Having a scan with your head in a rubber hat

NHS

Dr Jim Stevenson, reflects on life as a radiologist in the 1970s.

 

Jim StevensonI started my radiological life in the mid seventies at St George’s Hospital. Part of the rotation programme involved some time at the Atkinson Morley Hospital where I came across the first generation scanner. There was an old dental chair on which a patient laid back with his head in a rubber hat in the scanner porthole. It took 8 slices. Each slice took 5 minutes using an old fashioned tomogram X-ray tube. The image details were processed by a very large computer. The resultant image was printed on a photograph. The image matrix was 80 by 80, an advance since the original 40 by 40. How Jamie Ambrose invented the reports I do not know but his detailed knowledge of brain anatomy was quite outstanding.

Once when walking past the scanner I saw a porter in a brown overall walking round the machine. Being concerned about security, I spoke to Jamie Ambrose. “Don’t worry about him,” he said, ‘”That’s only Godfrey“ (Hounsfield from EMI).

Significant advances in CT occurred about every 5 years. When the first body images appeared we all had to learn cross-sectional anatomy. Since 1945 all anatomy was taught in longitudinal section – sagittal and coronal. I showed an image to my father-in-law. He had no problem with it but he had qualified in 1940. Before the war, all medics had to learn cross-section anatomy! The very best cross-section anatomy book I found was Eycleshymer and Schoemaker published in America in 1911. Still much better than the modern ones of recent times. The only difficulty is that all the labels are in Latin which can make interpretation difficult!

Over the past fifty years medical technology advances have been and will continue to be outstanding. The need to make proper use of them hasn’t changed. Wet films, fluorescent imaging, U/S, MRI and digital are all contributing to our future.


About Dr Jim Stevenson

Dr James Duncan Stevenson BSc. MB.BS, FRCR trained at St.Thomas’ Hospital Medical School, London and four years later turned to radiology at St.George’s Hospital, London. In November 1980 he became a Consultant Radiologist at Royal Victoria Hospital, Bournemouth and Poole Hospital. He retired in August 2007.

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From darkroom to digital: Tracing the transformation of Radiography

NHS

Stewart Whitley reflects on how technology has revolutionised radiographic imaging. 

 

Since the launch of RAD Magazine back in 1975, radiographic imaging as we know it has changed dramatically, far beyond the concept of what anyone could have imagined at that time. And just as smart mobile phone technology has revolutionised how we communicate, so too has the emergence of digital imaging technology transformed the X-ray department while at the same time providing both regional and national connectivity.

Fig 1

Figure 1: At work in the chest room at New Ealing Hospital, London. From RAD Magazine, July 1979

A few of us will remember with fondness those ‘bygone days’ when the darkroom was a hive of activity and was central to all that happened in the X-ray department; all permanent images, and for that matter, reporting was dependent on film/screen technology and film processing chemistry. Back then there was the gradual but necessary progression from manual processing, with those famous drying cabinets, to the first automatic dryers and then the emergence of automatic processing which was the first step in revolutionising film processing and the eventual demise of the darkroom. Even though those wonderful automatic film processors could eventually process film in 90 seconds, a great deal of care and attention was still necessary to keep rollers, processing tanks and processing chemicals in tip-top condition. And what department was without a silver recovery system to generate income? Then everything changed dramatically overnight with the introduction of daylight processing. Different manufacturers had different solutions but the overall effect was to transform the X-ray department and free up the darkroom technician, many of whom became X-ray helpers – the forerunners to the modern image support worker (figure 1). While image acquisition using modern film/screen technology progressed steadily with the introduction of more efficient and higher quality image systems, the focus was on radiation dose reduction, with X-ray manufacturers offering a range of general X-ray and fluoroscopic systems which provided welcome features to reduce patient and staff dose.

Fig 2

Figure 2: Radiologists and radiographers attending a preview of Agfa Gevaert’s daylight processing system in London. From RAD Magazine, March 1977

Older X-ray systems were powered with what would be considered today outdated X-ray generator technology and X-ray tube design, with corresponding limitations on short exposure times and geometric sharpness. Thanks howeverto consistent research and development in generator technology and X-ray tube design, the problem of high tube output and short exposure times with associated production of inherent high heat was resolved. This facilitated multiple exposure equipment for cardiovascular imaging and general angiography with their inherent demands for high quality sharp images at low radiation doses. Such changes have enabled the acquisition of motion-free images of the vascular tree, coronary vessels and heart anatomy, giving spectacular images of cardiac function and anatomy. The X-ray generator control desk is now hardly recognisable from those found in departments back in 1975 – some still had voltage compensation controls and meters for you to manipulate before you started the day (figure 2).

Gone are those massive exposure control dials for individual control of Kv, Ma and time. Such control desks were large and floor standing, unlike modern small desks which rest on a bench or can be wall mounted and synchronised to the X-ray tube housing/light beam display unit. For exposure factor selection, we are no longer confined to manual selection, thanks to the development of anatomical programming selection combined with the introduction of automatic exposure control – something that we take for granted nowadays – but its use still requires skill and knowledge of the location and use of the relevant ionizing chambers to select the most appropriate exposure conditions. Used correctly, image quality will be consistent with the optimum use of radiation dose. The design of X-ray tables and ceiling tube suspension systems has been a gradual process, developing from simple solutions to fully integrated motorised units where preprogramming of the location of the X-ray tube/table of a vertical Bucky is linked to the body part selected for examination, requiring less effort from the radiographer in positioning heavy equipment.

Fig 3

Figure 3: Coventry and Warwickshire Hospital’s ceiling-mounted equipment in its new X-ray unit. From RAD Magazine

We now see the control of exposure factor selection built in to the modern X-ray tube housing/light beam diaphragm display unit. This saves a great deal of time and releases more time for patient care, which has been further enhanced with the introduction of rise and fall tables with floating table tops – something which is taken for granted compared to the old days with fixed-height tables and no facility to move the patient other than brute force (figure 3). Overall, the advances in design with improved ergonomics have been complemented with a range of dose information and dose saving features such as the introduction of DAP meters (now a feature of all X-ray systems), additional selectable X-ray tube filtration for paediatric radiography, and the ability to remove grids in the Bucky systems to lower patient dose.

Over the years, changes in standard radiography requests and techniques have emerged which have been driven by the introduction of new technologies and patient pathways. No longer, for instance, are those well-loved isocentric skull units required because basic skull radiography has become a thing of the past and, if necessary, is replaced with the use of CT. As a result, there has been a loss of this skill, but as one modality is lost others like OPG and cone-beam computed tomography (CBCT) have found their way into the X-ray department. Continuing this theme, fluoroscopy procedures such as barium enema and barium meal procedures are no longer in favour, compared to yesteryear when they were undertaken mostly on equipment based on the undercouch X-ray tube design with over-the-table image intensifier. Not only have such fluoroscopy units in the UK diminished in number but they have been replaced with equipment with a more X-ray tube and image detector unit. This is complemented by a range of image selection features such as digital subtraction and road mapping for angiography, as well as a number of exposure and dose control options from the main control console or on a mobile control desk that can be positioned anywhere in the room.

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Figure 4: Blackpool Victoria Hospital’s Farage Unit equipped with a new Philips C-arm angiography unit with CBCT capability

Such C-arm systems can also support CBCT. This truly is a leap forward in design and capability, with such configurations providing volumetric CT capabilities which in the angiography suite provide the clinician with a 3D orientation of pathology as well as a feature to plan the optimum orientation for positioning a biopsy needle, without damaging vital organs or arteries (figure 4). Undoubtedly, however, the introduction of digital technology has transformed how we acquire images. The development of both computed radiography (CR) and direct digital radiography (DDR) has been fascinating to observe. In the early days of this development, DDR with large detectors was mostly fixed and integrated into the vertical Bucky and table design while CR was based mainly on conventional cassettes, thus giving the radiographer greater flexibility and the ability to undertake examinations in the conventional way. However, all of that has changed with DDR now presented with mobile flat detectors, built-in wi-fi technology, and in different sizes capable of being used in a similar way to film/screen cassette radiography. This has revolutionised the speed in which images are acquired and, with the development of mobile DDR based X-ray systems, its use in high dependency patient care units such as ITU and SCBU is providing the clinician with instant images, thus assisting them to make immediate and important treatment decisions. Overall the X-ray department has been changed forever – what next?

This article was first published in RAD Magazine, 43, 500, 22, 24. Reproduced with permission.


About Stewart Whitley

Stewart Whitley

Stewart undertook his radiography training in the Royal Army Medical Corps qualifying in 1967 at the Royal Herbert Hospital, Woolwich, London.  After serving in the Army he returned to N. Ireland working first at the Lagan Valley Hospital, Lisburn and then at the Royal Victoria Hospital, Belfast where he qualified as a Radiographer Teacher before moving to Altnagelvin Hospital, Londonderry as Deputy Superintendent Radiographer.

In 1978 he was appointed District Radiographer at Blackpool Victoria Hospital where he remained until the autumn of 2006 when he retired from the NHS as Directorate Manager of Radiology and Physiotherapy Services.

Shortly after leaving the NHS he established UK Radiology Advisory Services, a small company dedicated to providing medical imaging advice and support to various NHS and private sector organisations and educational establishments.

Stewart has a passion for Radiography and his professional body, the Society and College of Radiographers, and has served as a Council Member, Honorary Secretary of the N. Ireland Branch of the Society of Radiographers and as a DCR and HDCR Medical Photography examiner as well as serving on a number of SCOR committees.

He lectures on a number of courses and was an Honorary Lecturer and Coordinator for radiographer lecturers on the FRCR course at Manchester University.

Stewart took on the role of ISRRT’s Director of Professional Practice in April 2018

 

A pregnant goat in the machine: memories of working in radiology

NHS

From dark art to a pregnant goat in the machine, Dr Richard Keal reflects on his NHS career in radiology. 

 

RKeal

When I started training in medicine in 1971, radiology was literally a dark art. The Middlesex Hospital X-ray department was in the basement of the hospital, a gloomy place populated by pale individuals, some wearing red goggles, who were rarely seen outside and certainly never communicated with medical students. We heard rumours of strange investigations performed there, such as air-encephalograms, which sounded more like medieval torture than anything diagnostic. Radiology had very little impact on my life as a medical student apart from my elective in Hamilton, Ontario in 1975. Here I heard a lecture by an eminent neuro-radiologist from England lamenting that he had had to come to Canada to see images from the new “EMI Scanner” – the start of the revolution in imaging.

After qualifying, I tried several specialities before ending up as a cardiology registrar. Here I was responsible for all the emergency pacing and assisting at cardiac catheterisations. I had no radiation protection training other than being told that we had to wear lead coats and radiation monitoring badges. The portable image intensifier kept cutting out and it was only when I was training in radiology that I learnt that this was due to the permitted time limit being exceeded. I often wonder whether this was the reason I developed cataracts later on.

A further career change found me training in radiology in Aberdeen. This was an exciting time: Aberdeen had two CT scanners, new real time ultrasound machines and a completely new department no longer hidden in the basement. However the real star was the NMR (as it was called then) scanner. When I arrived to train in 1983, The Mark 1 (the world’s first whole-body MRI scanner) had been relegated to research use and was available for the radiology trainees to use. I had my head scanned on it. The 64 x 64 pixel image at least proved I had a brain! I was unfortunate to have been scanned just after a pregnant goat had been in it and the smell was indescribable. We were the first trainees in the world to be taught and examined on MRI imaging for our part 1 exam. Looking at the scanner, now in the museum in Aberdeen, it is impossible to believe that a machine built of copper plumbing components with a chicken wire and aluminium foil Faraday cage and a ZX81 processor could have ever produced images.

Coming to Leicester in 1986 was like a step back in time! No MRI, a B-mode ultrasound system and a CT scanner that no registrars were allowed access to. It was here that I did my first (and last) trans-lumber aortagram and saw other investigations such as cervical myleograms. I had learnt to do lymphangiograms in Aberdeen and I used to spend many a quiet morning performing them.

With my interest in cardiac imaging, I was appointed as a consultant cardiac radiologist at the cardio-thoracic centre. I was one of the few radiologists in the country with an interest in echocardiography and in close cooperation with the cardiac surgeons, introduced intra-operative trans-oesophageal echocardiography into the operating theatres, a technique now commonplace and performed usually by anaesthetists today. As a radiologist, the hospital management were used to me asking for expensive pieces of equipment and when it came to replacing our echocardiography systems, they didn’t ask any questions when I told them that digital imaging was now standard, replacing VHS tapes, and that we required a digital archive. The result was the largest digital echocardiography department in Europe complete with a 400 GB optical jukebox the size of a small room. I followed this up by persuading them to install the first dedicated cardiac MRI scanner in the country.

I started my career by learning invasive cardiac catheterisation and ended it by performing CT coronary angiograms, such has been the pace of change in the last 40 years. Unfortunately, imaging appears to have superseded history and the workload is now excessive. The hospital I worked in now has three MRI scanners (two cardiac), two CT scanners, numerous echocardiography systems, two SPECT systems and a PET scanner; all imaging techniques that didn’t exist or were in their infancy when I started in medicine. What does the future hold?


About Dr Richard Keal

1973

I was born in 1953 and educated at Alleyn’s School in Dulwich. I scraped into the Middlesex Hospital Medical School in 1971 with three Cs at A-level having never studied any biology. After an uneventful medical school career, apart from failing pharmacology twice, I qualified in 1976. I immediately married the lovely nurse I had met over the tea urn on the first ward I was on as a medical student. Uncertain as to what area to specialise in, I tried several specialities as a junior doctor including A & E, cardio-thoracic surgery, thoracic medicine and cardiology. I finally settled on radiology and was offered a registrar post in Aberdeen in 1983 after being sent to see a psychiatrist to ensure I was sane. I moved to Leicester in 1986 as a senior registrar and was appointed as a Consultant Cardiac Radiologist at Groby Road Hospital on 1April 1990. In 1995, I became Head of Department at Glenfield Hospital and continued in post until deposed by the merger of the three Leicester Hospitals in 2002. I spent the next years as the grumpy old man of the department gradually withdrawing from various modalities as new consultants were appointed. I retired in 2013, but continued part-time as clinical head of cardiac nuclear medicine and ARSAC license holder. I finally retired in 2017 when the MDU fees became greater than my private practice earnings. Our three sons are pursuing highly successful careers outside medicine.

When MRI created excitement in the air

NHS

Dr Adrian Thomas shares his experience of working as a radiologist and how excited he was to see the EMI/CT scanner for the first time. 

 

adrian thomas

Dr Adrian Thomas

In my time as a radiologist I have seen the amazing growth and flowering of radiology. I entered medical school in 1972, which was the year that the CT/EMI scanner was announced by Godfrey Hounsfield and James Ambrose at the BIR Annual Congress; and I started radiology at Hammersmith Hospital in 1981, which coincided with the opening of their MRI scanner. I don’t think that either of these events were connected!

 

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X-ray Television at Farnborough Hospital in 1970

When I started medical school everything looked so advanced and exciting to my young eyes. As I look back now it all seems rather primitive. Computers were in their infancy, and imaging was almost all traditional. However, I liked the X-ray departments that I saw, and was taught by Peter Bretland at the Whittington Hospital, and by the great George Simon who was a pioneer chest radiologist. Both were inspirational teachers.

OLYMPUS DIGITAL CAMERA

Old X-ray cassette, pre-digital

The juniors today will find it difficult to understand how very different things were. As a junior doctor, practising emergency medicine or surgery with only minimal imaging was not easy. Many assumptions were made. So for example, an older person with left iliac fossa pain and fever was assumed to have acute diverticulitis. They were treated with intravenous fluids, antibiotics and a nasogastric tube; a barium enema was then arranged as an outpatient. Many exploratory laparotomies were performed for undiagnosed acute symptoms, and the surgeon had only a limited idea as to what would be found. We had plain films, contrast studies and nuclear medicine, but no CT and only limited access to ultrasound. I can remember patients who would have been managed entirely differently today with modern imaging. In particular, an accurate diagnosis made by CT or ultrasound may preclude the need for invasive surgery.

5 Store for conventional film packets

Store for conventional film packets. Large storage rooms were needed for storing X-ray film packets, with many filing clerks

I was a surgical houseman in 1978-9, and I recollect one particular patient that had done something that you should never do, that is to polish the floor  underneath a carpet. He had come downstairs, and had stepped onto the carpet. The carpet had slid forwards, and he fell backwards hitting himself hard on the occiput. He presented with a severe headache, but no neurological signs. His skull plain film X-ray showed no fracture, and I admitted him for neurological observations. After 24 hours he remained well, but still had his severe headache. The surgical team decided to keep him in  hospital for further observation. We kept him for well over a week, and he remained well although with a persistent headache. We then finally sent him home. I had a phone call some days later from another hospital. My patient had unfortunately died, and the other team wanted to know what we had been doing. I explained what had happened, and the voice on the ‘phone said that this was all very reasonable and we could not be criticised. Today the patient would have been scanned, a potentially treatable lesion could have been found, and this young man could be alive today.

3 Traditional cassette opened to show intensifying screens and film

Traditional cassette opened to show intensifying screens and film

I had first seen the EMI/CT scanner when my consultant took his firm of neurology students to see the new scanner at the National Hospital in Queen Square, where he had clinical sessions. I was fascinated by the images we saw, and the radiologist Ivan Moseley showed us the capability of the scanner. I could feel the excitement in the air, and a knowledge as to how much we could learn about the natural history of various diseases. I was also aware of the excitement in the air when I was at Hammersmith Hospital as a registrar  in Radiology. We were being taught tradition imaging – plain films, barium meals and enemas, and IVPs. I became quite good at TLAs (trans-lumbar aortograms), when a long needle was passed into the prone anaesthetised patient, and contrast injected to show the peripheral vessels. However, whilst I was learning the traditional techniques, Graeme Bydder, from the MRI Unit, used to join us for our lunchtime meetings and show us the recent scans hot off the printer. This was long before the days of digital transfer of images and PACS. I remember being excited by the images of NMR as it was called then, and realising how the neurosciences would be revolutionised.

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Bags of films for reporting. Once a common scene in reporting rooms

Imaging has utterly transformed both the practice of medicine, and also how we look at ourselves. It is all too easy to be cynical about the modern world and whist things may always improve major advances have been made. However, all of these changes were quite unpredictable when the NHS was set up, and it is a major achievement that these new imaging techniques have been introduced. Modern imaging is readily available for our patients, and has transformed untold numbers of lives. Godfrey Hounsfield was always very humbled by the many letters that he received from patients and relatives thanking him for his invention.


About Dr Adrian Thomas

Adrian Thomas is a radiologist, and visiting professor at Canterbury Christ Church University. He has been President of the Radiology Section of the Royal Society of Medicine, and of the British Society for the History of Medicine. He is the Honorary Historian to the British Institute of Radiology. Adrian has written extensively on the history of radiology writing many papers, books and articles. He is currently, with a colleague, writing a biography of the first woman radiologist and woman hospital physicist.  He has had a long-term interest in role development in radiography, and teaches postgraduate radiographers.

 

A revolution in imaging: radiology memories for #NHS70

NHS

Professor Adrian K Dixon was born in the same year that the NHS began. Here he reflects on what the NHS has given him and the revolution he has experienced in the world of radiology.

 

Adrian Dixon

Professor Adrian K Dixon

I was born in 1948 and, 70 years on, I remain one of the most passionate supporters of the NHS. Like many of my generation, I have received huge personal benefit from the NHS over the years; both my elbow fractures were brilliantly treated in Accident and Emergency Units; joint replacements for osteoarthritis have provided renewed mobility latterly; audiology services have looked after my long-term inherited deafness and allowed me to function reasonably well so far.

Training in medicine in Cambridge (1966–9) and London (St Bartholomew’s Hospital, 1969–72) was very different from nowadays. On hour one, day one, as a young houseman, sister said to me: “There are three patients for myelography today –  there are three trays set up for lumbar puncture – all you have to do is to send some cerebrospinal (CSF) fluid off to the lab and instil the Myodil before they go down to radiology where Professor du Boulay will be waiting….!” I had not even seen a lumbar puncture at that stage but I learnt quickly at the hands of an excellent registrar. Then I went off for training in General Medicine at Nottingham General Hospital in the excellent Professorial Unit led by Professor Mitchell and Dr (later Professor) Hampton. Any patient over 65 then was ‘geriatric’. I well remember one elderly lady recovering from a cardiac event who was not quite well enough to go home where she lived alone – I said: “I think you need a few days in our convalescent home in Cleethorpes (yes, the NHS provided such things in those days!)”. Her reply: “Oh lovely; I have never seen the sea”. No package holidays or low-cost flights back then!

I was extremely lucky to train in radiology during the 1970s and to be involved with the beginning of the revolution in imaging, namely the introduction of ultrasound, CT and MRI. These advances were truly miraculous compared with the fluoroscopic techniques of old. Indeed image intensification was only just becoming sophisticated while I was training and I did my fair share of barium work using direct fluoroscopy following dark adaptation with red goggles! This even persisted after my move to Cambridge when I was given responsibility for imaging services at the local geriatric hospital where the ageing equipment was nearly as old as some of the patients!

Picture1

After a brief spell in paediatric radiology, I became fascinated by Computed Tomography and I was lucky to be appointed as a Research Fellow at St Bartholomew’s Hospital. There, Dr Ian Kelsey Fry had the foresight to install one cranial and one whole body CT systeminto 2 standard X-ray rooms (an excellent strategy – replacing old technology rather than merely adding on the new). This gave me the experience to be appointed as a young lecturer/Honorary Consultant at the newly emerging Clinical School in Cambridge (thanks to the risk taken by my lifelong friend Professor Tom Sherwood).

In partnership with NHS radiological stars in Cambridge (Desmond Hawkins and Chris Flower, to name but two), Tom Sherwood forged a highly successful combined University/NHS Radiology Department which continues to this day. I was fortunate to be given free rein to develop Body CT and the townspeople generously raised the money for a machine which was opened by HRH the Prince of Wales in 1981. But the NHS was not quite ready for CT! Not only did the town-based charity have to pay for the building, it also had to provide running costs for the first five years; we only received subsequent NHS funding in 1986 after a thorough Department of Health Audit of our work. Even then the local NHS was sceptical; the local oncologists saved the day by suggesting that they could manage more of their patients as outpatients if CT was available. The outstanding local fundraisers were so successful that the charity was able to fund top-of-the range MRI systems in Cambridge for some decades thereafter. Although there was one generous distribution of NHS funding for CT systems on the back of Sir Mike Richards’ cancer initiatives, NHS funding for high-end equipment has never really been properly addressed.


About Professor Adrian K Dixon

BIR Toshiba Mayneord Adrian Dixon 4

Professor Adrian K Dixon

Professor Dixon is Emeritus Professor of Radiology at the University of Cambridge and a retired Consultant Radiologist. He has published extensively on Computed Tomography and Magnetic Resonance Imaging and has edited several textbooks. He was Warden of the Royal College of Radiologists (Clinical Radiology, 2002–2006) and MR Clinical Guardian to the UK Department of Health (2004–2007). He has been awarded honorary Fellowship/Membership of Radiological Societies in Austria, Australia & New Zealand, France, Hungary, Ireland, Sweden, Switzerland and the USA. He was Editor-in-Chief of European Radiology 2007–12 and was awarded the Gold Medal of the European Society of Radiology in 2014. He has been awarded Honorary Degrees by Munich and Cork. He was Master of Peterhouse, University of Cambridge 2008–2016.