10 Tips for ‘X-cellent’ X-raying

‘Why do I need another x-ray? Is there something wrong?’

‘No, sir. It’s just that the first one didn’t come out quite right!’

Repeat x-rays: the bugbear of every radiographer. Agh, the extra radiation! What if I don’t get it right this time either?! What will my patient think of me? Will they think that I don’t know what I’m doing?

Unfortunately, we all know that repeat x-rays are par for the course. They happen. Every patient and situation is different. Hell, sometimes we just make mistakes. Who doesn’t? Still, like the true perfectionists we are, every repeat x-ray chips away at us like a 12-hour shift. We know the risks. It’s in our DNA (pardon the pun).

For every x-ray examination, we follow a process. This is, essentially, how we do an x-ray. Receive a referral, justify radiation exposure, and so on. Whilst we adapt this for each patient, the fundamentals remain the same. When there’s cracks in the process, we repeat more x-rays, make more mistakes, and our care standards slip. The x-raying process is one of the first skills we learn, and also one of the most overlooked when it comes to refreshing our practice.

So whether you’re a student radiographer looking to improve your practice, or a qualified radiographer seeking a back-to-basics refresher, here are 10 tips for ‘x-cellent’ x-raying (sorry, I couldn’t resist)…

1. Clean the room. Is there anything worse than hearing the words, ‘I’ll be fine, I don’t want any more children anyway!’? I doubt anybody would say that if an x-ray tube fired out lightning bolts during an exposure! Of course, just because you can’t see x-ray particles, doesn’t mean they aren’t dangerous. My point is that the same applies to cleaning: if our hands and x-ray room don’t appear dirty, it doesn’t mean they aren’t. My first tip is a simple one. Clean your hands and room before greeting your patient. Keep keen and stay clean!

2. Position IR/tube. Whether using computed or digital radiography, a manual or automatic tube, positioning the image receptor and tube before you greet a patient not only prevents a nice shiny black eye, it also helps to free your mind for positioning your patient later on.

3. Collimate. This is an easy one to apply, but also easy to forget. The benefits are clear: any increase in collimation will result in unnecessary radiation exposure. Simples. You can then reduce the collimation after positioning the patient, reducing radiation exposure further, and improving image quality. Remember that this is only true if the source-to-image receptor distance remains the same at the point of image acquisition.

4. Pre-set parameters. Identify the correct patient on your image processing software, and set exposure parameters for the first planned projection. If you do this before your patient enters the room, you can focus more of your attention on them when they arrive.

5. Take a breath. What’s the plan? Which projections, and in what order? Are you likely to need manual handling assistance? It’s really easy to fall into the trap of rushing, but no matter how experienced you are, it really does pay to take a moment to breathe. Don’t have time? Yes, efficiency is important. But is it not faster, safer and more caring to get it right first time around?


6. Say your name. You may be familiar with the inspirational campaign started by Kate Grainger, ‘Hello. My Name Is…’. It’s astonishing that we all occasionally neglect to properly introduce ourselves to patients. I know I do. It seems so simple on reflection, and in Kate’s words, it is the “first rung on the ladder to providing truly person-centred, compassionate care.” There’s nothing more I can add, really. Just say, ‘Hello. My name is…’

7. Reflect. Once you’ve met and talked to your patient, reflect on your plan. Do you think they will be able to safely achieve standard radiographic positions? Will they need some help? Will you need some help? Is there anything you can do to ensure the procedure is safe and comfortable for them? If necessary, think of another plan. We often reflect in a matter of seconds without realising, but I think it pays to step back even further. It prevents diving in head first without thinking, and creating an unsafe or uncomfortable experience for your patient.

8. Communicate. Most patients have no idea what to do during an x-ray examination. Many probably want to escape your company as soon as possible! If you talk them through it, explain what you’d like them to do and why, and afford them time to ask questions then who knows, they may just enjoy it! Great communication also engages patients in the process, and results in better outcomes. Think about the horizontal beam projection of the hip. If I had severe hip pain, felt confused, was only wearing a hospital gown, and somebody started moving one of my legs, I’d likely take a swing for them. If the same person took the time to explain what was happening, reassured me, and asked if they could move my leg, then I’d probably kiss them instead! Maybe.

9. Maintain position. Once you’ve acquired an image ask your patient to maintain their position. If you need to repeat, you’ve got a baseline to work from. Of course, sometimes patients are in too much pain for this to be possible. It’s best to consider whether it would be more painful for them to maintain the position, or potentially have to move again for a repeat x-ray. Even better, explain this to your patient and put the power in their hands.

10. Use the image. If you need to repeat a projection, it’s natural to go straight back to your patient and try once more to position them à la Bontrager/Clark. But what if you did it ‘by the book’ already? Then use the image (and your beautiful mind). Have you ever found yourself on the fourth odontoid peg x-ray, ready to rip your uniform off and walk out the door in a huff? Maybe that’s just me, but I know for a fact that if you’ve done a peg x-ray, you understand what I mean. Your original image is key here. It tells you how to adjust your patient/equipment position, in order to transform an undiagnostic image into an optimal one without multiple repeat exposures. This is, of course, much easier if the patient has managed to maintain their position.

Attention Student Radiographers…

Which x-ray projections do you find the most challenging? What are you struggling with? Tell me in the comments section below!

Comments 2

  1. Great blog!
    Excellent relating to our common problems we face daily!
    Palpate, feel the anatomy, visualize the anatomy you will project, imagine if you will your X-Ray vision.
    ~ X-Ray Technologist

    1. Thanks Katheryn, I’m pleased that you liked the article. And great point – we often forget to actually feel the relevant anatomy before acquiring an image!

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