Angie's CPD » Reflectives

Week 6 Year 2

February 13th, 2009

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 wasnâ€™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 couldnâ€™t understand how this technique could conform to the â€˜low as reasonably practicableâ€™ 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 seeÂ 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.

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Week 5 Year 2

November 22nd, 2008

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 donâ€™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 patientâ€™s stomach. We were able to see the tube on the film but couldnâ€™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.

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Week 4 Year 2

November 19th, 2008

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 patientâ€™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 didnâ€™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 HBLâ€™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 radiologistâ€™s report on theseâ€™s images to see if he remarks on the exostosis.

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Week 3 Year 2

November 9th, 2008

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 didnâ€™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 itâ€™s the correct menu for the image thatâ€™s
being performed then going on to check all the appropriate anatomy is on the image and thatâ€™s itâ€™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 donâ€™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.

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