standard practice guidelines radiographers

8/3/2019 Standard Practice Guidelines Radiographers

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Radiographer ResponsibilitiesBy Prof. Dr. Omar Hussein

Prof. of Diagnostic Radiology

STANDARD PRACTICE

GUIDELINES FOR

DIAGNOSTIC

RADIOLOGY


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Egyptian Swiss Radiology Projecti

Preface

It is my honor to be on the head of a such a successful project asESRP (Egyptian Swiss Radiology Project) A project that made a

huge leap in the management of radiology services in the MOH,

not only in Site Rehabilitation & Equipment Procurement, but

also in making use of the most advanced technology solutions as

Tele-radiology to improve peoples health & medical education.

The idea of having a project that is concerned with improvingthe services of the radiology departments at the different MOH

hospitals all over Egypt; The ESRP in 2002 was established with

a mixed Swiss/Egyptian fund. The project made a very huge leap

in the radiology services. In the first phase 80, and in the second

phase109 radiology departments have been developed, starting

from rebuilding infrastructure according to specific international

requirements ended by supplying the hospitals by the latesttechnology in the radiology field.

Owing to the great importance of having guidelines for the different

operational steps at radiology departments, we had developed

these 6 books of guidelines to help each one in the radiology

department to make a change & difference in his domain to the

best. These guidelines are the fruit of efforts exerted by manyexperts from different backgrounds related to radiology field to

ensure that all points have been tackled, & by going through these

books it will help each one seeking for the best performance &

latest updates in this field.


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Egyptian Swiss Radiology Projectii

I would like here to thank the different parties that helped us

to reach this stage top on the list his Excellency Dr. Hatem Al-

Gabally Minister of Health whom without his support & guidancethis project wouldnt have seen the light.

I would also like to thank the Swiss tropical institute for believing

that together we can achieve the improvement required in the

radiology service.

Finally I would like to thank all the coordinators working at theESRP as well as the experts from different fields collaborating to

achieve our fruitful desired targets.

Dr. Dorria SalemProf. of Radiology Cairo University

Advisor of HE Minister of HealthESRP Manager


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Egyptian Swiss Radiology Projectiii

1 Radiographer Responsibilities 1

1.1 Handling the patient 1

1.2 Radiological procedures in Emergency cases and Patient

Needing Special Care in Radiology Department2

1.2.1 Accident victims 2

1.2.2 Head Injuries 2

1.2.3 Spinal Injuries 3

1.2.4 Extremity fractures 31.2.5 Multiple Emergencies 3

1.2.6 Pediatric, Geriatric and Diabetic patients 4

1.2.7 Bedside Radiography 4

1.2.8 Neonatal Nursery 5

1.3 Patient preparation 5

1.3.1 Procedure for Preparation for conventional radiological studies 6

1.3.2 Preparation for contrast studies 6

1.4 Computed Radiography (CR) and Digital Radiography (DR) 7

1.4.1 Computed Radiography (CR) 7

1.4.2 Digital Radiography (DR) 8

1.5 Computed Tomography and Magnetic Resonance Imaging 9

1.5.1 Computed Tomography (CT) 9

1.5.2 Magnetic Resonance Imaging (MRI) 11

1.6 The Darkroom 15

1.6.1 Processing 17

Table of Contents


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Egyptian Swiss Radiology Projectiv

1.6.2 Responsibility 21

1.7 Quality Assurance 23

1.8 Documentation 26

1.9 Supplies and Consumable Storage and Handling 26

1.9.1 Handling and Storage of X-ray Films 26

1.9.2 Handling and Storage of Chemicals 29

1.9.3 Handling and Storage of Contrast Media 31


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Egyptian Swiss Radiology Project1

Standard practice guidelines for Diagnostic Radiology

1. Radiographer Responsibilities

1.1 Handling the patient:Procedure:

- Before starting any radiological technique

1. Avoid undue delay and do not leave the patient unattended in the waiting

area, take into consideration his anxiety and fear, unconscious or irritable

patient may fall from the stretcher if left unattended.

2. Careful identification of the patient`s name to know exactly what procedure

will be done.3. Talk to the patient in a friendly way , call him by his name and introduce

yourself, explain in a simple language what is going to happen, what he will

feel, what is expected from him to undergo successful procedures and how

long the examination will take. This will lead to his cooperation.

4. Ask if the instructions given for the preparation were correctly carried out

or not.

5. Enquire about any premedication given before starting the examination.6. Careful transfer of the patient from wheel chair or stretcher to x-ray table.

7. Beware of urinary catheters, collection bags or drainage tubes.

Responsibility and Documentation:

Radiographer should write in patient request form any observation

concerning patient preparation, premedication, presence of catheters or

collection bags.

- After the examination:

Procedure:

1. Check that the patient is feeling well and everything went right and that

the vital signs are back to normal.

2. Check film quality is satisfying and refer to radiologist for confirmation

3. Avoid undue delay in sending patient back to his room if hospitalized.


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1. Adverse reactions to contrast media must be promptly treated and

carefully reported on patient`s chart, including details of treatment.2. Report any patient discomfort, pain , bleeding especially after invasive

procedures to the radiologist in charge.

1.2 Radiological procedures in emergency cases and patient

needing special care in radiology department:

1.2.1 Accident victims:

Procedure:1.The most common emergencies in the radiology department are traumatology

cases.

2. By the time the patient arrives to department, airway should be secured with

iv infusion line in place.

3. Avoid cutting or tearing clothes before radiographic examination if patient

is still dressed.

4. Patient manipulation should be minimal to avoid exacerbation of trauma.

Responsibility:

1.When radiographs are taken and reviewed, they are sent with accompanying

nurse ( make sure patient identification clearly written on films).

Documentation:

Any observation regarding limited movement or positioning, patient`s

consciousness, distress should be:

1.2.2 Head Injuries:

1. Watch for deterioration in the level of consciousness and signs of increased

intracranial pressure (irritability, lethargy, slowing pulse and respiration).

2. The most important consideration in dealing with unconscious patients

is to maintain a free airway. The airway is commonly compromised by

accumulated saliva, blood or vomits, which can be aspirated in the lungs.


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3. The safest posture that will avoid these complications is the lateral decubitus

position. However, if the patient must be positioned for radiography

careful monitoring is necessary and the patient should be returned to lateraldecubitus position as quickly as possible.

4. Patients with head trauma may not show external signs of trauma. CT

examination when available is the first choice to evaluate both skull and

brain and should be done as fast as possible.

1.2.3 Spinal Injuries:

1. Suspected fracture spine are transported prone. Never attempt to put them

supine since any movement can increase the risk of cord injury.

2. Where possible exposures are made without moving the patient. A lateral

shoot through radiograph with a horizontal beam is taken and evaluated

before positioning the patient for additional views.

1.2.4 Extremity fractures:

1. When it is necessary to position a fractured limb without splint, avoid rough

handling and minimize movement of fractured segments. This can cause a

closed fracture to develop into a compound one or may injury a near by

vessel, plus the considerable patient pain.

2. The extremity must be supported at sites proximal and distal to the fracture

at least by two persons.

Responsibility:

1. Splinting devices should not be removed except after permission from

physician.2. Evaluate the taken films before positioning the patient for additional

views.

1.2.5 Multiple Emergencies:

Patients are usually admitted to the radiology department on a scheduled

or on a first to come first served basis. When more than one patient


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requires examination at the same time, highest priority should be assigned to

patients who:

- Have unstable vital signs.

- Have severe respiratory distress.

- Need immediate care, depending on the result of the examination.


In cases of major accidents, some of the victims may be with unknown

names. To avoid incorrect identification of the victims, these are usually

assigned numbers which are written on tags and attached to their wrists

or ankles. These numbers are recorded on the x-ray requests and are used

to identify the radiographs of each patient. This may prove to be very

important from the medicolegal point of view later on.

1.2.6 Pediatric, Geriatric and Diabetic patients:

Radiology departments always make it a practice to begin the daily routine

with patients who must fast in preparation of their examination, so that they

will not have to go without food for too long.

Procedure:

After the emergency patients have been examined, the next priority should

be on pediatric and geriatric patients where fasting is difficult for long

periods for them. Also diabetics who postpone their insulin shot after

their breakfast and come fasting for a barium study are considered of high

priority for examination .

1.2.7 Bedside Radiography:Bedside radiography by mobile or portable x-ray unit is requested when

patient condition makes it difficult or hazardous to transport the patient. It

is usually requested for:

1. Patients in I.C.U who are critically ill, or those injured who require constant

monitoring or ventilator dependent.


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2. Patients on orthopedic traction .

3. Fractured long bones with traction to maintain the alignment of the fragments

as they heal .4. Patients with major surgery in the immediate postoperative period, having

nasogastric tube, intercostals drainage tube,

Procedure :

1. Sterilization and special precautions are mandatory in I.C.U.

2. Gentle care in handling critical patients.

3. Take more than one film before leaving to film processing to avoid errors of

dosage or positioning of patient .

1.2.8 Neonatal Nursery:

Premature babies nursed in incubators, newborns with incomplete

lung expansion are all high risk patients. Some infants may be safely

removed from the incubator for brief periods of time and can be examined

radiographically on an open table. The neonate at risk must be radiographed

within the incubator.

Procedure:

Whether radiographed in x-ray department or in incubator, proper

immobilization and choosing the proper technical factors are important to

avoid re-exposure.

Responsibility:

It is the physician responsibility to decide the neonate to be radiographed

outside or inside the incubator according to his clinical condition and not

the radiographer.

1.3 Patient preparation:

Many requested X-ray studies need no special preparation and can be done

immediately according to the workload of the department or the acuteness

of the patient`s condition, e.g. patients with pneumothorax or suspected

fractures.


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Any investigation in the abdomen and pelvis needs a clear colon and empty

stomach practically in techniques using contrast media. Patients with

suspected volvulus or ileus do not need colonic cleansing before the study.

1.3.1 Procedure for Preparation for conventional radiological

studies:

Radiography of the skull, axial and peripheral skeleton , chest and heart

X-rays do not need any preparation.

Infants, babies and irritable , uncooperative patients may require mild

sedation and additional help to restrain their movement in order to obtain

optimal radiographs.

Responsibility:

Sedation should be given by a nurse.

1 or 2 teaspoonful of chloral hydrate will be sufficient to sedate infants and

children.

10 mg Diazepam (1 ampoule Valium) for adults i.m or i.v.

Uncooperative patients or babies should be attended by a member of their

family or a nurse to minimize their movement.

Documentation:

Any sedative agent and dosage should be reported in patient`s sheet.

1.3.2 Preparation for contrast studies:

Procedure for upper GI Baruim series:

No smoking as this increases gastric secretions.

Fasting for 6 hours at least.Procedure For lower GI Barium enema:

A meticulous cleansing of the colon is mandatory.

The day before the study give fluid diet aiming at reducing faecal residue in

the colon, e.g juice, tea, broth. Dairy products are to be avoided.

The night before the examination give light supper , eg a piece of bread and

cheese and a cup of tea or one fruit or one cup of juice.


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A laxative should be given to clean bowel, either castor oil 60cc flavoured

with mint extract, or tablets (alphalaxine or boldolaxine) 2 tablets at 6 pm

In the morning (day of study) , if patient still passes stools, make a lowenema (either ready made enemax or prepare one by mixing 1.5 l warm

water with 2 tablespoons sodium chloride) . Enema should be done 12-

hours before the study to give time to water in the colon to be absorbed or

otherwise it will dilute the barium enema.

Patient preparation for any radiographic examination of the abdomen,

urinary tract and pelvis (particularly contrast study) is similar to the

preparation for barium enema.

In urographic studies, no need for fluid restriction, on the contrary

encourage the patient to drink as much as possible. Newer contrast media

render excellent visualization of the urinary tract and well hydrated patient

is desirable

Responsibility:

If preliminary films taken before contrast administration revealed poor

patient preparation, the radiographer should report this to radiologist before

further continuation or postponing of procedure.

1.4Computed Radiography (CR) and Digital Radiography (DR)

1.4.1 Computed Radiography (CR):

Procedure:

Rather than utilizing conventional x-ray film to capture an image, computed

radiography uses an imaging plate contained inside the cassette. This plate

contains photo sensitive storage phosphors which retain the latent image.

When the imaging plate is scanned with a laser beam in the digitizer, the

latent image information is released as visible light.

This light is captured and converted into a digital stream to compute the

digital image.

The CR systems require the purchase of a reader/ eraser workstation with

computer and software.


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Dry printer camera is needed for printing the films (no chemicals are used

in the procedure).

1.4.2 Digital Radiography (DR):Procedure:

Utilizing this process, the image is captured directly on the flat panel detector

and the image is transmitted directly to the computer. No intermediate steps

or additional processes are required to capture the image. Process provides

a direct feed from panel to imaging workstation.

DR systems require the purchase of an imaging panel, cable, computer and

software.

Dry printer camera is needed for printing the films (no chemicals are used

in the procedure).

Advantages of Computed Radiography CR and Digital Radiography DR:

The storage phosphors on the Digital Imaging Plate have an extremely wide

dynamic range. This gives a high tolerance for varying exposure conditions

and a greater freedom in the selection of the exposure dose.

As a consequence, the need for retakes is drastically reduced Digital radiographic image:Ability to copy and duplicate without loss of

image quality, E-mail image which can be read on any PC, Software image

enhancement and analysis tools, Ability to zoom, compare multiple images

and perform a variety of analytical functions while viewing the images, No

image degradation over time, Rapid storage and retrieval.

CR can be placed inside or close to X-ray room.

No requirement for darkroom or chemical processing; environmentally

friendly.

Exposure time reduction from 5 to 20 times less than film.

Safe operation with minimum Small Controlled Area.

Up to 10,000 times re-usable phosphor flexible plates.

Less physical storage space required.


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The wide dynamic range makes it possible to investigate and evaluate more

complex shaped parts with a wider thickness range than possible with film

in only one exposure i.e. Reduces numbers of exposures for multi-thicknesssections.

Reduction in radiation exposure thus causing increases personal and

environmental safety.

Imaging Plate effectively substitutes for film using same basic set-up,

settings and using existing film holders.

Disadvantage of CR and DR:

Initial cost of equipment is high as compared to conventional radiography.


Patient identification is written through the workstation and printed on each

film.

Proper training and computer knowledge is mandatory for good film

processing and archiving data for follow up cases.

1.5 Computed Tomography and Magnetic Resonance Imaging

1.5.1 Computed Tomography (CT):

CT produces a volume of data which can be manipulated, through a process

known as "windowing", in order to demonstrate various bodily structures

based on their ability to block the X-ray beam. Although historically the

images generated were in the axial or transverse plane, orthogonal to the

long axis of the body, modern scanners allow this volume of data to bereformatted in various planes or even as volumetric (3D) representations

of structures.


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Process:

X-ray slice data is generated using an X-ray source that rotates around

the object; X-ray sensors are positioned on the opposite side of the circlefrom the X-ray source. The sensors are scintillation detectors based on photo

diodes instead of photomultipliers with more desirable characteristics. Many

data scans are progressively taken as the object is gradually passed through

the gantry. They are combined together by the mathematical procedures

known as tomographic reconstruction. The data are arranged in a matrix in

memory, and each data point is convolved with its neighbours according

with a seed algorithm using Fast Fourier Transform techniques. Thisdramatically increases the resolution of each Voxel (volume element). Then

a process known as Back Projection essentially reverses the acquisition

geometry and stores the result in another memory array. This data can then

be displayed, photographed, or used as input for further processing, such as

multi-planar reconstruction.

Newer machines with faster computer systems and newer softwarestrategies can process not only individual cross sections but continuously

changing cross sections as the gantry, with the object to be imaged, is slowly

and smoothly slid through the X-ray circle. These are called helical or spiral

CT machines. Their computer systems integrate the data of the moving

individual slices to generate three dimensional volumetric information (3D-

CT scan), in turn viewable from multiple different perspectives on attached

CT workstation monitors. This type of data acquisition requires enormousprocessing power, as the data are arriving in a continuous stream and must

be processed in real-time.

CT is used in medicine as a diagnostic tool and as a guide for

interventional procedures. Sometimes contrast materials such as intravenous

iodinated contrast are used. This is useful to highlight structures such as


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blood vessels that otherwise would be difficult to delineate from their

surroundings. Using contrast material can also help to obtain functional

information about tissues.

Pixels in an image obtained by CT scanning are displayed in terms

of relative radiodensity. The pixel itself is displayed according to the mean

attenuation of the tissue(s) that it corresponds to on a scale from +3071 (most

attenuating) to -1024 (least attenuating) on the Hounsfield scale. Pixel is a

two dimensional unit based on the matrix size and the field of view. When the

CT slice thickness is also factored in, the unit is known as a Voxel, which is athree dimensional unit. The phenomenon that one part of the detector cannot

differentiate between different tissues is called the "Partial Volume Effect". That

means that a big amount of cartilage and a thin layer of compact bone can cause

the same attenuation in a voxel as hyperdense cartilage alone. Water has an

attenuation of 0 Hounsfield units (HU) while air is -1000 HU, cancellous bone

is typically +400 HU, cranial bone can reach 2000 HU or more (os temporale)

and can cause artifacts. The attenuation of metallic implants depends on atomicnumber of the element used: Titanium usually has an amount of +1000 HU,

iron steel can completely extinguish the X-ray and is therefore responsible

for well-known line-artifacts in computed tomograms. Artifacts are caused by

abrupt transitions between low- and high-density materials, which results in

data values that exceed the dynamic range of the processing electronics.

1.5.2 Magnetic Resonance Imaging (MRI):Magnetic resonance imaging (MRI), is primarily a medical imaging technique

most commonly used in radiology to visualize detailed internal structure and

limited function of the body. MRI provides much greater contrast between the

different soft tissues of the body than computed tomography (CT) does, making

it especially useful in neurological , musculoskeletal, cardiovascular, , cancer

imaging. Unlike CT, it uses no ionizing radiation, but uses a powerful magnetic


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field to align the nuclear magnetization of (usually) hydrogen atoms in water

in the body. Radio frequency (RF) fields are used to systematically alter the

alignment of this magnetization, causing the hydrogen nuclei to produce arotating magnetic field detectable by the scanner. This signal can be manipulated

by additional magnetic fields to build up enough information to construct an

image of the body. MRI, on the other hand, uses non-ionizing radio frequency

(RF) signals to acquire its images and is best suited for non-calcified tissue,

though MR images can also be acquired from bones and teeth .

Contrast agents for MRI are those which have paramagnetic properties, e.g.

gadolinium and manganese.

Both CT and MRI scanners can generate multiple two-dimensional cross-sections

(slices) of tissue and three-dimensional reconstructions. MRI has a long list of

properties that may be used to generate image contrast. By variation of scanning

parameters, tissue contrast can be altered and enhanced in various ways to detect

different features.

MRI can generate cross-sectional images in any plane (including oblique

planes).

MRI is also best suited for cases when a patient is to undergo the exam several

times successively in the short term, because, unlike CT, it does not expose the

patient to the hazards of ionizing radiation.

Pacemakers and implants:

Pacemakers are generally considered an absolute contraindication towards

MRI scanning, though highly specialized protocols have been developed

to permit scanning of select pacing devices. Several cases of arrhythmia or

death have been reported in patients with pacemakers who have undergone

MRI scanning without appropriate precautions. Other electronic implants have

varying contraindications, depending upon scanner technology, and implant

properties, scanning protocols and anatomy being imaged.


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Many other forms of medical or biostimulation implants may be contraindicated

for MRI scans. These may include vagus nerve stimulators, implantable

cardioverter-defibrillators, loop recorders, insulin pumps, cochlear implants,deep brain stimulators, and many others. Medical device patients should always

present complete information (manufacturer, model, serial number and date

of implantation) about all implants to both the referring physician and to the

radiologist or technologist before entering the room for the MRI scan.

While these implants pose a current problem, scientists and manufacturers are

working on improved designs which will further minimize the risks that MRI

scans pose to medical device operations. One such development in the works is

a nano-coating for implants intended to screen them from the radio frequency

waves, helping to make MRI exams available to patients currently prohibited

from receiving them. The current article for this is from New Scientist.

Ferromagnetic foreign bodies (e.g. shell fragments), or metallic implants (e.g.

surgical prostheses, aneurysm clips) are also potential risks, and safety aspects

need to be considered on an individual basis. Interaction of the magnetic and

radio frequency fields with such objects can lead to trauma due to movement of

the object in the magnetic field, thermal injury from radio-frequency induction

heating of the object, or failure of an implanted device. These issues are especially

problematic when dealing with the eye. Most MRI centers require an orbital

x-ray to be performed on anyone suspected of having metal fragments in their

eyes, something not uncommon in metalworking.

Because of its non-ferromagnetic nature and poor electrical conductivity,titanium and its alloys are useful for long term implants and surgical instruments

intended for use in image-guided surgery. In particular, not only is titanium safe

from movement from the magnetic field, but artifacts around the implant are less

frequent and less severe than with more ferromagnetic materials e.g. stainless

steel. Artifacts from metal frequently appear as regions of empty space around

the implant- frequently called 'black-hole artifact'. e.g. a 3 mm titanium alloy


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coronary stent may appear as a 5 mm diameter region of empty space on MRI,

whereas around a stainless steel stent, the artifact may extend for 1020 mm or

more.In 2006, a new classification system for implants and ancillary clinical devices

has been developed by ASTM International and is now the standard supported by

the US Food and Drug Administration:

MR Safe signMR-Safe - The device or implant is completely non-magnetic, non-electrically

conductive, and non-RF reactive, eliminating all of the primary potential threats

during an MRI procedure.

MR Conditional sign

MR-Conditional - A device or implant that may contain magnetic, electrically

conductive or RF-reactive components that is safe for operations in proximity

to the MRI, provided the conditions for safe operation are defined and observed

(such as 'tested safe to 1.5 teslas' or 'safe in magnetic fields below 500 gauss in

strength').

MR Unsafe sign

MR-Unsafe - Nearly self-explanatory, this category is reserved for objects that

are significantly ferromagnetic and pose a clear and direct threat to persons and

equipment within the magnet room.


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Though the current classification system was originally developed for regulatory-

approved medical devices, it is being applied to all manner of items, appliances

and equipment intended for use in the MR environment.

In the case of pacemakers, the risk is thought to be primarily RF induction in the

pacing electrodes/wires causing inappropriate pacing of the heart, rather than the

magnetic field affecting the pacemaker itself. Much research and development

is being undertaken, and many tools are being developed in order to predict the

effects of the RF fields inside the body.

1.6 The DarkroomMany of the errors in X-ray diagnosis arise because of faults in processing. In

terms of patient care, a poor quality radiograph may be more harmful than the

patient not having an X-ray examination at all. An adherence to routine process

described in this book is extremely important in providing radiographs of high

quality and ensuring optimum health care.

The following recommendations should be taken into consideration whenever a

new darkroom is built or old places rearranged.

1. Location of darkroom:

The darkroom should be centrally placed next to the X-ray rooms.

2. Darkroom size and shape:

A long darkroom is more convenient than a square one because:

More wall space is available for equipment.

Less movement of personnel is required.

No wasted floor space in the center of the room.

A surface area of 6 square meters with a separate entrance is the minimal

requirement for a darkroom serving one X-ray examination room.

3. Light tightness:

There must not be any light coming into the darkroom. All potential openings

to the outside are light tight (doors, ventilation, windows). Entrances to

darkrooms are usually single doors which must be well fitted with stripped


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edges and have bottom seals. For most situations, simple devices such as

warning lamps on the door to indicate that film is being processed and clear

warning signs are appropriate.

4.Safelights:

All safe lights should be at least 1.3 m above the working bench and should

preferably be pointing upwards. The bulbs used in the safelights should never

exceed 25 Watts.

5. Ventilation:

The darkroom must be adequately ventilated and should have an adequate

extraction fan, which functions whenever the darkroom is in use. Air

conditioning should be considered if the temperature cannot be kept in the

range of 16o c to 24o c.

6. Finishing and wall color:

The color of the darkroom walls should not be black or dark. Maximal

reflection under safelight illumination is achieved if the wall color is white,

ivory, cream or a light posted shade.

Darkroom wall finishes should be resistant to splashes from processing

solutions; ceramic tiles are installed covering two meters above the floor.7. Dry and Wet areas:

The darkroom contains dry and wet areas.It must always be kept clean and

tidy.

The dry area contains a bench for the films, clean film hangers, film boxes

and cassettes. Your hands must be dry when you work at this bench.

The wet area consists of the processing tank holds the chemicals and washing

water for processing the X- ray films. The fixer must always be kept separatein their own tanks, which usually inside the processing tank.

8. Continuous warm and cold water supply:

An extra water outlet for automatic processor has to be provided. A pump

is installed to increase water pressure if automatic processing unit shall be

used.

9. Cleaning facilities:

Large sink for cleaning rollers and efficient water disposal system.


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1.6.1 Processing:

A-Manual Processing:

Processing is a series of actions by which exposed X- ray film yields an image.

In processing a film, the subsequence of actions should be as follows:

1. Mark the patients name on the film.

2. Develop the film.

3. Rinse developer from the film.

4. Fix the film.

5. Wash the fixer from the film.

6. Dry the film.

7. Check the name, date and patient number on the film, and check the right

and left marks.

The manual processing steps are:

1. Using separate paddles, stir the developer and the fixer thoroughly to

equalize the temperature and chemical activity of the solution. Adjust the

temperature at 20o c.

2. In safelight condition remove the film from the cassette and load it on a

processing hanger of an appropriate size (attach the lower corners first to

ensure correct tension of the film in hanger).

3. Keep fingers to edge of film only immerse the film smoothly in the developing

solution and set the timer for correct developing time, ensure that the film

does not touch the side of the tank or adjacent films. Agitate the film several

times and repeat this once every minute during development to remove

air bubbles and distribute developer all over the film. On the completionof development, remove the film from the developer. Development time:

a film is completely developed as soon as the development time has been

seven times as much as has been required for appearance of the first image

tracers.

4. Rinse the film in the running water or in the acid stop bath for at least 30

seconds. Lift from rinse bath and drain the hanger well before moving to

the fixer.


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5. Immerse the film in the fixer solution and agitate it until it becomes clear,

and the milky look has disappeared. Do next expose the film to while light

until the emulsion has cleared. Fixation time is double the clearing time, atleast 5 minutes.

6. Lift the film from the fixer and transfer directly to the washing tank and

leave the film in running water for 30 minutes.

7. Drain.

8. Dry in dust free atmosphere preferably by circulating warm air in a drying

cabinet or on an air-drying rack. Keep the films well separated during

drying.

9. Do not remove films from hangers until they are fully dry and trim corners

to remove clip marks, insert films in identified envelopes with the X-ray

request; they are now ready for reporting.

Important Recommendations for Manual Processing:

1. Measure the liquid capacity of solution tank (Width x length x total depth)

in inches divided by 277 (cubic inches per gallon) will indicate true capacity

of a tank. This to assure the use of correct amount of concentrate solution

when mixing chemicals.2. Mix solutions carefully and completely according to manufactures

directions.

3. Stir solutions thoroughly at least once a day or after they have stood idle for

a period of time, to prevent precipitation of chemicals.

4. Use a thermometer to check the temperature of solutions.

5. Keep the solution tanks, particularly the developer, covered when not in

use, to reduce evaporation and air oxidation.

6. Maintain scrupulous cleanliness around the tanks and wipe up any accidental

spillage of chemicals before some permanent damage results in accident. A

dirty darkroom produces dirty films.

7. Clean the processing tanks periodically. Even stainless steel will stain if not

cared for properly.

8. Maintain order in the darkroom. It should not be used as a storehouse;

however, it is a place for everything but everything is in place.


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9. Agitate film periodically during development and for the first few seconds

after placement in the fixing solution. This will prevent streaking of the

film or formation of air bubbles.10. Remove film carefully from the various chemicals to avoid splashing into

the other tanks.

Please Remember

1. Dont compound an error in exposure by sight developing the film. Sight

development does not work e.g. on over exposure a film is not corrected by

under development.

2. Dont handle film or cassettes and dont go near the workbench with wet

hands.

3. Dont place on hangers more films than can be accommodated in the

developer tank at one time. The extra- film is completely protected against

safelight fogging until put in the developer.

4. Dont crowd films in the solution tanks leave about one inch space between

hangers in the tank to prevent scratching or adhesions of films.

5. Dont forget to cover all unexposed films before turning on any white lightto avoid fogging.

6. Dont allow cassettes to stand open on the working bench.

7. Dont store films with the boxes lying on a flat side. Stand them on edge.

8. Dont over fix films, to avoid fading of silver image on the film.

9. Dont fail to have an adequate supply of developer replenisher mixed and

ready for use at all times to top up the tank level or prolong the life of the

developer. Never top up developer by adding water.10. Mix solutions carefully and completely according to manufactures

directions.

11. Stir solutions thoroughly at least once a day or after they have stood idle for

a period of time, to prevent precipitation of chemicals.

12. Keep the solution tanks, particularly the developer, covered when not in

use, to reduce evaporation and air oxidation.


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Automatic Processing:

The increase in films volume used, plus the ever present desire to see

radiography at the instant an exposure terminates, brought about andexpanded the use of the automatic X- ray film processing system. The

treatment of the film in the automatic processor is not a new method of

working, when compared to the manual development, as in the machine

also, the films have to undergo developing, fixing, washing and finally

drying.

The only difference remains in the fact that every film is treated exactly in

the same way and there is no rinse between the developer and fixer.

The main components of an automatic processor:

1. Transport system for passing the films through the processing solution and

dryer.

2. A series of thermostats for maintaining correct temperature in the different

phases.

3. A system for replenishment of the processing solution according to the

surface area of the films processed.

4. Circulation devices for chemicals and wash water which allow one to carryout consistent processing.

5. Hot air ventilation system for film drying in the roller processor, the machine

consists of a feed table, three vertical tanks (for development, fixing and

washing respectively a dryer and a collector.

Chemicals and films used in automatic processing units:

Automated processing is not just mechanization of the hand processing,

but a process depending on the interrelation of mechanics, chemicals andfilms. Special chemicals and films were developed to meet the particular

needs and conditions of automated processing (films and chemicals used in

manual processing cannot be used in the automatic processing machine).

Advantages of automatic processing:

The introduction of automatic processing has made a major impact in the

radiology departments and has benefited many other departments in the


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hospital as well e.g. outpatient clinics, causalities and emergency unit , to

the extent that the duties and routine steps in such departments have to be

reorganized according to the rapid rate of services offered by the radiologydepartment.

Technical advantages:

Constant processing parameters and stability of radiolographic quality.

Shortening of both processing and access time.

Economic advantage:

Small floor space occupied by the processor.

Film hangers and drying cabinet are not required. Saving in personnel, one trained technician can run the room efficiently

and produce large number of films.

Reduction in the patients waiting time.

Longer life of the X-ray tubes because of lower load on them as the repeat

exposures are kept to minimum.

1.6.2 Responsibility:

The working principles of the automatic processor :

Operating the processor is extremely simple, and does not need special

trained staff. The main point is to carefully observe the following

instructions, and to check at regular intervals that the machine is processing

the film satisfactorily.

Daily maintenance and periodical servicing:

Experience has shown that an automatic processor will stay mechanically

and photographically completely reliable in operation as long as regularmaintenance is carried out exactly as described in the instruction manual of

the processor (weekly, monthly, quarterly and yearly).

The working routine should include the following operation for the

automatic processor:


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1.6.2. a) Before startup the days work:

Remove the crossover and the tank lid, using water moisten cleaning pad,

wipe over the rollers and guide plates in the wet section of the processorwhich are above the liquid level.

Switch on the heater elements for the processing solution (which requires

about 15 -20 minutes to reach the working temperature).

Open the water valves, in the case of a processor with hot water supply, check

the temperature and delivery rate of the water and adjust if necessary.

Check whether the solutions in the processing and replenisher tanks are at

the proper level, color and smell, check replenishment hoses for binds or

leaks.

Start the dryer a few minutes before the solutions reach the required

temperature. In the case of the processor provided with a energy saving

device, the dryer is automatically switched on as soon as the first film is fed

into the processor.

Replace crossovers and tank lids.

When the machine is ready for processing, feed up four large waste (clean)

films into the processor in order to remove possible residual chemicalsfrom the rollers and guide plates or feed in one unprocessed 14X17 inch

film instead of the processed film as these are harder and contain fixer.

Inspect the processed clean up film. Feed a second film if feel necessary do

not proceed with the daily workload until you are satisfied that the rollers

are clean.

1.6.2.b) Procedure while the automatic processor is in operation:

Place the film on the feed table and hold it between thumb and forefinger to

avoid kinks. Without exerting any pressure and without bending the film,

push it into the feed slot until it is gripped between the first pair of rollers.

It is advisable to load films alternatively at the right and left hand side of the

feed table, so as to use the full length of the roller evenly.

After a film has been fed into the processor, wait for the visual or audio

signal before inserting the next one.


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Always feed the long side of the films into the processor, narrow films

can be fed two sides by side, provided that a space of about 4 cm is left

between them. Films should be allowed to freely drop into the receiving tray as they

leave the dryer. Films must never be pulled from the dryer, as this may

damage the film and or the transport system.

The processor is immediately and automatically switched off by a build

in a safety micro switch when the lid cover is removed. In case of any

abnormal noise or vibration; stop the processor by removing the lid cover,

check for the reason to prevent further damage.

Documentation:

Record in a separate document dates of regular cleaning of tanks, chemicals

renewal, expiry dates of chemicals .

1.7 Quality Assurance

A- The general principles associated with good imaging performance are:

1. Film identification or imaging annotation .

Documentation: Patents name, sex, age.

Date.

The hospital name.

The part examined and timing if sequential films are taken.

Positional marker R, L.

Technician ID.

These should not obscure the diagnostically relevant region of the radiograph.

2. Proper technical factor

- The proper K.V. & mAS and screen film combination The F.F.D. and the focal

spot size (large focal spot sizes are employed with large F.F.D. and smaller

foci are employed with faster screen film combination).

- Bucky or no bucky.

- Size of the film to be used and central ray.


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3. Patient positioning

Correct patient positioning plays a major role in the production of a diagnostic

radiogram. Suitable immobilization and compression devices have an importantrole to play in the production of satisfactory images.

A handling book of patient positioning should be available in the department

for learning and reference in special unusual positions

4. X-ray beam limitation

Image quality is improved and the radiation dose to the patient is reduced

by limiting the X- ray beam to the smaller field giving required diagnostic

information.

Radiosensitive organs should be excluded from the field of irradiation whenever

possible.

On no occasion should the x-ray beam fall outside the image receptor area.

Evidence of beam limitation on the film is desirable e.g. edge of the diaphragm

limiting he lumbar spine. An automated beam limitation device would be

helpful.

5. Protective Shielding

Lead shielding of the testis and ovaries particularly in young patient and in

repeated examination as in congenital hip dislocation is essential.

6. Diagnostic radiograph

The three properties of a diagnostic radiography are:-

a. Proper density or blacking.

b. Good contrast.

c. Clear definition.

Film density is the most important and in its absence the other properties lose

their significance.For the diagnostically relevant part of the film the overall range of optical

densities should be between 0.5 and 2.2, however film blacking is subject to

personal preference of the radiologist.

When a film has been found to be too dark it should be viewed with a bright

spotlight before a decision is made to repeat the examination.

A dark film is usually associated with a relatively higher patient dose.


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7. Radiographic exposure per examination

The number of radiographic exposure with one examination must be

kept to a minimum, consistent with obtaining the necessary diagnosticinformation.

8. Film processing

Optimal processing of the radiographic film has important implication on

the diagnostic quality of the image.

Proper darkroom technique should be followed.

Regular maintenance of the processing equipment.

9. Image viewing conditions

Proper assessment of the image quality and accurate film reporting can be

best achieved by proper viewing condition, means to restrict the area to the

radiography to avoid dazzling.

- Additional spotlight with iris diaphragm for viewing exceptionally dark

areas in the radiographic image

- The reporting room should be of a relatively low level of light.

10. Reject analysis

Rejected films should be collected, the reason for rejection should be

analyzes and corrective action should be taken.

A checklist for number of rejected films, cause, name of technician should

be revised every month.

A- Quality assessment of the radiographs:

The aim of the quality criteria is to characterize a level of acceptability of

normal basic radiogram.

Quality and safety is the hall works for efficient and successful medical

service using ionizing radiation.The quality criteria are designed to be carefully applied in any X-ray

department without the need for special equipment apart from a means of

measuring or estimating the dose to the patient.

There are indented to provide a standard of good practice both in terms of

a satisfactory level of image quality and acceptably low radiation dose to

the patient.


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The factors affect the radiographic quality:

Proper patient positing.

Proper imaging devices. The selection of the proper technical factors.

These factors are very much interrelated and for any given radiographic

examination, a proper interpretation and application of each of these factors

must be made. A smaller change in one may require a compensating change

in another.

1.8 Documentation:

Every patient data (Name, age, sex, date and type of examination) should

be registered and archived in a separate notebook or in a computer file.

Number and sizes of used and wasted films should be recorded (by using

CR or DR technology this record of wasted films is cancelled).

Any recorded allergy to contrast media, its nature and treatment should be

also recorded.

A copy of technician name and radiological report for any further follow up

or enquiry by clinician or patient.

A separate file concerning used radiologic tools ( cannulas, catheters, guide

wire, biopsy needles.) and contrast vials should be available with chief

nurse. These should be checked and reduced from storage stock every

month.

1.9 Supplies and Consumable Storage and Handling:

1.9.1 Handling and Storage of X-ray Films:

1) X-ray Films

a) Films sizes commonly used in medical radiography

Film sizes in inches Film sizes in centimeters8x10 18x24

10x12 24x30

12x15 30x40

14x14

14x17


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Less commonly used films

4x10 inches 13x18 Cm.

6.5x8.5 inches6x12 inches

11x14 inches

b)Packing of X-ray films

Some x-ray films are supplied in bulk with no interleaving; others are

supplied interleaved (folder wrapped).The films are packed sealed in

special waterproof polythene composite foils, which are packed in special

cardboard boxes.

Each box contains 25, 50, 75 or 100 films and they should not be opened

except under the recommended safelight condition.

c) Storage of x-ray films

All photographic materials deteriorate very gradually from the date of

manufacture, the rate deterioration depending on the storage conditions.

Under the recommended storage condition, the deterioration doesntbecome significant until after the expiratory date printed on the box.

Under poor storage conditions, the rate of deterioration may increase, and

in fact the film may become unsatisfactory before expiratory date.

The principle effects of deterioration are a gradual increase in the basic fog,

a fall in contrast and a change in speed (some films may gain speed and

others may lose speed).

Heat, light, humidity, x-rays, radioactive substances, chemical fumes,

pressure, rolling, bending, etc., are all capable of adversely affecting the

x-ray emulsion and consequently, care must be taken when storing x-ray

films to avoid these conditions.


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Procedure of Ideal storage conditions of x-ray films:

1. A temperature not exceeding 20oc and a relative humidity of not less than

50% and not more than 65% i.e. cool and dry. Sealed package of films areaffected by heat and opened package by humidity as well as heat. Normal

aging of photographic products occur four times quicker if these products

are stored at 30oc instead of 20oc.

2. Dont store films near heat sources such as radiators steam pipes, or where

gases such as vapours of formalin, hydrogen sulphide, or ammonia can leak

into the air and fog the films.

3. Fog due to ionizing radiations is not easily avoided since sensitivity to thesewavelengths is one of the essential characteristics of an x-ray film. This

problem can only be overcome by protecting the films from such radiation,

while they are in the storage area, in the darkroom or even in the exposure

rooms.

4. The x-ray films should be ordered in quantities to provide reasonably rapid

turnover and ensure freshness. In departments where large number of film

boxes is stored, the boxes should be placed vertically on their edge, oneclose to the other as books in such a way that narrow side on which expiry

date is printed is visible. They should never be stacked flat one on top of the

other as this would cause the lower box to bear the pressure of all the other

and, in time, would damage the coats of emulsion which are also sensitive

to mechanical injuries. The way the boxes are arranged should permit

easy access to the boxes, which have been in stock for the longest time,

this method avoids excessive aging of some films. Consequently, newly

requested boxes should be placed at the back of those which have been instorage for some time, or placed at their side and clearly marked with easily

readable numbers. If the boxes are used in numerical order the material will

always be fresh and upon, give good uniform result (first in, first out).


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5. Special fire precautions are not required because the x-ray films are made of

safely base with low inflammability.

If the films are kept in refrigerator, to ensure that the cooled films do not

become clouded when their packing is opened, it is essential that the boxes

or film should be left unopened for 12 hours after they have been removed

from the refrigerator.

1.9.2 Handling and Storage of Chemicals:

In manual processing:

The chemicals whether the developer or the fixer are supplied either in

powder form or as concentrated liquids preparation.

In automatic processing:

- The chemicals are supplied only as concentrated liquid preparation.

- They are stored in the darkroom if there is enough space, if not they can

be kept anywhere in the department.

- In preparing the solution follow the instruction of the manufacture.A) Preparation of Developer Solution in Manual Processing:

Preparation procedure of developer from powdered chemical:

Preparation of powdered chemical should be done in a separate room to

avoid contamination of sensitized material from chemical dust rising in the

air during processing.

If this is not practical, wipe the loading bench with a damp cloth to remove

any trace of chemical dust after the solution is mixed.The chemicals are supplied in two bags:

- Bag 1 (the bigger one) contains the developing agents.

- Bag 2 contains the accelerator, the preservative and the restrainer.

1) Pour water in clean tanks first. Add the contents of bag 1, till it is completely

dissolved, then the contents of bag 2 are gradually added with continuous

stirring till all the contents are dissolved.


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Proper stirring is particularly important to prevent caking or the formation

of lumps of chemicals. Keep dusting to a minimum by slow careful pouring

of the powder avoid dust inhalation or eye contact.2) Add cool water to top up the solution to the correct volume of the tank and

to the proper temperature.

- The developer shouldnt be used except on the next day or at least left to

stand for 12 hours before it is ready for use.

- The tank containing the developer should always be covered to reduce

evaporation, contamination and surface oxidation.

B) Preparation procedure of developer from liquid solution:

1) Dilute the concentrated solution with water with quantities indicated and

at the recommended temperature, so that all the ingredients will go into

solution properly.

2) Stir thoroughly so as to obtain perfect homogeneity of the liquid.

Preparation of Fixer Solution in Manual Processing:

The water used in preparing fixer solutions should not exceed 27.5O c,

otherwise the destruction of the fixing agents will be speeded up and the

possibility of forming sludge of aluminum hydroxide is increased.

Preparation of Chemicals in Automatic Processing:

The chemicals are always supplied in liquid form.

The developer is supplied in three parts:

Part A: containing the developing agent (hydroquinone), the alkali and the

preservative.

Part B: containing the developing agent (phenidone) and the fungicide.

Part C: the hardener.The solution is made up by dissolving the contents of A in 15 liters of water

at 40.5f c with continuous stirring, then add the contents of B.

After dissolving of A and B, add C with continuous stirring and top up with

cold water until the final volume of 20 liters is obtained.

Higher temperature during preparation results in irreversible damage, and

consequently in decomposition of the developer.


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A starter is added to the tank before it can be used (20-25 ml starter for each

one liter of the prepared solution).

The fixer is supplied in 2 parts:Part A: contains fixing agent, preservatives, buffer and antisludge agent.

Part B: contains the hardener and an acid

The content of A is added to the water tank then the content of B and

thoroughly mixed.

These chemicals when prepared must be allowed to stand not less than

12 hours before use. Non-observance of this rule may cause poor image

quality.

In automatic processing the prepared developer and fixer are used as areplenisher, while in manual processing for the developer there is a special

replenisher, but the fixer doesnt have special replenisher, the fixer itself is

used.

The replenisher of the developer in manual processing cannot be used as

original developer.

1.9.3 Handling and Storage of Contrast Media:After the final quality control made by the manufacturer, months or even

years may pass before the CM are actually used. During that period, the

products are transported and stored under varying conditions, which may

impair the quality of the CM solution.

1. The stability of CM is satisfactory at normal room temperature (15-25 degree

Celsius). There is no need to store the product in a cool place unless this is

clearly expressed on the label.

2. X-ray contrast media are sensitive to light and to some extent to irradiation.

They should be stored in a dark place (e.g. in a cupboard) and not nearX-ray equipment.

Although brown glass ampoules protect the solution from light, they have

the disadvantage that any fragment may go unnoticed in the solution (eg

fragments from the stopper, or crystals) or that changes in colour of the

solution are not easy to recognize. That is why colourless glass containers

are preferable. The outer pack is not removed until shortly before use.

Avoid direct sunlight exposure.


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3. Observe the expiry date storage under normal conditions is possible (shelf-

life of up to 5 years) Prolonged storage at a high temperature (eg 30 oc)

should be avoided as it accelerates degradation reactions .4. Examination of the contrast media solution for clarity before use

( discoloration, turbidity, cloudiness and precipitations are an indication of

imperfect quality and the solution should not be given to the patient).

Some compounds can crystallize at low temperature (in winter).These

crystals are easily seen and can be dissolved again in unopened container

by warming up to 30oc. Contrast media generally tolerate heating to this

temperature without problem since they are heated after manufacture to

120o

c for 20 minutes for purpose of sterilization.Warming of contrast media to body temperature (37oc) before use reduces

the viscosity of the contrast media to about a half, thus improving their

tolerance.

Risks of bacterial contamination:

Tri-iodinated urographic contrast media are originally developed from

antibacterial substances and conventional ionic contrast media display

distinct antimicrobial activity especially at high concentrations (300 mg/

ml and upward).Non-ionic contrast media are a good culture media for fungi and bacteria,

because of their chemical composition and tolerance.

To avoid the risk of microbial contamination :

1. Do not pour the contrast medium over non sterile lip of the original

container.

2. Do not keep open vials longer than 4 hours after first use.

3. Discard all remains at the end of the day .

4. Under no circumstances should unused solutions be returned to the original

vial .

5. Re-sterilization of solutions in opened containers is not permitted.

Bacterial contamination can , of course be recognized only macroscopically

at a very late stage.

The typical finding of fungal infection is a cloud of the suspensed particles

resembling a discolored cotton swab.


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