Journal

This week on placement I helped perform a skeletal survey on a patient with a condition called Monoclonal Gammopathy of unknown significance, often referred to as (MGUS). This condition is also sometimes referred to as paraproteinaemia. MGUS is often discovered by accident from a routine blood test. This is a condition which adversely affects the body’s white blood cells (plasma cells).

Although the immune system is composed of several types of cells working together, the main cell type of the immune system are lymphocytes: T cells and B cells. B cells respond to infection, they mature and change into plasma cells, which make the antibodies and help the body attack and kill germs.

Normal plasma cells are found in the bone marrow, they are an important part of the body’s immune system, and they produce proteins for the body, known as antibodies or immunoglobulins. Antibodies circulate in the blood attacking viruses and bacteria that may be present in the body.

When plasma cells become abnormal they can, in some cases, start producing abnormal antibodies. These antibodies will not fight infection as they are created by copies of the same plasma cell and are therefore just replications of themselves.

When an abnormally large amount of one particular antibody is produced, this is called monoclonal gammopathy. If these abnormal plasma cells do not produce an actual tumour or mass and do not cause any other problems then it is known as
monoclonal gammopathy of undetermined significance (MGUS).

Although MGUS suffers have high level of antibodies, the levels are not as high as with patients who have other forms of cancers, e.g. lymphoma or myeloma. Patients with MGUS don’t need treatment; however they are monitored closely due
to having an increased chance of developing a disease that does need to be treated (like multiple myeloma). This condition affects both men and women and has no known cause.

Our patient had been diagnosed with the condition many years previously and was suffering with increased breathing problems and pain. The skeletal survey was performed due to her having MGUS. Nether I or the radiographer had no knowledge or understanding of this condition at all and our patient was extremely distressed and unwell with multiple problems. I decided then to research this condition and follow up the report.

Journal

Ehlers-Danlos Syndrome

A case that really stood out this week was that of a patient who had a condition called Ehlers-Danlos Syndrome (EDS). He was visiting the department for a pelvis x-ray that had been requested by his general practitioner due to him suffering from pain in his hips.

Before the examination I familiarised myself with the patients past medical history in order to see if any previous pelvis examinations had been performed. It transpired that, as a result of his condition, there had been many previous
examinations. The x-ray went well and I was able to obtain a very good image. After viewing the image I could not see any obvious pathology or degenerative changes and advised him to return to his GP in 7 to 10 days.

Since I had no previous knowledge of this condition I decided to do some research to find out more about its causes and how it affects people. During my research I discovered that Ehlers-Danlos Syndrome (EDS) encompasses several
types of inherited connective tissue disorders. This connective tissue provides support to parts of the body such as the skin and muscles but in EDS sufferers, the collagen that gives strength and elasticity to connective tissue, is faulty. This results in hyper-elastic skin which is very fragile and bruises easily, excessive looseness of the joints, blood vessels that are easily damaged and, very rarely, rupture of internal organs.

There are six major types of EDS, categorised according to signs and symptoms, and the condition can range in severity from mild to life-threatening. All types affect the joints and most also affect the skin. Some of the more prominent signs and symptoms include joints that extend beyond the normal range of movement, and skin that’s especially stretchy or fragile.

This condition is relatively uncommon. The frequency of its occurrence depends on the type of Ehlers-Danlos syndrome. If a doctor suspects this condition they will generally refer the patient to a geneticist to determine the specific
type.

Currently there is no cure for EDS, and treatment usually focuses on managing the signs and symptoms of the particular type. After researching this condition it was apparent to me why the patient has had many previous examinations. This
condition can have many complications ranging from joint dislocations, fragile skin, excessive bleeding, gastrointestinal haemorrhage and a dissecting aneurysm.

Journal

Paraplegia

This week on placement I faced a new challenge when I found myself x-raying a patient who was referred from the orthopaedic clinic and was paraplegic. The clinical information on the card stated discharge sinus, querying osteomyelitis, with not a complete description of why she needed her pelvis andfemur x-rayed. However the patient and her husband informed us, she had initially been suffering from lesions on her buttocks and, while getting them cleaned and dressed, the nurse had found what she thought was a piece of bone. This led to the patient being referred for a pelvis and right femur examination in order to try and discover if it was a piece of bone and where the bone had originated from.

Prior to performing the examination, the radiographer had researched the patients’ previous medical history and then requested my help with the examination. She explained to me that the previous examinations did not provide
a very good view of the patients’ hip joints and her right neck of femurs. These would be the images that we would be attempting to achieve.

The patient and her husband had been placed in a cubicle in order to get the patient changed before the examination. When I invited them into the room the husband offered to transfer his wife (the patient) to the x-ray table. I think, understandably, she felt more comfortable being handled by her husband than members of staff. When she was comfortable and relaxed I then explained the procedure to her, emphasising that we were trying to achieve good images that show as much of her hips and femur as possible.

Before bringing the patient and her husband into the examination room I was quite nervous. I had never met anyone who suffers from paraplegia before and, although I knew what the condition entailed, I was not really sure what to expect.
However, they were a lovely couple and really made me feel at ease, although the patient seemed like she was slightly embarrassed by the situation. This was exasperated by the fact that the patient had no control of the lower part of
her body and could not straighten her legs. This made it very difficult to achieve a position that would give us the required image of her pelvis.

I concentrated on making the patient feel at ease as we tried to reconcile the situation. We attempted to prop her legs together with sand bags and pads but this was unsuccessful and the patients legs always reverted back to a ‘frogs
legs’ position. I then had the idea of holding her legs together by tying an apron around them. The patient was happy with this solution after I explained that this would allow us to view her hips properly. This technique, along with carefully placed pads and sand bags, allowed us to obtain an antero-posterior and a lateral projection of her right femur.

Although we managed to obtain good images it was obviously a very challenging situation. On the one hand I was very happy that I had managed to find a solution to obtaining the images we needed. However, on the other hand, I found it frustrating that there was not a piece of equipment in the department that was designed for examinations of this type or similar, involving a patient with paraplegia.

I feel that the fact that I had to ‘think outside the box’ in order to complete this projection enhanced the feelings of embarrassment for the patient. Luckily, this particular patient was very good humoured and we had a good conversation after the examination, joking about every day things. This allowed us both to connect and helped her see me as a person rather than someone in uniform who was simply there to prod and poke and examine her.

Journal

This week I have been working in the main department of the Queen Margaret Hospital. This particular department deals with patients being referred from the Accident and Emergency department, ward patients and requests from General practitioners. It was an incredibly busy week and, as always, there were many times that I had to adapt my technique in order to overcome potential difficulties in obtaining an image.

One case in particular that presented a huge challenge with regards to achieving a viable image was a 13 year old girl who had been transferred to the hospital from the “sick kids” hospital in Aberdeen. She had been diagnosed with a comminuted fracture of the left femur and the orthopaedic consultant required an up to date x-ray of her injury.

When she arrived in the x-ray department she was in traction lying on an orthopaedic cot. It was the first time I had seen a cot with all the traction and it was referred to a cot because it looked similar to a baby’s cot except that it had additional poles running along the top. There was also a boom and hoist fitted that allowed the patient to lift herself up.

There are several different types of traction used when treating thighbone fractures. These range from placing the leg in a cast to using sticky tape (skin traction) or metal pins (skeletal traction) in order to attach a series of strings which are in turn attached to weights. X-rays are then used in order to monitor the position of the bone so that the traction can be suitably adjusted.

Working with the radiographer on this particular case we firstly assessed how we were going to position the cassette for the examination. We managed to position the cassette under the patient and raise it at one end to run parallel
to her leg. This allowed the tube above her bed to be angled to the cassette to produce an AP radiograph. This projection was quite difficult for me to achieve for a number of reasons. Firstly, as the bed was quite tall I found myself
climbing onto the x-ray table in order to position the tube correctly. Also thet tube had a longer distance from the cassette than normal due to the bars running horizontally across the top of the bed which restricted the tube from gaining the correct focus to film distance. We overcame this last problem by increasing the mAs in order to achieve a good image.

The lateral projection presented another set of problems mainly due to the position of the metal rods running down the medial and lateral sides of the leg. The radiographer suggested that we try and obtain an oblique image, as the
previous lateral image did not show the displacement of the fracture very clearly. We agreed on this strategy and I slipped a foam pad under the patient, raising her off the bed, and positioned the cassette. The patients fracture was
in the lower two-thirds of her femur so the cassette was placed vertically on the medial aspect of the leg for a horizontal beam lateral (HBL). The radiographer positioned the tube for a HBL and then added an angle to the tube in order to try and displace the traction rods form obscuring the bone and the fracture. The resulting image was not as good as he would have liked due to the traction still obscuring part of the fracture, however, it did show most of the fracture and he felt that there was no need to repeat the examination.

I found this week to be a great learning experience. Trying different positions due to various obstacles such as restricted patient movement and the orthopaedic traction bed really helps to develop my experience and expertise as a radiographer.