12(2):190-204.
20.Smordal O, Gregory J. Personal digital assistants in medical education and practice. Journal of Computer Assisted
Learning. 2003;19:320-329.
21. McKenney RR. The next level of distributed learning:
the introduction of the personal digital assistant. J Oncol
Manag. 2004;13(2):18-25.
22.Ducut E, Fontelo P. Mobile devices in health education:
current use and practice. Journal of Computing in Higher
Education. 2008;20(2):59-68.
23.Cornelius F. Handheld Technology and Nursing Education:
Utilization of Handheld Technology in Development of Clinical
Decision-Making in Undergraduate Nursing Students [dissertation]. Philadelphia, PA: Drexel University; 2005.
24. Koeniger-Donohue R. Handheld computers in nursing
education: PDA pilot project. J Nurs Educ. 2008;47(2):74-77.
25.Hardwick ME, Pulido PA, Adelson WS. The use of handheld technology in nursing research and practice. Orthop
Nurs. 2007;26(4):251-255.
26.Luo JS, Ton H. Personal digital assistants in psychiatric
education. Acad Psychiatry. 2006;30(6):516-521.
27. Stengel D, Bauwens K, Walter M, Kopfer T, Ekkernkamp
A. Comparison of handheld computer-assisted and conventional paper chart documentation of medical records.
J Bone Joint Surg. 2004;86(3):553-560.
28.Kho A, Henderson LE, Dressler DD, Kripalani S. Use of
handheld computers in medical education. A systematic
review. J Gen Intern Med. 2006;21(5):531-537.
29.Sandars J, Pellow A. Handheld computers for work based
assessment: lessons from the recent literature. Work Based
Learning in Primary Care. 2006;4:109-115.
Jason S Applegate, MSRS, R.T.(R)(CT), CNMT, is an
assistant professor of imaging sciences at Morehead State
University in Morehead, Kentucky.
He wishes to thank the faculties of Midwestern State
University and Morehead State University Imaging Sciences
Departments for their guidance and support.
Reprint requests may be sent to the American Society of
Radiologic Technologists, Communications Department,
15000 Central Ave SE, Albuquerque, NM 87123-3909, or
e-mail [email protected].
©2010 by the American Society of Radiologic Technologists.
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DIRECTED READING
Domestic Violence
Bryant Furlow, BA
Domestic violence is a
neglected epidemic in the
United States that affects millions of children and adults
and leads to a sizable proportion of emergency department
visits — and possibly the
majority of nonfatal injuries
among women. Health care
encounters represent the most
promising opportunities
for identifying victims and
intervening in patterns of
abuse, and all health care
professionals have an ethical
obligation to help identify
cases of abuse.
In this Directed Reading, the
epidemiology and outcomes
of domestic violence are introduced, screening methods and
reporting requirements are
reviewed, and the roles of diagnostic imaging in detecting
and characterizing frequently
neglected but common domestic
violence injuries are discussed.
This article is a Directed
Reading. Your access to
Directed Reading quizzes for
continuing education credit
is determined by your area of
interest. For access to other
quizzes, go to www.asrt.org
/store.
After completing this article, readers should be able to:
n Identify the types of and risk factors for domestic violence.
n Explain the health care barriers to identifying domestic violence.
n Describe the roles of diagnostic imaging in confirming physical domestic abuse in children and adults.
n Explain patterns of injuries suggestive of domestic violence and the signs of shaken baby syndrome.
n Summarize the effects of domestic violence on victims’ health and behavior, including child
development.
n Describe screening strategies used to identify domestic violence victims.
n Explain health care workers’ screening and referral responsibilities, and states’ mandatory reporting requirements in suspected cases of domestic violence.
D
omestic violence includes
child abuse, elder abuse
and intimate partner violence (IPV). It represents
both a major human
rights abuse and a significant public
health challenge, directly affecting millions of Americans’ lives and contributing to violence, adverse health outcomes, lost economic opportunities and
substance abuse problems across the
nation.1,2 Although gang conflict and
stranger violence make headlines, the
majority of interpersonal violence is
domestic violence.3 IPV is the leading
cause of nonfatal injuries among
women in the United States; more than
half of women’s visits to emergency
departments result from domestic violence, and the lifetime risk of IPV for
American women is as high as 50%.1,4-6
Child and elder abuse represent criminal aggression against dependent infants,
children and elderly adults, respectively.
IPV is criminal aggression occurring
between married or unmarried partners
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
and is defined as physical, sexual or psychological harm by a current or former
intimate partner or spouse.7,8 In the
public health and medical literature, IPV
generally excludes dating violence and
acquaintance sexual assault. However,
some suspected risk factors for dating
violence and IPV (such as age and sex)
overlap, and it therefore appears likely
that victim populations also overlap.9
Because intimidation and threats
are commonly integral to the pattern of domestic violence, victims
are frequently reluctant to speak out.
Domestic violence includes verbal
coercion and the threat of violence,
physical assaults and attempted or
completed murder. Domestic violence
is often systematic — a prolonged pattern of violence rather than an isolated
incident — and frequently is perpetrated in an effort to exert control over
the victim. It often escalates in severity
over time; a leading risk factor for IPV
homicides, for example, is previous,
less serious IPV.10
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DOMESTIC VIOLENCE
Diagnostic imaging plays a potentially important
role in confronting the domestic violence epidemic.
First, all health care personnel have an ethical responsibility to identify and intervene in cases of abuse,
although the most appropriate form of intervention
remains controversial. Radiologic technologists and
radiologist assistants are in a position to identify evidence of physical injuries resulting from domestic
violence that may be missed by other health care
providers. Particularly in the case of infants, young
children and some elderly patients who may be unable
to describe their abuse, imaging can play a crucial role
in detecting and characterizing injuries. Health care
professionals are also better equipped than many other
potential interveners to deal with the denial, fear and
anger that result from patients’ pain and distress and
to respond to hostility with empathy. Second, diagnostic imaging plays a potentially important role in documenting the effects of suspected abuse, and the radiology report and proper documentation of evidence of
abuse in the patient record can represent a significant
source of forensic evidence in the legal prosecution of
domestic violence cases.11
Fulfilling those roles requires an understanding
of the:
■ Psychological, linguistic and cultural barriers to
intervention.
■ Locally available resources for victims.
■ Patterns of injury resulting from IPV.
■ Screening strategies and their limitations.
■ Psychological and health sequelae of this
pervasive problem.
Although gunshots and stabbings are tragic and frequent outcomes of domestic violence, particularly IPV,
these types of injuries are not discussed in this Directed
Reading. Nor will this Directed Reading detail sexual
trauma, which is largely assessed through clinical examination, or the diagnostic imaging techniques for postmortem autopsy assessments. Instead, emphasis is placed
on more cryptic or ambiguously abuse-related musculoskeletal and neurologic injuries among survivors.
Epidemiology and the Ecological Model of
Domestic Violence
The effects of violent acts and patterns of abuse
ripple through the lives of victims, abusers, their families, communities, economies and society at large.3 As
described in the following text, victims of domestic violence represent the obvious epicenter of these effects,
which include profound degradation of quality of life,
134
neurologic or other injuries with lifelong effects, adverse
health outcomes and behaviors, and the less readily
quantified effects of chronic stress and post-traumatic
stress disorder (PTSD) that can continue years after the
victim has escaped an abusive relationship.12 In addition,
that harm contributes to social ills outside the home,
from poor educational and employment performance
and increased medical costs to higher rates of abuse of
street drugs and prescription medications.
Just as the effects of domestic violence ripple
throughout communities, its roots are multivariate and
complex, and are not limited to the abusive household.
Although widely considered to be a crime that occurs
behind closed doors, many sociologists consider domestic violence to be the result of multiple intersecting factors involving the victim, the abuser, their relationship
and socioeconomic status, families, community, culture
and society at large. Domestic violence involves varying
attitudes and levels of awareness among abusers’ peers,
law enforcement and health care institutions.7,13,14 This
“ecological” model of domestic violence subsumes more
restrictive psychopathologic models that focus on risk
factors regarding abusers and victims; the model also
provides more opportunities for intervention than a
closed-door model because any member of the community who encounters signs of abuse can help empower
victims to escape their abusers.3,15 Home-visit programs
during and soon after pregnancy, child welfare and
social service visits, and employer referrals to IPV assistance programs are examples of intervention.8,15,16
Contact with health care professionals is an obvious opportunity to identify and intervene in domestic
violence, whether or not contact results directly from
abuse-related injuries. It is therefore the responsibility
of all health care professionals to be aware of the problem and its signs, and to recognize opportunities to
identify and responsibly intervene in possible cases of
domestic violence.
Typology of Domestic Violence
The Centers for Disease Control and Prevention
(CDC) identified 4 broad domains or types of domestic
violence and described to varying degrees the range of
child, elder and partner abuse.17 These types are:
■ Physical violence: traumatic assaults involving
the intentional use of physical force that could
or do cause injury, disability or death. Examples
include strangling, slapping, shoving, scratching,
throwing, grabbing, biting, burning, stabbing,
shooting or restraining the victim. A leading
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DIRECTED READING
form of physical violence against infants is shaking, which can profoundly injure the infant’s
brain and spinal cord in assaults as brief as 5 seconds and result in shaken baby syndrome.
■ Sexual violence: physically coercing sexual acts
with the victim (molestation and rape); sexual
conduct with individuals unable to understand
the act or to refuse participating in the act, or
unable to communicate their unwillingness to
engage in the sexual act because of illness, disability, or the influence of alcohol or other drugs,
or because of intimidation or pressure; or any
abusive sexual contact with the victim.
■ Emotional and psychological violence: traumatic
violence or threats of violence used to coerce and
terrorize the victim.
■ Psychological and emotional abuse: humiliating
or demeaning the victim, withholding access to
resources (such as money) to increase the victim’s
reliance on the abuser, and otherwise isolating
a victim from social support outside the abusive
relationship.
The CDC also notes that stalking is considered a
fifth type of IPV (but not other forms of domestic violence).17 Stalking generally refers to repeated harassing
or threatening behavior, such as following the victim
or appearing at the victim’s home or place of business,
making harassing phone calls, leaving written messages or objects, or vandalizing her or his property.17
Although stalking behavior has not been well studied, it
has been tied to acts of physical violence and homicide
and always should be taken seriously.
Prevalence and Risk Factors
Linguistic and cultural barriers complicate efforts
to quantify and study domestic violence.18 A recent systematic review of published studies found that reported
lifetime prevalence of IPV for women in the United
States varied from 1.9% in Washington state to 70%
among Hispanic women in the southeastern states, for
example.18 However, significant ascertainment bias issues
confound such assessments, which are frequently based
on data from psychiatric and gynecologic trauma clinics
— patient populations in which IPV victims appear to be
over-represented compared with other populations.18
There also are numerous controversies in the
research community surrounding the definitions and
measurement of domestic violence and its risk factors, such as survey and sampling methodology, that
complicate quantifying the different forms of domestic
violence.3 Inconsistencies between data on the proportions of victims and perpetrators who are women are
difficult to reconcile and may reflect different sampling
and survey methodologies.
Intimate Partner Violence
IPV against women represents an epidemic in many
U.S. communities, and the 1994 U.S. Violence Against
Women Act recommended examination of the epidemiology and incidence of IPV.1,18 However, because IPV
is an under-reported and underdetected crime, incidence rates have been very difficult to estimate accurately, and different ascertainment systems yield different estimates of prevalence and incidence. Several surveillance systems attempt to capture data regarding the
frequency and nature of IPV. Existing CDC estimates
based on the National Crime Victimization Survey data
for cases reported to law enforcement indicated that
at least 467 000 Americans are victimized annually by
IPV crimes.19 However, because this number is based
only on reported crimes that led to the involvement of
law enforcement agencies, it very likely vastly underestimates the real incidence of these crimes.7 Academic
researchers have estimated that 1 million women suffer
physical IPV each year.20
Between 65% and 80% of reported IPV victims
overall are believed to be female, although thousands
of heterosexual and homosexual men also fall victim
to these crimes each year.7 Girls and women of childbearing age, particularly between the ages of 16 and
24 years, are at greatest risk for IPV; however, women
of all ages are abused by their partners.8 There is some
evidence that the severity of IPV assaults on African
American women are frequently more severe and
involve increased risk of head and brain injuries than
other victim populations.21
It is surprising that despite the over-representation
of girls and women in IPV victimization rates, some
authors argue that differences in IPV perpetration
rates by men and women are unclear or do not exist.3
For example, the National Family Violence Survey,
based on self-reporting by women of their own and
their partners’ violent behavior, reported nearly identical rates of assault by men and women.3 IPV is frequently bidirectional, involving retaliation by the victim or mutually abusive relationships.3 Bidirectional
IPV ranges from 59% to 71% among couples with any
history of violence, with women initiating physically
violent interactions as frequently as do men.3 Some
authors have argued that this represents evidence
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against a self-defense model of female-initiated IPV
incidents, but the available studies do not control
for which partner first introduced violence into the
relationship, or the possible role of anticipatory selfdefense by women who recognize the antecedent
behaviors of physical violence.
Meta-analyses pooling data from studies of sex
differences in violence (including but not limited to
IPV) found that physical aggression is more common
among men regardless of age and culture, although
the sex difference in violent behavior peaked between
ages 20 and 30.22 One possible explanation for the
seeming inconsistency between similar rates of IPV
perpetrated by men and women on the one hand, and
the over-representation of women among IPV victims
on the other, is that violence against women may be
more severe and thus may more frequently lead to
hospitalization or the involvement of law enforcement
agencies. Another explanation may be ascertainment
inconsistencies for one or more of the datasets on
which reported patterns are based.
The CDC’s National Violent Death Reporting
System, active in only 16 states, lists 1200 confirmed
IPV-related homicides for 2005, an incidence rate of
0.8 per 100 000 Americans.7 African American and
American Indian populations have significantly higher
IPV death rates than other ethnicities: 1.5 per 100 000
and 2 per 100 000, respectively.7
Risk factors for IPV homicides include perpetrator
access to a firearm, previous threatening by the perpetrator of the victim with a weapon, recent separation and
the use of illicit narcotics by the perpetrator or victim.7
Physically and mentally disabled women are more
likely to experience IPV. Other reported risk factors for
IPV include intermittent perpetrator employment or
recent unemployment and perpetrator education level
lower than high school completion.1 Physical abuse
of animals is associated with perpetrators’ IPV risk;
women whose partners threaten or batter pets are 5
times as likely as other women to suffer IPV.23,24 Verbal
abuse and male domination also have been reported
as risk factors for physical IPV, but a recent systematic
review of 11 studies found that recall bias, selection
bias and resulting overestimations of such correlations
are difficult to rule out.25
The CDC lists several risk factors, but does not
detail the empiric strength of the evidence on which
the list was based, other than stating that perpetrators’ own psychological abuse is consistently “one of
the strongest predictors” of perpetrating IPV.19 Aside
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from perpetrator histories of psychological abuse and
poor or violent parenting as children, the CDC’s list
of perpetrator risk factors includes:
■ Individual (perpetrator) risk factors: low selfesteem, low income, young age, aggressive behavior as a child or teen, heavy alcohol and drug
use, depression, anger, hostility, antisocial or borderline personality disorders, history of physical
abusiveness, social isolation, emotional insecurity,
desire for control and belief in strict gender roles.
■ Relationship risk factors: marital conflict; marital
instability (separations, recent divorce); dominating or domineering control of relationships; and
economic stress or hardship.
■ Community, cultural and societal factors: poverty; crowding; low “social capital” (few institutions,
support networks or social norms discouraging
IPV); weak community sanctions (eg, neighbors’
reluctance to call the police); sexism and traditional gender norms (eg, beliefs that women
should stay at home, avoid employment and be
submissive, or that men should make household
and economic decisions).
A more accurate and precise picture of IPV rates
may emerge in the near future. The National Intimate
Partner and Sexual Violence Surveillance System
(NISVSS) is a long-anticipated collaborative initiative
started in 2010 by the CDC, Department of Defense
and National Institutes of Justice.19,26 The NISVSS
will collect population-based survey data in English
and Spanish to provide more accurate and reliable
incidence and prevalence estimates for IPV, sexual violence and stalking crimes in the United States.26 The
program also will attempt to identify the frequency of
these crimes in understudied American Indian and
Alaska Native populations, female military personnel
and military spouses.26
Child Abuse
Violence directed at children and child neglect by
parents is, like IPV, believed to be an underreported
crime. Methodologic differences between studies further complicate quantification of the problem because
some researchers include neglect and other forms of
maltreatment, such as shouting, in definitions of child
abuse, whereas others include only physical or sexual
abuse.3 The World Health Organization includes
neglect and commercial exploitation of children in
its definition of child abuse, and also includes human
rights verbiage about the dignity of the child, the abuse
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of trust and the responsibility of the adult caregiver.3
The prevalence of child abuse in the United States is
based primarily on data from law enforcement and
social service agencies.3
Data from child protective service agencies suggest
that more than 906 000 American children are victims of
abuse or neglect each year, which represents an incidence
rate of 12.4 per 1000 children.3 That estimated incidence
rate was based on an estimated 2006 U.S. population
of 307 million children. Of these, approximately 19%
were physically abused, and 10% were sexually abused.3
Neglect represents 60% of child abuse cases.
Infants and young children (younger than 3 years
of age) suffer higher rates of abuse than older children
(16.4 per 1000 vs 12.4 per 1000 for all ages).3 However,
these statistics include nondomestic forms of child
abuse, such as nonparent caregiver abuse, abuse by
teachers, neighbors and strangers. Overall, parents are
the perpetrators in 80% of child abuse cases.3 Girls are
4 times as likely to be sexually abused as are boys.3
Each year, approximately 1500 American children
die as a result of physical abuse or neglect.3 The vast
majority of child abuse deaths, 79%, involve children
younger than 4 years of age.3 Federal statistics on child
abuse are available online at http:www.acf.hhs.gov
/programs/cb/pubs/cm08/cm08.pdf.
Risk factors for child abuse include family poverty
and economic stress, male perpetrator, low self-esteem
of perpetrator, low levels of empathy and impulse control among perpetrators, young victim age (younger
than 3 years old), and victim’s disability or medical
complication. Low perpetrator educational attainment
is a risk factor for child sexual but not physical abuse.3
Importantly, IPV appears to increase the risk of physical violence toward children.3 Community and cultural
effects also have been identified; immigrant communities with extensive neighborhood ethnic social networks
have lower rates of child abuse — even in impoverished
neighborhoods.3 This is consistent with findings linking social isolation and small support networks with
increased maternal abuse of children.3
Elder Abuse
Elder abuse appears to be even more under-reported
than child abuse or IPV. The research literature on
elder abuse is relatively scant, but benefits from a
consistent definition that includes neglect; this definition has been officially adopted by the International
Network for the Prevention of Elder Abuse: “a single or
repeated act or lack of appropriate action, occurring
within any relationship where there is an expectation
of trust which causes harm or distress to an older person.”3 The majority of research on elder abuse involves
institutionalized patients in long-term, assisted-living
facilities rather than domestic violence.
In addition to verbal, physical and sexual abuse,
elder abuse includes financial exploitation and
medical-nutritional neglect.3 Between 700 000 and
2.5 million American elders are physically or sexually
abused annually.27
Risk factors for elder abuse have not been as well
investigated as those for IPV and child abuse, but
appear to include factors that increase the needs of
victims and demands on caregivers’ time, including
advanced victim age, illness, disability and coresidence.
History of violence in other relationships increases the
risk of becoming a perpetrator of elder abuse.3 Mental
illness, social isolation and substance abuse are other
reported perpetrator factors.3
Victim Outcomes
Domestic violence represents the most pervasive
form of human rights abuse in the United States
today. Victims’ quality of life and health status can be
profoundly affected by domestic violence, and these
effects ripple throughout society, the health care system and the economy. Published studies suggest IPV
victimization may affect parenting skills, coping skills,
employment and the success of subsequent intimate
relationships. It also increases the risk of sexually transmitted disease and impairs cognitive performance and
immune function.6,28 Victimization commonly leads to
chronic or severe headaches, confusion, anxiety, fear,
clinical depression and suicidality.6
As described in the following text, childhood abuse
(and possibly childhood witnessing of IPV) can have lifelong neurologic and developmental impacts, including
seizure disorders.29 Long-term physical and psychiatric
sequelae contribute to prolonged need for health care,
even among victims who are no longer in an abusive
relationship. PTSD is common among IPV victims and
abused children, as are traumatic brain injuries (TBIs).
The health-specific outcomes of domestic violence,
although poorly studied, are clearly many, complex
and potentially profound. IPV is associated with an
increased risk of human immunodeficiency virus/
acquired immunodeficiency syndrome infection, particularly among African-American women.30 Women
with a history of IPV are more than twice as likely to
report disabilities, including chronic pain, heart and
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circulatory disease, back problems, arthritis, asthma
and depression.31 IPV injuries are a dose-dependent
risk factor for disabilities and chronic pain; women
with more injuries directly attributable to physical IPV
also report more chronic pain and other disabilities.31
IPV-victimized women use roughly twice (1.6 to
2.3 times) the health care resources used by non-IPV
victims when health conditions and comorbidities are
statistically controlled, but are significantly less likely
to participate in screening for cervical or breast cancer.32,33 (One study found that hospitalization rates for
IPV victims were 3.5 times higher than rates for nonIPV victims.34)
Although IPV victims consume more health care
resources than others, they are more likely to have
negative interactions with health care professionals and
are less likely to receive the health care services they
need.6 Many hospitals lack the resources and programs,
or even a consistent strategy, for helping the victims of
domestic violence.6 Progress in health care assistance
for IPV victims has been described as “limited.”6
IPV frequently occurs in front of (and frequently
involves parallel or simultaneous victimization of)
children in the home. Witnessing IPV is defined in
many states’ laws and regulations as a form of child
abuse, even in cases in which the child is not directly
targeted by the perpetrator. However, studies have
found that child welfare–related social services detection of IPV and interventions on behalf of the child
do not always involve interventions that address IPV
itself. 8 Children exposed to pet abuse are more likely
to witness IPV of a parent as well, and are more likely
to abuse companion animals than children from nonviolent homes.23,24
Boys raised in homes where IPV occurs appear to
be more likely to become IPV perpetrators as adults. 35
The developmental and physiologic effects of IPV on
children are evident as early as infancy in the form
of abnormal attachment relationships; these effects
may well begin before birth, with prenatal exposure
to circulating maternal stress hormones and altered
immunologic development in offspring. 8,36 IPV in
the home has been identified recently as a risk factor
for unstable child residential histories, substandard
childhood housing, childhood asthma and preschool
obesity — even after economic and family structure
factors are statistically controlled. 37,38 Children who
are abused or exposed to IPV suffer neurodevelopmental and cognitive development disruptions,
including lower IQ scores. 39,40
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Shaken Baby Syndrome
Infants and children as old as 5 years, when vigorously shaken for as few as 5 seconds, can sustain neck,
spine, eye and brain injuries resulting in shaken baby
syndrome.40 Infants typically are shaken to quiet a crying spell, and the results can be catastrophic. Shaking
can slam the brain against the skull repeatedly, causing brain contusions (bruising), swelling, pressure
and bleeding.40 Tearing of meningeal veins along the
brain’s exterior can cause bleeding and increased
intracranial pressure, leading to permanent brain
damage or death.40 Because infants’ heads are relatively large compared with their bodies and their neck
muscles are poorly developed, shaken infants are prone
to developing whiplash injuries to the muscles of the
neck.40 Rib fractures, retinal detachment or bleeding
in or around the eyes are commonly seen in shaken
babies.40 However, behavioral symptoms may occur
without any outward physical signs of injury such as
bruising or pale or bluish skin. These include:
■ Seizures or convulsions.
■ Sudden extreme irritability.
■ Decreased alertness, lethargy, sleepiness and a
failure to smile.
■ Coma or unconsciousness.
■ Loss of vision.
■ Lack of appetite or vomiting.
Post-traumatic Stress Disorder
IPV and child abuse are risk factors for posttraumatic stress disorder, a syndrome involving
reduced emotional control, impaired memory and
cognitive speed and function.41 The severity of PTSD
symptoms is associated with the severity of domestic
violence, and also is associated with higher reported
levels of chronic pain among survivors.42 Wuest et al
advised that the correlations are strong enough to
justify routine assessment of pain clinic patients with
PTSD symptoms for domestic violence.42
Child abuse–related PTSD and brain injuries may
similarly disrupt brain structures and function. A
2005 meta-analysis pooling data from 9 studies of
magnetic resonance (MR) imaging volumetric measurements of the hippocampus — a brain region
involved in short-term memory and cognitive performance — found that chronic adult PTSD is associated
with smaller hippocampal volumes.43 A larger 2008
meta-analysis of data from 19 brain imaging studies
found that although PTSD resulting from childhood
abuse is not associated with impaired hippocampal
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growth during childhood, hippocampal volumes are
significantly smaller among adults with childhood
abuse–related PTSD compared with healthy controls.44
The meta-analysis also found atypical asymmetries
between the right- and left-hemisphere hippocampus
in adults with childhood abuse–related PTSD.44
The authors from the aforementioned study suggested
that disruption of hippocampal developmental pathways
does not yield volumetrically measurable effects until
adulthood, years after exposure to traumatic abuse. More
subtle hippocampal damage may be evident earlier in
childhood, however, and may underlie the association
between domestic violence and reduced child IQ noted
previously. The authors also cautioned that their metaanalysis should be considered a preliminary finding until
confirmed by longitudinal studies.44 (For example, it is
possible that individuals with atypical adult hippocampus
anatomies are more susceptible to developing PTSD.)
Patterns of Physical Injury
There is a long and controversial history of efforts
to identify hallmark injuries or patterns of injuries
for domestic violence screening purposes, an effort
motivated by the very frequent false attribution by victims and perpetrators of victims’ injuries to household
falls and other accidents. Relatively simple statistical
models can differentiate accidental injuries from those
resulting from IPV (eg, using age and injury patterns).
However, these models differentiate probabilistically,
and results do not represent proof of abuse in any
given case.5 Generally speaking, most studies suggest
that head, face and neck injuries are more indicative of
domestic violence than other injuries.
A systematic review and meta-analysis of 7 studies of physical injury patterns and IPV, published in
2010 by McMaster University researchers in Ontario,
Canada, compared IPV head, neck and facial injuries
with verifiable accidental injuries from witnessed falls
or motor vehicle accidents.45 The authors found that
IPV victims were 24 times as likely as accident victims
to have head, neck and facial injuries, compared with
women with injuries from verifiable accidents. In contrast, thoracic, abdominal and pelvic injuries were not
more or less likely among IPV victims, and injuries
to arms and particularly legs were significantly more
likely to have been sustained during verifiable accidents than IPV.45 The authors concluded that unwitnessed head, neck or facial injuries are significant
red flags for IPV, whereas extremity injuries alone are
not indicative of IPV.45 The findings were consistent
with previous findings that head and neck injuries are
the most common injuries among women attending
domestic violence counseling; the findings also support previous findings based on smaller emergency
department data sets and calls in the medical and
dental literature for both dentists and emergency
department personnel to screen women with facial,
head and neck injuries for IPV.4,46,47
Injuries to the soft tissues of the midface and the
lower third of the face are the most common form of
head and face trauma among female IPV victims.48 It
is not surprising that, given the frequency of assaults
targeting the head and face, brain injuries are common among IPV and child abuse victims, and neuroimaging is indicated in suspected cases of domestic
violence victimization involving blows to the head or
face. Strangulation, a life-threatening injury, commonly is associated with IPV. The victim is almost
always a female partner. Strangulation always should
trigger screening evaluations for domestic violence
victimization and imaging examinations of the neck
and brain. Strangulation assaults can be manual (the
perpetrator uses the hands to cut off the victim’s
air and blood supplies), ligature (using an object to
strangle the victim) or involve a forearm choke hold.49
Strangulation tends to occur late in an abusive relationship, and may represent the fatal or near-fatal
culmination of a progressively violent and dangerous
pattern of IPV. 50 Fatal and nonfatal attacks have very
similar patterns of injuries, which suggests similar
intensities of violence. 50,51
Strangulation is an under-reported form of physical IPV. One 2001 study found that victims of multiple
strangulation attacks by the same IPV perpetrator suffered throat and neck injuries, neurologic disorders
and psychological sequelae; but as few as 39% of victims had sought medical care.51
Victims should be interviewed carefully about their
stream of consciousness during the attack to determine
the victim’s state of mind and the likelihood of loss
of consciousness during the assault. Survivors report
characteristic stages of thought patterns during the last
moments of consciousness.52 These are:
■ Denial: A disconnected state of unreality prompting descriptions like “I couldn’t believe it was happening” or “It was like I was watching it on TV.”52
■ Realization: Victims quickly come to terms with
the reality that they are about to die.
■ Primal: Realization that death may be imminent
prompts a frantic struggle to regain air supply.
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■ Resignation: Unsuccessful resistance leads to
the victim’s recognition that she has been overpowered and that she is likely to die, described
by survivors as, “This is it — this is how I die.”52
All mothers surviving these attacks invariably
reported during clinical interviews their final
thoughts as being about who was going to care
for their children. 52
Head, neck and face trauma alone are not reliable
proof of domestic violence. The sensitivity of head,
neck and face trauma for IPV (ie, accurate IPV-positive
results) has been estimated to be 91%, but specificity (accurate IPV-negative results) is only 59%.53
Therefore, these injuries should be considered a trigger for questionnaire-based screening, described later
in this article. Bruises exceeding 5 cm in diameter on
the face, lateral right arm or back (posterior torso) are
indicative of physical abuse.54
It is surprising that the McMaster University metaanalysis also found that multiple injuries occur significantly more often — up to 15 times as frequently
— among victims of IPV than accident victims.45 A
study of women’s injuries resulting from IPV and other
assaults found that non-IPV assaults typically cause a
single injury, whereas the median number of injuries
for IPV assaults was 3.55
Traumatic Brain Injuries
Because more than 80% of women treated for IPV
injuries have facial and head trauma, it is very likely
that a large proportion of these patients have sustained
some degree of TBI. TBI has been described as “one
of the most serious, prevalent and often undiagnosed
results” of IPV.21 However, few suspected IPV victims
are screened for brain injuries or neuropsychological
effects.56 Like domestic violence, TBI is a dramatically
under-reported type of injury; some studies suggest
that as many as 85% of TBI cases go undiagnosed.57
Transient loss of consciousness and amnesia occurring with skull fracture or brain lesion that is confirmed by computed tomography (CT) or MR imaging
is a common form of TBI called concussion.58 The
severity of TBI can be assessed by the presence of concussion symptoms such as drowsiness, mood disorders,
anxiety, seizures, chronic headache, blurred vision,
nausea, insomnia, dizziness, memory lapses, concentration and attention deficits and sensitivity to noise or
light.58 Delayed recall and amnesic or “blank” memories of events causing injury are signs of concussion,
which is indicative of moderate TBI. African-American
140
IPV victims with clinical evidence of head injury may
be at particular risk because of a greater severity of the
violence reported for this population.21
Pediatric Patterns of Injury
Pediatric head injuries resulting from physical abuse
appear to have significantly worse outcomes than
accidental head trauma, with near-universal CT- or
MR-detectable brain atrophy and cerebral ischemia in
50% of abuse-related TBI cases.59 Subdural hematomas
and meningeal bleeding are common results of physical assaults on infants and young children.60,61
Bone fractures are one of the most common findings
in child abuse victims, following bruises and brain contusions.62 Multiple pediatric bone fractures, particularly
when different rates of healing are evident, and any
bone fractures in children with burn injuries, are suggestive of child abuse, and these findings should result
in screening and skeletal fracture surveys.63,64 Multiple
rib fractures are relatively rare in adult IPV victims,
but such findings are a red flag for shaking, kicking or
punching assaults on children (see Figure 1).63
However, rib fractures are less indicative of assault
among children from France and other countries in
which kinesitherapy is widely practiced because chest
compression used in kinesitherapy is known to sometimes cause rib fractures.64,65 Multiple rib fractures that
exhibit different stages of repair and healing are suggestive of a pattern of domestic violence, whether the
patient is a child or an adult, male or female.63 (Sternal
fractures may not be as rare among children as believed
because of the difficulty of detection on standard chest
radiographs, and they are not alone strongly indicative
of abuse.66
Screening
Consistent active screening is necessary to detect
most cases of domestic violence.6 It is widely agreed
that women with unwitnessed injuries to the head,
neck or face — or who have multiple injuries — and
children who have multiple bone fractures should
be screened or assessed for domestic violence victimization.45 Numerous health care professional organizations recommend IPV screening, including the
American Medical Association, American Nursing
Association and American Congress of Obstetricians
and Gynecologists.6
Many — but not most — hospitals have policies to
screen for suspected domestic violence, but fewer have
developed the cultural and linguistic resources or
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Figure 1. Multiple rib fractures in different stages of healing in
an infant victim of child abuse. Red and green arrows indicate
rib fractures sustained at different points in time. U.S. National
Institutes of Health. Public-domain U.S. government figure available at: http://commons.wikimedia.org/wiki/File:Fractured_ribs.
jpg. Accessed September 9, 2010.
domestic violence expertise to assist victims.67 Detected
cases are sometimes referred to other institutions, such
as battered women’s shelters, counseling services or
social service agencies outside the heath care setting.
Very frequently, even disclosed or confirmed cases of
domestic violence victimization are not properly documented or referred to appropriate treatment or social
services.6
Well-intentioned victim profiling by health care workers tends to emphasize patients’ age, ethnicity, income
level and educational level — an approach that may lead
to underscreening and underdetection of white, middleaged and middle- or high-income women.6
Numerous health care screening tools have been
proposed to aid in identifying probable cases of IPV
victimization among trauma patients, but few have
been developed for languages other than English or
Spanish; and few exist specifically to identify elder
abuse victims.68 These instruments are reviewed in
this section. However, it should be kept in mind that
most studies have not directly assessed the validity of
screening instruments or studied the efficacy of health
care screening for domestic violence in reducing the
frequency or severity of that violence.67,68 Instead, most
studies use endpoints such as referral to social services,
shelters or law enforcement.68
Current interventions include victim (battered women’s and children’s) shelters; confidential mail drop
services or mail forwarding services operated by some
Secretary of State offices to help abused women hide
their current physical location; court-issued restraining orders preventing perpetrator contact with victims;
prosecution and/or treatment and counseling for
perpetrators; marital counseling and therapy; and preventive monitoring (eg, home visits by social services
agency personnel).3
Screening instruments are vulnerable to recall
bias, and are therefore designed to capture information only about the patient’s experiences over the previous 12 months.69
The Partner Violence Screen questionnaire is the
simplest screening tool, which requires approximately
20 seconds to administer orally.70,71 It consists of 3 yesor-no questions with 1 follow-up question:
1. Have you been hit, kicked, punched or otherwise
hurt by somebody in the past year? If yes, by
whom? (current relationship/previous relationship/other)
2. Do you feel safe in your current relationship?
3. Is there a partner from a previous relationship
who is making you feel unsafe now?
The Hurt Insulted Threatened or Screamed at
(HITS) instrument has 4 questions. Each is answered
on a 5-point scale from 1 (never) to 5 (frequently):
1. How often does your partner physically hurt you?
2. Insult or talk down to you?
3. Threaten you with harm?
4. Scream or curse at you?
(HITS is available online at www.healthyplace.com
/psychological-tests/domestic-violence-screening-test/.)
The longer, 8-item Woman Abuse Screening Tool
(WAST)72 asks:
1. In general, how would you describe your relationship? (a lot of tension/some tension/no tension)
2. Do you and your partner work out arguments with
(great difficulty/some difficulty/no difficulty)
3. Do arguments ever result in your feeling put down
or bad about yourself? (often/sometimes/never)
4. Do arguments ever result in hitting, kicking or
pushing? (often/sometimes/never)
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5. Do you ever feel frightened by what your partner
says or does? (often/sometimes/never)
6. Has your partner ever abused you physically?
(often/sometimes/never)
7. Has your partner ever abused you emotionally?
(often/sometimes/never)
8. Has your partner ever abused you sexually?
(often/sometimes/never)
A shorter version, called the short-WAST, asks only
Questions 1 and 2 from the preceding list.71 Combining
injury location data (head, neck and face involvement
or other) with either the Partner Violence Screen or
short-WAST questionnaires yielded similar proportions
of respondents reporting IPV.71
Even longer instruments, such as the 30-question
Composite Abuse Scale, also are available.73
Although studies have shown that these screening
instruments result in women disclosing IPV histories,
very few studies have extensively validated the instruments or compared their relative efficacy. One randomized trial undertaken by the McMaster Violence Against
Women Research Group in Ontario, Canada, compared
interview-based, computer-based and paper questionnaire-based screening of emergency department, family practice and women’s health clinic patients using 3
instruments in each group: the Partner Violence Screen,
the WAST and the 30-item Composite Abuse Scale.69 No
significant differences were found in the IPV prevalence
indicated by the different instruments or presentation
methods, although women in this study preferred computer and paper self-administered questionnaires over
interviews.69 A separate study conducted in Tennessee
reported that patients preferred interview-style screening and the WAST, and that the Partner Violence Screen
was the least-preferred approach.74
Regional and individual variation in preferences
may suggest that patients should be offered a choice:
After a brief oral explanation of the health professional’s concerns, the patient could be asked whether
she or he would prefer to complete a written questionnaire or to talk it over. Most studies indicate, however,
that most women do not object to being asked about
domestic violence and that most victims disclose their
abuse when asked.6
Traumatic Brain Injury Screening
Simple questions about the frequency and severity of
blows to the face and head, and resulting memory lapses
or losses of consciousness, can identify domestic violence
victims who are at greatest risk of having suffered TBIs.57
142
The “HELPS” mnemonic screening instrument is a
widely used TBI tool.75 It asks:
1. H: Have you ever been Hit on your Head or Hit
your Head?
2. E: Were you ever seen in the Emergency room,
hospital or by a doctor because of an injury to
your head?
3. L: Did you ever Lose consciousness or experience
a period of feeling dazed or confused because of
an injury to your head?
4. P: Do you experience any of these Problems
in your daily life since hitting your head?
Headaches; dizziness; anxiety; depression; concentration difficulties; difficulty remembering;
difficulty reading, writing or calculating; poor
problem-solving; difficulty performing your job/
school work; changes in relationships with others;
poor judgment (being fired from jobs, arrested,
fights)?
5. S: Have you any significant Sicknesses?
Affirmative answers to items 1 (H), either 2 (E) or 3
(L), and the presence of 2 or more problems from item
4 (P) represent a positive indication for TBI. A positive
HELPS screening result is not sufficient to diagnose
TBI, but it does indicate that further clinical and diagnostic imaging examination is warranted.57 A June 2010
search of the medical literature yielded no validation
studies regarding the use of the HELPS instrument for
domestic violence victims.
In addition to the HELPS questionnaire for assessing whether TBI is likely, the Glasgow Coma Scale commonly is used to assess the severity of TBI. The Glasgow
scale was designed to be used repeatedly over time to
track patient cognitive recovery or decline.58 This scale
ranks TBI severity by assessing a patient’s eye opening
activity and motor and verbal responses to commands
and conversations (see Table 1).58
Because TBI involves both focal and diffuse
trauma to different brain tissues and regions, it results
in diverse and complex neuropsychological and behavioral symptoms, which complicates diagnosis and care.
When TBI is suspected, CT or MR brain imaging is
indicated to identify life-threatening trauma and to
document and characterize the number and severity of
brain injuries.58
Screening for Infant and Child Abuse
Older children may be asked how injuries were sustained but should not be closely questioned without a
child psychiatrist or psychologist.
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Table 1
Glasgow Coma Scale Scoring58
Eye Opening (E)
1 = None
2 = In response to pain
3 = In response to speech
4 = Spontaneous
Motor Response (M)
1 = None
2 = Extensor response
3 = Abnormal flexion
4 = Withdrawn
5 = Localized response
6 = Obeys
Verbal Response (V)
1 = None
2 = Incomprehensible sounds
3 = Inappropriate words for conversation
4 = Confused conversation
5 = Oriented
Note: Glasgow Coma Scale score = E + M + V; range
of possible scores is 3 to 15.
Diagnostic imaging plays an important role in
screening infants and young children for domestic
violence victimization. Infants and young children
cannot describe their abuse, and symptoms such as
vomiting, fever, lethargy, seizures or coma are nonspecific to assault and alone do not constitute strong
indications for child abuse screening. But in the presence of head injuries or bruising of the face, neck, or
chest — particularly when inconsistent with the presenting injury or the history of the injury as provided
by the parent — these may indicate child abuse.64
Unexplained injuries, particularly head injuries, bone
fractures, bruising of the neck or face, burns and
delayed care seeking by parents are all suggestive of
child abuse.64
Because no self-reporting instrument is available for
suspected child abuse victims, a radiographic skeletal
survey is undertaken to characterize the number, timing and severity of bone fractures, and CT or MR brain
imaging is performed to screen for TBIs.
Approach and Patient Preparation
Health care visits represent a major opportunity
to identify and intervene in patterns of domestic violence.6 But barriers to detection prevent the effective
use of that opportunity, and all too often, health care
encounters that should serve as gateways to intervention become just another barrier.6
Barriers to identifying abuse include victims’ fearfulness, inadequate training of health care workers to
recognize or assess suspected cases, insufficient staffing
and other resources at health care facilities, linguistic
barriers, cultural barriers such as gender norms or
cultural tolerance of domestic violence, and social
isolation of the victim.6 The presence of the suspected
abuser is another significant barrier to identification
and intervention in suspected cases of IPV and domestic violence, and few hospitals have explicit policies to
separate suspected victims of domestic violence from
suspected abusers for screening purposes.
Health care professionals are busy and frequently fail
to screen, refer or report suspected cases of domestic
violence. This is partly due to an underappreciation
among many health care professionals and medical and
nursing students for how pervasive domestic violence is.
For example, a recent survey of orthopedic surgeons in
Canada revealed that 80% believed fewer than 1% of
women experience IPV.4 Surveys also have revealed that
health care professionals commonly hold victim-blaming
attitudes or a reluctance to risk offending suspected victims by asking about victimization.6
It is important that health care personnel exhibit
empathy, respect and concern; create an environment
of support and confidentiality; and avoid expressions,
comments or gestures that may communicate judgment or indifference to a suspected victim of domestic
violence. Health care workers should be prepared to
explain the health impacts of abuse and the effects on
child development, and to also explain local resources
for intervention. Fear and shame are common among
victims, and trust is integral to patients’ disclosure
of abuse. A 2006 meta-analysis of data from 29 studies found that IPV victims’ priorities for health care
encounters in which they disclose abuse include nonjudgmental responses.76
Demanding or interrogative approaches to obtaining disclosures likely will fail. Emphasis should be
placed on educating and empowering suspected
victims.77 A gentle and nonjudgmental approach will
avoid making a patient feel interrogated or accused. If
a patient seems to be covering up her or his abuser’s
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conduct through false denial, direct accusation of lying
may be counterproductive. Instead, a quick description of locally available (and linguistically appropriate)
resources and a contact sheet or card with numbers for
local resources, such as battered women’s shelters, can
be offered to any suspected victim encountered in a
health care setting.
English-speaking IPV victims prefer self-completed
written or computer screening questionnaires to faceto-face interviews.69 The presence of a translator for
non-English speakers from some cultural backgrounds
may complicate accurate completion of domestic violence screening instruments. Health care institutions’
linguistic and cultural competency policies should
include the availability of translations for patientadministered tests and written materials such as information sheets, and translators to administer domestic
violence screening instruments to victims who speak
locally common minority languages.
Reporting Suspected Abuse
All suspected victims of abuse should be referred
to local support resources, such as battered women’s
and children’s shelters, social service agencies, law
enforcement and counseling services. In addition to
referral, many states require that specific types of suspected abuse also must be reported to state agencies
and law enforcement.
All states have laws mandating the reporting of
child abuse to state agencies.20 However, 8 states
do not require health care workers to report elder
abuse: Colorado, Illinois, New Jersey, New York,
North Dakota, South Dakota, Pennsylvania and
Wisconsin.20 Mandatory reporting of IPV is even less
common. A 2007 review found that only California,
Colorado, Kentucky, Mississippi, Ohio and Texas have
passed laws requiring physicians to report cases; only
California requires physicians to report IPV with or
without the victim’s consent.20 However, 42 states have
mandatory reporting laws for assaults involving gunshot or knife attacks.
Despite criminal penalties for failing to comply with
domestic violence reporting laws (up to 6 months in jail
and $1000 in fines), physicians frequently fail to report
abuse.78 Some physicians express the perception that
reporting requirements reduce physicians’ ability to
determine what is best for their patients.78 Others have
argued that reporting IPV cases when adult victims
have not sought to report those cases themselves can do
more harm than good; reporting and law enforcement
144
or social service agency contact can prompt violent episodes by perpetrators. Also, cohabitation, cultural expectations and the presence of children can lead to unintended consequences.79 Furthermore, it has been argued
that mandatory reporting could well discourage IPV
victims from speaking candidly with their physicians.79
Nurses also under-report domestic violence.80,81
Inadequate training has repeatedly been identified as
a major factor in the failure of health care workers to
comply with reporting laws.80,81
Hospice and palliative care workers are less likely
than others to report suspected cases of elder abuse, or
even to know the appropriate agencies to which such
cases should be reported.82
Diagnostic Imaging
Diagnostic imaging plays a crucially important
role in assessing and characterizing injuries caused by
domestic violence, particularly for children and elders
who cannot disclose abuse orally. This section describes
the roles of diagnostic imaging in characterizing child
battering; TBI; and head, neck and facial assault injuries. Abdominal injuries are rare in domestic violence,
although gastrointestinal imaging of severely neglected
seniors may evidence life-threatening constipation with
fecal compaction and blockage in the intestines, which
is a common result of chronic dehydration and neglect.
Skeletal Survey in Suspected Child Battering
Because infants and young children cannot describe
their abuse, screening is conducted as a diagnostic imaging skeletal survey for fracture histories rather than a
questionnaire.64 Even severe behavioral signs of abuse
such as seizures and coma are not specific to abuse.
However, facial and chest bruising as well as a sudden
increase in infant head circumference — when accompanied by other, nonspecific signs or the presence of
skin burns or retinal hemorrhaging — are highly suggestive of physical assaults and represent clear and urgent
indications for skeletal survey imaging.64
Retinal hemorrhage, traditionally diagnosed with
a hand-held ophthalmoscope by an ophthalmologist
or other clinician, is present in 85% of assault-related
child head trauma cases.64 It also is visualized as focal
hyperintensities within the eye globe on axial T1 MR
images or as hypointense foci on axial T2 images.83
A skeletal survey consists of a series of radiographic images encompassing the entire skeleton.84
Radiography alone is sufficient for detecting most bone
fractures, and CT, MR, scintigraphy and ultrasound
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should be used only in follow-up examinations of specific anatomic regions as indicated by the radiographic
skeletal survey.
Imaging results are not considered in isolation.
Rather, results are weighed alongside clinical histories,
bruises, burns and patterns of injury. If radiographic
images are equivocal or suggest no fractures, but clinical evidence supports suspicion of physical abuse of
the infant or child, follow-up bone scintigraphy may be
indicated.62,64 Scintigraphy appears to have increased
sensitivity for rib, skull and possibly long bone shaft
fractures. (A literature search on June 12, 2010 identified no meta-analyses comparing radiographic and
scintigraphic skeletal surveys. However, a 2006 review
identified some studies suggesting that scintigraphy is
more sensitive for identifying bone fractures and other
studies suggesting radiography is more sensitive; the
authors concluded that neither modality is clearly superior in all cases.85)
The American College of Radiology (ACR) has
issued guidelines on skeletal surveys for child battering and other indications, including metabolic disorders and genetic syndromes. 84 According to the ACR
guidelines, detailed skeletal surveys with centered
views at the joints as well as brain imaging with CT
or MR are indicated for any suspected child battering involving patients younger than 2 years. These
imaging modalities are also indicated for any sibling
of a suspected child abuse victim or other child living in the same household as the suspected victim
who is younger than 2 years. 64,84 Skeletal surveys
generally are not recommended for children aged 5
years and older. 64
These examinations should be interpreted by a
pediatric radiologist whenever possible to avoid misinterpretation of artifacts, dysplasias or metabolic bone
disease signs as indications of abuse. Incorrect interpretations that either miss real abuse or indicate abuse
where there is none can have catastrophic effects on
children’s well-being.84
MR imaging traditionally has been used to clarify
CT findings on follow-up, but is increasingly used as a
first-line abuse trauma imaging modality for specific
examinations, such as identifying vein thrombosis in
the brain.83 Because of concerns about the adverse
health consequences of radiation exposure from
radiography, some authors advocate the use of wholebody MR imaging for skeletal surveys. However, MR
examinations are longer procedures, and immobilizing
young children can be challenging.
A recent study found that fluorine 18-labeled
sodium fluoride positron emission tomography (PET)
more sensitively visualizes skeletal fractures in abused
children, particularly for rib fractures, than radiography.86 However, PET exhibited less sensitivity in detecting classic metaphyseal lesions (CMLs) at the joints of
long bones (see Figure 2). Because CMLs are strongly
indicative of child abuse, the authors recommended
that PET remain a follow-up imaging modality for skeletal survey, rather than a first-line modality.86
Single-view “babygram” radiographs of the entire
infant skeleton do not sensitively visualize many fractures
and should not be used as a skeletal survey technique.64
Skeletal surveys involve relatively high-dose radiation
exposures for children because of the following factors:
(1) extensive radiography of different bone regions, (2)
repeat imaging resulting from the need for very highquality images, and (3) the use of follow-up radiography
to identify bone fractures and evidence of healing.
Limited evidence suggests that CT may more sensitively identify rib fractures than does traditional chest
radiography.87 However, CT is not recommended for
initial skeletal survey screening because of its much
higher average per-examination radiation dose and
scant empiric support for its superiority in identifying
abuse-indicative fractures. However, CT follow-up may
be indicated to better characterize complex fractures
in the spine, pelvis and scapula identified in radiographic surveys.64
In all radiologic imaging, the ALARA principle (as
low as reasonably achievable) always should be applied
to minimize child radiation doses. MR imaging is
becoming the preferred imaging modality for assessing
brain damage resulting from domestic violence.
The ACR skeletal survey protocol calls for separate
exposures with uniform image density to ensure maximum image sharpness.84 According to the ACR guidelines, appendicular bones — including the right and
left humerus, forearms, hands, femurs, lower legs and
feet — should be radiographed at least in the frontal
projection. Additional images should be taken as needed to assess suspicious lesions in follow-up, including
projections centering on joints:
■ Humerus: anteroposterior (AP) image.
■ Forearms: AP.
■ Hands: posteroanterior (PA) image.
■ Femur: AP.
■ Lower legs: AP.
■ Feet: AP.
According to the ACR guidelines, many of the bones
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■ Lumbosacral spine: lateral image.
■ Cervical spine: AP and lateral images.
■ Pelvis: AP image.
A final radiographic report should be
included in the child’s medical record,
describing precisely the sites and projections
examined and the specific abnormalities or
suspected abnormalities identified.84 Skeletal
survey findings are either “typical” for child
abuse, “equivocal,” or evidence “no radiographic injuries.” Strong indications of abuse
should be explicitly stated as such in the
report and communicated to the referring clinician as urgent findings.84 Radiologic reports
should (1) describe the quality of the images
and abnormalities detected; (2) exclude alterB
A
native explanations for abnormalities, such as
skeletal dysplasias or metabolic bone diseases;
and (3) explicitly state the level of suspicion
for abuse based on imaging examinations.64
All states require referring physicians to
report child abuse. As mentioned previously,
equivocal or no-injury radiographic findings, in the presence of compelling clinical
or other evidence of child abuse, can be confirmed using bone scintigraphy imaging.
One hallmark of chronic child battering is
the presence of bone fractures of varying age,
as evidenced by different degrees of healing.
Diagnostic imaging-based estimates of the
age of fractures and brain injuries are inexact, but the presence of fractures and lesions
with different degrees of repair is evidence of
C
multiple violent assaults on the child.64 Some
authors recommend a repeat skeletal survey
10 to 15 days after initial imaging to allow
Figure 2. Metaphyseal lesions at the distal ends of long bones are highly
assessment of fracture healing.64 No change in
indicative of physical abuse of infants. A, Fracture that would appear
fractures suggests nontraumatic origins.64
as a metaphyseal radiolucency on a radiograph. B, Displacement or tipMultiple rib fractures in children who
ping of metaphyseal fracture will frequently cause a “bucket-handle” or C,
have no history of kinesitherapy exposure
concave appearance on radiographs (arrows). Reprinted with permission
and CMLs in infants are strongly indicative
from Kleinman PK, Marks SC, Blackbourne B. The metaphyseal lesion in
of assault-related child injuries.64 Assaultabused infants: a radiologic-histopathologic study. AJR Am J Roentgenol.
1986;146:900-902.
associated CMLs are shearing injuries, sometimes called “corner fractures” or “bucketof the axial skeleton, in contrast, should be imaged using
handle fractures” (see Figure 2).62
at least 2 projections, with additional images as needed in
Long bone shaft fractures are increasingly likely to
follow-up examinations:
be caused by accidental trauma with increasing child
■ Skull: frontal and lateral images.
age; however, in infants these fractures may indicate
■ Thorax: AP and lateral images, including ribs
assault, particularly if the fracture is a transverse or
and the thoracic and upper lumbar vertebrae.
spiral fracture of the humerus or femur.62
146
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In a similar way, skull fractures are more suggestive
of abuse in younger children and infants than in older
children. However, simple skull fractures are less likely
to have been caused by assault than depressed or complex fractures (see Figure 3).62
The vast majority of pelvic fractures are due to
motor vehicle trauma, but these findings are sometimes
identified in sexually abused girls.62
Brain Imaging in Suspected Child Abuse
Pediatric brain imaging also is indicated when physical assaults on infants and young children are suspected.
Assault-associated head injuries typically involve multiple
subdural hematomas at distant sites on the brain surface
and hypoxic-ischemic brain lesions.64 Vigilant monitoring
of changes in infant head circumference is vitally important in suspected cases of abuse-related head injury or
TBI. Brain swelling causing sudden or marked increases
in infant head circumference should be imaged to detect
possible chronic subdural hematomas.64
CT is indicated when intracranial hemorrhage or
rapid change in neurologic symptoms is suspected.64
Suspected abuse involving behavioral symptoms (eg,
shaken baby syndrome) requires imaging with noncontrast CT, which can sensitively identify brain hemorrhage. Imaging of suspected abuse-related head trauma
without neurologic or behavioral symptoms is indicated
for children younger than 2 years.64
MR imaging sensitively visualizes brain contusions,
hypoxic-ischemic injury and thrombi in brain veins.64
T1- and T2-weighted sequences and T2 gradient-echo
sequences are used in abuse neuroimaging to identify
regions of cell death or hemorrhage.64 A few functional
MR (fMR) imaging studies suggest this might become
a promising modality for assessing TBI- and PTSDrelated cognitive prognoses in the future.88
Chronic abuse-related brain trauma reliably causes
CT- and MR-detectable cerebral atrophy due to regional
brain cell death, although the true extent of cellular
damage is not always clear from anatomic brain imaging.59 CT or MR brain images can detect major focal
damage but cannot confirm that a patient is truly free
from significant diffuse or cellular brain damage.
Structural imaging rarely detects diffuse microscopic
TBI that has not caused reductions in regional or wholebrain volume.
Patients with seemingly normal brain CT images
routinely suffer from TBI symptoms and can suffer lifethreatening microscopic bleeds.58 TBI evolves over time;
images taken on the day of injury or presentation may
Figure 3. Depressed skull fracture in an infant. U.S. National
Institutes of Health. Public-domain U.S. government figure available at: http://commons.wikimedia.org/wiki/File:Skull_Fracture
.jpg. Accessed September 9, 2010.
not reveal the eventual extent of brain damage. Followup neuroimaging examinations are therefore necessary
to accurately assess TBI.
Brain Imaging in Adults
TBI scanning is underutilized; it is rarely performed
in IPV victims (even though head and face trauma is
very common among IPV victims) or elder abuse victims.
In addition to head CT and MR imaging to characterize maxillofacial bone fractures (eg, nasal,
mandible, zygomatic or skull fractures), noncontrastenhanced CT and MR examinations should be
performed because both modalities can sensitively
visualize large brain contusions and bleeding. Diffuse
cellular damage that can impair cognitive function is
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detected on CT and MR as brain atrophy or volume
loss over time.88
As with pediatric TBI, brain imaging may miss
subtle but life-threatening lesions and should be followed up with subsequent imaging over a period of
several weeks. Furthermore, neurodegenerative processes resulting from TBI may not be detectable using
structural neuroimaging until months after injury; MR
imaging several months after the injury better predicts
long-term outcome than day-of-injury CT.58,88
CT is the imaging modality of choice for acute
TBI assessment in emergency settings; it sensitively
visualizes focal lesions and skull fractures with short
acquisition times. Detecting skull fractures is crucial
because their presence often indicates the presence
of intracranial hematomas (see Figure 4). A fully conscious adult patient with no skull fracture has a likelihood of only 1 in 7866 for acute hematoma, whereas
the risk of hematoma in a fully conscious patient with
skull fracture is 1 in 45. 58 Among patients with altered
consciousness, the risk of hematoma is 1 in 180 for
patients without skull fracture and 1 in 5 for patients
exhibiting skull fracture. 58
The most common CT rating scale for TBI is the
Trauma Coma Databank, which involves 7 distinct
categories. 89 The score reflects the severity of brain
damage and establishes a baseline for comparison
with future neuroimaging results. 89 The scale classifies TBI as:
■ Diffuse injury I: No visible intracranial pathology.
■ Diffuse injury II: Midbrain, midline cisterns
shifted up to 5 mm or lesions or bone fragments
are present, but no high- or mixed-density lesion
exceeding 25 cc.
■ Diffuse injury III: Swelling within the midbrain,
midline cisterns compressed or absent, but no
high- or mixed-density lesion exceeding 25 cc.
■ Diffuse injury IV: Brain midline shift exceeds
5 mm, but no high- or mixed-density lesion
exceeding 25 cc.
■ Evacuated mass lesion V: Lesion surgically
evacuated.
■ Non-evacuated mass lesion VI: High- or mixeddensity lesion exceeding 25 cc, but has not been
surgically removed.
■ Brainstem injury VII: Focal lesion on brainstem
but no other lesions.
MR imaging offers excellent anatomic detail with
resolution superior to CT and is preferred over CT for
long-term follow-up monitoring applications. Because
148
Figure 4. Computed tomography image of skull fracture–
associated hematoma. Wiki Commons. http://commons.wiki
media.org/wiki/File:Epidurales_Haematom.jpg.
MR involves longer acquisition times and is incompatible with some life-support equipment, it is rarely used
in emergency or acute care settings. Frequently, MR
is used to monitor degenerative changes and changes
in hemorrhage over time as well as to detect lesions
contributing to TBI-associated seizures. MR images
acquired more than 45 days after initial injury better
detect the ultimate extent of brain damage from TBI
than day-of-injury images.58 MR sensitively visualizes
water and edema, white matter damage and generalized cerebral atrophy measured as ventriculomegaly
(expansion of the brain’s cerebrospinal fluid-filled ventricles) as well as thinning of the corpus callosum, the
thin wall of tissue dividing the brain’s left and right
cerebral hemispheres.58,88
Traditional T1 MR is used to detect focal brain atrophy, whereas combined T1 and T2 MR is superior for
detecting ventriculomegaly.90 White-matter abnormalities are visualized in MR imaging as hyperintensities,
often at the same sites where tiny, dotlike hemorrhages
were visualized in day-of-injury CT images.58,88
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Strangulation
Neck trauma from strangulation is a common and
life-threatening form of IPV. Clinical signs include
petechiae in the upper eyelid skin and hemorrhage in
the whites of the eyes.52
The extent of internal neck injuries from strangulation assaults is not always evident in clinical examination of external anatomy. Approximately 10% of violent
deaths in the United States each year involve strangulation, and many victims die without “a single visible
mark to the neck.”52 Subcutaneous hemorrhage identified in MR examinations is frequently more extensive
than external clinical examination suggests and sometimes correlates better with patient reports of painful
areas than does external bruising.49
Clinical assessment involves evaluating petechial
hemorrhage, pain, voice hoarseness and painful swallowing. Pulse oximetry using a fingertip transducer
should be undertaken immediately, particularly if the
patient has suspected mental status alterations indicative of hypoxemia.52 Pharyngoscopic or fiberoptic
laryngobronchoscopic examinations of the upper airways usually are performed during initial evaluation
of strangulation assaults, but these should be followed
up with radiography and other diagnostic imaging
examinations. 52
Chest radiography allows rapid detection of lung
edema, pneumonia or aspiration. Nasal radiography is
undertaken to determine whether coughed-up blood is
from internal nasal fractures, and soft-tissue neck radiography allows evaluation of larynx fracture and tracheal hematomas.52 Cervical spine radiographic examinations allow evaluation of hyoid bone fracture, which
is a signature injury from severe strangulation assault
and a marker in autopsy of strangulation as a cause
of death. (The hyoid, a horseshoe or U-shaped bone
sitting above the larynx in the front of the neck, is frequently fractured by force to the front of the neck.)
CT and MR imaging allow for (1) detailed crosssectional anatomic imaging of neck tissues and
vertebrae and (2) TBI assessment for brain injuries
incidentally sustained during the strangulation assault
or resulting directly from the assault (eg, stroke [cerebral infarction]).
Because carotid Doppler ultrasonography can confirm intact blood supply to the brain, this modality
should be undertaken if there are signs of stroke.52
Carotid arterial dissection and thrombosis are associated with stroke and frequently may be missed
in strangulation cases.91 Doppler ultrasonography
visualizes thrombosis and dissection of the arteries.
Subsequent CT scans in dissection-positive patients
can reveal brain infarction foci near the cerebral
arteries as hypodensities.91 Lymph node hemorrhage
is frequently detected as hyperintense MR foci.49
Attempts have been made to differentiate life-threatening from non–life-threatening strangulation assaults
using diagnostic imaging scoring systems.49,92 Studies
using very small case sample sizes (eg, 41 patients92)
suggested that MR-detected intramuscular hemorrhage
or edema, intracutaneous and subcutaneous bleeding
and lymph node hemorrhage all may indicate lifethreatening strangulation.92 However, these findings
and scoring systems must be confirmed by additional
studies before they are adopted in routine practice.
Patients with both suspected child abuse and stroke
symptoms should be evaluated for strangulation and
arterial dissection; in addition, these patients should
undergo neuroimaging examinations to confirm and
characterize stroke.93 CT scans of the neck vertebrae
and hyoid bone should be undertaken to identify
bone fractures.
Conclusion
Domestic violence is a common but frequently
undetected source of injury and death in the United
States. All health care workers should be aware of the
signs, symptoms and patterns of injuries associated
with domestic violence, and all hospitals and health
care facilities should have consistent policies in place
regarding the detection, treatment, referral and reporting of such cases.
Diagnostic imaging plays a crucial role in the detection, characterization and follow-up monitoring of the
effects of domestic violence–related physical assaults.
However, brain imaging and imaging of strangulation
injuries are frequently not performed, which leaves
potentially life-threatening injuries undetected and
results in failure to document the extent and nature
of injuries that could be used in legal interventions
against perpetrators.
It is the ethical responsibility of every health care
worker to follow policies that will improve the identification of domestic violence victims and assist appropriate interventions.
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3. Tolan P, Gorman-Smith D, Henry D. Family violence.
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...
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153
Directed Reading Continuing Education Quiz
#10806-01
Expiration Date:
Dec. 31, 2012*
Approved for 2.0
Cat. A+ CE credits
Domestic Violence
To receive Category A+ continuing education credit for this Directed Reading, read the preceding article and circle
the ­correct response to each statement. Choose the answer that is most correct based on the text. Transfer your
responses to the answer sheet on Page 160 and then follow the directions for submitting the answer sheet to the
American Society of Radiologic Technologists. You also may take Directed Reading quizzes online at www.asrt.org.
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*Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date.
1. More than _______ of women’s visits to emergency
departments result from domestic violence.
a.one-sixth
b.one-third
c.one-half
d.two-thirds
4. Up to _______ % of reported IPV victims are
female.
a.75
b.80
c.85
d.90
2. The lifetime prevalence of intimate partner
violence (IPV) for women in the United States
varies from _______ % in Washington state
to _______ % among Hispanic women in the
southeastern U.S.
a. 1.9; 35
b. 4.5; 35
c. 1.9; 70
d. 4.5; 70
5. Female victims between _______ and _______ years
of age are at greatest risk of IPV.
a. 16; 24
b. 20; 28
c. 24; 32
d. 28; 36
3. According to the National Crime Victimization
Survey, at least _______ Americans are victimized
by IPV each year.
a. 167 000
b. 267 000
c. 367 000
d. 467 000
6. Rates of mutual or bidirectional IPV range up to
_______ % among couples with any history of IPV.
a.51
b.61
c.71
d.81
Continued on next page
154
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
Directed Reading Continuing Education Quiz
7. African American and American Indian IPV
homicide rates are _______ and _______ per
100 000, respectively, compared with the national
average of 0.8 per 100 000.
a. 1.5; 2
b. 2.5; 3
c. 3.5; 4
d. 4.5; 5
8. Risk factors for domestic violence perpetration
include the:
1. perpetrator’s low educational achievement.
2. perpetrator threatening abuse of pets.
3. victim’s disability or impairment.
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2 and 3
9. In 80% of child abuse cases, the perpetrators are:
a.babysitters.
b. older siblings.
c.parents.
d. other relatives.
10. Unwitnessed _______ injuries are a significant
indicator of domestic violence.
a.abdominal
b. head, face or neck
c. upper and lower extremity
d. hand and foot
11. Multiple injuries are _______ times as common
among IPV victims as in accident victims.
a.5
b.10
c.15
d.20
12. Up to _______ % of traumatic brain injuries
(TBIs) go undiagnosed.
a.55
b. 65 c.75
d.85
13. Multiple _______ fractures represent a red flag
highly indicative of shaking, kicking or punching
assaults on children.
a.rib
b.forearm
c.foot
d. simple skull
14. The simplest IPV screening questionnaire
reviewed in this Directed Reading is the 3-item
_______ questionnaire.
a. Partner Violence Screen
b.HELPS
c. WAST
d.HITS
15. Which of the following is used to assess the need
for TBI evaluation?
a. Partner Violence Screen
b.HELPS
c. WAST
d.HITS
16. Which of the following are barriers to identifying
domestic violence victimization in health care
settings?
1. language barriers
2. inadequate training
3. insufficient staffing
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2 and 3
Continued on next page
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
155
Directed Reading Continuing Education Quiz
17. Reporting child abuse to state agencies is
mandatory in all 50 states.
a.true
b.false
22. _______ states require referring physicians to
report child abuse.
a.Many
b.All
c.Few
d.Some
18. If radiographs are equivocal but clinical evidence
suggests physical abuse of a child, which follow-up
examination may be indicated?
a. magnetic resonance (MR) imaging
b. repeat skeletal survey
c.ultrasonography
d. bone scintigraphy
19. Skeletal surveys generally are not recommended
for children aged _______ years and older.
a.2
b.3
c.4
d.5
20. Which imaging modality exhibits better sensitivity
for visualizing rib fractures than a radiographic
skeletal survey, but less sensitivity for detecting
classic metaphyseal lesions?
a.ultrasonography
b. positron emission tomography (PET)
c. computed tomography (CT)
d. MR imaging
21. _______ may be indicated for characterizing
complex fractures in the spine, pelvis and scapula.
a.Radiography
b.PET
c.CT
d.MR
23. Some researchers recommend follow-up skeletal
surveys after an interval of _______ days to assess
whether bone fractures are healing and therefore
are likely due to trauma rather than metabolic
disorders or other causes.
a. 10 to 15
b. 15 to 20
c. 20 to 25
d. 25 to 30
24. The Trauma Coma Databank rating scale for
TBI is used with which diagnostic neuroimaging
modality?
a.radiography
b.PET
c.CT
d.MR
25. MR images acquired more than _______ days after
initial injury better detect the ultimate extent of
brain damage from TBI than day-of-injury images.
a.35
b.45
c.55
d.65
26. Approximately _______ % of violent deaths in the
United States each year involve strangulation.
a.5
b.10
c.15
d.20
Continued on next page
156
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
Directed Reading Continuing Education Quiz
27. Clinical assessment for strangulation involves
evaluating _______.
a. lymph node edema
b. petechial hemorrhage
c. intramuscular hemorrhage
d. subcutaneous hemorrhage
28. According to this Directed Reading, which
imaging modality allows early detection of lung
edema, internal nasal fractures, larynx fractures
and tracheal hematomas caused by strangulation
attacks?
a.radiography
b.PET
c.CT
d.MR
29. Which of the following bones is frequently
fractured by force to the front of the neck?
a. C2 vertebra (axis)
b. C6 vertebra
c.hyoid
d.zygomatic
30. If there are signs of stroke, carotid Doppler
ultrasonography can confirm intact blood supply
to the brain.
a.true
b.false
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
157
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Diagnosis and Treatment
Of Scaphoid Fractures
Cynthia N Patrick, BS, R.T.(R)
The scaphoid bone in the
wrist is the most frequently
fractured carpal bone. This
Directed Reading discusses
types of scaphoid fractures,
issues of special concern (eg,
the risk of avascular necrosis
and delayed union or nonunion), steps involved in bone
fracture healing and various
imaging modalities used for
scaphoid fracture diagnosis.
Types of fracture management
such as casting and surgical
intervention are examined.
Factors that can negatively
influence bone healing, such
as certain disease processes
and tobacco use, are also
investigated.
This article is a Directed
Reading. Your access to
Directed Reading quizzes for
continuing education credit
is determined by your area of
interest. For access to other
quizzes, go to www.asrt.org
/store.
After completing this article, readers should be able to:
n Describe the anatomy of the scaphoid bone and types of scaphoid fractures.
n Identify the prevalence of scaphoid fractures by their anatomic location.
n List and describe the 5 stages of fractured bone healing.
n Explain how and why avascular necrosis can occur in scaphoid fractures.
n List diagnostic modalities used for imaging scaphoid fractures.
n Summarize treatments for optimal scaphoid fracture healing management.
n List comorbidities that may contribute to suboptimal fracture healing.
T
he wrist joint is arguably
the most complex joint in
the body and comprises
many bony articulations.
Eight small carpal bones
align in 2 rows, enabling great range of
motion as well as hand strength and
dexterity (see Figure 1).1 The scaphoid
bone is the first in the proximal carpal
row and articulates with 5 bones: the
distal radius proximally, the trapezium
and trapezoid distally and the capitate
and lunate medially (see Figure 2).2
The scaphoid has a twisted and curved
shape and spans 2 rows of carpal bones,
which allows a hinge effect. The scaphoid has many vital ligamentous
attachments, including the scapholunate interosseous ligament that links
the scaphoid to the lunate, and the
radioscapholunate ligament that connects the radius, scaphoid and lunate.3
The scaphoid is covered almost completely with articular cartilage, which
enables complicated wrist movement.
However, this structure leaves the scaphoid prone to suboptimal fracture
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
healing due to the anatomy of its vascular supply.4
The origin of the term scaphoid is
Greek, which means shaped like a boat.3
Sometimes the scaphoid is referred to as
the navicular,5 which becomes further
complicated because both the wrist and
ankle contain navicular bones: the carpal navicular and the tarsal navicular,
respectively. The Latin term navicular
also describes the boat or curved shape
of these bones. The carpal navicular,
the first of the 8 carpal bones forming
the wrist, is most often referred to as the
scaphoid bone in current medical literature. Because of its location and physiology, a fall on an outstretched hand can
cause the scaphoid to fracture.
The scaphoid can be palpated by
locating the anatomic “snuffbox,” which
is a hollow depression on the dorsomedial aspect of the wrist between the
extensor pollicis brevis and abductor
pollicis longus tendons (see Figure 3).6
The scaphoid is fed mainly by the volar
scaphoid branch of the radial artery,
which is located at the distal end of the
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SCaphoid fractures
A
of avascular necrosis (AVN).4 AVN is a condition
in which reduced blood supply to an area of bone
leads to osteonecrosis, or death of bone tissue. The
scaphoid is especially vulnerable to AVN following
a fracture because of the structure and location
of its arterial supply. When arterioles are severed,
part of the bone may become cut off from its
blood supply. The specific anatomic location of a
scaphoid fracture determines whether there is risk
of damage to or loss of arterial blood supply.4
Scaphoid Fractures
B
The scaphoid is the most frequently fractured carpal bone, accounting for approximately 60% to 70% of all carpal fractures.3,7
Scaphoid fractures usually occur in patients
aged 15 to 40 years,8 the majority of whom are
active males between ages 15 and 29.9 Scaphoid
fractures most often result from a fall onto an
outstretched hand.4,7 This mechanism of injury
often results in a Colles (distal radius) fracture
in an elderly patient, or an epiphyseal displacement of the distal radius in a child.4 Perron
et al described the fall on outstretched hand
(FOOSH) injury as well as hyperextension at
the wrist as the causative mechanism in approximately 97% of scaphoid injuries.7 The treatment
method for a scaphoid fracture depends on the
fracture’s stability and anatomic location.3,4 A
displaced scaphoid fracture is present if there
is 1 mm or more of displacement.3,4 A displaced
scaphoid fracture is considered unstable and at
risk for nonunion.
Types of Scaphoid Fractures
Scaphoid
fractures are classified according to
Figure 1. Posteroanterior radiographs of wrist bones: A. Unlabeled.
3 main regions of the bone: the proximal pole,
B. Labeled. Reprinted with permission from Richardson M. University
the waist and the distal pole or tubercle.10 They
of Washington Radiology website. http://uwmsk.org/RadAnat
are further classified in several ways.10,11 Filan
/WristPA.html.
and Herbert described 2 types of stable scaphoid
fractures, A1 and A2, plus 4 types of unstable
scaphoid (see Figure 4).6 Dorsal and volar branches of
fractures, B1-B4, as follows10 :
the anterior interosseous artery also supply blood to
■ A1 — fracture of the distal pole or tubercle.
the scaphoid toward its distal end. Because of this vas■ A2 — incomplete waist fracture.
cular pattern, the proximal one-third of the bone may
■ B1 — distal oblique fracture.
not receive optimal blood circulation.
■ B2 — complete fracture of the waist.
The shape and location of the scaphoid bone makes
■ B3 — proximal pole fracture.
it prone to missed fracture on initial diagnosis, and its
■ B4 — fracture dislocation (see Figure 5).
tenuous vascular supply presents additional challenges
Gelberman described type B4 as a trans-scaphoidto timely healing because of a proclivity for development
perilunate fracture dislocation of the carpus.11 Type C
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Figure 2. The carpals and metacarpals: anteroposterior or pal-
mar aspect. Reprinted with permission from Standring S. Gray’s
Anatomy: The Anatomical Basis of Clinical Practice. 40th
ed. Philadelphia, PA: Elsevier/Churchill Livingstone; 2009:862.
fractures are delayed unions, but they are omitted from
the classification because they do not form natural
groups.10 Type D fractures are nonunions older than 6
weeks, and are subclassified as follows10 :
■ D1 — fibrous union (no deformity).
■ D2 — pseudarthrosis (early deformity).
■ D3 — sclerotic pseudarthrosis (advanced deformity).
■ D4 — avascular necrosis (fragmented proximal
pole [see Figure 5]).
Treatment recommendations vary based on the
classification of the fracture and other factors.
According to Filan and Herbert, all classifications
except type A1 require surgical intervention.10
Haisman and coauthors stated that the majority
(approximately 75%) of scaphoid fractures occur at
the waist, with only approximately 20% occurring in
the proximal third or pole of the scaphoid.3 The least
common location is the distal third or pole of the
scaphoid, including the tubercle.3,4,12 Skinner stated
that “on average, middle third fractures heal in 6 to
12 weeks, distal third fractures in 4 to 8 weeks, and
proximal third fractures in 12 to 20 weeks.”12
Figure 3. The anatomic snuffbox (arrow) and location
of the scaphoid bone. A. Extensor pollicis brevis tendon. B.
Abductor pollicis longus tendon. Reprinted from Hobbs DL.
Carpal box and open cup radiography. Radiol Technol.
2006;77(5):345.
Delayed healing and nonunion scaphoid fractures
are often attributed to poor blood supply that leads to
AVN. According to Nishihara, “a delayed union is considered to be present if there is no evidence of healing after 3 months. A fracture nonunion is defined
as absence of evidence of healing at 6 months after
injury.”4 Nonunion of scaphoid fractures is reported
at rates ranging from 3% to 10% 4 and 5% to 25%.3
There are numerous sources of information regarding scaphoid fracture healing rates, and these data
may vary widely because they reflect different fracture
types and the presence of other factors that may affect
bone healing. According to Haisman et al, “the factors
associated with nonunion include fracture displacement of greater than 1 mm, proximal fracture, osteonecrosis, vertical oblique fracture, and smoking.”3 The
complexities and possible complications of scaphoid
fracture healing can be further explored after first
establishing what constitutes the normal healing process for fractures.
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SCaphoid fractures
Figure 4. Arterial blood supply to the scaphoid bone. The wrist
is positioned in ulnar deviation. A. Radial artery. B. Volar
scaphoid branch. C. Anterior interosseous artery. Scaphoid waist
fracture is observed. Reprinted from Hobbs D. Carpal box and
open cup radiography. Radiol Technol. 2006;77(5):345-349.
The Bone Healing Process
Bone is a constantly changing and complex type of
connective tissue. The human skeleton comprises both
cancellous (dense) and spongy (less dense) bone tissue.
To maintain homeostasis in healthy bone tissue, some
bone cells (osteoclasts) are constantly breaking down
bone matrix. Other cells (osteoblasts) rebuild bone
matrix. Bone tissue is permeated with blood vessels, and
long bones contain marrow that generates blood cells.
Bone fracture healing is a multistep process that
begins with the impact that causes the injury. Skinner
described bone healing as a process with 5 stages:
impact, inflammation, soft callus formation, hard callus formation and finally remodeling.12 Bone healing
proceeds somewhat differently depending on whether a
fracture is stable or unstable — that is, whether or not
the fracture surfaces are held in place sufficiently to
prevent motion relative to each other.13 Most scaphoid
164
fractures are treated with fixation to stabilize them.3,10
However, in some cases diagnosis and treatment may
be delayed for weeks or months and the healing process may have already begun in unstable or suboptimal
alignment.
When a bone fractures, both bleeding and an
inflammatory response occur at the site of the break.
A hematoma forms and surrounds the fractured bone
surfaces and the torn outer surface (periosteum); the
hematoma occupies any voids, including the medullary canal. Bone cells (osteocytes) and other tissues
within the bone, such as blood vessels and nerves,
are physically disrupted in the immediate area of the
fracture. The lack of vascular supply caused by the
disruption of the blood vessels in the area of the fracture causes these tissues to die from lack of nutrients
and oxygen. Necrotic material and the blood platelets
in the hematoma release messenger chemicals called
inflammatory mediators. The most obvious aspect of
the inflammatory response is edema or swelling due
to blood plasma building up in the area of injury. The
body also responds by sending leukocytes, macrophages and lymphocytes to the affected area. These cells
begin resorbing necrotic material and other debris at
the fracture site.
Leukocytes, macrophages, and lymphocytes also
stimulate the body to begin the process of angiogenesis
— the production of new blood vessels — to restore
the blood supply to the affected region.13 Necrotic
bone material is resorbed by osteoclasts. As the hematoma is resorbed, it is replaced by granulation tissue.
Granulation tissue temporarily replaces lost tissue in a
wound and helps enable vascular formation during the
healing process.
As the inflammatory response begins to subside
and the newly forming blood vessels begin to resupply fresh blood to the fracture area, bone repair can
begin. The first repair cells to arrive are fibroblasts
and chondrocytes, which begin producing the new
bone matrix, or soft callus. Fibroblasts produce
fibrillar collagen, which is the main component
(approximately 90%) of the organic portion of bone
matrix. Chondrocytes produce cartilagenous proteins. Fibrillar collagen is a protein that forms helical
strands of protein that become entangled with each
other to produce a 3-D mesh called osteoid, which
becomes the scaffold for the new bone. The new
bone produced initially is called woven bone because
of the resemblance of the entangled collagen fibers
to woven cloth.13
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inner part is called the soft callus and remains longer as fibrous
and cartilaginous tissue before it
too starts to mineralize.
Essentially, the fracture callus proceeds to harden from
the outside in, with peripheral
areas mineralizing earlier and
the central areas mineralizing
later. The new bone material
produced is woven bone, and
it eventually fills in the space
between the fracture surfaces
and typically surrounds the
fracture site on the exterior of
the bone as well. When enough
hard callus has formed to stabilize the fracture and prevent
relative motion between the
fracture surfaces, the healing
has reached the stage called
clinical union.13
The final stage of bone healing consists of remodeling. The
woven bone material of the
hard callus is weaker than the
original lamellar bone material
was. Remodeling is a complex
process in which osteoclasts
Figure 5. Modified staging system for scaphoid fractures. Type A fractures are not illustrated.
slowly break down the woven
Types B5 (comminuted) and C (delayed union) have been omitted from the classification
bone, while at the same time
because they did not form natural groups. Other researchers noted the questionable validity of
osteoblasts replace the woven
type C. Reprinted with permission from Filan SL, Herbert TJ. Herbert screw fixation of
bone with lamellar bone. Over
scaphoid fractures. J Bone Joint Surg [Br]. 1996;78-B(4):519-529. www.jbjs.org.uk/cgi
time, the remodeled bone even/reprint/78-B/4/519.pdf. Accessed September 21, 2010.
tually achieves normal strength
and the hard callus that had
formed exterior to the original
At this stage, according to Weinstein and Buckwalter,
bone is resorbed. This restores the bone to very close to
the bone healing process will take one of 2 paths,
its original shape before the break.
depending on whether the fracture surfaces are stable or
In the case of a fracture that is rigidly stabilized, the
unstable.13 In the case of an unstable fracture, an assemrepair process is somewhat simpler.13 Considered at the
blage of osteoid, cartilaginous tissue and fibrous tissue
microscopic level, in a stabilized fracture there are some
forms in and around the fracture site. This is called
areas where the opposite fracture surfaces are in direct
the fracture callus. Once the fracture callus has been
contact, and other areas where there are microscopic
formed, osteoblasts and cells from the periosteum begin
gaps between the bone surfaces. In the areas of direct
to produce osteocytes to occupy the fracture callus.
contact, new lamellar bone can be formed directly, withOsteocytes promote mineralization of the bone by mediout the intermediate step of the fracture callus. New
ating the production of calcium phosphate, which forms
lamellar bone is formed by osteoclasts that first break
the hard part of the bone. The outer area of the fracture
down the interface where the 2 fracture surfaces are in
mineralizes first and forms the hard callus, whereas the
contact; this stage is followed by osteoblast production
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of lamellar bone that connects both surfaces. New blood
vessels then grow into the new bone matrix. In areas
where there are gaps between the fracture surfaces too
large for the osteoblasts to fill directly with new lamellar
bone, woven bone is formed instead by the same process
as described previously for the unstable case. These
pockets of woven bone are later remodeled into lamellar
bone much as if they had been part of a fracture callus.
Although many factors can affect the timeline of
individual healing, on average a bone fracture takes
approximately 6 to 8 weeks to heal completely. After
the initial injury, the inflammation stage lasts for several days. Once soft callus begins to be replaced with
hard callus, the hard callus formation becomes visible
on radiographs, usually within 2 to 3 weeks of injury.
The final remodeling stage of bone healing can continue for several months after the majority of the healing
process is complete.
It is important to recognize that some scaphoid fractures are not diagnosed or treated until weeks or even
months after the initial injury. Some patients may delay
seeking treatment because they assume that they only
have a sprained wrist, as there is often no deformity
and sometimes little to no swelling present. Therefore,
callus may already be forming at the fracture site by the
time the patient seeks care; or, because of insufficient
blood supply, a scaphoid nonunion may occur. Also,
if a patient obtains medical care at the time of injury
but for some reason the scaphoid fracture diagnosis is
missed, he or she may not receive proper treatment or
follow-up.
Imaging Scaphoid Fractures
Radiography
Before a patient comes for initial radiographs, a clinician will have determined a suspicion of a wrist fracture based on the patient’s injury and examination.
Tenderness in the anatomic snuffbox area (see Figure
3) 6 should cause a clinician to suspect that a scaphoid
fracture may be present.3 Depending on the clinical
setting, the clinician’s experience and the patient’s
symptoms and presentation, either routine wrist radiographs or wrist radiographs with additional images
of the scaphoid may be ordered. Clinicians also will
consider whether referral to an orthopedic specialist
and follow-up studies may be advisable, even if initial
radiographic findings are negative. Haisman and colleagues suggested wrist immobilization and follow-up
radiographs in 1 to 2 weeks for patients with anatomic
snuffbox tenderness whose initial radiographic
166
findings are negative. If a scaphoid fracture is suspected but repeat radiographs fail to show a fracture, computed tomography (CT), magnetic resonance (MR)
imaging or a bone scan should be performed.3 Brydie
and Raby observed that scaphoid fractures can take
up to 6 weeks to become evident on radiographs and
highly recommended MR imaging for early definitive
diagnosis of scaphoid fracture.14
Initial radiographic images of the wrist vary among
facilities. Merrill’s Atlas of Radiographic Positioning and
Procedures15 lists standard images of the wrist as posteroanterior (PA), lateral and PA oblique; it also describes
several scaphoid images, including the PA with ulnar
deviation and the PA axial or Stecher method, with the
image receptor placed on a 20° angle sponge and the
central ray directed perpendicular to the table.15 Frank
et al also described the Rafert-Long method for scaphoid imaging. This method is a series of 4 images with
the wrist in ulnar deviation. Four separate exposures
are made with 0°, 10°, 20° and 30° cephalic tube angles.
Scaphoid images are obtained to demonstrate the
scaphoid without superimposition or overlap of bones
around it.
Another positioning resource used by RTs and
students is Radiographic Procedures: A Pocket Index by
Kirby and Cockbain.16 These authors explained that
radiology departments have established protocols for
the images to be obtained in cases of suspected scaphoid fracture. In many patients, scaphoid fractures are
not apparent on radiographs taken immediately after
a traumatic event. These patients typically require
additional imaging 10 to 14 days after the injury.16
The authors described the most common series of
images for suspected scaphoid fractures as the anterior
oblique, posterior oblique, lateral and PA with ulnar
deviation, plus an additional image, the PA with ulnar
deviation and 45° angulation, with the central ray
angled 45° toward the elbow.16
Hobbs described and illustrated the carpal box and
open cup methods of nontraditional scaphoid radiography.6 These are both methods of obtaining magnified views of the scaphoid. Hobbs cited the finding
of Toth et al17 that the carpal box magnified imaging
technique is effective as a primary diagnostic tool in
place of more expensive CT and MR scans.6 In addition
to routine wrist views, Perron et al described a scaphoid
view with a clenched fist and the wrist held in ulnar
deviation.6 Malik et al cited the need for standardization of scaphoid imaging.18 Plain radiographs are the
primary imaging modality for the initial diagnosis of
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scaphoid fractures, but Malik and colleagues documented that a variety of images are taken by radiographers when they are asked to perform scaphoid imaging.18 They suggested that 5 specific images represent
the most effective protocol: anterior oblique, posterior
oblique, lateral, PA with ulnar deviation, and PA with
ulnar deviation and 20° beam angle.18
The significance of how soon after the injury
initial radiographs are taken must be considered.
Breitenseher et al observed that immediately after
injury up to 65% of scaphoid fractures remain radiographically occult.19 In a study by Memarsadeghi et al
of 29 patients with initially negative findings on posttrauma conventional radiographs, 20 patients were
found to have fractures of 1 or more bones on 6-week
follow-up radiographs. Eleven (38%) of these fractures
were scaphoid fractures, and 2 of these patients had
additional fractures in other wrist bones.20 Three of the
11 patients with scaphoid fractures had evidence of trabecular involvement only, whereas the other 8 patients
had evidence of cortical involvement. Fractures found
in other patients included 6 distal radius fractures,
2 triquetral bone fractures and 2 lunate fractures.
Memarsadeghi and associates recognized that their
study was small and that their findings should be further explored and validated in future studies.20 Further
research could raise awareness about the possibility of
radiographically occult scaphoid fractures and what
can be done to decrease the incidence of missed diagnosis of these fractures.
CT and MR
Both CT and MR imaging are used widely to diagnose scaphoid fractures. A broad array of research has
been published detailing appropriate applications of CT
and MR for imaging various types of scaphoid fractures.
Ty et al found that CT scans were useful in diagnosing
suspected scaphoid waist fractures in the emergency
department (ED).21 They reported that unnecessary
immobilization in cases of a suspected scaphoid waist
fracture could be avoided by immediately performing
a CT examination. They also noted that CT is a widely
available modality in EDs, and the cost of the CT examination is less than that of MR imaging. In their studies
“no fractures were missed or undertreated.”21
Memarsadeghi and associates compared multidetector CT and MR imaging in 29 patients who were
suspected of having a scaphoid fracture but who had
normal initial radiographs.20 MR imaging correctly
identified and localized all 11 occult scaphoid fractures
that were later verified on 6-week follow-up radiographs. This resulted in 100% sensitivity and 100%
specificity for the detection of fractures. CT imaging
depicted all 8 scaphoid fractures with cortical involvement, resulting in 100% sensitivity and 100% specificity for identifying cortical involvement.20 The authors
concluded that “multidetector CT is a highly accurate
method for detecting occult cortical scaphoid fractures
and is superior to MR imaging for identifying cortical
involvement, but CT appears inferior to MR for identifying solely trabecular injury. Thus a positive CT scan
is diagnostic, while a negative CT scan may warrant
further evaluation.”20
Brydie and Raby studied the use of MR imaging
to assess clinically suspected scaphoid fractures when
radiographic findings were normal.14 Their study
included 195 patients who were scanned within 14
days of injury. MR demonstrated occult fractures in
nearly two-fifths of the study group, with 37 scaphoid
fractures representing about half of the injuries. Other
findings included 28 distal radius fractures and 9 fractures of other carpal bones. Perhaps more significantly,
the MR results changed the medical management for
92% of the study group, which led the authors to conclude that MR should be considered the gold standard
for imaging these types of injuries.14 Previous smaller
studies also demonstrated the effectiveness of MR in
scaphoid fracture diagnosis.22
Other Imaging Techniques
Nuclear medicine bone scanning also is used to
diagnose scaphoid fractures,23,24 but not as widely as
CT and MR. Although bone scans are highly sensitive
in demonstrating the presence of a fracture, they are
not as specific as MR.25 Many orthopedic specialists
use both MR and CT, as well as radiography and bone
scans, in the diagnosis and follow-up of scaphoid nonunions.3,26 Fluoroscopy is used routinely during surgical
procedures for internal fixation of scaphoid fractures.26
Orthopedic specialists may prefer to use MR or CT
imaging at various stages of their patients’ treatment,
depending on the age, location and type of scaphoid
fracture and the progress of the fracture healing.
Treatment for Scaphoid Fractures
Treatment approaches for scaphoid fractures vary,
and may include the use of casting, open reduction
internal fixation (ORIF) surgery and screw fixation, and the use of bone grafts to optimize healing.
Surgical intervention for newly diagnosed fractures
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differs from surgical approaches for patients with nonunions. Recommendations for the most effective treatment of scaphoid fractures vary and depend on the
anatomic location of the fracture.
Casting
Cast immobilization is intended to facilitate the rigid
stabilization of fracture fragments necessary for bone
healing to occur. Many types of fractures respond well to
treatment with cast immobilization. However, Haisman
et al stated that casting for scaphoid fractures is best used
only when there is not great concern over delayed union
or nonunion (eg, distal pole/tubercle fractures, type
A1).3 Haisman and associates also observed that the best
method of cast immobilization is controversial, and studies have yielded conflicting results regarding the efficacy
of immobilizing the elbow and thumb.3
Herbert observed the detrimental effects of long cast
immobilization time on the joints of the wrist, hand and
arm adjacent to the scaphoid. Herbert wrote that “ joints
should move,”27 and he has decreased or eliminated
the need for cast immobilization of scaphoid fractures
with innovative improvements to ORIF techniques.10,27
Haisman and colleagues described the disadvantages of
immobilization compared with surgery:
…more frequent office visits to check that the cast
fits properly, more frequent radiographs to check
fracture alignment, potential skin breakdown,
prolonged immobilization until complete healing
has occurred, stiffness of immobilized joints, and
even perhaps a longer time to healing. The immobilization period after surgery is shorter or even
unnecessary.3
Surgical Intervention
An orthopedic specialist’s decision to recommend
surgical intervention for a scaphoid fracture depends
on many variables, including the location of the fracture (see Figure 5),10 the age of the fracture and the
presence of displacement. Surgery currently is recommended much earlier and more aggressively because
of the historical prevalence of suboptimal healing of
scaphoid fractures without surgery and the documentation of more rapid healing and better treatment outcomes when surgery is done early on.3,10,27
ORIF and Screw Fixation
Timothy Herbert was an innovator in the specialty
field of hand and wrist orthopedic surgery in England
during the 1970s and has since been considered a
168
Figure 6. The Herbert screw bridges a scaphoid fracture.
Reprinted with permission from the University of Washington,
Department of Radiology Web Services. Musculoskeletal radiology:
Orthopedic hardware. www.rad.washington.edu/academics
/academic-sections/msk/teaching-materials/online-musculoskeletalradiology-book/orthopedic-hardware. Accessed September 3, 2010.
world-renowned expert on scaphoid fractures.27 He
invented the Herbert compression screw for fixation
of scaphoid fractures (see Figure 6).28 Herbert saw the
need for a hardware device that would compress the
scaphoid fracture fragment surfaces together and hold
them in better contact with each other. Before Herbert
invented the compression screw, Kirschner wires
(K-wires) were used for fixation of scaphoid fractures;
however, these wires did not have the compressive effect
that promotes optimal bone healing. The cannulated
titanium Herbert screw became generally available
in the United States in 1978.27 The term cannulated
refers to the screw’s hollow central shaft, which allows
accurate placement of the screw over a guidewire under
fluoroscopic guidance. The Herbert screw also features
multiple threading, which allows variable thread pitch
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threading also may contribute to increased
holding power. 28
Bone Grafting
Filan and Herbert,10 as well as many other
orthopedic surgeons, described the addition
of bone grafting with the compression screw to
facilitate healing of scaphoid nonunions. Jones
and associates described ORIF techniques involving cannulated screw fixation and the use of
autologous vascularized bone grafts harvested
from the patient’s femur to facilitate bone healing at the scaphoid fracture site.29 These authors
emphasized the significance of harvesting a wellvascularized piece of bone for the graft as well
as careful protection via elevation of the vessels
before making the bone cuts for the graft.29
Other Treatment Modalities
Novicoff and associates30 studied the application of various treatment modalities for
delayed or impaired bone healing. Induction
of bone healing by chemical, biophysical and
hormonal means is a rapidly growing area.30
Treatment options ranging from autogenous
bone grafting, pulsed electrical and electromagnetic fields (bone stimulators), extracorFigure 7. Acutrak screw bridging a scaphoid fracture. Reprinted with perporeal shock wave therapy and parathyroid
mission from the University of Washington, Department of Radiology Web
hormone treatment were studied. The authors
Services. Musculoskeletal radiology: Orthopedic hardware. www.rad.washing
concluded that additional randomized clinical
ton.edu/academics/academic-sections/msk/teaching-materials/online-muscu
studies with strict inclusion and exclusion criteloskeletal-radiology-book/orthopedic-hardware. Accessed September 3, 2010.
ria are needed to more accurately analyze each
of these unique modalities for enhanced bone
healing.30 Future studies will need to address
27
the feasibility and role of these modalities in fracture
and is an improvement over single-threaded screws.
repair.
Additionally, the Herbert screw was innovative because
of its headless design, which allows it to be implanted
Impediments to Healing
below the surface of the bone.
Nonunion in Scaphoid Fractures
The Acutrak screw (Acumed, Hillsboro, Oregon)
Haisman and associates indicated that nonunion has
later improved on the Herbert screw design (see
occurred if there is no evidence of healing after 3 to 4
Figure 7).28 Orthopedic surgeons at the University of
months of conservative treatment for a scaphoid fracture.3
Washington use the Acutrak screw for fixation of most
There are several recognized causes of scaphoid nonscaphoid fractures treated surgically at their institution.
union. One main cause is nondiscovery of the fracture
The Acutrak screw has basic similarities to the Herbert
on the patient’s initial presentation for diagnosis and
screw in that it uses compression and variable thread
treatment. Additionally, nonunion can occur as a result
pitch to provide effective fixation of bone fragments,
of incomplete immobilization of the scaphoid fracture.
but the Acutrak screw also has threading along its entire
Causes specific to the injury itself include fragment dislength. This feature allows engagement of bone material
location severe enough to prevent union without surgical
along the full length of the screw, better securing fracintervention and instability of one or more of the other
ture fragments and bone graft pieces. The full-length
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adjacent carpal bones. Finally, proximal scaphoid fractures present special healing challenges that may lead to
nonunion. Approximately 20% of all scaphoid fractures
occur at the proximal pole, where retrograde blood supply can be interrupted and thus may put the patient at
risk for AVN.3
Awh observed that MR is of great value in diagnosing scaphoid fractures effectively.31 The resolution and
specificity available with MR have made it a preferred
imaging modality for diagnosis of scaphoid fractures
as well as for evaluating possible AVN of the scaphoid.
Typically, in patients with a scaphoid waist fracture and
associated AVN of the scaphoid’s proximal pole, the
necrotic bone regions appear with diffusely low signal
intensity in both T1- and T2-weighted images. If the
regions of concern show both high signal intensity in
T1-weighted images and signs of edema on T2-weighted
images, those findings may be considered an indication that the proximal pole of the scaphoid still has
adequate vascularity.31
In cases of scaphoid nonunion, evaluation of proximal pole vascularity can be enhanced by use of intravenous paramagnetic contrast. The appropriate technique is to obtain fat-suppressed T1-weighted images
immediately after administration of the contrast. The
degree and rapidity of enhancement produced by the
contrast in the region of interest indicate how well
vascularized the region is. A viable proximal pole will
show significant uptake of the contrast in the bloodstream, whereas a proximal pole with poor vascularity
or AVN will show less uptake at an abnormally slow
rate. Awh concluded that in cases of suspected AVN
of the scaphoid, contrast-enhanced MR is the most
accurate imaging modality for determining the vascular status of the proximal pole.31 Enhancement of the
proximal pole also has been found to correlate with the
presence of punctate bleeding at surgery; this enhancement is a positive indication of bone tissue vascularity
and indicative of likely success for bone graft healing.31
Comorbidities
The term comorbidity refers to a patient having 2 or
more disease processes or conditions at the same time.
Risk factors and disease processes that can negatively
affect bone fracture healing include osteoporosis,32
nutritional deficiency, endocrinologic disorders,33
diabetes mellitus34,35 and use of tobacco.36 These risk
factors and conditions affect bone healing in different ways, and the specific mechanisms by which they
inhibit healing are not fully understood. Comorbidities
170
that can affect bone healing are relevant to all types of
fractures, but some are of particular interest in relation
to scaphoid fracture healing.
The scaphoid is especially vulnerable to AVN following a fracture because of the location of its supplying
arteries and the tendency of arterioles within the bone
to be severed by a fracture, which leaves parts of the
bone without a fresh blood supply. Any comorbid condition that restricts peripheral circulation generally will
compound such vascular insufficiency; and in the case
of scaphoid fractures, healing may be delayed or inhibited. Conditions that have a negative effect on peripheral circulation include tobacco use (whether by smoking or use of smokeless tobacco products) and diabetes
mellitus. “It has been well documented that diabetes
mellitus (DM), a systemic disease affecting 17 million
Americans, causes increased healing time with a concomitant increase in delayed unions and nonunions.
Unfortunately, the specific mechanism for the delayed
fracture healing in patients with diabetes has yet to be
elucidated.”37 Nevertheless, nicotine has been found to
inhibit the activity of osteoblast cells, which are critical
for the formation of new bone tissue.38
Vasoconstrictors are substances that cause the
smooth muscle of blood vessels to contract and narrow,
which can restrict blood flow. McKee et al stated that
nicotine acts as a vasoconstrictor and has been found
to inhibit angiogenic response and tissue differentiation essential to bone healing. Additionally, nicotine
affects skeletal metabolism and adversely affects the
function of osteoblasts.38 Dinah and Vickers found
that the success rate for operative treatment to correct
established nonunion of the scaphoid was 82.4% for
nonsmokers, but only 40.0% for tobacco smokers.36
Compounds present in tobacco other than nicotine
are likely involved in suppressing normal bone healing.
In a 2006 animal study it was found that even nicotinefree tobacco caused reduced strength in healed fractures.39 Patients recovering from a scaphoid injury or
undergoing surgical fracture repair should therefore
not use any form of tobacco product or alternative
nicotine delivery products such as dermal patches or
chewing gum containing nicotine.
In their investigation of the effects of cigarette smoking on the operative treatment of scaphoid nonunions,
Dinah and Vickers cited wide variations in the rate of
nonunion in scaphoid fractures, from between 5% to
12% to as high as 47%.36 They also cited several studies documenting good results of screw fixation with
autologous bone graft, with postoperative union rates
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of approximately 80% to 90%. Variable factors that can
reduce the success rate of this type of surgery include
but are not limited to AVN, osteoarthritis and smoking.
Dinah and Vickers also explored the effects of smoking
on the surgical repair outcome of the scaphoid. They
concluded that there is a significant association between
smoking and failure of operative treatment for scaphoid
nonunion, with the nonunion rate being 3 times higher
in smokers than nonsmokers.36
According to Brinker et al, fracture nonunion is a
multifactorial phenomenon, including such variables as
inadequate vascularity, cigarette smoking and malnutrition. The authors stated that they are not aware of any
prior studies that documented a relationship between
metabolic and endocrine abnormalities and fracture
nonunion.33 They studied fracture healing in patients
with vitamin D deficiency, hypothyroidism and many
other disorders. In their examinations of 37 patients
with nonunion of various bone fractures, they found
that 31 suffered from at least one metabolic or endocrine abnormality. Sixty-eight percent of the nonunion
cases involved vitamin D deficiency.33 Other conditions
found included calcium imbalances, hypogonadism
and other hormone disorders. Brinker et al concluded
that further studies are needed to confirm the causal
association of metabolic and endocrine abnormalities
with fracture nonunion.33
Another possible factor contributing to nonunion
is the use of nonsteroidal anti-inflammatory drugs
(NSAIDS).40 In a study of femoral nonunion cases,
Giannoudis et al found that the most significant predictor of nonunion was the patient’s use of NSAIDS; the
authors suggested that the reported inhibitory effects of
NSAIDS on osteoblasts were probably the explanation.40
Patients with osteoporosis who experience any fracture, including a scaphoid fracture, may experience
slower than normal or suboptimal healing. However,
the majority of scaphoid fracture patients are male,
younger than 40 years or both. Hodgkinson et al
found that the demographic group in which scaphoid
fractures most commonly occurred is men and boys in
the age range of 15 to 29 years old. 8 They found these
patients had higher rates of nonunion than other
groups and also required on average the longest time
for the fracture to achieve union. These young male
patients also spent longer periods as outpatients than
other groups and missed more work because of their
injuries and treatment. 8 Therefore, osteoporosis per
se is not usually a primary concern regarding scaphoid fractures because the population most prone to
osteoporosis is postmenopausal women.
According to the National Osteoporosis Foundation,
millions of Americans are at risk for osteoporosis.
Men as well as women can suffer from osteoporosis.
However, women account for 4 times as many cases of
the disease than do men.41 Risk factors for osteopenia
(low bone mineral density [BMD]) and osteoporosis
include advancing age, female gender, white or Asian
ethnicity, low body mass index and sedentary lifestyle,
among other factors.32 According to World Health
Organization 1994 statistics, the patient population
with osteopenia included 54% of postmenopausal
white women in the United States.32 The 1994 statistics also indicated that 30% of postmenopausal white
women in the United States have osteoporosis. Patients
with osteoporosis are most likely to experience vertebral, hip and distal radius fractures due to thinning
of the bone in these areas.32 A distal radius or Colles
fracture more frequently occurs rather than a scaphoid
fracture after a FOOSH injury because of trabecular
bone weakness in the distal radius of individuals with
osteoporosis. Increased awareness and education about
prevention and diagnosis combined with availability of
BMD testing have recently allowed for more effective
management of osteoporosis. Because osteoporosis
is so prevalent, it is considered a major public health
threat41 and is therefore relevant when wrist fractures
are discussed.
It is important for patients to be educated regarding the many factors that can influence bone fracture
healing. A combination of factors, such as diabetes and
heavy smoking, can have very negative effects on fracture healing.
Physiology of Nonunion Vascularization
Kulenovic stated that scaphoid nonunion develops in stages.42 First, zonal demineralization occurs
around the fracture cleft, and then pseudocystic areas
of resorption develop in both fragments. Next, there
is progressive widening of the fracture cleft and formation of osteophytes, which results in a gap between
the bone pieces. At this final stage, ischemia of the
proximal fragment often occurs. Neovascularization,
the development of new blood vessels in tissues with
compromised circulation due to trauma or disease,
can result if a vascularized bone graft is inserted into
the nonunion gap. When vascularity is restored to
the proximal pole of the scaphoid, such as in cases
wherein vascularized bone grafts are employed, a successful outcome is typically visible on MR images. The
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restored vascularization at the healing site can often
be seen as a zonal marrow edema visible as low signal
intensity in T1-weighted images and high signal intensity in T2-weighted images. Additionally, this region
will sometimes show a visible border of bandlike
sclerosis called the “double line sign,”43,44 which is considered to be an indication of increased osteoblastic
activity (see Figure 8).42
Illustrative Cases
Figure 8. Coronal T2 and T2 fat saturation magnetic resonance
images demonstrating scaphoid fracture nonunion of the distal pole
(distal oblique fracture, classification B1) and resulting osteonecrosis. “Double line sign” is seen in the proximal pole. Patient history:
scaphoid fracture 2 years previously. Reprinted with permission
from Kulenovic D. Osteonecrosis of the proximal fragment in scaphoid nonunion. www.mskcases.com. http://mskcases.com/index
.php?module=article&view=104. Accessed June 19, 2010.
172
Scaphoid fractures are frequently overlooked
in emergency departments, yet the consequences
of a missed or delayed diagnosis can be significant
— including long-term pain, loss of mobility and
decreased function. This section presents 3 case studies
from Perron and colleagues that describe the diagnosis
and treatment of scaphoid fracture in an ED setting.7
Also presented are 3 case studies from Pandit and
Wen45 that illustrate some of the complexities and challenges involved in diagnosing and treating scaphoid
fractures.
Case 17 : A 16-year-old boy fell on his outstretched
left hand while skateboarding without wearing wrist
guards; he then felt immediate pain in his left wrist.
When the patient arrived at the ED, the staff observed
that the wrist was mildly swollen and diffusely tender.
The patient also experienced snuffbox tenderness and
pain with axial compression along the length of the
long axis of his right thumb. Pain limited his dorsiflexion and palmar flexion.
PA and lateral radiographs were taken. The PA radiograph demonstrated a middle third scaphoid fracture
with no displacement or angulation; the other images
appeared normal. Initial treatment consisted of a longarm thumb spica splint. The patient was released and
referred for an orthopedic appointment in 7 days. By that
time, the swelling in the wrist had decreased, and he was
placed in a long-arm thumb spica cast for 6 weeks. The
patient was subsequently placed in a short-arm thumb
spica cast for another 6 weeks. At 12 weeks, radiographs
demonstrated union of the fracture. Two years following the injury, the patient felt no pain, and his range of
motion was normal.7
Case 27 : A 44-year-old woman fell on her outstretched right hand while intoxicated. She suffered
immediate pain and swelling in her right wrist, but had
no other injuries. Diffuse wrist swelling was found on
clinical examination in the ED. Tenderness was noted
on the dorsal area of the radial side of the wrist and
in the snuffbox area. PA and lateral radiographs were
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taken. These images did not demonstrate any definite fracture of the scaphoid. However, because
of the clinical findings, an additional scaphoid
image of the wrist was taken. This allowed diagnosis of a subtle distal-third scaphoid fracture.
Treatment consisted of a long-arm thumb
spica splint. However, the patient did not go to
the follow-up appointment. Two years later, the
patient returned to the ED and reported continuing wrist pain and decreased range of motion.
During her interview, she stated that she had
removed the initial splint after only 24 hours.
Repeat radiographs indicated advanced degeneration of the scaphoid. The patient was referred
to orthopedic surgery and underwent a proximal
row carpectomy to relieve her chronic pain. One
year following this procedure, she stated that her
residual pain was minimal.7
Case 37 : A 33-year-old man presented to the
ED approximately 24 hours after a fall onto his
outstretched right hand while playing softball.
He complained of persistent right wrist pain.
Clinical examination indicated snuffbox tenderness, and the patient’s range of motion was
limited because of pain. Plain radiographs demFigure 9. Transverse fracture through waist of scaphoid occurring
onstrated no fracture on PA and scaphoid views.
1 year previously. No displacement or avascular necrosis is evident.
Because of the patient’s clinical examination
Reprinted with permission from Pandit S, Wen D. Scaphoid fractures
findings, he was placed in a short-arm thumb
with unusual presentations: a case series. Cases J. 2009;2:7220. www
.ncbi.nlm.nih.gov/pmc/articles/PMC2740206/pdf/1757-1626-0002spica splint and instructed to follow up with an
0000007220.pdf. Accessed September 2010.
orthopedic specialist in 10 to 14 days. At that
appointment, the patient again presented with
radial-sided pain. Palpation of the waist of the scaphoid
snuffbox tenderness and had repeat radiographs that
via the snuffbox, and over the distal pole of the scaphoid
demonstrated a middle-third scaphoid fracture. He
on the palmar side, both failed to induce tenderness.
was treated with a long-arm thumb spica cast for 6
Radiographs taken at this time showed a nondisplaced
weeks, and then changed to a short-arm thumb spica
transverse fracture through the waist of the scaphoid,
cast for 5 more weeks. He was found to have good
but no AVN was observed (see Figure 9).45 MR imaging
radiographic union of the fracture at 11 weeks.7
showed the fracture but not AVN. Treatment consisted
Case 445 : A 39-year-old woman presented at a clinic
of 6 months of splinting with electromagnetic bone
complaining of diffuse radial-sided wrist pain in her
stimulation. This treatment did not result in complete
right hand. Her injury had occurred 1 year previously,
healing, but after 6 months only symptomatic treatment
when she had been practicing mock combat with a
was continued.45
medieval sword. While holding the sword, she hyperCase 545 : A 20-year-old, right-handed man presented
pronated her wrist without any direct impact to her
to the clinic 5 years after sustaining an injury to his left
hand or the wrist itself. Radiographs taken shortly after
wrist. The injury had occurred while he was playing
the incident had apparently been negative, and she
soccer. The soccer ball struck his left hand, forcing a palreceived only symptomatic treatment for the continumar flexion of his wrist. He immediately reported pain,
ing diffuse radial-sided wrist pain.
but radiographs at the time failed to show a fracture.
When the patient was examined in the clinic 1 year
His treatment was a removable splint that he wore for
after the original injury, no swelling was visible, but
a few weeks, which somewhat improved his symptoms.
passive extension and flexion of the wrist caused her
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However, he continued to suffer from intermittent radial
wrist pain, which became progressively worse.
Clinical examination of the wrist 5 years subsequent
to the injury showed no swelling, but the patient’s
range of motion was restricted in both flexion and
extension. There was no tenderness noted at the
waist of the scaphoid, but there was tenderness at the
proximal pole of the scaphoid near the scapholunate
junction. Radiographs taken at this time showed a nondisplaced transverse fracture in the proximal portion
of the scaphoid. Additionally, the proximal fragment
of the scaphoid showed sclerosis and lucency, which
indicated the possibility of AVN. Treatment at this time
was internal fixation with vascularized bone grafting,
which resulted in adequate healing.45
Case 645 : A 16-year-old boy presented to the clinic
1 month after an injury causing right wrist pain. The
injury had occurred while wrestling with a friend, but
the patient could not recall any specific trauma other
than his wrist and forearm being rolled on by his
friend. He reported that he had not had any immediate
pain at the time, but that a few minutes afterward he
noticed severe diffuse pain in his right wrist, including
the radial side, ulnar side, palmar side, and dorsal side.
Clinical examination revealed diffuse swelling over
the volar and middorsal areas of the wrist. The wrist
was diffusely tender on the dorsoradial side, with
tenderness noted at the waist of the scaphoid. Range
of motion for the affected wrist was only slightly less
than that of the opposite wrist, with minor discomfort
at the extreme ranges. Radiographic images showed
a minimally displaced transverse fracture at the junction of the distal and middle thirds of the scaphoid,
and slight widening of the scapholunate interval (see
Figure 10).45 Treatment consisted of internal fixation
with bone grafting.45
Cases Summary
Figure 10. Fracture through scaphoid located just distal to waist
with mild displacement. Slight widening of the scapholunate
interval is also noted. No AVN is evident. Reprinted with permission from Pandit S, Wen D. Scaphoid fractures with unusual
presentations: a case series. Cases J. 2009;2:7220. www.ncbi
.nlm.nih.gov/pmc/articles/PMC2740206/pdf/1757-1626-00020000007220.pdf. Accessed September 2010.
Case studies are of significant value in demonstrating different types of scaphoid fractures and the diversity of injuries experienced by individuals. Taking into
account each mechanism of injury, the diagnostic workup of each case, what type of treatment the patient
underwent (including patient compliance) and the
resulting outcomes can enable a deeper understanding
of the intricacies of individual scaphoid fracture diagnosis and treatment.
Pandit and Wen45 reminded us that historically, diagnosis and treatment of scaphoid fractures has always
been difficult. Even with current medical imaging
technology, effective diagnosis of a scaphoid fracture
at the time of the patient’s initial presentation remains
a challenge to clinicians. The classic signs of scaphoid
fracture, such as tenderness in the anatomic snuffbox, are still valuable guides. Likewise, patient reports
regarding the mechanism of injury — particularly a fall
on an outstretched hand — can provide an important
clue. However, many cases remain in which these classic
symptoms and signs are not present, but the patient has
nevertheless suffered a scaphoid fracture.45
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Conclusion
It is important for radiographers and radiology
assistants to continue to expand their foundational
knowledge to more fully understand the complexities
of the many disorders, injuries and diagnoses they are
involved with as part of the diagnostic team. Focusing
on one anatomic area such as the scaphoid bone and
then subsequently exploring a variety of case studies
can help radiographers expand and renew their knowledge and expertise. There is abundant literature about
scaphoid fractures, and research in this specialty area
of orthopedics is ongoing. For radiographers, it is especially important to consider and practice effective diagnostic radiographic techniques and to be well informed
about scaphoid fracture management because of the
high percentage of these fractures that require surgical intervention to heal successfully. Radiographers
who have a deeper understanding of the complexities
of scaphoid fractures can facilitate better care for their
patients from initial diagnosis through treatment, and
therefore can contribute directly to the overarching
goal of optimal fracture healing.
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and endocrine abnormalities in patients with nonunions.
Curr Orthopaedic Practice. 2007;19(4):430-442.
34.Segalman K, Clark G. Un-united fractures of the distal
radius: a report of 12 cases. J Hand Surg. 1998;23A:914-919.
35.Wukich D, Kline A. The management of ankle fractures in
patients with diabetes. J Bone Joint Surg Am. 2008;90:15701578.
36.Dinah A, Vickers R. Smoking increases failure rate of
operation for established non-union of the scaphoid bone.
Int Orthop. 2007;31:503-505.
37. Lin S. Impaired bone healing in patients with diabetes
mellitus. The University of Medicine and Dentistry in New Jersey
Research. 2004:5(4). www.umdnj.edu/research/publica
tions/fall04/11_bone_healing.htm. Accessed September 3,
2010.
38.McKee M, DiPasquale D, Wild L, Stephen D, Kreder H,
Schemitsch E. The effect of smoking on clinical outcome
and complication rates following Ilizarov reconstruction.
J Orthop Trauma. 2003;17:663-667.
39.Skott M, Andreassen T, Ulrich-Vinther M, et al. Tobacco
extract but not nicotine impairs the mechanical strength
of fracture healing in rats. J Orthop Res. 2006;24:1472-1479.
40.Giannoudis PV, MacDonald DA, Matthews SJ, Smith
RM, Furlong AJ, De Boer P. Nonunion of the femoral
diaphysis: The influence of reaming and non-steroidal
anti-inflammatory drugs. J Bone Joint Surgery Br. 2000;82B(5):655-658.
41. National Osteoporosis Foundation. www.nof.org. Accessed
July 7, 2010.
42.Kulenovic D. Osteonecrosis of the proximal fragment in
scaphoid nonunion. www.mskcases.com http://mskcases
.com/index.php?module=article&view=104. Accessed
June 19, 2010.
43.Zurlo J. The double line sign. Radiology. 1999;212(2):541-542.
44.Saini A, Saifuddin A. MRI of osteonecrosis. Clin Radiol.
2004:59(12):1079-1093.
45.Pandit S, Wen DY. Scaphoid fractures with unusual presentations: a case series. Cases J. 2009;2:7220. http://casesjournal
.com/content/2/1/7220. Accessed June 12, 2010.
176
Cynthia N Patrick, BS, R.T.(R), is a graduate student at
the Warner School of Education and Human Development at
the University of Rochester in Rochester, NY. She is an adjunct
instructor for the Health Professions Department at Monroe
Community College in Rochester, NY, and a full-time instructor at Everest Institute in Rochester, NY.
Reprint requests may be sent to the American Society of
Radiologic Technologists, Communications Department,
15000 Central Ave SE, Albuquerque, NM 87123-3909, or
e-mail [email protected].
©2010 by the American Society of Radiologic Technologists.
Errata
There was an error in the article titled “Factors
Related to Radiation Safety Practices in California,”
which appeared in the July/August 2010 issue. Table
6, question 7 on Page 542 should have indicated
that best practice for C-arm set up is never to place
the x-ray tube above the image intensifier tube.
The images on the September/October 2010
Patient Page on stereotactic breast biopsy were
incorrectly oriented. Our thanks to readers who
called the error to our attention.
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
Directed Reading Continuing Education Quiz
#10806-02
Expiration Date:
Dec. 31, 2012*
Approved for 1.5
Cat. A+ CE credits
Diagnosis and Treatment
Of Scaphoid Fractures
To receive Category A+ continuing education credit for this Directed Reading, read the preceding article and circle
the ­correct response to each statement. Choose the answer that is most correct based on the text. Transfer your
responses to the answer sheet on Page 182 and then follow the directions for submitting the answer sheet to the
American Society of Radiologic Technologists. You also may take Directed Reading quizzes online at www.asrt.org.
Effective October 1, 2002, new and reinstated members are ineligible to take DRs from journals published prior to
their most recent join date unless they have purchased a back issue from ASRT. Your access to Directed Reading
quizzes for Continuing Education credit is detemined by your area of interest. For access to other quizzes, go to
www.asrt.org/store.
*Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date.
1. Which of the following bones does not articulate
with the scaphoid?
a.capitate
b.lunate
c.hamate
d.trapezoid
4. Which of the following is not a region of the
scaphoid bone?
a. proximal pole
b. styloid process
c.waist
d. distal pole
2. Because of its vascular pattern, the _______ of
the scaphoid may not receive optimal blood
circulation.
a. proximal one-third
b. distal one-third
c. distal radius
d. lateral tubercle
5. Delayed union scaphoid fractures are classified as
type _______.
a.A1
b.B3
c.C
d.D
3. The term osteonecrosis means _______.
a. bone tissue regeneration
b. narrowing of a joint space
c. death of bone tissue
d. revascularization of bone
6. A scaphoid fracture is said to have a delayed union
if there is no evidence of healing _______ months
after injury.
a.2
b.3
c.6
d.9
Continued on next page
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
177
Directed Reading Continuing Education Quiz
7. A scaphoid fracture is said to have a nonunion if
there is no evidence of healing _______ months
after injury.
a.2
b.3
c.4
d.6
12. The majority of the organic part of bone matrix
consists of _______.
a. fibrillar collagen
b. calcium phosphate
c. cartilaginous proteins
d.osteoclasts
13. Calcium phosphate mineralizes from the outer
area of a fracture first, forming _______.
a. lamellar bone
b. hard callus
c. trabecular bone
d. soft callus
8. One reported range for nonunion of scaphoid
fractures is:
a. 1% to 3%.
b. 3% to 10%.
c. 20% to 30%.
d. 25% to 40%.
9. Skinner’s 5 stages of bone healing are _______.
a. impact, inflammation, hard callus formation,
soft callus formation, remodeling
b. impact, inflammation, soft callus formation,
hard callus formation, remodeling
c. impact, soft callus formation, inflammation,
remodeling, hard callus formation
d. impact, soft callus formation, hard callus
formation, remodeling, angiogenesis
10. The formation of new blood vessels is called
_______.
a.angiogenesis
b.osteogenesis
c.hematogenesis
d.pathogenesis
11. Cells that resorb necrotic bone material are called
_______.
a.osteoblasts
b.osteoclasts
c.osteocytes
d.chondrocytes
14. During the remodeling phase of normal fracture
healing, woven bone is replaced by _______.
a.leukocytes
b.lymphocytes
c. granulation tissue
d. lamellar bone
15. For the PA axial or Stecher view of the scaphoid,
the image receptor is placed _______.
a. on a 45° angle sponge
b. perpendicular to the central ray
c. on a 20° angle sponge
d. 72 in from the tube
16. Malik and colleagues suggested that the most
effective protocol for radiography of suspected
scaphoid fractures includes all of the following
images except _______.
a. posteroanterior with ulnar deviation
b.lateral
c. anteroposterior with ulnar deviation
d. anterior oblique
Continued on next page
178
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
Directed Reading Continuing Education Quiz
17. In the study by Brydie and Raby, magnetic
resonance (MR) results changed the medical
management for _______% of the study group,
leading the researchers to conclude that MR
should be considered the gold standard for
imaging these types of injuries.
a.63
b.72
c.82
d.92
18. According to Haisman et al, which of the
following is not a disadvantage of immobilization
compared with surgery?
a. potential for skin breakdown
b. need for more frequent radiographs to check
alignment
c. higher likelihood of avascular necrosis
d. joint stiffness
19. Compression screws enable shorter healing times
for scaphoid fractures because they _______.
a. enable rapid remodeling of bone
b. compress the bone fragments together to
optimize surface contact
c. allow for less revascularization
d. leave some space between the fracture
fragments and the bone graft
20. The main advantage of using cannulated screws
for bone fixation is that they _______.
a. have a hollow central shaft that enables accurate insertion over a guidewire under fluoroscopic guidance
b. are solid and not hollow
c. are made of stainless steel
d. do not compress bone fragments together
21. The term comorbidity refers to _______.
a. an individual who cannot recover from a
disease
b. a condition that can lead to a sudden stroke
c. a patient who dies because of complications
d. a patient who has 2 or more disease processes
or conditions at the same time
22. According to this Directed Reading, all of the
following are comorbid conditions that delay
healing of scaphoid fractures except _______.
a.osteoporosis
b. aortic stenosis
c. diabetes mellitus
d. tobacco use
23. Nicotine acts as a _______.
a.vasoconstrictor
b. promoter of osteoblast cell function
c. promoter of angiogenesis
d.vasodilator
24. The term neovascularization means _______.
a. undesirable development of new blood vessels
b. a decrease in blood flow
c. lack of new vascular development in tissue
where circulation has been impaired by
disease or trauma
d. development of new blood vessels in tissue
where circulation has been impaired by
disease or trauma.
25. The “double line sign” seen on an MR image is
best described as an indication of _______.
a.infection
b. increased osteoblastic activity
c. avascular necrosis
d. decreased osteoblastic activity
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
179
✁
Carefully cut or tear here.
...........................................................................................................
TEACHING TECHNIQUES
Group Project: A New Online Tool
Lynda N Donathan, MS,
R.T.(R)(M)(CT)(MR), is
assistant professor of imaging
sciences at Morehead State
University in Morehead,
Kentucky. Misty Hanks is
an instructional designer at
Morehead State University.
“Teaching Techniques”
discusses issues of concern to
educators. The primary focus of
the column is innovative and
interesting approaches to teaching. Comments and suggestions
should be sent to
[email protected].
Many radiologic science educators
are experienced with online teaching.
However, some of them struggle to
understand the many paths that can
be taken to create meaningful online
assignments and how to grade them. In
an editorial, Jeffrey Legg, PhD, R.T.(R)
(CT)(QM), described the inertia we must
all overcome to keep our teaching fresh
and engaging.1 Dr Legg admitted that
he rarely challenges himself to make his
courses more learner-centric or engaging. I found myself in the same teaching
rut a few years ago and sought the help
of an instructional designer. Working
with this designer helped me improve
my course, and it was relatively painless!
The group project described here has
been tested and proven in many semesters of online teaching and is the result
of continuous improvement and several
instructional design sessions. I hope my
experience will help you.
Why a Group Project?
There are those in the radiologic
sciences who say courses should not or
cannot be taught online because it is
impossible to duplicate the interaction
that occurs in a face-to-face classroom.2
Adding a group project like the one
described here increases the interactivity
of an online class. Group projects mandate student interaction, thereby cultivating engagement with diverse students,
developing their skills in conflict management and providing them with experience in giving and receiving constructive
feedback.3 It is important for students in
the imaging sciences to share knowledge
and real-world experiences. This group
project encourages active learning and
fosters a sense of community.
An often overlooked benefit of group
projects is that they allow instructors to
step out of lecture mode and into the
role of “guide on the side.” In describing a similar group project structure for
students in the United Kingdom, Leese
stressed that the online group project is
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
not about increasing technology use just
to include new tools but instead about
moving “from a teacher-led delivery
to student-centered learning.”4 Online
teaching shifts instructors from content
experts to context experts.2
Whether you are new to online teaching or you just want to add a new tool to
your toolbox, the group project is a great
option you can apply immediately to your
online classroom. There are many reasons for using a group project: to incorporate creative and critical thinking, to
increase student engagement, to add
interest to the course and to remove the
instructor from center stage.
How Does an Online Group
Project Work?
The instructor divides students into
groups of 5 or fewer members. Each
group has the following tools: group
discussion board, group e-mail and file
exchange. While groups occasionally try
to exchange telephone numbers, this
practice is discouraged. There are no
shared files of group work conducted
by telephone, whereas work conducted
in the course management system is
recorded and available to the instructor
for grading.
Each group is assigned a topic from
the textbook and a deadline to be prepared to conduct the class discussion. I
give the students a detailed description
of the requirements. These requirements
include the following: create a summary
of the topic, develop meaningful discussion questions and lead the class discussion on the assigned topic. Each group of
students researches its assigned topic and
posts a summary in the class discussion
board. My students often choose to summarize topics with a PowerPoint presentation (Microsoft Corporation, Redmond,
Washington). The summary also can be
a video, Web page, document, podcast or
other media that suits the content area.
Each group also must lead an online
discussion by developing pertinent
183
...........................................................................................................
TEACHING TECHNIQUES
questions and facilitating participation of the entire
class. The summary, quality of discussion questions and
facilitation of class discussion are a portion of the total
grade. The remaining portion of the grade is a combination of individual and team work.
Components of a Group Project
Grading Rubric
I developed my own rubric to grade this assignment.
It allows me to assess up to 5 students’ group work at one
time using one grading sheet for the entire group. The
group project grading rubric includes 5 components:
research, topic summary, discussion board, team work
and individual work. Students receive full credit if:
■ Research is from a reliable source and includes
appropriate content.
■ Topic summaries are complete, posted to the class
discussion board and written in a student-friendly
manner.
■ Discussion board questions are posted, and team
members lead the discussion.
■ All team members participate, work together as a
group and meet the project deadline.
■ Each individual team member completes his or
her portion of the work.
The research, topic summary and discussion board
make up 75% of the grade; team work is 15% of the
grade; and individual contribution is 10% of the grade.
Conclusion
This online group project is based on the experiences
of an imaging science faculty member and an instructional designer. Collaboration with an instructional designer
is a great way to develop a new tool. Input from a design
expert and continuous improvement are essential to the
success of online courses and programs. Think in terms
of baby steps, and capitalize on our discoveries. ◆
References
1. Legg J. Learning new tricks. Radiologic Science & Education.
2009;14(1):1.
2. Martino S, Odle T. New instructional technology. Radiol
Technol. 2008:80(1):67-74.
3. Gross Davis B. Collaborative learning: group work and study
teams. http://teaching.berkeley.edu/bgd/collaborative.html.
Accessed March 4, 2010.
4. Leese M. Out of class — out of mind? The use of a virtual
learning environment to encourage student engagement in out of class activities. British Journal of Educational
Technology. 2009;40(1):73.
184
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
...........................................................................................................
MY PERSPECTIVE
Building the Body of Knowledge
Laura Aaron, PhD,
R.T.(R)(M)(QM); Sarah
Baker, EdD, R.T.(R),
FASRT; Julie Gill, PhD,
R.T.(R)(QM); Melissa
Jackowski, EdD, R.T.(R)
(M); James Johnston,
PhD, R.T.(R)(CV); Nina
Kowalczyk, PhD, R.T.(R)
(CT)(QM), FASRT; Jeffrey
Legg, PhD, R.T.(R)(CT)
(QM); Tricia Leggett,
DHEd, R.T.(R)(QM); Kim
Metcalf, EdD, R.T.(R)
(T); Diane Scutt, PhD;
and Bettye Wilson, MEd,
R.T.(R)(CT), RDMS, FASRT,
are members and former
members of the Editorial
Review Board for Radiologic
Technology.
“My Perspective” features guest
editorials on topics in the
radiologic sciences. Opinions
expressed by writers do not
necessarily reflect those of the
ASRT. Those interested in writing an editorial should e-mail
[email protected].
Each of us is a part of the radiologic
science profession. A profession is an
occupational group that possesses a
specific set of skills and knowledge
base. Individuals who are members of
a profession continue to learn as the
profession evolves, perform professional
responsibilities competently and conscientiously and add to the profession’s
body of knowledge.1 It is widely accepted
that a unique body of knowledge that is
created and supported by research in a
specific discipline is an essential component of professional identity. To build
the body of knowledge within a profession, publication is needed. All professions benefit from the publication of
peer-reviewed articles, and peer review
is an accepted method to advance professional knowledge.
Radiologic Science Research
One problem that faces the radiologic
science profession is the limited research
foundation. Anyone who has ever had to
search the radiologic science literature
for a class, clinical problem or any other
reason can attest to the limited amount
of available information. There are many
issues we face in daily practice on which
there is little or no research we can
consult for answers. In fact, most of the
knowledge used to inform our profession
in the United States is built on research
conducted by physicians, physicists,
nurses and other allied health professionals rather than radiologic technologists.
There is some research that has been
conducted internationally; however, more
often we must look to other professions to
answer our questions. This may present
problems because it may not fit our particular circumstances.
The challenge of scientific inquiry in
allied health professions was identified in
the late 1980s by the Institute of Medicine
and the National Commission on Allied
Health. Although other allied health professions have met this challenge in terms
of research and publication, it appears
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
that the radiation sciences lag behind
many other professions. Considering that
scholarship is core to improving clinical
practice, why are we not meeting this
challenge?
Perhaps looking at our profession
from an international perspective will
provide some valuable information. The
United Kingdom and Australia have purposely focused on developing a culture
that embraces research and writing in
the radiation sciences. Entry-level radiography education was elevated to the
baccalaureate level in the UK in the early
1990s, helping radiation science professionals acquire research and writing
skills. Following the Research Assessment
Exercise in 2001 conducted by the
Higher Education Funding Council
(UK), the College of Radiographers2 and
Scutt3 reported on fundamental evidence
of a positive attitudinal change and commitment to scholarly activities by radiography professionals.
So what barriers exist in the United
States that prevent us from making
similar advancement? Are the issues
educational, motivational, institutional,
professional, or a combination of these?
What is the next step in moving toward
the goal of developing a professional
culture in which scholarship is esteemed
and valued?
Increasing the Body of
Knowledge
We all have responsibilities in our
life that can range from family and personal to professional obligations. The
question is, “Who has the responsibility
to build the body of knowledge?” The
answer is: To improve, grow and legitimize our profession, it is essential that
we expand our body of knowledge. The
radiologic science profession has developed and evolved sufficiently from other
disciplines. While research from other
professions may be helpful, it does not
solve our problems or answer our discipline-specific questions. We have grown
185
...........................................................................................................
MY PERSPECTIVE
enough as a profession
Table 1
that it is time for us to
Education Level of ARRT-Registered Technologists
take this step forward.
Level
Year
The education level
of technologists regis1999
2004
2009
tered by the American
No. (%)
No. (%)
No. (%)
Registry of Radiologic
High
school
or
high
school
+
RT
certificate
54
510
(26.7)
51
414
(22.4)
20
336 (7.2)
Technologists (ARRT)
has fluctuated during
Certificate
25 202 (12.4) 28 093 (12.3)
56 924 (20.0)
the past 10 years (see
Associate degree
87 117 (42.7) 104 352 (45.5) 141 298 (50.0)
Table 1). Changes
Baccalaureate degree
30 071 (14.8) 37 305 (16.3)
53 464 (18.9)
have occurred at every
education level. Figure
Master’s degree
4599 (2.3)
5779 (2.5)
8075 (2.9)
1 shows the percent of
271 (0.1)
351 (0.2)
450 (0.2)
technologists with asso- Doctoral degree (PhD)
Doctoral degree (MD)
335 (0.2)
366 (0.2)
465 (0.2)
ciate, bachelor’s, and
master’s and higher
Other
1751 (0.9)
1564 (0.7)
1959 (0.7)
degrees. Gains in all
Total
203
856
229
224
282 971
categories have been
Source: American Registry of Radiologic Technologists.
made. When examining the percentage
of ARRT-registered technologists who hold a master’s
with the best methods, then we are doing a great disdegree or higher, there have been some increases. While
service to our patients and the general public. Research
these changes have been subtle, it should still hold true
evidence needs to be used in our profession. Conducting
that our published research should be increasing as well.
and publishing research initiates critical analysis, leading
As the entry-level standard for the profession increases,
to further research and advancements in the profession.
the responsibility for radiologic science professionals to
Research yields organized information that can be put
conduct research and grow the profession
increases as well.
All of us have a professional obligation to help expand our body of knowledge. However, many may not feel their
research skills are adequate to address this
task. And, those who have had adequate
research training may not have the motivation to publish. So, how can we as a profession increase our contributions to the body
of knowledge? Obviously, this process in
any profession is evolutionary, but we have
enough time for members of this profession
to embrace research.
The scope of things that are not yet
known within and about the radiologic sciences is infinite because our profession can
be considered fairly young compared with
medicine and nursing. The advancement of
technological changes is significantly faster
than original research being completed.
Why is this such a crucial issue? If the pracFigure 1. Percentage of technologists with associate, bachelor’s and master’s and
higher degrees. Source: American Registry of Radiologic Technologists, 2010.
titioners in our profession cannot perform
186
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
...........................................................................................................
into action (many times, immediately). This action usually manifests itself as making a sound decision. Often,
incorrect or bad decisions are made because people are
not patient enough to either conduct or wait for others to conduct research that will provide the evidence
needed for a sound decision. In the radiologic sciences,
making sound decisions is imperative to provide the best
patient care possible.
We have a professional obligation, so it follows that
taking control of areas where one is expert is fundamental to moving the research agenda forward. Publishing
the results of research can be considered a moral obligation, and writing is critical to the process. Writing for
publication does not come easily to all, but there is no
doubt that practice makes perfect, and the editorial process can go a long way in aiding this. Also, collaboration
with other radiologic science professionals can facilitate
the process.
Many radiologic science professionals believe that the
level of respect that the profession receives is not adequate or fair. To be seen and treated as a professional,
each of us has a responsibility to act as a professional.
One way to act as a professional is to add to our body of
knowledge through publication. As radiologic science
professionals, each of us should be learning every day. As
we strive to create diagnostic images and provide quality patient care, we often find ways to do our job better
or more efficiently. It is important that we share these
thoughts with other professionals through publishing so
our colleagues within the profession as well as patients
can benefit. Likewise, it is also important for us all to
become better consumers of knowledge. As aware consumers, we may better understand and analyze the information confronting us from research articles, our own
institutions and manufacturers, for example. We also
may become more aware of the objectivity and quality
— or lack thereof — of the information with which we
build upon and base our decisions. All of us can add to
and better comprehend the body of knowledge, whether
we are students, clinicians, educators or managers. It is
time for us to embrace this responsibility and meet this
challenge for the sake of our profession. ◆
Radiography. 2002;8:195-200.
3. Scutt D. The Research Assessment Exercise (RAE) 2001
revisited; the University of Liverpool UoA11 experience.
Radiography. 2004;10:127-130.
References
1. Cant R, Higgs J. Professional socialization. In: Higgs J,
Edwards H, eds. Educating Beginning Practitioners: Challenges
for Health Professional Education. Woburn, MA: ButterworthHeinemann; 1999:46-51.
2. College of Radiographers. Research, radiography, and the
RAE: Lessons from the 2001 research assessment exercise.
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
187
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WRITING & RESEARCH
Qualitative Research Methods
James Johnston, PhD,
R.T.(R)(CV), is associate
professor of radiologic sciences
and director of interdisciplinary education for the College of
Health Sciences and Human
Services at Midwestern State
University in Wichita Falls,
Texas. He also is vice chairman of the Editorial Review
Board for Radiologic
Technology.
“Writing & Research” discusses issues of concern to writers
and researchers and is written
by members of the Editorial
Review Board. Comments and
suggestions should be sent to
[email protected].
188
In general, research is a planned
course of action with the goal of understanding a phenomenon or finding
answers to research questions. There
are 2 broad types of research: quantitative and qualitative. Quantitative
research may be more familiar and
uses numerical data collection processes, research designs and statistical
procedures. It is based on the assumptions that social facts have an objective
reality, variables can be identified and
relationships measured. Quantitative
research seeks generalizability and causal explanations. Qualitative research,
on the other hand, uses strategies to
gather data and seeks to ensure objective analysis of subjective meanings. It
is based on the assumptions that reality
is socially constructed, and variables
are complex and difficult to measure.
Qualitative research seeks contextualization and interpretation. Both types
of research certainly have a place and
value in increasing human knowledge.
There are some major differences
between quantitative and qualitative
research. The role of the researcher in
qualitative methods is quite different
in that he or she serves as the data collection instrument. To gain the desired
insight and understanding to answer the
“why” questions, the researcher often
is directly involved with the informants
(called subjects in quantitative studies) or environment of the study itself.
This can pose quite a challenge for the
researcher, who must remain objective
and unbiased in collecting data. In addition, researchers must be well trained
and well versed in qualitative methods.
The qualitative approach also seems
opposite of quantitative research in that
it ends with hypotheses and grounded
theory. That is, once the data are collected, the researcher analyzes them,
looking for patterns, meanings and
explanations that are grounded in the
data but lead to hypotheses that explain
what was observed. Finally, the write-up
of purely qualitative studies is also different. It takes on a narrative form and
is often quite lengthy. But there are also
more concise qualitative studies. In fact,
mixed methods designs (using both
quantitative and qualitative elements)
are becoming increasingly popular in
health care disciplines. The following is a
brief description of 4 common qualitative
research designs.
Ethnography
An ethnographic study is anthropological research whereby the researcher
seeks to learn about the culture of a
society by immersing himself or herself
in that society and directly participating
in it. In this way, the researcher hopes
to “see” things through the eyes of the
members of that culture and understand
from their perspective. Such studies
take place over a period of time. The
researcher develops a rapport within the
culture, identifies informants and takes
copious notes along the way. He or she
works to develop understanding of the
people and influences of the environment in which they live through longterm observations. These studies are not
about making improvements in a society
but understanding it.
Case Studies
Case studies can be either quantitative
or qualitative. In the qualitative method,
they are studies of “cases” in their reallife context using multiple sources of
data collection. They tend to be narrow,
focused investigations that are explanatory, exploratory or descriptive in nature.
They can involve single cases or multiple
cases (one subject or several subjects).
The cases are selected based on characteristics that reflect the research focus
or interests. Each case remains separate,
and multiple data collection methods
are used to gather information from
each case, such as a review of records,
interviews, observations, etc. Because
case studies generate a large amount of
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data from multiple sources, systematic organization of
the data is critical. At the conclusion of data collection,
the researcher examines the raw data, deliberately using
many interpretations to find links between the research
cases and the original research questions. A report of
findings then is written. The researcher presents conclusions supported by sufficient evidence so that the
reader may draw similar conclusions independent of the
researcher.
Participant Observation
As the name implies, participant observation is a
method of research in which the researcher participates
directly in the events and/or environment being studied.
The researcher may be covert or overt about his or her
real reason for taking part in the events or environment
being studied. This raises ethical issues that must be
addressed during an institutional review board approval
process. The researcher also should be sensitive to the
subjects and have a good understanding of the language
and environment. Otherwise, the differences he or she
introduces into the environment could change the setting and the outcomes. Because of the nature of this
type of research it creates a “role play” dynamic for the
researcher. As such, the researcher must consider how
he or she appears and his or her purpose for being
there. This method also requires copious notes (another
consideration for the “role”) and good organization.
Disciplined note processing, coding and categorizing
are critical. As with the other methods of qualitative
research, a lengthy narrative of the results is written that
interprets the data from an insider’s perspective.
data from each interview are then analyzed, interpreted and reported in a detailed narrative form.
Conclusion
Qualitative research can provide valuable insight and
meaning in many areas of study. It also can be quite
challenging to conduct. Much of the quality, reliability
and validity of the study will depend on the knowledge,
planning and skill of the researcher. He or she often will
serve as the data collection instrument and as such must
be disciplined and well versed in the method. With the
ever-increasing complexity of health care services, qualitative research may provide valuable meaning and help
decipher key issues. ◆
Interviewing
Interviewing as a qualitative method is a process of
gathering in-depth information about a research question from an informant. It is based on a set of interview
questions that address the research question or questions. The interview can be conducted in either a structured or unstructured format. In the structured format, each informant is asked the same questions in the
same order without elaboration or explanation. The
unstructured format also asks the same questions but
allows for a more conversational tone and the freedom
to elaborate and ask follow-up questions. The researcher decides which format to use during the planning
stage and sticks with it throughout the interviews. The
researcher must be adept at conducting and guiding
the interview while at the same time taking detailed
and accurate notes of the informant’s responses. The
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TECHNICAL QUERY
To See the Unseen
Krys Geissler, MEd,
R.T.(R)(M), is a former
radiography instructor at the
University of Alabama at
Birmingham.
“Technical Query” is a
troubleshooting column that
covers image acquisition and
processing.
The Problem
The screening chest radiograph
remains the standard general survey
film for initial diagnosis of pathology
of the chest, lungs and thorax region.
However, many forms of pathology can
present similar to normal variants in
a chest radiograph. Optimal exposure
factors and a well-positioned patient can
reduce the possibility of inaccurate findings. However, other modalities, such as
computed tomography (CT), are used
to confirm the presence, size or progression of pathology.
A 61-year-old woman recently developed an acute sinus infection, productive
cough and shortness of breath. The chest
radiographs did not reveal any significant
findings except for some mild chronic
obstructive pulmonary disease thought
to be related to her 20-year smoking history (see Figures 1 and 2). Her symptoms
worsened during the next 10 days despite
the use of antibiotic therapy for an upper
respiratory infection. The patient sought
the opinion of a specialist in pulmonary
medicine, who ordered a CT scan of
the chest/thorax after
a clinical examination
and review of her chest
radiographs. What did
the CT scan reveal that
is not evident in the
chest radiographs?
The Answer
In the chest radiographs, the pathology is
concealed because of a
loss of lung expansion
in the right upper lobe
and unclear areas in
Figure 1. Posteroanterior chest radiograph.
the shadow of the mediastinum. Because the
patient’s symptoms did not improve significantly, a CT of the chest was ordered
10 weeks later. The CT scan with contrast revealed a 9- x 10-cm mass in the
right lower lobe, posterior segment (see
Figure 3). The lung mass most likely
190
Figure 2. Lateral chest radiograph.
represented a bronchogenic carcinoma,
with hilar adenopathy and/or paratracheal involvement indicated by the widened mediastinum.
A detailed patient history revealed that
she had a persistent cough, a 15-pound
weight loss and symptoms of chronic
bronchitis for the past 9 months. The
areas of concern were examined further
with CT-guided tissue biopsy to establish
a diagnosis and plan for treatment that
would definitely exceed another round of
◆
antibiotic therapy.
Thanks to Sue Weaver of Leeds, Alabama,
for her contributions to “Technical Query.”
Figure 3. Sectional CT scan.
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
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LITERATURE REVIEW
Quality for Technologists
Literature Review
features contributions from
volunteer writers from the
radiologic ­sciences, reviewing
the latest in publications
and communication
materials produced for the
profession. Sugges­tions and
questions should be sent to
[email protected].
QUALITY MANAGEMENT IN THE
IMAGING SCIENCES.
4th ed. Papp J. 2010. 532 pgs. Mosby
Elsevier. www.us.elsevierhealth
.com. $59.95.
Quality
Management
in the Imaging
Sciences, 4th
edition, by
Jeffrey Papp,
PhD, R.T.(R)
(QM), is a valuable training
tool for entrylevel radiologic
technologists as
well as an excellent resource for veteran
professionals pursuing postprimary certification in quality management.
The introductory chapter gives a
good historical perspective on the origins of quality management (QM) in
the radiologic sciences and the state of
QM in the 21st century. It makes the
distinction between quality assurance
and quality assessment and provides
concise definitions for the many acronyms and terms used in QM programs.
Terminology new to the 4th edition
includes key quality characteristics and
key process variables. Identifying and
analyzing problems and specific quality
improvement processes are thoroughly
covered, providing a good foundation
for subsequent chapters. An overview
of statistical terms and graphics helps
readers present data. The graphics use
radiography examples that correlate
well with real-life scenarios.
The equipment detailed in the 4th
edition is very similar to the 3rd edition,
although the material has been reorganized. For example, chapter 3, Film/
Screen Image Receptors, Darkrooms
and Viewing Conditions, covers much
of the same information as the chapter
titled Film Darkrooms in the 3rd edition, but then moves on to film/screen
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
image receptor information previously
found in chapter 8. Grid information
included in chapter 3 of the previous
edition has been moved to chapter 7.
It was surprising to see 2 chapters
devoted to film processing and processor quality control. While the American
Registry of Radiologic Technologists
continues to include content on processors and processing, the amount of coverage in the text seems disproportionate
to current practice. A technologist in
an imaging department with a chemical
processor should be aware of the need
for processor quality control. However,
most departments contract a processor
maintenance company to perform cleaning and preventive inspections.
The opening paragraph of chapter
6 acknowledges the digital revolution
in diagnostic imaging. It is interesting
that this statement is made in a chapter
devoted to silver recovery. Practicing
radiographers in a clinic using film
should be aware of the justification for
silver recovery and the regulations governing the process. However, the text
includes a whole chapter with detailed
information about recovery methods.
Perhaps information about silver recovery could be consolidated and included
with processor quality control in subsequent editions.
The quality control chapters reinforce information radiography students
learn in physics and image analysis by
providing concise information about
x-ray generators, ancillary and fluoroscopic equipment. Equipment testing
procedures and the tools needed to
perform the tests are included. The
required specifications are listed at the
end of each procedure. This provides
technologists with all the information
needed to implement a QC program.
The 4th edition contains expanded
coverage of QC for digital systems.
Because this technology is so vendor specific, there is no universal QC program;
however, the program recommended by
191
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LITERATURE REVIEW
the American Association of Physicists in Medicine is
outlined, and there are suggestions for basic QC procedures common to all systems.
Many of the artifacts described in the outcomes
assessment of radiographic images relate to processing,
handling and storage. Again, these topics are less relevant in modern imaging departments. It seems likely
that more emphasis will be placed on computed and
digital radiography artifacts in future editions.
The final 5 chapters of the text are modality specific, detailing quality management for mammography,
computed tomography, magnetic resonance imaging,
ultrasonography and nuclear medicine. Mammography
quality standards are very specific, and this is the
longest chapter in the book. The Mammography
Quality Standards Act has updated the standards, and
these revisions are included. The remaining modality chapters are not as detailed as the mammography
chapter, but provide a good overview of procedures.
The online resources that accompany the book
have been upgraded in this edition. PowerPoint presentations are available as an instructors’ resource.
The slides include salient points from each chapter.
However, some chapters’ slides are mostly text, with
the images available for downloading in a separate
location. The slides are editable, so most instructors
are likely to import these into the PowerPoint presentations. The 165-question practice tests are a valuable
resource for technologists pursuing postprimary certification in quality management.
This publication provides very detailed information
on specific equipment tolerances. In some areas, there
may be more detail than is warranted. Nevertheless,
this book exposes radiologic technology students to the
information they need to build a solid understanding
of quality management. Additionally, this text would be
a valuable addition to imaging departments for use as a
reference when QM questions arise.
Amy Freshley-Lebkuecher, MS, R.T.(R)(T)
Associate Professor
Radiologic Technology Clinical Coordinator
Austin Peay State University
Clarksville, Tennessee
192
CT OF THE AIRWAYS. Boiselle PM, Lynch DA, eds.
2009 (paperback edition). 408 pgs.
Humana Press. www.humanapress.com. $99.
The purpose of this
book is to explore the fascinating world of imaging
of the airways. It was written by physicians for physicians, primarily radiologists and pneumologists.
With state-of-the-art
CT equipment, images
of entire airways can be
created in a few minutes.
CT has established itself
as the pre-eminent noninvasive imaging modality
for assessing functional
airway abnormalities.
This textbook contains new information in 4 sections. First, the introduction is an up-to-date review of
the anatomy, physiology and pathology of the airways
and CT imaging methods for the chest and lungs.
Next, in the section titled Large Airways, the reader
learns about CT imaging of tracheal disorders in
children and adults. Third, under the heading Small
Airways, many lung diseases are considered, such
as bronchiolitis, asthma and smoking-related smallairway and interstitial lung disease. The fourth section,
Pediatric Airway Disorders, covers large-airway pediatric disease and emerging techniques in CT that are not
standard practice.
This textbook was a collaborative effort by many
prominent physicians from around the world, and is of
particular use to radiologists. For the CT technologist,
the last chapter, Imaging Overview, is of great interest.
The figures and images in this textbook are of
high quality, as is the paper, which turns easily in the
hand. I would recommend this book for use in any
radiology department.
Anna F Hess, C.R.T.
Napa, California
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RE: REGISTRY
Compare and Contrast: ASRT, ARRT
Jerry Reid, PhD, is the
regular contributing columnist
for “RE: Registry,” which
addresses issues concerning the American Registry
of Radiologic Technologists.
Dr Reid is executive director
of the Registry. Questions or
comments may be sent to his
attention at the ARRT, 1255
Northland Drive, St Paul,
MN 55120-1155.
Individuals sometimes confuse
the American Society of Radiologic
Technologists (ASRT) and the American
Registry of Radiologic Technologists
(ARRT). Sometimes even those who recognize them as separate organizations
confuse their functions. This confusion
is easy to understand given the shared
interests and historical connections
between the 2 organizations, and considering their acronyms differ by only
one letter. Although the organizations
work closely together, they are separate
and distinct entities with different roles.
Comparing and contrasting the organizations on several factors highlight some of
the ways that they are different and some
of the ways they are alike.
Historical Roots
ASRT was founded in 1920 by a
group of 13 technologists and Ed C
Jerman for the purpose of forming a
professional membership society for the
growing number of technologists. Mr
Jerman was elected as the first president
of the society. That same year, a committee of the Radiological Society of North
America (RSNA) recommended the
establishment of a certification mechanism for identifying technologists who
met standards of education, experience
and ethics. RSNA invited the American
Roentgen Ray Society to join this effort.
The Registry was launched in 1922.
Ed C Jerman was appointed as the
examiner for the Registry. Clearly, the
cross-pollination between the 2 organizations started from the outset. This is
just the first instance of a luminary in
the profession serving as an important
connection between the organizations.
The founding of the professional
society and the certification agency
as separate organizations, while not
entirely unique, is not always the case in
other professions. Frequently, the certification organization is founded by the
professional society and may actually be
a component of the society. This model
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
creates challenges in maintaining separation of purposes. In fact, the bodies
that accredit certification organizations,
such as the National Commission for
Certifying Agencies, require a firewall
to avoid undue influence over the decision making for certification by the professional society and prevent conflicts
of interests. Incorporation as separate
legal entities is the most effective way to
achieve this separation.
Mission and Vision
The ASRT’s mission is to “to advance
the medical imaging and radiation
therapy profession and to enhance the
quality of patient care.” ARRT’s mission
is to “promote high standards of patient
care by recognizing qualified individuals in medical imaging, interventional
procedures, and radiation therapy.”
The inclusion of the patient in the missions of both organizations highlights a
major commonality in purpose. ASRT’s
vision states that it “will be the premier
professional association for the medical
imaging and radiation therapy community through education, advocacy
and research.” ARRT’s vision states that
it “will be the premier organization
for credentialing healthcare technology professionals in medical imaging,
interventional procedures and radiation
therapy.” Combining the information
in the missions with information from
the visions points out a difference.
The difference lies in how patients are
served. ASRT focuses on enhancing the
profession by “education, advocacy and
research,” whereas ARRT enhances the
profession by setting and administrating
standards for the qualifications of individuals in the profession.
Members and Registrants
ASRT has approximately 137 000
members. The ARRT bylaws establish
that ARRT has only 9 members — the 9
trustees. The roughly 300 000 R.T.s are
registrants as opposed to members. This
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RE: REGISTRY
distinction is not a “distinction without a difference,”
but in fact has important consequences regarding how
the governance mechanism is created and how policies
are set.
productively, it provided funding to the ASRT Education
and Research Foundation to produce the Online Digital
Imaging Academy. This illustrates how ARRT can support education without directly providing it.
Governance
Geography
The ASRT Bylaws establish that the governance for
the organization will be through a House of Delegates
and a Board of Directors. Voting members of the ASRT
elect representatives to the House and to the Board.
The bylaws of the ARRT establish its governing body
as the 9-member board of trustees. ARRT trustees are
appointed to the board by the ASRT and the American
College of Radiology (ACR). All ARRT policies are
established by the board of trustees.
Policy Creation
ASRT members vote for representatives who in turn
set ASRT policies. ARRT policy, on the other hand, is
set by the ARRT board of trustees. ARRT’s proposed
policies are published for public comment, and the
board carefully considers the comments received.
However, the board ultimately sets the policy based
upon its judgment of how best to achieve the organization’s mission.
Initial Education
ASRT develops national curricula for radiography
and radiation therapy education. ARRT establishes educational standards for certification as a “higher order”
standard. That is, ARRT requires that candidates for certification complete an accredited educational program
and requires that graduates of the program complete a
nationally recognized curriculum such as that developed
by ASRT. ARRT representatives participate in ASRT’s
curriculum development and revision process, and
ASRT representatives participate in ARRT’s certification
standards development and revision process.
Continuing Education
ASRT both provides continuing education (CE)
activities and evaluates CE as one of ARRT’s Recognized
Continuing Education Evaluation Mechanisms. ARRT
does not provide any type of educational activities
because it is generally viewed as a conflict of interest for
a certification organization to both set the requirements
for certification and to provide the education. ARRT
certainly has a stake in high-quality education. For
example, when ARRT saw the need for better education
in digital imaging so that it could be examined more
194
ASRT’s headquarters is located in Albuquerque,
New Mexico. ASRT made a deliberate decision to
relocate from Chicago to Albuquerque in 1983 for a
number of business reasons. ARRT headquarters has
been in St. Paul, Minnesota, since the 1920s. ARRT’s
location was determined by historical happenstance.
The Registry was initially staffed by the editor of the
RSNA’s journal, Radiology, which was based in Omaha,
Nebraska. When responsibility for publishing Radiology
was moved to J.R. Bruce Publishing in St. Paul, the
Registry operations came with it. Although the ARRT
has considered relocation several times during its history, the nature of ARRT’s work is such that a central
location is more important than any other business
factors. Being centrally located is an advantage given
the large number of consultants who meet at the ARRT
office twice a year to develop examinations.
Staff
ASRT has a staff of approximately 110 to serve its
137 000 members. ARRT has a staff of about 65 to
serve its 300 000 registrants. The staff-to-member and
staff-to-registrant ratios reflect the different purposes
of the organizations. ASRT, as a professional membership organization, has a broad scope of activities ranging from peer-reviewed journals, advocacy campaigns,
education and other membership-related offerings. As
with all certification organizations, ARRT has a much
narrower range of activities that fall within its mission
compared with professional membership societies.
ARRT’s laser-like focus on determining and applying
standards of qualification allows it to carry out its work
with a smaller staff.
Disciplines Covered
Both ASRT and ARRT include the full range of
medical imaging and radiation therapy in their scopes
of interest. Both organizations serve as umbrella groups
under which all technologists, regardless of discipline,
are served.
Conclusion
The factors compared and contrasted here represent only a sampling of the many that could be used
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to illustrate how ASRT and ARRT are both alike and
different. The 2 organizations are connected across
time by common interests and individuals serving
those interests. Even this “RE: Registry” column illustrates that connection: The tradition of including
a column by the ARRT in the professional society’s
Journal goes back to 1933, when The X-ray Technician,
forerunner of Radiologic Technology, began including a
section listing newly ARRT-certified individuals and,
later, news from the Registry. ◆
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STUDENT SCOPE
Dose Reduction in CT
Elizabeth Hemme, AAS,
R.T.(R), is a student in the
Radiation Science Technology
baccalaureate degree program at the University of
Cincinnati’s Raymond
Walters College in Ohio. She
is employed by Mercy Health
Partners as a staff radiographer.
Computed tomography (CT) has
gained immense popularity as a diagnostic tool since its introduction in
the 1970s. Because of its widespread
and ever-growing use, the exposure to
radiation from CT scans has become an
important issue. CT scans offer a much
higher ionizing dose of radiation than do
other methods of imaging. For example,
a typical chest CT scan has an effective
dose of between 5 and 7 mSv, which
would be equivalent to about 2 years of
natural background radiation. A typical
chest radiograph has an effective dose
of only 0.02 mSv, comparable to only
10 days of natural background radiation.1
Although it is evident that the radiation dose received is considerably more
for CT than for radiography, the dose
received from one diagnostic CT is still
within acceptable limits of exposure.
Although CT examinations make
up only 12% of all diagnostic radiology
examinations, they contribute more
than 45% of the population’s medical
radiation exposure,2 and this percentage
is only expected to rise. When performing any radiologic imaging study, keeping patients’ dose as low as reasonably
achievable (ALARA) is an ethical issue
that always should be taken into consideration. For this reason, much research
has been done to develop ways to reduce
dose during CT scans.
Literature Review
In 2007, approximately 62 million
CT scans were performed in the United
States alone.3 Four million of those
examinations were on children. The
most effective dose reduction tool is
to decrease the number of CT studies
prescribed overall. To avoid needless
procedures, the physician must thoroughly review the risks vs the benefits
on an individual patient basis. When a
CT scan is warranted by medical necessity, the associated risk is small compared with the diagnostic information
obtained. Brenner hypothesized that
196
about one-third of all exams performed
were not justified by medical need.3 If
Brenner was correct in his assumption,
more than 20 million adults and 1 million children are needlessly exposed to
radiation each year.3
When CT is absolutely necessary,
optimization of dose and scan protocols
should be the priority, in keeping with
ALARA principles. “The principle of
optimization should be applied on an
individual basis so as to achieve image
quality sufficient to provide diagnosis
with the minimum dose to the patient.
Intuition suggests that it would be reasonable to expect to use more radiation to
get a satisfactory image with larger and
less with smaller patients and vice versa.”4
The International Atomic Energy Agency
conducted a study to prove just that. The
agency also suggested that the diagnostic
information offered by a CT scan was not
affected by increasing technique (thereby
increasing dose), but resulted in images
with less noise and fewer streak artifacts.
It also assessed changes in dose while
employing different scanning techniques
and noted different techniques that vendors offered on equipment.4
Shrimpton and associates suggested
many ways to minimize the patient’s
exposure to radiation, including the use
of automatic exposure control (AEC),
altering tube current and using noise
reduction filters. They also suggested
employing equipment that indicated
patient dose after completion of the
examination. This would allow the actual
patient dose to be compared to the estimated dose for the examination.5 Blatant
overexposure would be monitored and
eliminated during future examinations.
In addition, Shrimpton et al emphasized
that applying lead shielding devices
whenever possible greatly reduces patient
dose during CT procedures.
Lead shielding is an obvious option
in reducing the amount of scatter radiation that reaches the patient. Sudheendra
conducted a study in 2006 that tested
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the difference in radiation exposure when not using a
shield, using a single or double layer of 180° shielding
and using a single or double layer of 360° shielding.6
Scans were done for the head, chest, abdomen and pelvis using a different method of shielding for each test.
Although the reduction in scatter radiation was different
for each organ and test, a reduction was seen in all cases
when a lead shield was used. This is a simple and economical method of dose reduction that could be easily
adopted by facilities worldwide.
Many companies have capitalized on this aspect of
dose reduction by producing lead shields to ensure that
critical organs not intended to be scanned are protected.
One such company, RadPad, has shields designed to protect the brain, thyroid, chest and abdominal areas.7
Machines with AEC systems eliminate much of the
radiation dose produced by CT scanners that do not
have AEC technology. With AEC, the technique is
adjusted according to the patient’s body habitus (height,
width, depth). McCollough and associates wrote, “AEC
systems in which the tube current is modulated along
the x-, y-, and z-axes and in which the acceptable level of
image noise is varied according to patient size, anatomic
region and diagnostic task can provide significant levels
of dose reduction with minimal operator intervention.”8
As a result, these authors speculated that AEC systems
eventually will become mandatory and easily available.
Along with optimizing scan protocol, using shielding
and considering the justification for the examination,
Mozumdar suggested further education of consumers.9
Without formal education, a patient may not be aware
of the fact that an abdominal CT scan is equivalent to
500 chest radiographs and more than 3 years of natural
background radiation.1 Education empowers patients
and allows them to form opinions on their own regarding diagnostic tests.
Requiring that all CT scans be ordered by an experienced radiologist instead of a general physician
also would help justify examinations and eliminate
unnecessary tests. If the radiologist were the one to
prescribe an imaging study, magnetic resonance (MR)
imaging or ultrasonography might be chosen in lieu
of a CT scan. This would eliminate radiation dose altogether. Although there are definite disadvantages to
Mozumdar’s suggestions, the benefit of less radiation
exposure is immense.9
On February 25, 2010, the Medical Imaging and
Technology Alliance (MITA) publicized that CT equipment manufacturers would begin installing new radiation dose safeguards.10 One such safeguard is an alert
when the recommended radiation dose is surpassed for a
particular scan. The dose limits will be specific per examination and established by the facility. MITA also stated
that these same manufacturers are working to set maximum dose limits on the equipment so unnecessary radiation is impossible. A spokesperson for the organization
wrote that, “This feature is designed to prevent the use
of hazardous levels of radiation that could lead to burns,
hair loss or other injuries.”10 The upgrades should be
implemented this year on new equipment and can even
be offered as a software upgrade for existing scanners.
Manufacturers worldwide are taking proactive roles
in decreasing patient dose during diagnostic examinations. For example, Philips, a leading equipment manufacturer, acknowledges that dose reduction and maintenance are among its top priorities. Consequently, Philips
employs DoseWise Radiation Management, which is a
set of techniques, programs and practices based on the
ALARA principle.11 DoseWise Radiation Management
is always implemented during new equipment design
and development. Philips’ most recent application is
iDose, which “enables up to an 80% reduction in dose
while maintaining diagnostic image quality and fast
reconstruction times. iDose overcomes limitations, such
as image noise, of conventional filtered back projection
(FBP) reconstruction.”11
Palacio believes that advanced visualization (AV) also
may play a role in lowering radiation dose during radiology studies. AV systems may be able to reduce the noise
in images and produce higher-quality images at lower
dose to the patient. He quoted Robert Taylor, PhD, president and chief executive officer of TeraRecon, a leading
medical equipment manufacturer:
If you look at the way CT data is processed, the
data is always managed with advanced visualization
— we derive stenosis, vessel diameter or bone quality and these solutions, the quality of these algorithms, directly impact the dose needed to achieve
a viable clinical workup. Our software is designed
to make the algorithms and the advanced tools
work even if it is a noisy low-dose image.12
Implementing new technology and software definitely
will allow facilities and technologists to reduce dose with
no additional effort on their part.
Implications
Reducing patient exposure in CT is extremely
important. All imaging technologists should strive
to provide quality images using the lowest amount
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STUDENT SCOPE
of radiation possible. Because dose from CT scans is
greater than for all other imaging modalities, minimizing dose is especially crucial for this modality.
The National Council on Radiation Protection and
Measurements (NCRP) establishes policies and procedures regarding radiation exposure based on ALARA
principles. A spokesperson for the NCRP stated, “The
primary goal is to keep radiation exposure of the individual well below a level at which adverse effects are
likely to be observed during the individual’s lifetime.
Another objective is to minimize the incidence of
genetic effects.”13 It is the ethical responsibility of each
technologist to follow this instruction, whether by
confirming scans ordered, using optimal protocol and
AEC, or using various lead shields. By employing such
dose-reduction techniques, technologists can help to
minimize or eliminate the occurrence of deterministic, stochastic and even genetic responses.
Not only is ALARA important for the patient’s
benefit, it also is significant from a risk management
standpoint. The litigious society in which we live does
not accept mistakes, no matter the situation. A lawsuit regarding radiation overexposure not only would
compromise the facility in which the technologist is
employed but also could jeopardize the career of the
technologist.
Conclusion
CT imaging is a very important aspect of modern
medical technology. These scans quickly and easily aid
in visualization and diagnosis of pathologies that might
otherwise be missed. Although CT scans can be very
beneficial, the patient exposure during a scan is far
greater than exposures from other imaging modalities.
A typical chest CT scan provides 73 times the amount of
effective dose than a standard 2-view chest radiograph.1
Although a significant amount of radiation, this exposure is acceptable in any life-threatening situation.
Lee, Brenner, Shrimpton, Sudheendra, Palacio,
Taylor, McCollough and many others set out to prove
that there are relatively easy ways to reduce radiation
dose during CT examinations. Not only does the ordering physician have a responsibility to ensure that the
examination is medically necessary, the technologist
also needs to be conscientious about reducing dose by
using optimal technique factors, AEC and filtration.
Manufacturers are altering CT equipment, placing a
greater emphasis on reducing radiation exposure to
the patient and producing shielding devices fitted to
specific anatomic areas. Education of the patient and
198
continuing education of radiology professionals will
improve decision making and raise awareness about
the risks involved. ◆
References
1. Radiological Society of North America Inc. Safety in medical imaging procedures. http://radiologyinfo.org/en
/safety/index.cfin?pg=sfty_xray#3. Accessed January 28,
2010.
2. Lee K. Radiation safety: radiation dosimetry and CT dose
reduction techniques. In: Budoff MJ, Shinbane JS, eds.
Handbook of Cardiovascular CT. New York, NY: Springer;
2008:1-14.
3. Brenner D, Hall E. Computed tomography — an
increasing source of radiation exposure. N Engl J Med.
2007;357(22):2277-2284.
4. International Atomic Energy Agency. Dose reduction in
CT while maintaining diagnostic confidence: a feasibility
/demonstration study. www.pub.iaea.org/ MTCD/publica
tions/PDF/te_1621_web.pdf. Accessed February 18, 2010.
5. Shrimpton PC, Hillier MC, Lewis MA, Dunn M. National
survey of doses from CT in the UK: 2003. Br J Radiol.
2006;79(948):968-980.
6. Sudheendra D. Diagnostic and interventional CT shielding: a dramatic decrease in scattered radiation for
patients. http://radpad.com/Images/SIR2006-181.pdf.
Accessed January 25, 2010.
7. RadPad Scatter Protection. www.radpad.com/pg2CT.html.
Accessed May 22, 2010.
8. McCollough CH, Bruesewitz MR, Kofler JM Jr. CT dose
reduction and dose management tools: overview of available options. RadioGraphics. 2006;26(2):503-512.
9. Mozumdar B. The control of radiation exposure from
CT scans. The Internet Journal of Radiology. 2003;3. www
.ispub.com/journal/the_internet_journal_of _radiology/.
Accessed January 5, 2010.
10. HealthImaging.com. CT vendors to install rad dose safeguards; ACR calls for mandatory accreditation. www
.healthimaging.com /index. php? option=com_articles&
view=article&id=20891:ct-vendors-to-install-rad-dose-safeguards-acr-calls-for-mandatory-accreditation. Published
February 26, 2010. Accessed April 11, 2010.
11. Higher Expectations, Lower Dose: Philips CT
iDose Iterative Reconstructive Technique. Philips
Healthcare website. www.healthcare.philips.com
/asset. aspx?alt=&p=http://www.healthcare.philips
.com/pwc_hc/main/products/ct/products/iDose
/brochure/452296259621_CTiDose_LR.pdf. Published
March 2010. Accessed July 2, 2010.
12. Palacio M. Technology trends: advanced visualization.
Appl Radiol. 2010;39:27.
13. Gurley LT, Callaway WJ. Introduction to Radiologic
Technology. 6th ed. St. Louis, MO: Mosby; 2006.
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
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PATIENT PAGE
Contrast Agents
This patient education page
provides general information
concerning the radiologic sciences. The ASRT suggests that
you consult your physician for
specific information concerning your imaging exam and
medical condition. Health care
professionals may reproduce
these pages for noncommercial educational purposes.
Reproduction for other reasons
is subject to ASRT approval.
Although bones show up clearly on
x-ray images, some other organs and tissues do not. Contrast agents, also known
as contrast media, often are used during medical imaging examinations to
highlight specific parts of the body and
make them easier to see. Contrast agents
can be used with many types of imaging
examinations, including x-ray exams,
computed tomography scans and magnetic resonance imaging.
Contrast agents are administered
in different ways: Some are given as a
drink, others are injected or delivered
through an intravenous
line or an enema. After
the examination, some
contrast agents are
harmlessly absorbed
by the body; others are
excreted through urine
or bowel movements.
Contrast agents are not
dyes; they do not permanently discolor internal
organs. Instead, they
temporarily change the
way x-rays or other imaging tools interact with
your body.
If the exam your
physician requested for
you requires a contrast
agent, a radiologic technologist will explain
how it is used before the
An x-ray film showing the large intestine filled with
exam begins. Radiologic
barium, a common contrast agent.
technologists are skilled
health professionals who
have specialized education in the safe use
of contrast agents as well as in radiation
protection, radiographic positioning and
procedures. The technologist will answer
any questions you have about the examiFor more information,
nation or the contrast agent.
contact the American Society
Some contrast agents carry a small
of Radiologic Technologists,
risk of allergic reaction, so it is impor15000 Central Ave SE,
tant to tell the radiologic technologist
Albuquerque, NM
who will perform your examination if
87123-3909,
you have any type of allergy. Also, if you
or visit us online at
notice any unusual or uncomfortable
www.asrt.org.
RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2
symptoms during the examination, be
sure to tell the technologist. It is his or
her job to make you as comfortable as
possible while obtaining the best image
possible.
One of the most commonly used
contrast agents is barium sulfate.
Barium blocks the passage of x-rays, so
barium-filled organs stand out better on
x-ray exams. For an examination of the
esophagus or stomach, patients are asked
to drink a mixture of barium sulfate and
water, sometimes with vanilla or fruit
flavoring added. This mixture usually is
thick and white.
For an examination of the rectum or
colon, barium is administered rectally
through an enema tube. After the exam
is finished, you can go to the bathroom
and expel the barium. It is a good idea to
increase your fluid intake after the exam
to help remove the contrast from your
body. Your bowel movements may be
white for a few days.
Contrast agents containing iodine
are used to image the urinary tract,
blood vessels, spleen, liver and bile duct.
Iodine contrast agents are clear liquids
and usually are injected. Patients who
are allergic to iodine should not receive
this type of contrast agent. Nonionic
contrast may be available. Be sure to
tell the technologist which medications
you are taking and your current medical conditions before the exam begins.
Some conditions and medications make
the use of iodine contrast agents riskier.
You may notice side effects associated with the use of iodine-containing
contrast agents. These include a feeling
of warmth or flushing, a metallic taste
in the mouth, light headedness, nausea,
itching and hives. Usually, these symptoms are mild and disappear quickly.
However, it is a good idea to tell the
radiologic technologist if you experience
any of them. In extremely rare instances,
these side effects can be serious. The
technologist will monitor you carefully
for signs of side effects. ◆
203
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................
PATIENT PAGE
Medios de Contraste
Esta página educacional del
paciente provée información
general en cuanto a la ciencia
radiológica. ASRT sugiere que
usted consulte con su doctor
para obtener información específica concerniente a su examen
de imagen y condiciones
medicas. Los profesionales del
cuidado de la salud pueden
reproducir estas páginas para
ser usadas sin recibir lucro
económico. La reproducción de
estos documentos para ser usadas para otros objetivos necesita
la autorización del ASRT.
Para más información,
contáctese con la
Sociedad Americana de
Tecnólogos Radiológicos,
15000 Central Ave SE,
Albuquerque, NM 871233909, o visítenos en la web
electrónica: www.asrt.org.
204
Aunque los huesos aparecen claramente en las imágenes de rayos-X, algunos órganos o tejidos no. Los agentes
de contraste, también conocidos como
medios de contraste, a menudo se utilizan
durante los exámenes médicos de estudios
de imagen para resaltar partes específicas
del cuerpo y hacerlas más fáciles de ver.
Los medios de contraste pueden utilizarse
con muchos tipos de exámenes de imagen, incluyendo rayos-X, tomografía axial
computerizada y resonancia magnética
nuclear.
Los medios de contraste se administran de diferentes formas. Algunos son
administrados como una bebida, otros
son inyectados o administrados a través de
una vía intravenosa o un enema. Después
del examen, algunos medios de contraste
son absorbido por el cuerpo sin causar
daños; otros son excretados en la orina o
en las heces. Los medios de contraste no
son tintes; no manchan de forma permanente los órganos internos. Estos cambian
temporalmente la forma en que los rayosX u otras herraamientas de estudios de
imagen interactúan con su cuerpo.
Si el examen que su médico solicitó
para usted requiere un medio de contraste, un tecnólogo radiológico le explicará como se utiliza antes de empezar el
examen. Los tecnólogos radiológicos son
profesionales especializados de la salud
que tienen una educación especializada
en el uso seguro de medios de contraste
así como también en protección radiológica, posicionamiento radiográfico y procedimientos. El tecnólogo le responderá
cualquier pregunta que tenga sobre el
examen o el medio de contraste.
Algunos medios de contraste llevan
un pequeño riesgo de reacción alérgica,
así que es importante comunicarle al tecnólogo radiológico, quien realizará su examen, si usted tiene algún tipo de alergia.
También, si usted siente cualquier síntoma
inusual o de malestar durante el examen,
asegúrese de comunicárselo al tecnólogo;
es su trabajo hacerle sentir tan cómodo
como sea posible mientras se obtiene la
mejor imagen posible.
Uno de los medios de contraste más
utilizados normalmente es el sulfato de
bario. El bario bloquea el paso de los
rayos-X, de forma que los órganos llenos
con bario salen mejor en los exámenes
de rayos-X. Para un examen del esófago
o del estómago, se pide a los pacientes
que beban una mezcla de sulfato de bario
y agua, al que se le ha añadido algunas
veces esencia de vainilla o de fruta. Esta
mezcla normalmente es espesa y blanca.
Para un examen del recto o el color, se
administra bario por vía rectal a través de
un enema. Después de haber terminado
el examen, usted puede ir al baño y expulsar el bario. Es una buena idea aumentar
su ingestacion de líquidos después del
examen para ayudar a eliminar el medio
de contraste de su cuerpo. Sus deposiciones o heces pueden ser blancas durante
unos cuantos días.
Los medios de contraste que contienen
yodo se utilizan para obtener imágenes
del, el tracto urinario, los vasos sanguíneos, el bazo, el hígado y las vías biliares.
Los medios de contraste con yodo son
líquidos transparentes y normalmente son
inyectados. Los pacientes que son alérgicos al yodo no deben recibir este tipo de
medio de contraste. Asegúrese de comunicar al tecnólogo los medicamentos que
está tomando y sus condiciones médicas
actuales antes de comenzar el examen.
Algunas condiciones y medicamentos
pueden hacer el uso de los medios de contraste con yodo más riesgoso.
Usted puede que sienta los efectos
secundarios asociados con el uso de
los medios de contraste que contienen
yodo. Estos incluyen un sentimiento de
calor o sofoco, un saber metálico en la
boca, mareos, náuseas, picor y ronchas.
Normalmente, estos síntomas son leves y
desaparecen rápidamente. Sin embargo,
es una buena idea comunicarle al tecnólogo radiológico si usted experimenta cualquiera de ellos. En casos extremadamente
raros, estos efectos secundarios pueden
ser graves. El tecnólogo le monitorizará
atentamente por la aparición de signos de
efectos secundarios. ◆
November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY
Physicians, Medical Physicists and Radiologic Technologists —
TAKE THE PLEDGE TO IMAGE WISELY ™
Image Wisely,™ a campaign to build awareness
and engage participation in adult radiation optimization, is
sponsored by the American College of Radiology, Radiological
Society of North America, American Society of Radiologic
Technologists, and American Association of Physicists in
Medicine. It is an initiative of the ACR/RSNA Joint Task
Force on Adult Radiation Protection.
BE SURE TO VISIT IMAGEWISELY.org
NEW website featuring in-depth information on
adult radiation dose safety for imaging physicians,
medical physicists, radiologic technologists, referring
practitioners, equipment manufacturers and patients.
Website highlights:
• Journal articles and white papers from leading contributors
• Image Wisely™ pledge form
• Patient Medical Imaging Record
• Patient primer on radiation benefits and risks
• Vendor equipment data
Be among the first to Image Wisely™
Stop by any of these booths at RSNA to learn more
and take the pledge:
• ACR booth #2809
• ASRT booth #605
• AAPM booth #400
• Radiologyinfo.org
RSNA services area