This was my second week back at Crosshouse and I had been placed to attend wards and theatres for the week. One particular morning there were two theatre cases which I found to be interesting. The first was a hip arthrogram on a 10 month old girl. The second was for an osteotomy of the hip/femur on an 11 month old female patient. Both had been born with varying degrees of Development Dysplasia of the Hip (DDH).

DDH is discovered as part of a routine hip examination check performed on all new born babies. High risk babies are female Caucasian as determined by Pretorius and Solomon (2006). This condition occurs when the formation of the hip joint is dysplastic (abnormal development or growth) or malformed later after birth. The femoral head of the femur and the socket of the acetabulum are made up mostly of cartilage and must be properly orientated for the correct formation. An examination described by Pretorius and Solomon (2006) describes a routine examination on new born babies as the Barlow manoeuvre which dislocates the femoral head rearwards and the Ortolani manoeuvre which reduces the recently dislocated hip usually with a resultant clunk. This examination is carried out for any subluxtion (partially out of alignment) or any instability in the hip joints. Treatments for hip dysplasia depend on the age of the patient. Treatment used for children less than six months of age is a Pavlik harness. The harness holds the hip in an abducted and flexed position. This position allows the best orientation between the femoral head and the acetabulum and allows the hip joint to remodel and develop normally. The harness is then worn full time for six to eight weeks until the hip has stabilised.

The first procedure was an arthrogram of the hip; this was being performed to allow visualisation of the hip joint space and shape. The consultant explained she was hoping to achieve good visualisation of the hip joint to determine any future treatment. An arthrogram is performed by injecting contrast media into the hip joint; this then defines the cartilage surfaces of the joint on an x-ray image. This helps the consultant determine when the hip is reduced and how much instability is present. There is also a possibility if a child reaches about twelve months of age, their hip is difficult to reduce by a closed reduction because the hip socket becomes filled with extraneous tissue and there is secondary contracture of surrounding structures. If this is the case then the patient needs to undergo an open reduction, as in this case the patient required an open reduction.

The second patient required an osteotomy. This patient had previously worn a brace to gain shape and stability of her hip; however the hip stabilised with the leg in the wrong position. The surgeon wanted to leave the hip in the joint and cut and realign the femur in the correct position. Attached to this piece of reflection are image from the osteotomy surgery. These images show the new position of the leg and the metal work used to stabilise the position.

Pretorius, S. E. and Solomon, J. A. 2006. Radiology secrets 2nd ed. Philadelphia: Elsevier.

Dislocated femur. 2011. [online image] Available at: http://samsinfo.com/wkl/developmental%20dysplasia%20of%20the%20hip%20ddh%20clicky%20hips.html [Accessed October 20 2010].

Pavlik harness. 2010. Available at; http://www.eorthopod.com/content/developmental-dysplasia-of-the-hip-in-children [Accessed October 20 2010].
Developmental Dysplasia of the hip. 2010. Available at: http://www.pediatric-orthopedics.com/Topics/DDH___Hip_Dysp/ddh___hip_dysp.html [Accessed October 20 2010].

 

DDH ortho

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

http.web site for hip dysplasia

 

This was my first week back on placement. I was at Crosshouse hospital and in Computed Tomography (CT). It was quite nerve racking being back and in my final year. It was also intimidating to be placed in CT on my first week back as I knew I was expected to perform five CT head examinations in order to prove my CT competency.
On the first day after the summer break I expected to be gently eased into the environment, however I was mistaken. As usual in any CT environment it was fast paced and on this occasion, as with my last CT placement, there was a shortage of staff. I had previously undergone a week in CT in another hospital which was also extremely busy and with a shortage of staff and this affected my confidence of achieving my required competencies.
Throughout the morning the staff explained what procedures and examinations they were performing, and it was not long before I was carrying out patient ID checks and safety checks for the administration of intravenous (IV) contrast. By early afternoon I was being talked through setting up examinations for head CT scans and by the end of the first day I had performed my first solo CT head examination. Patient ID checks are IRMER regulation and all patients under going any examination which involves ionising radiation needs to be identified by, name, address, date of birth and examination to be carried out.
Throughout the week my confidence grew, and the staff helped me relax, it felt easy to fit into the department. By the end of the week, I had performed eight CT head examinations and two abdomen/pelvis examinations. There are many reasons that head CT scans are performed. A few of the more common reasons are to detect brain injuries through trauma such as fractures of the skull or bleeds in the brain, another common referral for head CT examination are to detect bleeding due to a ruptured aneurysm or blood clots in the event of strokes.
I found utilising CT to look for pathologies extremely interesting although, due to its fast pace, there is limited amount of time to examine and study the images carefully. I also felt that, unless you were able to canulate patients and administer IV contrast, CT scanning could become very repetitive. It has very clear advantages from the patients’ point of view, the speed and ease of the examination enables patients to tolerate examination even through pain and discomfort. Even though some patients are on beds and may need to be manually transferred with the use of a PAT slide on to the CT table top, overall CT examinations seem to be well tolerated.
Throughout the week there were many examinations which required IV contrast. Contrast agents (which are usually an iodine compound) used in CT are available in several different forms, some of the more common contrast agents used are, Iodine, Barium, Barium sulfate and Gastrografin. These can be administered in different ways; intravenous injection, oral administration and rectal administration. IV contrast is used in CT is to help highlight blood vessels and to enhance the tissue structure of various organs such as the brain, spine, liver and kidneys.
Patients requiring any contrast agent for examinations require safety checks to be carried out. This is to determine any conditions such as diabetes, asthma or any allergic reactions they may have experienced in the past. They are then required to sign an “informed consent form” prior to having their contrast administered and CT exam. This form outlines the potential side effects of the contrast. Some patients experience mild side effects from the contrast agent such as a warm or hot “flush” during the actual injection, a “metallic” taste in the mouth, which usually lasts less than a minute and a sensation like they have to urinate. The patients are told about these potential side-effects and are reassured that these sensations quickly subside. Experiences vary depending on the type of contrast used, the rate at which it is administered and individual patient sensitivity. Milder reactions that may take place following the administration of contrast is itching over various parts of the body with hives, lasting from several minutes to several hours after the injection. This type of reaction is usually treated with medication. A more serious reaction, although much less likely, may include breathing difficulty, swelling of the throat, or swelling of other parts of the body. These reactions can be more serious if not treated immediately.
Overall my week in CT was interesting and very fast paced. I am extremely happy to have achieved my competences and enjoyed learning on new equipment. Attached to this piece of reflection is an image of a CT brain taken from, http://www.radiologyinfo.org.

 

 

 Images taken from; http://www.e-radiography.net/index.htm, showing various contrast used in CT imaging.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

contrast for CT

This week was my second week at Crosshouse hospital. Crosshouse hospital is classed as the centre of excellence for Cochlear implants in Scotland. After the observation of a few patients attending the department for x-rays to check the position of the implant I then decided to do some research into the subject. I had previously only heard of cochlear implants through my studies of Magnetic Resonance Imaging (MRI) safety, and the contra indications that cochlear implants have with MRI scanning.
A cochlear implant is different from a hearing aid. These devices bypass the damaged portion of the ear and directly stimulate the auditory nerves. Signals generated by the implant are sent by way of the auditory nerve to the brain, which recognises the signals as sound. From my studies of this topic I have found out that hearing through these implants is different from normal hearing and needs to be learnt or relearned. However it does allow people to recognise things like warning signals and understand other sounds and enjoy conversations in person or by telephone.
Both children and adults who are hard of hearing or deaf can be fitted with a cochlear implant. Adults who have lost all or most of their hearing later in life can benefit from these implants, as they learn to associate the signals provided by the implants with sounds they remember. Cochlear implants, along with intensive post-implantation therapy are used as aids to help young children to acquire speech and language.
These implants are used because there is damage or destruction to the hair cells in the cochlear which results in total deafness. However even with this damage the auditory nerve can still be intact.
The cochlear implant works by conveying weak electric stimuli to the vicinity of the auditory nerve. The electric stimulus activates the nerve, which then transmits a signal to the brain. The brain then recognises the signal and the person experiences this as hearing. A cochlear implant has the same function as the hair cells, in that it transforms sound into electric current that stimulates the auditory nerves. This device can help provide a sense of sound to a person who is profoundly deaf or severely hard of hearing.
Hearing is not absolutely normal and research carried out on users who have lost their hearing later in life have stated that the acoustic impressions from the implant differ from normal hearing. Some users describe the sound as, mechanical, or synthetic. This does however change over time and the artificial sound quality is reduced or unnoticed after a few weeks.
Risks from this type of surgery may include facial nerve damage, numbness in the area of the scar, intensification of tinnitus and change in taste sensation and dizziness.
Children who are implanted very young and adults who become deaf later in life, but have already learnt to talk, respond better to the implants than adults with congenital deafness or prelingual deafness. Patients who undergo this operation have to wait 3 to 6 weeks after their operation before beginning training, so any swelling can subside and the initial fitting of the processor can be done. A program consists of 3 phases, firstly adjustment of device. This is adjusted until the patient experiences sounds as being pleasant. Audiological tests are then performed to check whether the adjustments are correct and also to find out what the patient perceives before the training begins. Then last familiarisation with the device and aural training.
The technique used for imaging patients attending the department for the positioning of a cochlear implant is called modified stenvers which is a project that I was unfamiliar with prior to working at Crosshouse hospital. I found it very interesting to see these projections being undertaken and also understanding the whole patient journey. I was also extremely surprised at how common cochlear implants were and have a better understanding in reference to MRI safety. Attached to this piece of writing are images of cochlear implants and an x-ray image.

This week I have been at Crosshouse hospital. Despite the fact that this was my first time at this particular hospital and department, I was looking forward to it as it had a reputation for being a good place to work.

Following an initial tour of the department I was allocated the room where I would be working throughout the week. After familiarising myself with the room I enquired about their system and procedures regarding the examination process of patients. It was explained how the request cards are received and the order they were taken. The radiographer then took me through the entire procedure from finding a patient on the system, all the way through to post processing. The cassettes that were used at Crosshouse hospital were different from the ones I had used previously and the system of post processing was completely different to the systems I had encountered in the past.

The system they used is called Radiographic Image Interpretation System (RISS) and the Computed Radiography (CR) system they use is called an AGFA system. Both systems were completely new to me and, initially, they were quite daunting.

The AGFA system is reportedly widely used, but unfortunately for me, I had no experience of it. This system has a cassette buffer which is designed to eliminate waiting time and allows for a continuous workflow within a department. The system has an automated cassette system which requires no buttons to operate it.

The RIIS system is a computerised system used for every aspect of a patient’s medical imaging history. It aids a department to manage work flow, and maintains records of a patient’s history of examinations.

Once I learned and mastered the systems that the hospital utilises then I found them to be beneficial and quite straight-forward. However the unfamiliarity of the department, the people and the systems really compounded my difficulties on the first day.

Throughout my first day it felt like I was being bombarded with information about the new things I had to learn. One of the hardest things about working in a new department is conquering my nerves, especially when I’m on my own. Luckily I was accompanied by another student during this placement and it was comforting to be working alongside a familiar face.

On the second day I was much more relaxed and it didn’t take me long to settle in. I also became quite adept at working with the new systems as well as learning some of the more technical details of their operation.

By the end of the week I had really settled into the department, I enjoyed working with the people I had met. I had enjoyed my clinical assessment and, for the first time, I hadn’t been nervous. I also went to theatre and performed my first ever femoral nailing. This surgery was a new experience for me and one that I had been keen to observe. I really look forward to opportunities to attend theatre as I find it invaluable experience and quite exciting. This is a common procedure and one I was really looking forward to although I had been warned that it could be gory and wasn’t really for the squeamish.

After entering the theatre and setting up the machine the radiographer talked me through entering the patients’ details into the system, and then explained what was going to happen. Once the surgery was underway I was then given full control of the Image Intensifier (II) and instructed to do the screening for the surgery.

Everything was going well until the surgeon was fitting the screws at the distal end of the femur and I needed to acquire a true lateral of the knee and distal femur. The patients’ leg was supported by a stirrup and her foot supported in a boot which was angled so that it was slightly turned out laterally. This made getting a true lateral difficult. The surgeon instructed me that I needed to turn the II through to the lateral position. However the II was turned as much as it could go. I explained it only rotated 180 degrees in either direction and I would need to rotate it 360 degrees to get a true lateral. This wasn’t possible as it would mean the machine would breach the sterile area. He still insisted that he couldn’t proceed without these images and suggested that the II would rotate further than I had told him. The supervising radiographer then confirmed my assessment of the situation was correct. The surgeon then requested one of us to call the department and request a specific radiographer attend and help obtain the required images. This radiographer assists in a large number of trauma surgeries in theatre. While we waited for the other radiographer to arrive I advised the surgeon of another potential problem. It was going to prove very difficult to obtain the lateral image due to two reasons. The patient was of small stature and therefore her legs were quite short and wouldn’t raise high enough to allow the image receptor access. This problem was compounded by the fact that she also had fractures to her inferior and superior pubic ramus, so her good leg could only be supported at a certain height.

When the requested radiographer arrived we explained the problem to him and he confirmed to the surgeon the difficulties that were being experienced were not due to a problem with the machine or the staff. The problem was finally resolved by the having four nursing staff lift the patient’s good leg as high as possible and then tilting the table in order for us to obtain the required projections.

We attained the images that the surgeon required and he managed to complete the surgery successfully. When the surgery was over the nursing staff apologised for the surgeons’ attitude. It was an embarrassing situation that was difficult at the time but could have easily been avoided if the surgeon had believed what he was being advised and didn’t think the problem was due to either of us being unable to work the machine.

Even though this proved to be a difficult situation, I think we both dealt with it very professionally and I loved the experience of observing the surgery. Overall it has been a good week and I have really enjoyed my experience at Crosshouse hospital. Although it is nerve-wracking to enter a new department and work with equipment that I am unfamiliar with, I do find that I gain invaluable experience by doing so. It is really good experiences to see how different departments work, encountering new students from other universities and being able to compare courses and exchange views. Attached to this piece of writing are images of a femoral nailing.

 

This week I was in the ultrasound department at the Western General. I had previously worked in an ultrasound department as an assistant so knew what to expect.

The week mainly consisted of obstetrics, and gynecological examination with a little general ultrasound. Through out the week I observed a number of gynecological examinations on women who were perimenopausal and post menopausal. One of the main difficulties I had with these examinations was identifying the ovaries. I generally found it difficult to pick out the ovaries in pre-menopausal women but found it increasingly difficult and sometimes nearly impossible on women who were of peri and post menopausal years. Another issue with this type of exam was that the anatomy changes with women who have had a hysterectomy.

One of the more interesting cases I dealt with was a patient who attended the department for a kidney scan due to a condition called Birt-Hogg-Dube syndrome (BHD). I had never heard of this condition and asked the patient all about it. He went on to tell me he had previously had a pneumothorax and his doctor had heard a crackling in his chest. He was then sent to a cardiologist because they suspected the crackling was coming from his heart. On investigation they could not find anything wrong with his heart and continued with more tests. On further investigation it was found that the patient had tumours in both kidneys, and tests revealed BHD syndrome. This led to him undergoing a partial bi-lateral nephrectomy. The patient was on a follow up appointment checking for any reoccurrence of tumours in his kidneys. This patient had no previous skin lesions and the condition was only identified due to him having a pneumothorax.

After further research I discovered that Birt-Hogg-Dubé (BHD) syndrome is a hereditary condition that was originally identified as a skin condition by three Canadian doctors. They found certain kinds of skin lesions on the faces and necks of several members of an extended family. In recent years, more symptoms have been linked to this syndrome, namely lung collapses and kidney cancer.

BHD syndrome is caused by mutations in the folliculing gene (FLCN). People who have the mutated gene may have lung cysts or experience collapsed lungs, and may develop kidney cancer. There is no typical BHD patient.

People with BHD syndrome may have none, one, or all of the physical symptoms associated with the condition. The fact that kidney cancer can be one of the symptoms of this syndrome makes it potentially serious. However, only a small percentage of those with BHD actually develop kidney cancer.

Attached to this piece of writing are images of BHD syndrome.

http://www.nature.com/jid/journal/v128/n1/full/5700959a.html

Article from the journal of investigative dermatology.

BHD syndrome

 

This week I was in the Royal Hospital for Sick Kids (RHSC). I had expected this week to be particularly challenging due to the different skills and techniques required while working with children. Being a mother I found myself acutely aware of the thoughts and feelings that some of the children and parents were experiencing.

There were difficulties involved in performing examinations on children while the parents were in the room, especially when the examination required immobilisation and the child was very young. I was constantly aware that I had to display professionalism and confidence in order to gain the trust of the parents, however it was a few days into the week before I was familiar enough with the environment to relax.

Over the week I encountered a number of children with medical conditions that were new to me. One patient I performed a knee examination on suffered from a condition called Dystonia (Sigawa syndrome). This condition is a rare genetic disorder which is characterised by an uncoordinated or clumsy manner of walking and dystonia. Dystonia is a general term for a group of muscle disorders generally characterised by involuntary muscle contractions that force the body into abnormal, sometimes painful, movements and positions.

The request card for this patient advised she had a previous diagnosis of dystonia in her feet, and was now experiencing the inability to straighten her left knee unless she was asleep. I found this difficult to understand how this patient was able to have her knee straight while sleeping but was unable to straighten her knee when she was awake. I have since researched this condition for a better understanding.

Dystonia in Segawa syndrome usually affects the legs; however some children may first develop dystonia in the arms. In some cases, the symptoms of Segawa syndrome may become noticeably worse or more pronounced in the afternoon and evening than in the morning. The symptoms of Segawa syndrome usually become apparent around the age of six years. Children with this condition usually show a dramatic and sustained improvement when treated with a drug called levodopa. Levodopa is an amino acid that is converted to dopamine, a brain chemical that serves as a neurotransmitter. Dopamine is deficient in children with Segawa syndrome. The disorder is caused by mutations of the GCH-1 gene.

The RHSC is also the main centre for Paediatric and Young Adult Spinal Deformity (Scoliosis) in Scotland. During my time there I encountered a number of children attending for a spinal x-rays either pre-operative surgery on their spine or to review their condition to ascertain if there had been any changes in the degree of curvature to their spine. I found performing spinal examinations to be difficult. Mainly due to my lack of experience with this type of examination. I observed and assisted in a number of these examinations and gained a better understanding to what is evolved and the skills needed to produce a good image. It was not always clear by looking at some the children attending for a review x-ray that they had scoliosis until you had x-rayed them. I found it interesting to see how some children manage to compensate their posture to maintain what looks like a normal posture.

Overall my week at RHSC was very interesting and I encountered many new challenges and situations. The staff were very supportive and encouraging which helped to relax me in the new environment. I do feel, however, that I need much more experience in adapting techniques around babies and small children in order to gain confidence in this field. Attached to this piece of writing is an x-ray image of a child with scoliosis, this image is similar to images taken through the week.

http://members.optusnet.com.au/physio/scoliosis.html

A scoliosis is a lateral or sideways curve in the spine that is apparent when viewing the spine from behind.

http://www.nsd.scot.nhs.uk/services/specserv/spinaldeformity.html

Paediatric and Young Adult Spinal Deformity (Scoliosis) Scotland

 

 

 

 

 

 

 

 

 

 

 

 

This week I was in the Western General Mammography department. This department has a reputation for being a good department to work in, especially in an observational role, as the staff are highly skilled and very willing to teach.

Prior to attending the department, I had refreshed my memory on the techniques required to these types of examinations, and therefore didn’t have any reservations about what work lay ahead. However, one factor that I was completely unprepared for was the emotional side of type of radiography.

After witnessing my first examination, I quickly realised how difficult breast screenings can be due to a number of factors. The most obvious factor being how personal and intimidating the situation was for the patient. Even I, as the observer, felt that I was intruding in what was a very personal and frightening examination for the patient, and couldn’t help considering how vulnerable they must feel. It was only from my observations and being new in this environment that the impact and nature of this type of examination became evident.

On my first morning the radiographer spent some time showing me around the department before starting the morning list. She proceeded to inform the first patient that she had a student observing in the department and asked her before entering the room if she minded if I observed. The patient didn’t express any issues with this and seemed happy for me to be there and allow the radiographer to explain to me technique and positioning.

Throughout the week I observed many examinations from a number of different areas of referral. The referrals mainly came from one of three areas; new patients from the breast screening unit, ladies who attended the department regularly due to the removal of malignancies and the genetics unit for patients who were in a high risk category due to breast cancer being in the family. I was also able to observe a number of patients attending for stereotactic breast biopsy, ultrasound guided breast biopsy, and core biopsy’s performed in the breast screening unit.

I witnessed a few women with new diagnoses of Ductal Carcinoma in Situ (DCIS). DCIS means that cells inside a patients breast duct have started to turn into cancer cells. With DCIS, these cells are all inside the breast ducts and have not started to spread into the surrounding breast tissue. DCIS is usually impalpable and has different grades from 1 – 3, with 3 being expected to be the most invasive. In the first examination the radiographer performs a stereotactic guidance using one of two biopsy procedures:
§ Core needle (CN) which uses a large hollow needle to remove one sample of breast tissue per insertion.
§ Vacuum-assisted device (VAD) which uses a vacuum powered instrument to collect multiple tissue samples during one needle insertion.
Stereotactic mammography improves accuracy by pinpointing the exact location of a breast mass by the use of a computer and x-rays taken from two different angles. Using these computer coordinates, the radiographer inserts the needle through the skin, advances it into the lesion and removes tissue samples. After confirmation of diagnosis the patient returns to the department for surgical removal of the lesion. Before surgery, the exact location is confirmed by performing another stereotactic procedure called a “localiser” locating the exact position and depth of the tumour. A localising needle is placed near the area of concern and then guided to the cancer with the aid of mammogram or ultrasound. On locating the area they then leave a guide wire in the exact position and depth as a guidance aid for the surgeon. The patient is then able to attend theatre for removal. This type of surgery is classed as Breast-Conserving Surgery and has to be followed up regularly to exclude recurrence.
In my time at the department I was able to observe patients with DCIS not only attend their stereotactic examination, but also proceed to theatre for the removal of the lesion.
Overall it was a very interesting week and I found it quite emotionally intensive. Attached to this piece of writing are images of breast DCIS, which look like tiny grains of salt, with an image of a guide wire in position along with an image of DCIS recurrence.

http://www.breastcancer.org/symptoms/types/dcis/treatment.jsp

This link explains the disease DCIS and the different methods of treatment.

http://cancerhelp.cancerresearchuk.org/type/breast-cancer/about/types/dcis-ductal-carcinoma-in-situ

Explains what the disease is, with a guide to the different grades and treatments and follow up.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This week I had been allocated to the rooms that deal specifically with orthopaedic clinics and walk-in GP patients. I have performed many images for the orthopaedic clinics and I feel my ability and skills have grown throughout the week.

There have been audit and review clinics all week and I have had lots of hands on experience. As well as my skills improving I feel I have established a good routine. This is something that I have been working towards for quite a while and it is good to finally have the consistency in my work that a good routine brings. I hope that I will be able to maintain this routine and carry it forward with me on my next placement.

One of the more interesting experiences I have had during this placement involved a patient who had been referred to the department from an orthopaedic clinic. This patient had undergone an internal fixation to her left humerus due to a comminuted fracture 3 weeks previously but the consultant was questioning the alignment of the humerus. A comminuted fracture of a bone is where the fractured bone is in three or more pieces.

The patient was very frightened and was experiencing a large degree of pain. Due to this pain she was unwilling to move her arm. I was able to persuade her by explaining the procedure first and allowing her to manoeuvre her arm by herself; I did however advise her I would help if she needed assistance. She was understandably reluctant to remove her arm from the sling that it was in. I explained I had to take her arm out of the sling to obtain the views needed for her consultant.

To obtain the anterioposterier (AP) view I placed a set of steps with a high support handle attached to them to the left side of the patient, this allowed her to support the weight of her lower arm while she stood in position for the AP view. I explained she would be able to support her arm for the next view by placing her hand on her tummy and holding her arm away from her body. Lifting her arm from the support caused her to cry out in pain. I heard what sounded like a loose screw in the metal and a crepitus sound.

On viewing the images it was clear that 3 of the screws had dislodged from the metal work and away from the bone and the patients arm was not fixed into position. You were also able to view the segments of bone on the images which were in three separate parts. The patient was instructed to return to the orthopaedic clinic for remedial procedures.

Before leaving Perth I managed to follow up on the patient to see if she returned to theatre. The patient had been admitted to one of the wards and was scheduled to return to theatre in the next day.

Attached to this piece of writing are images of comminuted humerus fracture and fixations. The first image resembles my patient fractured humerus.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This was my first week of a two week elective placement. On arrival to the department I was introduced to staff and shown round by the superintendent. I had been looking forward to this placement and was happy with the schedule that had been arranged for me during my visit. I had specifically requested I would like some hands on with any A & E patients.

It took me a few days to familiarise myself with the systems and equipment, as every room had different types. The department has designated areas for different patients. For my first week I was placed in the rooms which are specifically for A & E and ward patients. I found it all a bit overwhelming at first as the radiographers do almost everything. When a patient arrives from A & E or a ward, the radiographer enters their details and examinations required into the system, after checking their previous history and justifying the examination. They then proceed with the request and then post process the details when finished. Every exposure taken is recorded in detail. They are written on the back of the patients’ request card, the card is then scanned into the system. The exposures are recorded once again during the post processing.
I expected things to be different here but I wasn’t quite prepared for just how different everything was. The equipment here is quite dated such as a Siemens Polydoros 80s which, luckily, I have used previously.

Protocols at the Perth Royal Infirmary are also very different as each orthopaedic surgeon has their own preferences of what views they would like for each examination. So if you have a patient who has had a knee replacement you have to refer to the consultants’ lists and see which views he requests before you perform the examination. Once I understood the procedures and protocols I found this to be a very good system of working.

The A&E patient list wasn’t as exciting as I initially thought. However there were lots of post operative patients arriving from the wards and this gave me the opportunity to practice horizontal beam laterals (HBL). In the past I haven’t had much of an opportunity to have hands on practice for this type of examination. It is performed at Queen Margaret Hospital, using the air gap technique with the up-right bucky for trauma patients with a suspected neck of femur fracture. Here they perform their HBL without the air gap technique but the principals are the same. This examination is performed on patients who are post operative, trauma and some orthopaedic clinic reviews. I was given the chance to perform a few and through practice I found them not as difficult as I initially thought.

My other experience this week was performing an examination on a patient coming in through A&E with a suspected dislocated shoulder. The examination was quite difficult due to the patients’ pain, although the pain relief began to work and I was able to assist with the views needed. Once the examination was finished I was allowed to return with the patient to the resuscitation unit at A&E and observe while the doctor manipulated the shoulder back into position. It took a doctor and 2 nurses to perform the manipulation. While the doctor was pulling the patients arm down and away from the patients body, one nurse has a bed sheet placed around the top of the patients arm to pull the shoulder up, with the other nurse held the patient on the bed. After a few minutes of pulling, you were able to hear the patients arm slide back into position.

Attached to this piece of writing are images of fractured neck of femur and a hip replacement. A patient with a suspected fracture or a new replacement requires a HBL to show positioning of the fracture or replacement. There are also images of shoulder dislocations.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This week’s placement was my out of hour’s week at Queen Margaret Hospital. I had been really looking forward to this week as I knew there were just two other radiographers working and I was hoping I would have a better chance of being involved with more of the trauma patients arriving in the department. This would give me the opportunity to deal with more challenging situations and the experience of adapting my technique.

Apart from the week having some quiet spells I had quite a few situations to deal with which required me to adapt my technique. I was also able to experience how the department works at night. I found this to be very exciting and I really loved my time in the department. I had advised the radiographers that I had been really looking forward to this week and was hoping to gain as much experience as possible in dealing with any trauma situations.

The first situation I was given was the chance to deal with was an elderly patient with a suspected fractured neck of femur (# NOF). There are a high number of elderly patients attending this department with this type of suspected injury due to the hospital being the main trauma centre. This type of injury has an increasing incidence with age thought to be due to a bone density loss and is more common in elderly females. This is usually due to a lack of oestrogen, which is common due to the menopause. Bone density loss can also been seen in patients taking a variety of medications, such as corticosteroids and thyroxine, with injury mostly due to only minor trauma. Classical features for this type of injury are the patients leg is usually shortened and externally rotated and pain on rotation and tenderness over the femoral neck.

The protocol for views needed at Queen Margaret for trauma situations dealing with suspected #NOF are an anterioposterior (AP) pelvis view and an air gap technique for the lateral (Lat) view. I had previously assisted in this situation before while on placement here, but had never been given the opportunity to perform these views. I had mixed emotions, excited, nervous and very cautious. I was comfortable with the radiographer I was working alongside knowing that they would allow me to proceed with the examination under supervision. I also knew they trusted me not to proceed with the exposure without them checking my positioning was correct first.

The AP pelvis was relatively straight forward although it can be difficult sometimes to see if all the correct anatomy will be on the cassette as patients tend not to lie in the middle of the trolley. I took my time and obtained an AP pelvis with all the relevant anatomy included for a #NOF, which was confirmed on viewing. I then positioned for the horizontal beam lateral (HBL), making sure everything was lined up as I thought it should be and then got the radiographer to check my positioning. I took the exposure and processed the image. On observing the image it was apparent that I could have centred down just a few more centimetres; however, the image showed clearly that the angulation of the head of femur was not in the correct position and the patient’s femur was displaced. We went on to repeat the HBL image which gave me the opportunity to repeat the examination and correct my positioning for a perfect image.

I was also able to visit resus on a few occasions, one occasion being for a gentleman who had fallen down the stairs and had injured has lower right leg. The patient had previous x-rays on his leg as he had a history of Osteomyelitis. This was my first time in resus in a long time so while the doctor was finishing his discussion with the patient the radiographer familiarised me again with the department. I had forgotten that they performed all the examinations with a mobile machine and had been expecting to be using a ceiling mounted tube. Realising this added to my nerves as I immediately thought the examinations were going to be difficult to achieve.

I had observed the patient while I entered the department and had observed that he was covered in blood and his leg was in an unnatural position. I had been advised a fractured tibia is usually associated with a fractured fibula and deformities are common. Deformities or angulation may be obvious on observation due to the foot being abnormally rotated. I obtained the request card to find out what views the doctor was requesting and advised the radiographer what views I thought would be the most appropriate projections.

The doctor had requested an AP and lateral views of the patient’s tibia and fibula from the knee down an AP foot and an AP hand. The most difficult part of the examinations was obtaining the distance for the lateral tib/fib, due to the room size. Moving the patient’s leg for positioning was relatively easy as he had self-anesthetised on alcohol.

I found both examinations very exciting to perform. They were new and challenging situations which I really enjoyed. On the whole the department was quiet due to my shifts being evenings and weekend. I felt I had more of an opportunity to relax and perform more challenging examinations without the pressure of a busy department, although I do feel one week is not enough. I would personally like more of an opportunity to do more out of hours work.

Attached to this piece of writing are images of fractured neck of femur and tib/fib.