Angie's CPD » Reflectives

Week 4 Nuclear Medicine Year 3

October 17th, 2009

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

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Week 3 Year 3

October 17th, 2009

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

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

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

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Week 2 Year 3

October 3rd, 2009

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

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

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Week 1 Year 3

September 23rd, 2009

This was my first week back to University and we went straight out onto clinical placement in the Western General. I had been here on a few occasions so I was familiar with the surroundings and I already knew some of the staff so I was quite excited about being there.

I was working in the main department and I was glad to be back, however I was nervous about going straight back to producing images. Part of me felt worried that it had been so long since I had any practical experience that I may have forgotten everything I had learnt, despite the fact that I had spent time going over books to refresh my memory before I started back. However I do recognise that this was no substitute for hands on experience. The fundamental principles are the same, but there are lots of other factors that are not described in books that only become apparent by doing the job.

My first day went great although, by the end of it, I was exhausted. Being my first day back I was double checking everything and then checking again before I proceeded. While working it was quietly comforting to realise that the knowledge I had gained throughout the previous yearâ€™s course was still with me and I was still able to enjoy the job.

Tuesday however wasnâ€™t a good day. The day was going great until late afternoon when I made a very careless mistake. The request was for a chest and femur examination. I was happy performing the examination despite being told that the male patient could possibly be difficult. I proceeded to bring the gentleman into the examination room and after gaining his trust he was happy to co-operate with the procedure. I produced a lovely image of his chest and helped him onto the bed for the femur examination. I had another look at the request form to see which femur was to be examined, put a left marker on the cassette, and discussed with the radiographer that I would proceed to obtain an image from the hip down and then another view from the knee up. The image I produced was extremely clear but I mistakenly x-rayed the right hip. There was no excuse for this mistake and I felt extremely bad for the rest of the day. I obviously went on to obtain a left femur radiograph, but couldnâ€™t shake the guilt of being so stupid.

Under departmental protocol and IRMER regulation 6.8.2 and 6.8.3, patients who undergo a procedure that was not intended, as a result of mistaken identification or other procedural failure, and consequently have been exposed to an ionising radiation dose, should be considered as having received an unintended dose of radiation. My mistake is classed as a radiation incident, and due to this my supervisor then had to report the incident by filling out the appropriate documentation detailing what had happened. Attached to this piece of writing is a copy of the IRMER regulation.

That same afternoon I had another incident that arose from carelessness. I had been working in the same room all day producing good images of chests without any problems. Later that afternoon a projection I performed of a chest had the apices cut off the top. After examining the machine to check my positioning it quickly became apparent how the mistake had arisen. At the Western they perform the chest examinations in the bucky and the person using the room before me had pushed the button on the side of the bucky, moving the positioning of the cassette by accident. This meant that when I had placed the cassette in the bucky, it had not automatically moved up to the correct position for a chest examination.

My mistake was to not check the position of the cassette and become too inattentive. I repeated the examination successfully but the incident taught me a valuable lesson that I was getting in to a bad habit automatically expecting the cassette to be in the correct position. I now make a point to check the position of the cassette every time. The staff were very supportive in the face of my mistakes, reassuring me that they have all made mistakes of their own and reassuring me that I am a good student who produces good work.

I spent that night feeling remorseful about my mistakes and mentally going through the circumstances that led up to the mistake in order to ensure that I didnâ€™t repeat them. The next day I didnâ€™t really want to go back, I really found these mistakes hard to come to terms with, as they were both down to lapses in concentration and therefore preventable.

The rest of the week went well and without incident, it was a hard week, but it is nice to be back.

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