Angie's CPD » Reflectives

Week 2 Year 4

January 4th, 2011

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

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Week 1 Year 4

January 4th, 2011

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 patientsâ€™ 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 â€œinformed consent formâ€ 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 “flushâ€ 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.

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

contrast for CT

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Week 13 Year 3

March 29th, 2010

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.

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Week 12 Year 3

March 29th, 2010

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 patientâ€™s medical imaging history. It aids a department to manage work flow, and maintains records of a patientâ€™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 Iâ€™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 didnâ€™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 hadnâ€™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 wasnâ€™t really for the squeamish.

After entering the theatre and setting up the machine the radiographer talked me through entering the patientsâ€™ 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 patientsâ€™ 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 wasnâ€™t possible as it would mean the machine would breach the sterile area. He still insisted that he couldnâ€™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 wouldnâ€™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 patientâ€™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 surgeonsâ€™ 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 didnâ€™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.

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