CHAPTER II

REVIEW OF RELATED LITERATURE

This Chapter contains a review of related literature and studies which have bearing on

the present study. These related readings taken from material are very necessary in

coming up with comprehensive research.

According to the U.S. Food and Drug Administration (2014), medical radiography

is a broad term that covers several types of studies that require the visualization of the

internal parts of the body using x-ray techniques. For the purposes of this page

radiography means a technique for generating and recording an x-ray pattern for the

purpose of providing the user with a static image(s) after termination of the exposure. It

is differentiated from fluoroscopy, mammography, and computed tomography which are

discussed elsewhere. Radiography may also be used during the planning of radiation

therapy treat is used to diagnose or treat patients by recording images of the internal

structure of the body to assess the presence or absence of disease, foreign objects,

and structural damage or anomaly. During a radiographic procedure, an x-ray beam is

passed through the body. A portion of the x-rays are absorbed or scattered by the

internal structure and the remaining x-ray pattern is transmitted to a detector so that an

image may be recorded for later evaluation. The recoding of the pattern may occur on

film or through electronic means.

Diagnostic imaging has predominantly been the province of two groups of

workers, radiographers and radiologists. Diagnostic radiographers are health

professionals who employ a range of sophisticated equipment to produce high quality

images to diagnose an injury or disease. Radiographers have to be registered with the

regulatory Body, the Health Professions Council (HPC) to practice in the United

Kingdom. Radiologists are registered medical practitioners with the General Medical

Council and use imaging to diagnose, treat and monitor various disease processes.

Following the discovery of X-Rays by Rntgen in 1895 there was much interest in

the application of the new rays in diagnosing and treating disease. Non-medical and

medical workers were soon to engage with the new technology and initially there were

no boundaries or lines of demarcation separating the work of the practitioners (Larkin,

1983). This was soon to change and the role of non-medical radiographers was

challenged by the medical-radiographers who were later to become radiologists. The

role boundary between the professions was established in 1924 after much discussion

and bitter argument (Larkin, Price 2001). The argument largely centered on the practice

and autonomy of radiographers reporting their findings directly to referring medical

practitioners. This practice was challenged by radiologists who wished to establish the

new discipline of radiology with consultant status within medicine. To do this they went

to great lengths to stress their difference from radiographers (Larkin, 1983). In the

dispute regarding who had the right to report, radiologists questioned radiographers

ability and competence to perform such tasks, even though some had performed such

tasks satisfactorily for a number of years. Following the conclusion of the dispute over

the division of labor between Radiologists and radiographers the boundaries between

the two professions remained unchanged for approaching seventy years, with

radiologists concerned primarily with the interpretation of the image and radiographers

with its production. Within that period there are instances of radiologists position being
strengthened, for example, Furby (1944), a radiographer, stated that the primary

function of the radiographer was to be of utmost service to the radiologist and the

function of the radiologist was the interpretation of the radiograph.

Moreover, Krans (2015) emphasized on how to prepare for a radiograph. X-rays

are standard procedures and involve almost no preparation from the patient. Depending

on the area under review, you may want to wear loose, comfortable clothing that you

can easily move around in. You may also be asked to change into a hospital gown for

the test. You will be instructed to remove any jewelry and other metallic items from your

body before the X-ray is taken. You should always tell your doctor if you have any metal

implants from prior surgeries. These can block the X-rays from passing through your

body. If your test requires contrast dye, a doctor or nurse will give it to you as an

injection, an edema, or a pill to swallow before the test. If your X-ray is examining your

intestines, your doctor may tell you to fast for a certain amount of time beforehand, or to

clear out your bowels. He also tackled about how x-ray is performed. X-rays can be

done in a hospitals radiology department, a dentists office, or a clinic that specializes in

diagnostic procedures. Once you are fully prepared, a radiologist (X-ray technician) will

tell you how he or she needs you to be positioned in order to get the right view. The

technician will most likely require you to lie, sit, or stand in several positions during the

test. Some images may be taken while you stand in front of a specialized plate that

contains X-ray film or sensor. In some cases, the technician will move a large camera

connected to a steel arm over your body. This can capture the X-ray images of your

body using film or sensors held in the table. You will have to hold your breath and

remain still while the images are being taken. This provides the clearest images
possible. The test is finished as soon as your radiologist is satisfied with the images

gathered.

Radiographer must conscientiously avoid unnecessary radiation exposure as

well as strive to keep patient dose to an absolute minimum. Radiographer must follow

the ALARA Principle (As low as reasonably achievable) as they carry out their tasks.

The Radiologic facility must undergo appropriate Radiation surveys. Staff must be

proper oriented and regular in service education on radiation safety must take Place.

Proper radiation monitoring and review of monthly radiation report is essential

According to Dorothy A. Saia (2008) Occupational Radiation sources (A) Scattered

radiation is when primary photon intercept an object and undergo a change in direction.

(B) Grid both stationary and moving, function to remove a large percentage of scattered

(primary Compton) radiation from the remnant beam before it reaches the image

receptor, thereby improving radiographic contrast, But necessitate an increase in

exposure. The most significant occupational radiation hazard in diagnostic radiology is

scattered radiation from the patient, particularly in fluoroscopy, where the use of high

voltage results in energetic Compton Scattering emerging from the patient and posing a

real occupational hazard to radiologist and radiographer. The intensity of Scattered

Radiation one meter from the patient is about 0.1% of the intensity of the primary beam.

That is why in term of radiation protection the patient is considered the most important

source of scatter. Other Scattering object includes the x-ray table. The bucky-slot cover/

closer and the control- booth wall.

According to Stewart C Bushong (2009) Production of Scatter Radiation two

types of x-rays are responsible for the optical density and contrast on a radiograph
those that pass through the patient without interacting and those that are scattered

within the patient through Compton interaction X-ray that exist from the patient are

remnant x-ray and those that exit and interact with the image receptor are called image-

forming x-rays. Proper collimation of the x-ray beam has the primary effect of reducing

patient dose by restricting the volume of irradiated tissue. Proper collimation also

improves image contrast. Ideally, only those x-rays that do not interact with the patient

should reach the image receptor. As scattered radiation increase the radiograph loses

contrast and appears grey and dull. Three primary factors influence the relative intensity

of scatter radiation that reaches the image receptor: Kvp, field size, and patient

thickness. Control of scatter radiation , effect of scatter radiation on image control One

of most important characteristic of image quality is contrast, the visible different between

the light and dark areas of an image contrast is the degree of difference in OD between

areas of radiographic image. Contrast resolution is the ability to image and distinguish

soft tissue. Even under the most favourable condition, must remnant x-ray are

scattered.

Bushong (2008), in order to reduce radiation exposure it is necessary to

decrease the area of the x-ray beam. Proper beam restriction will reduce the amount of

primary photons emitted from the tube and collimator thereby reducing the dose to the

patient. Also, beam restriction will keep the total amount of tissue irradiated to a

minimum so fewer scattered photons are created consequently the image quality will be

improved. It is important to control scatter since it has no useful diagnostic effect.

Another principle factor in reducing scatter is kilovoltage or the penetrability of the

beam. As kVp is increased, fewer atoms interact with the tissue, and more pass through
to end up on the image receptor. In radiography, kilovoltage is selected based

predominantly on the size of the part examined. Whenever kilovoltage is increased

more scatter will result unless it is accompanied by a reduction in mAs thereby reducing

scatter and the dose to the patient. Thus beam restriction along with technical factors

are very important aspects of radiation protection by reducing the patient dose and

improving the image quality (Carlton & Adler, 2006).

Aperture diaphragms are the simplest type of beam-restricting device. It is a flat

piece of lead containing a hole in the center that attaches to the x-ray tube port. The

opening can be made in any size or shape, but rectangular is the most common. The

main advantages of aperture diaphragms are there simple design, low cost, and ease of

use. The main disadvantage is the increase in the unsharpness around the periphery of

the image known as penumbra. Other disadvantages include off-focus radiation and no

light field for use in positioning. Aperture diaphragms are used in special procedure

angiography studies.

Diagnostic imaging has predominantly been the province of two groups of

workers, radiographers and radiologists. Diagnostic radiographers are health

professionals who employ a range of sophisticated equipment to produce high quality

images to diagnose an injury or disease. Radiographers have to be registered with the

regulatory Body, the Health Professions Council (HPC) to practise in the United

Kingdom. Radiologists are registered medical practitioners with the General Medical

Council and use imaging to diagnose, treat and monitor various disease processes.
 The exclusion of radiographers from reporting remained unchallenged for nearly

fifty years until the debate around the potential for radiographers to develop and extend

their role was prompted by Swinburne (1971). He recognised the potential for

radiographers and others to comment on images as a means of alleviating radiological

workloads and in the face of a chronic shortage of radiologists. Swinburne (ibid) also

commented upon the fact that radiographers seemed to function below their full

potential and on this point he compared radiographers with laboratory technicians who

accepted greater professional responsibilities by reporting the findings of their work. His

opinion was that radiography should have graduate status which would improve

recruitment and lead to an improved radiographic career structure. Swinburne (ibid)

considered it was time that official recognition was made of the fact that radiographers

all over the world assisted in the interpretation of x-ray films. He recognized the

interdependency of radiology and radiography and his view was that under the best

conditions there was no need for boundary disputes. Swinburne (ibid) had proposed a

training program and a system of working which were radical and ahead of their time.

Following Swinburnes article further concerns began to be expressed about the

increasing radiological workload and the shortage of radiologists. The British Journal of

Radiology (1975) published an editorial Must radiologists do all the reporting? and in

the same edition a letter was published from a leading general practitioner (Emrys-

Roberts, 1975) who thought that it was a waste of time for radiologists to attempt to

report every image. The editorial and the letter prompted a number of responses

including those from two radiologists, Aberdour (1975) and McLachlan (1975) who

suggested that there was a role for radiographers in this field.

 It was not until the 1980s that the work of the radiographer began to diversify

when ultrasound imaging signaled a new role for radiographers. This included providing

results to patients and reports to medical practitioners of both numerical and

interpretational data (Witcombe and Radford, 1986). There remained no sign of any

return to plain film reporting by radiographers but the work of Berman, DeLacy,

Twomey, Welch and Eban (1985) and Cheyne, Field-Boden, Wilson and Hall (1987) on

the detection of abnormalities in x-ray films by radiographers was launched in 1984 at

accident and emergency (A&E) departments at two hospitals in the London area. This

became known as the red dot system which involved a radiographer placing a coloured

paper dot onto a film which was determined to be abnormal in an attempt to alert

medical staff to the presence of trauma and/or pathology. Interest in the feasibility of

radiographers playing a role in abnormality detection grew and in the early 1990s

Renwick, Butt, and Steele (1991) conducted a study to investigate how well

radiographers could triage films in an accident and emergency department, in effect,

this appeared to be a variation of the red dot system. Radiographers were asked to

place films in one of four categories; normal, abnormal, insignificantly abnormal and

further advice required. The radiographers selections were compared independently

to an assessment made by radiologists. The study concluded that while radiographers

could offer useful advice on radiographs to casualty officers, because of a high false

positive rate they could not perform to the required level of accuracy to extend their role.

The results were perhaps not surprising given that the radiographers had not

undergone any training, and the study was criticised for this fact by Nawrocki and

Nawrocki (1991), who suggested that radiographers had considerable potential in

abnormality detection and should undergo a short period of training for the task. In

response, Renwick (1991) agreed that radiographers were an under utilised resource

and believed that they should be given the opportunity of extra training and that his

Department was seeking funding for such an initiative. The red dot system gained

momentum and by 1991 a study reported 25% of major casualty departments had

adopted some form of flagging system (James, Bracegirdle and Yates, 1991).

According to Royal Australian and New Zealand College of Radiologist (2013), a

radiologist is a specialist medical doctor who has had specific postgraduate training in

performing and interpreting diagnostic imaging tests and interventional procedures or

treatments that involve the use of xray, ultrasound, and magnetic resonance imaging

equipment.

As is the case for all physicians, education and training required to

become a radiologist takes several years. Four years of college are followed by four

more of medical school (some universities offer combined bachelor's and medical

degrees in six year programs that shave off two years).

After graduating from medical school, radiologists spend another five years in a

residency program. Radiologists must pass several tests along the way, including the

MCATS from college into medical school, and exams administered by the National

Boards or other testing agency from medical school into residency

Radiologists are trained to assist other doctors and specialists to treat

their patients by making a diagnosis and providing treatment using medical imaging.

Radiologists have the medical knowledge to understand and explain your medical
problem or symptom through the images or pictures that are taken of various parts of

the inside of your body.

Radiologists can choose to work in various sub-specialties of radiology

such as breast imaging, interventional radiology, musculoskeletal imaging, cardiac

imaging, or paediatric (childrens) imaging, x-ray radiography, Ultrasound,

Computerized tomography (CT), Magnetic resonance imaging (MRI), Positron emission

tomography (PET) and Nuclear imaging. Radiologists generally work behind the scenes

analyzing studies, making diagnoses and consulting with physicians. In some cases,

they get involved in the procedure in order to help prepare the patient or outline further

instructions to the technician.

Most radiologists work in a public or private hospital or private radiology

practice. They are there to help other doctors diagnose and treat illness. They do this by

understanding when an imaging test may be needed to answer a doctors question

about a symptom, disease, injury or treatment, etc., and also when imaging is unlikely to

be helpful. If an imaging test is needed, radiologists know which test is likely to be the

best one to answer the question, or, if more than one test is needed, in which order the

tests should be done to get the best result. When a radiologist receives a request for a

test or interventional treatment of a problem, he or she considers the different imaging

tests available, considers the risks and benefits of the different ways of obtaining

imaging to assist in answering the question, and determines what test or treatment to do

and how best to do it.

 Radiologists communicate the results of diagnostic and interventional imaging to

the doctor who has sent you for the test or procedure, by a written report sent to your

doctor. Sometimes, the radiologist will discuss the report verbally (e.g. over the

telephone) with your doctor too.

Radiologists work as part of the clinical team taking care of you so that they can

participate actively in decision making about imaging tests that your doctor is

considering. Excellent communication between your doctor and the radiologist,

regarding your clinical problem, helps the radiologist best understand how to answer

your doctors question(s). Your doctor and the radiologist will communicate through the

written referral your doctor gives you to take to the hospital or radiology practice. Your

doctor may talk with the radiologist to discuss how best to answer a question using

imaging, or to clarify information about your problem before the radiologist can make a

diagnosis based on the imaging (pictures) you have had taken at the hospital or

radiology practice.

There are three types of radiology diagnostic, interventional and therapeutic

(called radiation oncology).

Diagnostic imaging uses plain X-ray radiology, computed tomography

(CT), magnetic resonance imaging (MRI), ultrasound and nuclear medicine imaging

techniques to obtain images that are then interpreted to aid in the diagnosis of

disease.Interventional radiologists treat as well as diagnose disease using imaging

equipment. Interventional radiologists may sub-specialise further so that they only treat

abnormalities of the brain or spinal cord (neurointervention) or of the blood vessels

elsewhere in the body (angiointervention) Interventional radiology is a minimally

invasive procedures using X-ray, magnetic or ultrasound images to guide the

procedures, usually done with tiny instruments and thin plastic tubes called catheters

inserted through an artery or vein.

Radiation oncology uses radiation to treat diseases such as cancer, using

radiation therapy. These specialists are not called radiologists, but radiation oncologists,

even though they belong to the Royal Australian and New Zealand College of

Radiologists.

Not all diagnostic and interventional radiology tests and procedures are

performed by radiologists. Nuclear medicine physicians are not always radiologists as

many specialise first in internal medicine. Vascular (blood vessel) surgeons may

perform ultrasound, angiography (taking pictures of the blood vessels using X-rays and

contrast medium) and interventional procedures on the arteries and veins using X-ray

equipment like radiologists. Some obstetricians perform their own ultrasound, and some

choose to subspecialise in obstetric and gynaecologic ultrasound and confine their

practice to this area. Cardiologists perform ultrasound on the heart and are increasingly

involved in MRI and CT scanning of the heart as well. You may be referred to have a

test involving imaging but it will not always be performed by a radiologist.

Many radiologists teach undergraduate medical students and

postgraduate trainees. Some radiologists hold academic positions in university

departments, some work in public hospitals or private practice, and some do all or a

mixture of these.
 Physicians who thrive on intellectual stimulation find radiology an

especially rewarding area of practice. Because the field advances so rapidly, there is

always something new and exciting to learn. These specialists are among the first to

pilot cutting-edge imaging technologies and procedures developed in research

laboratories. Radiologists also enjoy the challenge of interpreting complex studies and

putting together medical clues to arrive at an accurate diagnosis.

Though most radiologists still work in hospitals and outpatient diagnostic centers,

advances in digital technology now allow imaging studies to be transmitted

electronically. This practice, which is known as telemedicine, means radiologists can

now practice in any location equipped with a computer, high-resolution monitor and

Internet connectivity. Telemedicine helps emergency departments and intensive care

units obtain emergency consultations after hours and also promotes consultation among

experts around the globe.Unlike most other physicians, radiologists have limited patient

contact. In fact, some go weeks without a face-to-face consultation. Instead, these

specialists spend their time analyzing image results and formulating

diagnoses.Radiologists who work in the hospital work long, irregular shifts that include

nights, weekends and holidays. Those employed by outpatient centers are more likely

to work regular business hours.

The first step in becoming a radiologist is to obtain a bachelors degree.

Pre-medicine students may major in any subject but need to meet prerequisites in math,

biology, organic and inorganic chemistry, physics and the humanities. Students can

strengthen their medical school application by earning academic honors, volunteering,

conducting scientific research and achieving high scores on the Medical College
Admission Test (MCAT). Many four-year colleges and universities have pre-med

advisors who assist students in planning an appropriate program of study.

Next, aspiring radiologists move on to medical school. Because radiology

is an extremely competitive specialty, candidates must excel academically in order to

compete for available residencies. They will also benefit from top scores on Steps I and

II of the United States Medical Licensing Examination (USMLE). During the final year of

medical school, students should apply for a four-year diagnostic radiology residency

through the National Resident Matching Program (NRMP). Residents work an average

of 60 hours per week and spend some nights on call. Upon completion, some

candidates pursue a 1-3 year fellowship in a subspecialty such as neuroradiology or

interventional radiology.

State licensure is mandatory for all practicing physicians, including

radiologists. Most employers require radiology candidates to hold board certification.

Effective 2013, this will require passage of a two-part examination covering medicine,

anatomy, imaging modalities and physics. Because competition for radiology

residencies is fierce, students seeking to enter this field must be top academic

performers with excellent test scores. More so than other medical specialties, radiology

requires a strong interest in and knowledge of physics and math.

Radiologists earn excellent salaries throughout their careers. As they

advance, many choose a more comfortable lifestyle over pay increases. This usually

takes the form of fewer nighttime, weekend and holiday shifts. Other radiologists

advance their careers by gaining new skills and expertise. It is not uncommon for an
interventional radiologist to be the only professional in the region performing certain

cutting-edge procedures. This allows the person to command a higher income and may

present opportunities for leadership, research and community outreach.

Experienced radiologists sometimes leave the clinical setting to pursue research

opportunities, take teaching positions or move into health care administration. According

to the Bureau of Labor Statistics, the job outlook for physicians in general is strong, with

growth of 18% expected between 2012 and 2022. This is faster than average growth.

Radiologists in particular may find their job prospects better than other physicians as

well, due to the needs of an aging U.S. population.

O*Net projects the growth rate of radiology positions to be 15-21% between 2012

and 2022. The American College of Radiologists (ACR) conducted a 2013 survey of

radiologists nationwide and concluded that job growth would remain stable and provide

jobs for the number of new radiologists projected to look for work through the year 2016

(the extent of their survey). Their study did conclude, however, that while overall growth

was projected to be adequate for job candidates, those candidates might need to be

flexible in terms of job location and chosen subspecialty within radiology.

However the Radiology Schools gave a Radiologic Technologist Job

Description (2006), Radiologic Technologists, also known as Rad Tech's or RT's, assist

the Radiologist physician with the process of imaging and diagnosing illness. Radiologic

Technologist job descriptions include tasks such as: capturing the image, obtaining the

best quality image, and ensuring the patients are comfort and safe. The RT; however,
does not do the actual diagnosing as this is the function of the physician or Radiologist

M.D. The Rad Tech must be able to effectively explain the procedure to the patient and

be sure that they are comfortable and at ease during the procedure; however, it is very

important that they do what is necessary to obtain a high quality image that will be

sufficient for thorough examination by the physician and allow for correct diagnosis.

Positioning a patient for an exam may sound simple; however, it is commonly

known among RT's that patient positioning can be challenging for a number of reasons.

The patients may be sick and at different levels of severity of illness. They may have

trouble maintaining the position needed to get the best quality image because of their

illness or simply because they are elderly or handicapped. Other reasons include

patient anxiety or even anger about the possibility that they have an illness. A major part

of the radiologic technologist job description is to have strength of character to work

through these challenges with the patient in a calm, compassionate, and professional

demeanor. After all, it is in the best interest of the patient to get the best quality images

taken to aid in their road to recovery. As an RT, you will have a full understanding of the

protocols and requirements of positioning depending on what the specific case warrants

and what the ordering physician has requested.

o prevent unnecessary exposure to radiation during certain procedures, an RT

will use protective devices such as lead shields. The amount of radiation you exposure

yourself to is documented and tested on an ongoing basis to ensure that there will be no

adverse side effects to you. Patients are of course, also protected from radiation

exposure and there are strict protocols for the amount of radiation used depending on

the type of procedure being performed. Different organs and tissues within the body
have various levels of sensitivity to radiation. Rad Tech's are trained to understand this

and to adjust radiation levels and precautionary measures according to radiology-

info.org.

Radiologic Technologists can operate in a wide variety of settings from

emergency room and trauma assistance, bedside, or in a standard medical imaging

facility. Jobs are available most commonly in hospitals and medical imaging centers, but

also in physician offices, veterinary offices, and dental practices. The types of

procedures performed are many and the radiologic technologist job description may

vary depending upon the size and scope of the facility. Some of the most common

include CT (Computed Tomography), MRI (Magnetic Resonance Imaging), and

Ultrasound (Diagnostic Medical Sonography).

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