Current Situation

This is my plan of action for my PDP. I aim for development is in A & E radiography. I feel I haven’t had enough practice in adapting my technique in difficult situations. As a student you are not given the opportunity to perform and carry out examination in trauma situations or trolley patients. I feel I have the ability to logically carry out some of the examination I have come across but I very rarely been given the opportunity to carry them out.
I feel the experience in A & E would be of great benefit to me. Giving me the experience and build my confidence when performing them, hopefully making me a better radiographer.

Ideal Situation

My next block for clinical placement I have two ideal situations. First I am in Queen Margaret Hospital for 2 weeks, and 1 of them is my out of hours placement. This hospital is the main hospital for any trauma and I am hoping to be working with someone who will allow me to perform these examinations with supervision.
The following 2 weeks I am on my elective placement at Perth Royal Infirmary. This is a general placement and I have requested time within the department dealing with any trauma and A & E patients. I am hoping to have gained some experience and confidence from my time at Queen Margaret Hospital before proceeding to Perth Royal Infirmary. I am hoping these 2 weeks will be a great experience and of great benefit to me.

Steps to success

• My 2 weeks placement at Queen Margaret Hospital.
  Learning to adapt my technique and keep calm in difficult situations. While performing as many trauma and trolley examination the 2 weeks I am there.
• By performing as many examinations as possible on  trauma and trolley patients. by 04 December 2009
• My 2 weeks at Perth Royal Infirmary.
• By spending 2 weeks in A & E, and performing as many examinations as possible. Learning the best way to adapt techniques in difficult situations. by 18 December 2009

Overall Completion Date

18 December 2009

SWOT analysis

Strengths

My strength is that I friendly and good at chating to patients in a difficult situations. However this kind of situation is different to what I have ever experienced. I am also entering a new environment in Perth with new staff which I have never met.

Weaknesses

My biggest weakness is my confidence. Even though I know I am capable of most things that are asked of me I still question my ability. I am not sure if this is because we as students don’t get enough clinical time and are not always out on placement. My confidence begins to rise just as we are finishing our clinical placements.

Opportunities

I contacted Perth Royal Infirmary in the hope to get this elective placement. I spoke to a superintendent called Beryl Pritchard and explain what my goals were and what I was hoping to achievement while there.
I have a book which I will be referring to titled, Interpreting Trauma Radiographs. This book covers everything from, Pattern Recognition, Anatomy, Physiology and Pathology of the Skeletal System, Skeletal Trauma, Pelvic Fractures, Chest Trauma, and the Skull and Face.

Threats

Threats to this achievement are radiographers who don’t like students carrying out and performing examinations on patients in a trauma situation or in trolleys.
Another threat is the department is under staffed and I am asked to carry out general examinations to lower patient waiting times while the other staff deal with the trauma patients.

Supporting Resources

Books / journals

Interpreting Trauma Radiographs written by, J McConnell, R Eyres and J Nightingale.

Web links

http://www.wikiradiography.com/page/Pelvic+Trauma+Radiography
http://www.wikiradiography.com/page/Protocol+-+Trauma+Series

Other

Presentation

Reflection

I have just finished a 4 week placement comprising of 2 weeks and Queen Margaret’s Hospital, Dunfermline and 2 weeks at Perth Royal Infirmary and Perth. My experience at Queen Margaret hospital did not give me as much hands on experience as I was hoping for as my out of hours week was quiet. However I did get some opportunities to perform examinations where I had to adapt my technique in order to get good views.

I had the opportunity to practice and obtain a horizontal beam lateral (HBL) on a trauma patient who had a suspected neck of femur fracture. I also had to obtain views on a patient in resuscitation who had fallen down some stairs and fractured his lower leg.

Perth Royal Infirmary (PRI) was completely different from anywhere I had been previously. Being there presented many opportunities to refine and adapt my technique. The Accident and Emergency department is quite small and therefore there are generally not a lot of trauma cases passing through it. There was a big orthopaedic department which allowed me to see and perform techniques I have never observed before. This proved to be a great department to work and learn in, and I feel I have gained knowledge that is invaluable.

On the whole I feel that I have greatly benefitted from this placement. I learnt a large amount regarding adapting my technique for trauma and also views that I have previously read about but have never seen performed before. I think the main thing that I will take away from this placement is the fact that different trusts work in such different ways. I did find the number of changes quite over-whelming initially but by the end of my first week I was starting to adapt to the new routine and understand the system.

I feel writing this PDP has given me an opportunity to evaluate my own capabilities and has also highlighted my fears. By thinking of what aspects of my skill set I want to grow it has allowed me to set a realistic goal for my future development. I do feel this kind of experience is invaluable for me. My confidence did grow by the end of placement however I think this will diminish again the longer I am away from the department.

On week four of clinical placement my work was split between nuclear imaging and Dexa scanning. DEXA stands for dual energy X-ray absorptiometry. It is used to check bone density. Generally, the denser your bones are the stronger they are, and the less likely they are to break.
My time in nuclear imaging was very interesting. For the majority of the time there was only one radiographer, however I feel this was beneficial to my learning as I was able to work extremely closely with her. This was great as she would spend the time to explaining examinations and pathologies in detail to me. The radiographer also reported most of the scans she performed and I would accompany her while she dictated the reports on the day’s scans. She would explain her findings and explain how she had arrived at her conclusions. There were a few scans the radiologist reported which I was able to sit in on while the radiographer and the radiologist reported these.
My time in nuclear imaging greatly increased my knowledge and understanding of the modality. Previously, I was under the misconception that, anyone receiving a radioactive isotope was receiving a really big dose of radiation. I now know this not to be the case. In fact, in the majority of cases the dose a patient receives is usually a lower dose than a normal x-ray. I am not sure why I previously thought that the radiation dose for nuclear imaging was really high; however, I think my misconception is shared by a lot of the general public. Educating the general public about nuclear imaging is maybe an area that the department should look into in order to correct these false assumptions.
On the whole the general public know very little about radiography and I feel all departments should try to educate and inform people about their role in the Allied Health Profession. There were a few occasions while in nuclear imaging when I had to reassure patients that the radiation dose they received was negligible. Further to this, on one occasion, I had to reassure a patient that had incorrectly jumped to the conclusion that they had metastatic bone cancer without any diagnostic evidence. The patient mistakenly presumed that nuclear imaging was used exclusively to find cancer and nothing else.
This lack of understanding or misinformation was also apparent when I worked within the Dexa scanning department. In general I found that the majority of people had never heard of DEXA scanning before and I found myself explaining to friends and family what happened within the department and the reasons we use DEXA scanning. My time in Dexa scanning was very short as I only had about 4 hours there in total. I found this discipline more interesting than I first thought. DEXA scans are used to help find out whether a patient has osteoporosis or possibly at risk of developing it. Most patients who had been referred were conversant with the department as most had a previous history of a fracture. Even with my limited time in this department I gained a lot of knowledge about osteoporosis and bone density.
The radiographer advised me who possibly referrers patients and the different reasons why patients were referred. It was explained how they calculated whether patients were at risk of osteoporosis. This is done by standard deviation, by cross-referencing the patients’ age against an average bone density chart. The graph has been created by scanning hundreds of patients at the age of 35 and recording their average bone density. There are three categories that bone density can be classified as; they are normal, osteopenia and osteoporosis. Osteopenia is the name of the category between normal and osteoporosis. By the end of my time in Dexa the radiographer was allowing me to take some of the patients’ details. I would register patients’ weight and height before positioning them on the table for their scans. In general there are two scans taken, one of the lower spine and one of the hip, two of the main areas at risk from osteoporotic fractures. These are then measured and compared with the osteoporosis risk chart. I found my experience in Dexa scanning very interesting and enjoyable and a very informative and rewarding experience.
Overall my week in Nuclear Medicine and Dexa Scanning has been really enjoyable. Even though both departments were short staffed I was able to have plenty of hands on experience.

My third week of placement was spent at the Victoria Hospital. This was the beginning of my special modalities and I spent 2 days in Magnetic Resonance Imaging (MRI) and 2 days in Computed Tomography (CT).

I did some research before going into the MRI suite hoping to have a better understanding of the modality. Prior to attending my placement, my knowledge of the MRI was only basic. Such as the issues surrounding patient safety, patient positioning, how the machine was constructed and how MRI is best used for soft tissue imaging. However, it soon became apparent, that there was a lot more safety issues than I had previously been aware of. The staff put a large emphasis on the importance of knowing all the safety issues involved when working with an MRI machine with regards to both patients and staff. Considerations have to be given to patients wearing makeup, having tattoos and wearing skin patches. Makeup and tattoos are included in the safety protocol due to some having metallic contents within them and skin patches have to be considered due to the possibility of a metal backing which could heat while in the scanner causing burns to the patient. Also pregnant and breast feeding patient are included in the safety check list due to problems that may arise when administering intravenous contrast agents. I was also surprised to learn that patients having an MRI examination can experience an increase in body temperature due to the radio frequency. The repetitive use of RF pulses deposits energy which in turn causes heating in the patient.

Over my two days in the MRI I was shown how to plan and execute routine examinations. Starting with a localiser scan which was done in a coronal plane and called a scout image. They then proceeded with the different scans available such as axial, sagittal and coronal, and also the angles they use for position slices for different examinations. These are not always obvious, for instance, the angulations for a female pelvis vary from a male due to the fact that the patient has a uterus. If the patient has a uterus the angle is such that the slices are parallel to the endometrial cavity. Other idiosyncrasies include the fact that when a T1 scan is performed the fluid shows up as dark, however, when a T2 scan is performed the fluid shows up bright. Scans are also done removing all the fat from the image; these are called a fat saturation scan.
My next two days were in CT. I found this to be much more stimulating and felt very much more in contact with the patients. It is a very busy department and unfortunately suffering from staffing issues. Because of this, staff was unable to spend time explaining procedures to me, and I was only able to observe. CT imaging, which is also referred to as computed axial tomography (CAT), involves the use of rotating x-ray equipment, combined with a digital computer, to obtain images of the body. Using CT imaging, cross sectional images of body organs and tissues are produced. These images can provide detailed views of soft tissue, bone, muscle, and blood vessels, without sacrificing clarity. I observed quite a few examinations which needed intravenous contrast administered and was able to view examinations with a delayed time sequence for an arterial scan and a portal venous scan.
Overall I enjoyed my time in MRI and CT and hope I have gained a better insight to these modalities. There was an interesting case at the beginning of the week when a patient arrived for an MRI after being referred by an ear, nose and throat (ENT) consultant. The patient had a possible lesion and the ENT consultant wanted to see the position and size. It became clear the lesion had possibly erupted through the skull and embedded itself into the anterior part of the brain. The radiologist referred him immediately for a CT and, unfortunately, this proved to be the case and the patient was referred to the Western General. I would have like to have followed this case up, however again due to the shortness of staff, it wasn’t practical for me to pursue this case any further.

CHANGES IN BONE MASS & STRUCTURE

Osteoporosis Document

Vol._2_Thorax_Heart_Abdomen_Pelvis 38

Vol._2_Thorax_Heart_Abdomen_Pelvis 39

Vol._1_Head_and_Neck 77

Vol._1_Head_and_Neck 78

Vol._2_Thorax_Heart_Abdomen_Pelvis 104

Vol._2_Thorax_Heart_Abdomen_Pelvis 105

This week my placement was in the minor injuries department at the Western General. During this week I was aiming to pass my clinical mobile assessment. The minor injuries department deal with the all of the mobile requests for the entire hospital. I was hopeful that I would be provided with enough requests to gain confidence in my work and therefore be competent in performing my assessment.
I encountered a number of difficult situations throughout the week, such as difficulty entering small rooms due to beds, equipment and tables which severely impede the manoeuvring area of the mobile machine. Another problem was the reluctance of some people to move away from an area when a mobile x-ray is being exposed.
The most difficult situation I encountered involved a female patient who required a chest x-ray. The x-ray was due to the fact that she was suffering with progressive shortness of breath (SOB). When we arrived on the ward we identified ourselves to the nursing staff and enquired where to find the patient. The nurse advised us the doctor was still with the patient but we could go in. I could hear the patient who seemed in obvious distress and very agitated. A nurse and doctor were in the room trying everything they could to try and elevate the patient’s condition and help calm her down. However she repeatedly shouted for help stating she just wanted an injection to end her suffering and she wanted her life to be over. The doctor advised her that if she tried to calm down this would help her breathing and she would feel better, she also advised the patient she had phoned for her daughter who she had been asking for, and that she would be arriving shortly. The patient was not responding to the doctor’s efforts to calm her and began to threaten that she was going to jump from her room window.
I found this situation quite distressing and advised the accompanying radiographer that I was unsure how to deal with this from a radiography standpoint. The radiographer was also unsure what to do in this situation and advised the doctor she didn’t feel comfortable performing the request with the patient in the condition she was in. The doctor advised that she needed the x-ray to exclude any underlying conditions and to also plan future treatment. The doctor reassured us that it was in the patients’ best interest to have the x-ray. We duly performed the procedure and, although the patient didn’t refuse the x-ray, she wasn’t very co-operative.
Afterwards, while reflecting on the incident with a radiographer, I wondered what the correct course of action was ethically. In a situation whereby a doctor requests an x-ray in the interests of the patient, however, the patient themselves is in obvious distress about receiving any help or treatments. This seemed like such a grey area. From the patients point of view I can understand if they are in pain and distress and they want to stop the interventions that are keeping them from passing. However, from most patients and relatives point of view, doctors are there to help to alleviate the pain and suffering and must be seen to be doing so. I really felt for this doctor as she was in an awkward situation, for us as radiographers not to perform the x-ray would have made her diagnosis impossible and therefore it would have hindered the patients’ treatment and prolonged her suffering. However, whilst obtaining the projection it felt like we were coercing the patient into something she obviously didn’t want with a complete disregard for her wishes.
Since this experience I have revisited and attached to this piece of writing, The Code of Conduct, as well as The End of Life Strategy document provided by the Society and College of Radiographers (SCoR). Section 3.1in the Code of Conduct states, “Frequently, you may work as part of a multi-professional team and you need to respect the skills, knowledge and contributions of colleagues from other professions and other team members.” While the End of Life Strategy advises, “the SCoR wishes to raise the profile of end of life care within its membership, and to encourage radiographers to consider skills around end of life care as part of continuing professional development”: this document also states, “Radiographers, and imaging and radiotherapy staff in general, need to have a good basic grounding in the principles and practice of end of life care, and many have unmet training needs. They need to have the necessary core competences to enable them to deal with these situations without adverse consequences for the patient, family members and themselves”.

I feel that, after this experience, it is necessary for all radiographers to have situations of this nature, and the appropriate steps to be taken, defined with clear policies and procedures.

sor_end_of_life_strategy