Why use x-ray markers?

Why use lead x-ray markers? 

I decided to write an article on the history of side markers given my interest in them. However, once I started researching, I found it difficult to find historical documentation on the history and the use of side markers in radiology. I decided to start looking at old films to see what markers were used and I wasn’t really surprised to find that Radiographers have been using markers since the beginning of x-ray imaging. Using any radiopaque materials that are handy to mark anatomical sides, wound entry points and regions of interest. I dare any radiographer not to admit they have used the odd paperclip, coin or pin to make their mark! I guess that’s why I have such an interest in them. The mark you make on that image is forever and, if you take pride in your work, placing your initials ensures a high standard of imaging. 

X-ray markers are used in hospitals, industrial workplaces, veterinary and dental practices. Lead x-ray markers, pb markers, lead markers, radiographic markers, anatomical side markers – whatever you wish to call them – all have the same identifying job. Most x-ray markers have a right or left letter, which determines the anatomical side of the body, and also the radiographers’ initials. Other markers can indicate body position such as supine or erect. The annotation of x-ray images is 100 percent determined by the radiographer, “It has been noted that in routine, as well as in forensic radiography, anatomical side markers must be included on the image to be admitted as a legal document. It was also reported that absence of an anatomical side marker is a strong risk factor for misdiagnosis by radiologists, as well as wrong side surgery by surgeons, with attendant medico-legal and fatal consequences” (Adejoh, 2020).  

The use of side markers is considered best practice as a radiographer, and important for patient safety. The Medical Radiation Practice Board of Australia (MRPBA) states in their professional capabilities for medical radiation practitioners, that radiographers are to perform projection radiography examinations in a range of settings with evidence of this capability being the appropriate use of anatomical and directive radio-opaque markers (2020, p12). “Using radiopaque anatomical side markers is best practice, and lack of any anatomical side markers may have dire consequences in terms of patient safety” (Chung et. al., 2020). There have been avoidable instances where “a patient died after his healthy left kidney was removed instead of his diseased right kidney. The patient’s radiographic images may have been inverted when the surgeon viewed them, potentially informing the decision to operate on the incorrect side. In another example, two premature babies were reported to have had wrong-sided treatment for pneumothorax, one fatally, due to clinical decisions based on images without anatomical side markers” (Titley et al., 2014).  

The introduction of digital radiography, has given radiographers the ability to digitally add annotations in the post-production process. “Rather than increasing compliance, however, the addition of digital markers has been found to increase the incidence of incorrect or missing anatomical side markers” (Barry, 2016). The NHS has reported that recently, anatomical side marker usage does not meet the ‘best practice standard’ (Titley et. al., 2014). The Health Care Professions Council, UK (HCPC) as well as the MRPBA state that accepted best practice necessitates that “a correct radio-opaque anatomical side marker must be placed within the primary collimation when the image is acquired, ensuring its presence on the subsequent radiograph. The anatomical side marker is ‘correct’ if it corresponds to the anatomical side demonstrated.” (Titley et al. 2014). Whether radiographers regularly use lead markers or post process them, seems to be different in each workplace and dependent on the workplace culture. New radiography students are all taught to use their markers, and there is an underlying expectation that radiographers should use lead markers. “Discouraging students from using radiopaque side markers should be condemned as a dangerous practice. A failure to develop this and other safe practices as a student could be a precursor to a working life of bad habits” (Fuller, 2016). The culture in my workplace is certainly pro lead side makers, with an expectation that all radiographers have a pair of personal markers to use at the time of acquisition. Adejoh also suggests that every radiographer should use x-ray side markers and states that an abundance of radiopaque x-ray markers should be made available in every department to ensure that each radiographer possesses their own personal markers (2020). A colleague of mine recently said that we have very little tools in our jobs compared to plumbers etc, and for the sake of a few dollars, lead markers should be an investment we make as part of the job.

I personally like using lead side markers as I believe it gives me an opportunity to double check the correct side on the request and correspond it to the correct side on the patient. When I do the 3 c’s (correct patient, correct procedure, correct side) I always take this opportunity to also check I have the correct marker. Especially in a busy fracture clinic. I put the x-ray marker I am going to use on the bucky or on the detector before positioning the patient. Ensuring the side marker is moved within the primary collimation before the image is acquired. A final check of marker placement should always be performed before sending images to PACS. This is why I like to use side markers, because it gives you a few times to check correct side annotation of markers compared to only placing in post production. “It should also be considered that the action of placing a radiopaque side marker within the primary x-ray beam could be considered a cognitive forcing function: the action of placing the radiopaque side marker is forcing the radiographer to think about its correct placement. If the placing of a radiopaque side marker is characteristically cognitive, the equivalent post-processing annotation can be characteristically heuristic” (Fuller, 2016).

Even with the best intentions, sometimes the use of lead x-ray markers is difficult. A study by Chung (2020a) surveyed radiographers to find out why radiographers do and don’t use lead x-ray markers. Most of the respondents mentioned that the size of the patient in special care baby unit (SCBU) or neonatal intensive care unit (NICU) make it difficult to use markers. A senior radiographer stated that: “I must admit, if I go to NICU or SCBU I don’t [use a radiopaque ASM], mainly because I think sometimes you’re doing a little 500g baby and you’re collimating down to that… because they’re so small that I will admit, I don’t use them [radiopaque ASM] there.” (Chung 2020a). Others elaborated saying “Sometimes the marker, if the patient moves, causes more problems because it ends up over the area you want to image and you end up doing a repeat… for neonates, the marker is almost sometimes as big as the child. . . the chances of you covering the marker with the baby is quite high” (Chung, 2020a). When working with children often the radiographer needs to work with speed and the use of distraction is often required, the side marker use may be overlooked in preference to obtaining diagnostic images (Barry, 2020). Participants also mentioned factors such as “patient distress, time sensitive conditions, cognitive challenges, medical attachments, or infection control pre-cautions as reasons for not using anatomical lead side markers (Chung, 2020). The discussion that markers can have the potential to spread bacteria, can be said of all radiography equipment. Like anything that medical professionals use, wiping down between patients should be common practice. Just like cleaning the bucky, detector etc. I also use marker adhesive (like Radtack) when I can because its more environmentally friendly than using sticky tape, its washable which allows better infection control than tapes.

Chung states that Medico-legal reasons such as Non Accidental Injury (NAI) or mortuary cases were factors that influenced Radiographers to use radiopaque side markers. One radiographer said: “The reasons for using lead [radiopaque] markers for NAI or mortuary is [that] I know that they will go to court, so I always use them for that reason.” (2020). The imaging protocol for NAI at my workplace requires that lead x-ray markers are to be visible in every acquisition.   This is also the protocol for NAI in Children at the Royal Children’s hospital in Melbourne, where lead markers must be used on all images in the skeletal survey (The Royal Childrens Hospital Melbourne, 2009).  

Fuller states that the “radiopaque side marker is to radiography as the seatbelt is to travelling in a car. It should be an automated reflex to buckle up a seatbelt when you are first seated in a car. Equally, it should be an automated reflex to place a radiopaque side marker within the primary X-ray beam before you expose the patient to radiation (Fuller, 2016). One Radiographer in Chungs study was quoted “I guess it’s just taking pride in your work and having things labelled properly. . . I think it’s much more professional. . . it shows a good standard of practice I think, but I guess it’s just best practice. I pride myself taking the best images [I] can in each situation no matter how tricky it is so I think it’s always better to have it [radiopaque ASM] on there.” (2020).

Atlhough I agree that there are some situtations where lead markers are difficult to use, I do believe that radiographers should use radiopaque side markers where possible. I believe they do improve efficiency and definitely can improve accuracy and have safety benefits if there is any doubt that an image has been flipped AP or PA. I also believe that lead x-ray markers are more aesthetically pleasing, there is a lasting, confident more permanent look about a lead anatomical side-marker. Fuller agrees that if you use a radiopaque side marker that includes your initials, you are attaching your name to your images. “Your reputation as a radiographer is on display and your work is under continuous review.” “Placement of a radiopaque side marker within the primary beam is not an outdated practice – it is a safe practice.” (Fuller, 2016).

References

Adejoh, T., Elugwu, C.H., Sidi, M. Ezugwu, E, Asogwa, C, & Okeji M. (2020). An audit of radiographers’ practice of left-right image annotation in film-screen radiography and after installation of computed radiography in a tertiary hospital in Africa. Egypt J Radiol Nucl Med 51, 253. Available: https://doi.org/10.1186/s43055-020-00371-3

Barry, K., Kumar, S., Linke, R., Dawes, E. (2016). A clinical audit of anatomical side marker use in a paediatric medical imaging department. Journal Medical Radiation Science. 63(3):148-154. doi:10.1002/jmrs.176. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016612/

Chung, L, Kumar S, Oldfield J, Phillips M, Stratfold M. (2020). A clinical audit of anatomical side marker use in a pediatric medical imaging department: A quantitative and qualitative investigation. PLoS One.15(11), doi:10.1371/journal.pone.0242594. Available: https://en.x-mol.com/paper/article/1331420090584965120

Chung, L., Kumar, S., Oldfield, J., Phillips, M., Stratfold, M. (2020). The Use of Anatomical Side Markers in General Radiology, Journal of Patient Safety: May 9. doi: 10.1097/PTS.0000000000000716. Available: https://journals.lww.com/journalpatientsafety/abstract/9000/the_use_of_anatomical_side_markers_in_general.99151.aspx

Fuller, M. (2016). Side marker creep: have radiographers changed their side marker habits? Journal Medical Radiation Science. 63(3):143-144. doi:10.1002/jmrs.181. Available: https://www.researchgate.net/publication/308006490_Side_marker_creep_have_radiographers_changed_their_side_marker_habits

Medical Radiation Practice Board of Australia (MRPBA). (2020). Professional capabilities for medical radiation practitioners. Available: https://www.medicalradiationpracticeboard.gov.au/Registration-Standards/Professional-Capabilities.aspx

The Royal Childrens Hospital Melbourne, (2009). Protocol for Imaging Non-Accidental Injury (NAI) in Children. Available: https://www.rch.org.au/vfpms/guidelines/protocol-imaging-for-non-accidental-injury-in-children/

Titley, A., & Cosson, P. (2014). Radiographer use of anatomical side markers and the latent conditions affecting their use in practice. Radiography. 20(1), 42-47. doi:101016/jradi201310004. Available: https://www.radiographyonline.com/article/S1078-8174(13)00119-3/fulltext