The Importance Of Radiopaque Markers In Digital X-Ray

Radiographers are taught from day one in school to place radiopaque anatomical markers within the primary beam of radiographs.  We do so as a method of “best practice” to properly distinguish the patient’s right from left on the radiographic image per legal requirements. Conditions like dextrocardia (when the heart is positioned on the right instead of the left) and situs inversus (when all of the internal organs are on the opposite side compared to normal anatomy) exist which can easily be misinterpreted and would normally cause a technologist to inappropriately orient the image to appear similar to normal anatomy.  But when radiographs misrepresent right from left, this presents a huge risk for medical errors.

Computed Radiography & Digital Radiography

When Computed Radiography and Digital Radiography entered the scene, radiologic technologists were provided with a method of digitally annotating right and left.  This further led some to question the necessity of placing radiopaque anatomical markers within the primary beam of each radiograph.  If you’re like me, you’ve more than likely witnessed a decline in the use of markers in your radiology department but make no mistake; they are more necessary now than ever with the introduction of digital radiography.

A Cautionary Tale

Several years ago when I was working with a new Computed Radiography system in a hospital, I was on portable-duty which consisted of 50-60 portable chest and abdomen exams per day on average.  Another technologist, who was assigned the “float” shift, was asked to rotate where needed within the department.  I asked this technologist for help with a STAT portable chest x-ray in ICU around mid-morning, and by mid-afternoon I found myself in the Chief Radiologist’s office with the Radiology Director and Manager.  The door was closed, faces were red, and it was uncomfortably quiet.

After what seemed like an eternity, the Chief Radiologist displayed a portable chest radiograph on his monitor and asked “do you recognize this exam?”  I looked for several seconds and said, “No, I actually don’t.”  They looked at one another confused, and then asked me to critique the image.  I started to go through my image critique steps learned in school one by one, noting the presence of what I thought might be a pneumothorax, and they stopped me when I said there was no marker present.  The radiologist then asked me, “How would you know if this exam was oriented properly on the screen?”  I rattled off some details that would give anyone clues, but when I discussed the location of the heart, he stopped me again.  He horizontally flipped the image and stated “is this hung correctly?”  Ultimately, I concluded that there was no way to know whether the exam was hung appropriately due to lack of a radiopaque anatomical marker or a blocker (which we could use in film/screen imaging to determine if we knew the projection – PA vs. AP).

They all looked at one another again and the radiologist asked me “Did you perform this radiograph?”  I did not remember viewing an image similar to that one during my exams performed that day, so I let them know I didn’t remember performing it.  They asked me if anyone was helping me throughout the day, and my heart sunk, knowing I had to name the only person I had asked for help that day.  They invited me to exit the room and resume my shift.  My manager encouraged me to continue using my markers, and he informed me he would follow up with me before I left for the day.  The door closed behind me.

Later that afternoon, I was called back into the same room that displayed the same chest radiograph.  The radiologist was a bit less intimidating, but not much.  He explained to me that the radiograph indeed displayed a pneumothorax… a “tension pneumothorax.”  He asked if I knew what that was, and at the time I did not.  A tension pneumothorax occurs when one lung is punctured and air enters the pleural cavity around the punctured lung.  The “tension” portion occurs because air entering is not allowed to escape the pleural cavity, and the mediastinal structures as a result are shifted to the opposite side (in this case, from the patient’s left to their right).

After their investigation, it was concluded that the technologist exposed the image without placing a radiopaque marker within the primary beam.  When the image displayed at the computer terminal during processing, it was most likely appropriately displayed.  Due to the appearance of the mediastinal organs on the patient’s right side, the technologist viewed prior radiographs to ensure the patient had normal anatomy (which he confirmed).  He then mistakenly flipped the image horizontally so that the heart appeared on what he thought was the patient’s left side, digitally annotated a “left” marker, then sent the image to the radiologist for dictation.

The radiologist, upon viewing this STAT exam, called the physician who was in ICU and informed them that the patient had a pneumothorax on the right side, although it was actually a tension pneumothorax on the patient’s left.  Because the technologist had inappropriately flipped the image, the ordering physician inserted a chest tube on the wrong side, into the unaffected lung, causing further complication which lead to a Code Blue being called and a much longer recovery process for the patient who was already undergoing treatment for several other problems.

I found out I was originally called into the Chief Radiologist’s office immediately following a 30-minute scolding by that patient’s physician who inserted the chest tube on the wrong side because of an error made in the radiology department.  The patient eventually recovered, but imagine what could have happened as a result of the technologist’s error.  I was glad to be off the hook, but I never found out if the technologist was disciplined or if charges were ever pressed against the hospital.

Lessons Learned

Having experienced something like this, it is easy to see the importance of radiopaque markers on a radiograph.  It is discouraging to know that many departments see a decline in their usage simply because we can place one there after the image is processed; because it’s easy.  It may be true that it is more difficult to remember to place a marker or to remember to simply bring your markers to work with you, however, It is my opinion that allowing this to happen not only encourages error, but causes liability for the technologist, radiologist, and institution that is providing radiographic services.  It should be a goal to have radiopaque anatomical markers on 100% of radiographs.  It is required for images to be admissible in a court of law, and it truly is “best practice.”

Risks vs. Benefits

Whether images need to be repeated if a marker is occasionally not visible on an image, warrants a risks vs. benefits discussion with on-site personnel including the radiologist/s.  Technologists can be held accountable, however, during evaluations and upon the occurrence of failure to use these markers.  Furthermore, it is important for employers to encourage and enable technologists to use these markers and have a quality assurance process with follow-up.  It would also be wise to consider other options such as purchasing disposable, single-use markers which can be utilized for isolation cases which infection control becomes an issue, or for when a technologist misplaces their markers.  There are tools at our disposal which are cost-effective that can prevent situations like the one mentioned earlier.

About the Author 

Jeremy Enfinger is an experienced Radiologic Technologist, Radiography Program Instructor, and published author. He has served in leadership roles in hospital, outpatient and academic settings. His experience includes writing examination questions for the national ARRT Radiography Exam and multiple – modality training. He continues to pursue excellence in education and patient care. An avid blogger, Jeremy strives to promote standards of excellence in imaging through his online community with the sharing of veteran tips and techniques for high-quality imaging.

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