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.

On clinical placement this week, as part of my continual learning, I went on a number of mobile x-ray examinations. I had helped perform a few previously and although mobile x-rays have their own inherent challenges, I enjoyed the experience. However this week was exceptionally difficult for a number of reasons.

One of the biggest challenges was seeing some of the conditions the patients were suffering from. Doctors only generally request a mobile examination if the patient is extremely unwell and unable to travel to the department. This is due
to radiation protection issues but also because the image from a mobile x-ray is not of the same quality as a static machine. However I don’t think I was prepared for just how unwell some of these patients were.

Among the wards I attended were the oncology ward, theatre recovery and the high dependency unit. I don’t think anything can prepare you for seeing some of the patients’ conditions and illnesses and therefore the difficulty is maintaining your professionalism. Trying to not look shocked or frightened and keeping composed whilst performing the x-ray. I tend to talk a lot when I’m nervous and found this to be an advantage as it helped to both relax the patient and myself.

Another challenge I had to overcome was positioning the cassette under the patient when they had numerous tubes and wires attached to them. Also removing the cassette after the exposure and trying to take care not to cause any pain
or discomfort to the patient. This was made easier in cases where I went to theatre recovery or the high dependence unit as there were nurses there to help manoeuvre the patient in order to facilitate positioning the cassette.

Mobile x-rays are not always straight forward, and the radiographer needs to be capable of problem solving. For example, some considerations are, is the patient in a small room or on a ward? In the case of a patient being in a small room you may have to position the cassette before bringing in the machine. Once the machine is in the room, it can be difficult positioning the tube correctly, and at a required distance for you to achieve the best possible image. One difficulty I ncountered in achieving distance was solved by lowering the patient’s bed to achieve a greater distance for the image.

I enjoyed my experience and feel I gained a lot of practical knowledge in patient management. Attached to this piece of writing is an image of a good portable chest x-ray, it highlights the fact that the quality can be diagnostic, however the image is not as good as one performed on a static machine.

Journal

This week on placement I have been at the Royal Victoria Hospital. The hospital is part of the Western General and is dedicated to care of the elderly and an open access service for GP patients and clinics.

I encountered a few challenges throughout the week, these ranged from transferring uncooperative patients and adapting technique to allow for patients conditions. Some patients encountered fear due to suffering pain on movement or weight bearing on fractures. I also encountered many patients with limited or no range of movement. In these instances I had to adapt my technique to obtain the best possible image.

Some patients were a challenge when helping them transfer from their chairs to the table. I found a lot of patients wanted the staff to lift them rather than them transferring themselves on their own.

There was a particular case which I found to be challenging; this involved a patient attending the department from a ward for an ankle x-ray. The patient was brought down to the department in a chair. After confirming all the details I moved the chair to the side of the table. The patient informed me she was frightened to stand, so I advised her to put most of her weight on her good leg while transferring. Getting assistance I assured her we would help her on to her feet and be by her side while transferring her from her chair. On helping her to her feet she seemed to use little effort to support herself making us support most of the weight. After a difficult transfer I then had to try and achieve a good projection. The patient suffered with oedema in her legs and ankles and found it difficult to move them, making positioning difficult.

The AP projection wasn’t too difficult to obtain using the little toe as a marker. However the lateral projection caused a few problems. The patient couldn’t turn onto her side so I then had try and turn her with the use of a pad to hold her in position. It was difficult to see if the patient’s leg was in the correct position due to the swelling but I was able to achieve a good projection.

Journal

This week on placement I had a number of patients from an oncology clinic for follow up chest x-rays. These patients were all referred due to having conditions called seminoma and teratoma. Both these conditions are cellular cancers which
started, in these cases, in the testes. Seminoma is a radiosensitive malignant neoplasm of the testis, and teratoma is a germ cell tumour composed of multiple cell types derived from one or more of the 3 germ layers.

According to emedicine, 3% of testicular teratomas are known to metastasize in adults and adolescents. There are two types of teratomas, mature and immature. Mature teratomas are usually found in women and are usually found to be benign, whereas the immature teratomas are usually found to be malignant and more commonly found in males. Teratomas are thought to be congenital, but are often not diagnosed until later in life.

The patients had all been referred for follow up chest x-rays by their consultant to check for any metastases in the lungs. I had never heard of any of these diseases before and looking over the request cards I noticed all the patients were all young men, between the ages of twenty five and thirty five. After some research into these diseases I discovered they were both cellular cancers, beginning in the embryonic stage. Once discovered, these diseases are monitored carefully as there is the possibility for them to metastasize.

All patients x-rayed had no obvious signs of metastases and were due to see their consultant after their x-ray. Attached to this piece of writing are images and a website I used to research these diseases. Throughout my research I found out both male and females can have this condition, however in this case, all patients were male.

Both seminoma and teratmoas can be found in different parts of the body. According to emedicine, the most common location is sacrococcygeal. As they arise from totipotential cells, they are encountered commonly in the gonads.
The most common location being the ovary, and occurring less frequently in the testes. Occasionally teratomas occur in midline embryonic cell rests and can be mediastial, retroperitoneal, cervical, and intracranial. Cells differentiate along various germ lines, essentially recapitulating any tissue of the body. Examples include hair, teeth, fat, skin, muscle, and endocrine tissue.

Testicular cancer treatment involves radical surgical. This surgery involves the removal of the testicle. As part of the diagnosis of testicular teratoma, tissue diagnosis and distinction from other forms of testicular cancer is important in subsequent management. Regional lymph nodes may also be sampled or removed during surgery. Teratoma of the testicle is relatively resistant to radiotherapy but responds well to chemotherapy as an additional testicular cancer treatment to surgery or as a primary treatment in advanced disease.

Following the surgery or chemotherapy the patient will be closely followed to detect any recurrences early. Follow up includes self-testicular examination, measurement of tumour markers in the blood, serial chest x-ray and regular
abdominal and thoracic CT scanning.

Journal

This week I have been on placement in the Western General hospital. This was my first time in this particular hospital so I was naturally a bit apprehensive, not knowing where to go, or knowing any of the staff. However these fears were soon
allayed and, in the end, I really enjoyed it. The staff were lovely, so friendly and helpful and it wasn’t long before I relaxed into my placement. This allowed me to concentrate on familiarising myself with the equipment and finding out how the department runs.

I was curious to see that they performed chest x-rays with the upright bucky. Previously I had only seen a chest x-ray performed with the cassette placed outside the bucky without the use of a grid. I wondered why they chose to perform the examination this way and also how they could be sure they were going to get the entire chest on the image.

After observing this technique a few times, I began to understand the difference between placing the cassette inside or outside of the bucky. The radiographer showed me how the cassette is centred to the bucky, so this gave the radiographer a reference with which to firstly position the patient and then collimate the beam. Once I performed a chest x-ray using this technique I found it quite straight forward.

After performing the examination, I noticed the exposure set on the console seemed very high. When using the bucky for the examination, there is then a need to increase the KVp, which I thought would increase patient dose. I couldn’t understand how this technique could conform to the ‘low as reasonably practicable’ rule regarding radiation, as set out by IRMER 2000 (Ionising Radiation (Medical Exposure) Regulations). However it was explained that this was the radiologists request as this would allow him to see behind the mediastinum and heart for any pathology.

I have since looked at two chest x-rays, one of which I performed using the high KVp and in the bucky, and one taken out of the bucky using the lower KVp from a previous hospital. On comparison, in my opinion, it was possible to see much more detail in the image using the higher KVp and the grid. There is better detail in the lungs and behind the heart as well as through the spine. I found this an interesting method and at some point would like to investigate this method further. I have done some research and since found out the technique used at the hospital can be used to reduce exposure error. An
iontomat is used in collaboration with a high KVp and a grid, while using the smallest possible mAs, therefore reducing patient dose. I have included a link for a website I found while researching the different exposures and techniques,
which gives examples of images at different exposures.

Journal

This week on placement I performed a number of chest x rays. I felt quite confident at performing these as I had performed a good number throughout each week. However this week was more challenging as I began performing these on patients arriving in the department on trolleys and wheel chairs. Most of these patients were unable to stand for their X ray, meaning we had to adapt the examination to the patient. Observing the radiographer setting up these one after another looked straight forward, however when it came to my turn I was extremely nervous. Several times I asked the radiographer to assist and double check the positioning of the patient and the alignment of the tube.

Once I understood the tube needed to be angled parallel to the cassette it was easier to understand the positioning techniques needed. However I found it difficult to constantly have to examine every individual situation and then try
to evaluate the situation to obtain a good projection.

A routine chest projection is done erect to show any fluid or air levels or possible consolidation. Elderly patients on a trolley, who are very ill or in extreme pain, may create possible problems if they don’t want to sit up or be moved. I found it helped in these situations to take the time to explain to the patients the importance of them sitting up for the projection, as this enables us to achieve a better image for the doctors. It also helped if I reassured them that I would assist them to sit up in their own time. I found when I was nervous in these situations explaining and talking to the patient also gave me
time to calm down and not panic, allowing me time to think about what I needed to do and how I was going to achieve it.

I have learnt numerous things throughout the week, ranging from possible problems that I might face to understanding different situations. One thing I learnt was when patients arrive in the department lying on a trolley with a possible perforation, you need to sit them up and they need to be erect for at least twenty minutes before their examination. Another problem I encountered was a patient who was unable to hold their head up. This meant I had to ask the nurse
who was accompanying them if she minded assisting while I performed the x ray. This required her to be wearing a lead apron while stabilizing the patients the head, as their head could be obscuring part of their chest which could possibly
hide a pathological problem.

I performed a number of (Antero-posterior) AP chests throughout the week, some more challenging than others. However by the end of the week, I found them easier to perform, adapting my technique to a number of what I still thought of
as difficult and challenging situations.

My last challenging situation was on a male patient who had a nasal gastric tube. The request was a chest x ray for positioning of the tube. The challenge with this patient was he had difficulty in standing. I adapted this projection by performing a PA examination, allowing the patient to stay seated in his wheel chair, while taking down the back of the his chair. I was able to get quite a good image, but it only showed the top part of the patient’s stomach. We were able to see the tube on the film but couldn’t see the end. I then asked if it was appropriate to repeat the examination to obtain views of the lower part of the stomach, hopefully allowing us to see the end of the tube. I repeated the examination lowering the cassette and asking the patient to sit upright supporting his self with the top of the cassette. I then coned down to
the appropriate position for the projection and obtained the information needed to show the end of the nasal gastric tube.

Journal

The patient arrived on a trolley in extreme pain, with a suspected fracture to her neck of femur or pelvis. Our initial problem was the patient was lying towards one side of the trolley, with the suspected fracture pressed against the trolley sides. This caused a potential problem as I needed to drop the trolley side in order to position the cassette, however I was very conscious of preventing movement in the injured leg.

The way I overcame this problem was to request assistance from three other members of staff in order to help reposition the patient towards the centre of the trolley. This required us to organise and discuss with the other members of staff the best way to do this, so that everyone knew what was required and moved the patient at the same time. Although the movement caused some discomfort to the patient I ensured that she was fully aware of the reasons behind the move.

Once the patient had been repositioned my next problem was to position the cassette and grid. I am not yet comfortable positioning these as I know a lot of the positioning is done by judgement, usually by drawing an imaginary line with the patient’s position and the cassette from the side and the top of the bed. This helps ensure you have all the appropriate anatomy on the projection. Once I positioned them, I then asked the radiographer to check the position in order for us to gain a good image. After we obtained the image it was clear that the patient had a subcapital fracture of the neck of femur (see attached link).

We then required a lateral image in order to ascertain the extent of the fracture. The protocol for this is horizontal beam lateral (HBL) using an air gap technique. The lateral projection of the hip was done by placing a cassette in the wall stand and not using a grid. Although I didn’t ask why it was obtained without the use of a grid, I think it was done like this to reduce the patients radiation dose by using a low KVp, as a higher KVp would be needed if using the grid. However, when I return in the year I will ask their reasons for using it.

I had seen a few HBL’s using an air gap technique so I understood what was involved, but had never participated before. I placed the cassette in the wall stand out of grid, and then positioned the trolley and patient, placing a 45 degree pad under the sheet, lifting the affected side of the mattress. The trolley was positioned so the neck of femur ran parallel to the cassette. I then lifted the good leg onto the leg box so it was away from the area of interest. We then positioned the tube allowing a horizontal beam which was perpendicular to the cassette. Once I had finished, the radiographer checked
all my positioning before the image was exposed.

On examination of the projections we noticed she also had an exostosis at the top of the femur, which seemed to be coming from the lesser trochanter, I found this very interesting as I had never seen this before.

I now plan to read the radiologist’s report on these’s images to see if he remarks on the exostosis.

Journal

This week on placement I had to perform a chest x-ray on a female patient. The clinical reason on the request card advised the patient had a mastectomy of the right breast 5 years ago and had previously undergone a bone scan showing hot spots with increased uptake of the radioactive substance at certain points. A radionuclide bone scan was performed, this helps show whether a cancer has metastasized to bones, and with the results the consultant had requested the chest x-ray.

The chest x-ray was straight forward; PA erect on the wall bucky, the patient seemed fit with no obvious aches and pains. From reading the request card and before I met the patient, I expected her to possibly be in a lot of pain and possibly a bit weak, however she surprised me, she looked fit, well and happy. I didn’t encounter any problems obtaining this projection as the patient was very slender in build, and I ensured there was no rotation by measuring the distance either side of the patient by slipping my arms between the patients arms and chest and measuring the distance between the cassette and the patients ribs and the distance between the clavicles and the cassette.

This week I have been paying particular attention to critiquing my images and trying to get into a routine. When critiquing my images I start with the patients name and CRIS number, check it’s the correct menu for the image that’s
being performed then going on to check all the appropriate anatomy is on the image and that’s it’s a good diagnostic image with the correct marker on the image. While examining this particular image on the screen it was possible to see a fracture of the 5th rib and a few spots which looked denser than the rest of the bone which I was told may coincide with the hot spot that showed up during the bone scan.

Although I don’t know the full medical history of this patient, she had been sent for a chest x ray after her bone scintigraphy. This is a diagnostic study used to evaluate the distribution of active bone formation in the body, this is done by administering a radioisotope which is used for diagnosis, and to help plan any treatment.

Radioactive isotope can provide diagnostic information about a person’s internal anatomy and the functioning of specific organs.

Reflection

I don’t know much about nuclear medicine yet and haven’t been involved with any patients, however I will spend the time trying to find out a little bit more regarding what is involved when a patient has to undergo a bone scan.

Journal

This week on placement I have had a few challenging situations, which I feel I have benefited from. I had a patient who suffers from tremors, so obtaining a good lumbar spine view was more difficult but ultimately successful. However the account I would like to reflect on is my experience with a nine year old patient who had Cerebral palsy. The patient arrived from the orthopaedics clinic with his lower leg in plaster, for a review on a fractured tibia and fibula, querying positioning and alignment of the fracture.

After speaking with his parents and explaining I was a second year student, I asked if they would be happy for me to perform the examination. After being given consent from the little boy’s mother I then explained to her what I
needed to do. The situation was difficult due to the patient being frightened, and strong. His parents had adapted his push chair due to his lower leg being in plaster, and had used a sledge jammed in the chair so their son could sit comfortably. I decided to perform the projections with him sitting in his chair as he was very anxious due to his surroundings and all the new people around him. Once all the appropriate checks were done, i.e. name, address and date of birth, I managed to reassure him as much as possible by spending a bit of time speaking to him and letting him hold my hand, as well as, allowing him touch the cassette to reassure him it wasn’t going to hurt him. This benefited the situation as it calmed his anxiety and he didn’t seem to be as frightened. His mother had to stay with him during the procedures as he kept trying to push the cassettes away, but I was able to get two very good images, with all the detail needed. Although this was not a trauma I had to obtain the lateral projection using a horizontal beam. This situation was a great experience as I had to keep calm in a difficult situation and think outside the box due to the patient’s circumstances.

Reflection

I feel I managed to cope with these situation well. I do feel it was due to being comfortable in my surroundings, due to
working in the department thoughout the summer.

I’m not sure if I would be able to cope so well if I were to be in new or strange surroundings.

I would like to think I would be able to cope in any situation where ever I am, but I have learnt very quickly things are not always that easy.

Journal

This week on placement I have had a few challenging situations, which I feel I have benefited from. I had a patient who suffers from tremors, so obtaining a good lumbar spine view was more difficult but ultimately successful. However the account I would like to reflect on is my experience with a nine year old patient who had Cerebral palsy. The patient
arrived from the orthopaedics clinic with his lower leg in plaster, for a review on a fractured tibia and fibula, querying positioning and alignment of the fracture.

After speaking with his parents and explaining I was a second year student, I asked if they would be happy for me to perform the examination. After being given consent from the little boy’s mother I then explained to her what I needed to do. The situation was difficult due to the patient being frightened, and strong. His parents had adapted his push chair due to his lower leg being in plaster, and had used a sledge jammed in the chair so their son could sit comfortably. I decided to perform the projections with him sitting in his chair as he was very anxious due to his surroundings and all the new people around him. Once all the appropriate checks were done, i.e. name, address and date of birth, I managed to reassure him as much as possible by spending a bit of time speaking to him and letting him hold my hand, as well as, allowing him touch the cassette to reassure him it wasn’t going to hurt him. This benefited the situation as it calmed his anxiety and he didn’t seem to be as frightened. His mother had to stay with him during the procedures as he kept trying to push the cassettes away, but I was able to get two very good images, with all the detail needed. Although this was not a trauma I had to obtain the lateral projection using a horizontal beam. This situation was a great experience as I had to keep calm in a difficult situation and think outside the box due to the patient’s circumstances.

Reflection

This was a great learning curve for me. Learning not to always judge thing without having any experince. I now know its better to try something and then learn from the experience.