Archive for the ‘Radiography’ Category

Work Experience

Recently the SoR tabled a motion about whether to make work experience mandatory prior to commencing a radiography degree in the UK. Surprisingly, it failed to pass, even more surprisingly for the reason that apparently some students find it difficult to get work experience as their local hospital may not allow it.

I feel that this raises a few issues which need to be addressed:

1) Radiography degrees in the UK are funded by the NHS for domestic students. This means that upon graduation, you end up with an internationally accepted degree, with good job prospects, and nowhere near the £27k debt that your flatmates were lumped with. It also means that a lot of money is wasted when students drop out of the course, which happens, a lot. Attrition rates are around 40% nationally, which is shocking, and surely must be at least in part due to students not being prepared for what they’re expected to do.

In my year group, 53 started the course in September 2009, but only 39 graduated in 2012, and I know from talking to some prior to their departure that it was because they were not expecting it to be what it was. Our first placement was within 10 weeks of the course starting, and this was the point of the first exodus. Obviously the academic workload was a major factor for some people, but other reasons I’ve heard range from “I didn’t know I’d get vomited on” to “I can’t stand the sight of blood!”. Even a day’s shadowing would give enough insight into our exposure to bodies and their fluids. One student I spoke to recently asked me how long it takes to become a radiologist once you begin radiography training. I explained the difference, and she seemed genuinely surprised that one didn’t lead to the other.

Personally, I find this level of ignorance unacceptable; in the internet age where information is a few clicks away, and emails can be sent with minimal effort, it really isn’t difficult for people to show an interest in the career they’ve decided to pursue. Which brings me to:

2) Apparently some hospitals don’t accept work experience students. This is an issue which needs to be fixed but it can also be avoided; if a hospital isn’t interested in teaching the next generation of healthcare workers then quite frankly, it’s not somewhere a student should be interested in visiting anyway, because that’s a crappy attitude. I’d be interested to hear the reasons a department could give, so please, if you’re aware of any, leave a comment or two below.

So then it’s up to the student- if your local hospital won’t let you visit, go somewhere else! You’ll have to travel to your placement sites once you’re enrolled anyway, so this really can’t be regarded as extraordinary effort. I appreciate that people have jobs and kids and other commitments, but this is your future career we’re talking about. Is it really too much to ask?

 

As everyone is probably aware, the NHS is under constant pressure to cut costs, and like most huge organisations is quite wasteful in places. Stupid things like paying over the odds for toner cartridges, or allowing boxes of sterilised orthopaedic equipment to expire, unused, in store rooms, spring immediately to mind as things that I’ve personally encountered. On the subject of NHS funded education, one idea I’ve heard thrown around is to make drop-outs to pay the NHS for the tuition that they received, but I fail to see how that’s enforceable. Especially from students who drop out of further education entirely.

Another way of ensuring value for money could be to make it so that NHS funded students must work for the NHS for n years post graduation, something I assumed was already in place prior to fully researching the degree. This wasn’t an issue for me before signing up as I wanted to work within the NHS anyway*, but I was genuinely surprised to discover that the NHS would pay for your education and then you could bugger off to a private practice as soon as you graduate. Interestingly, in my research for this post I discovered from a UoP lecturer (thanks Mark) that of my year group only two graduates went into the private sector immediately, which isn’t terrible. Also, one went into the priesthood, so that’s… different. And apart from another graduate who left healthcare entirely, and one who has successfully avoided the Alumni’s radar, the rest went into the NHS for their first posts.

*There was a short period of time where after meeting Noel Fitzpatrick (the Supervet) at the UK Radiological Congress in 2012 and talking to his chief radiographer when I desperately wanted to work at a veterinary practice, but after composing an email to them with my (not exactly huge) CV attached, I let it sit in my drafts for a while before deciding to get some experience in the human world first.

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Smile for the cameras!

When I first began looking at a career in health care, I spent some time thinking about what it was that attracted me to the idea, and whether the areas I was looking at would satisfy my interests. One of the things which drew me to radiography was the variety within the job, covering all of the different modalities (CT, ultrasound, theatre imaging, plain film, dentals, mobiles, interventional, fluoroscopy…) and then within even the most “vanilla” modality it can take some quick thinking and improvisation to get a decent image. Our patients vary in condition, regardless of what we’re x-raying; sometimes due to disability, disease, injury, cognitive state, fear, language barriers etc, and these can all affect how we have to interact with them, and can mean deviating quite considerably from the textbook methods of radiography.

An area which can really challenge a radiographer is Accident and Emergency, for the reasons listed above, but also throw in a very real sense of urgency, a suffering patient (who may be terrified and confused), anxious relatives, inpatient doctors (probably an unhelpful orthopod too for good measure) and it can feel like everything is against you.

Often we get called to resus to attend a trauma call (when a patient is handed over from the paramedics following serious accident or injury) and we have to take x-rays while the team are still working hard assessing and stabilising the patient. This requires a certain amount of assertiveness from the radiographer, as you need to be able to judge exactly which moment you will be able to take the exposure, as well as warning the team not to get in the way.

If you have watched the excellent Channel 4 series 24 Hours In A&E you’ll be somewhat familiar with this process. If you haven’t watched it, the program is one of the few reality TV shows worth your time; 90 static cameras were installed around the A&E department at King’s College Hospital and controlled from a separate location, allowing the medical staff to carry on with their work without interruption. The show typically follows 4 or 5 patients from their arrival at A&E, all the way through to a follow up a few months later. Obviously this is all done with the full consent of the patients and their relatives, as well as the staff involved in their care.

The series first aired when I was a radiography student and I was instantly hooked. As diagnostic radiographers it’s not often that we get to follow a patient’s story outside of the brief snapshot that we get to see, so it was interesting to watch what else a patient experiences during an A&E visit.

So you can imagine my surprise when I heard that Channel 4 were moving out of King’s and into my hospital! The cameras are being installed over the next few weeks and filming begins in May. Naturally some of my colleagues are dubious, but personally I think it’s brilliant news, and a clever move for Channel 4 as our helipad opens next week, meaning that the A&E department will be significantly busier by the time the cameras are switched on. I don’t know when it will be aired, but I imagine it’ll be late Autumn at the earliest, so keep an eye out for the trailers!

Incidentally this means that my place of work will no longer be a secret, but I still won’t name it openly so please don’t ask!

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Out in the Open

So some exciting things are happening at work this summer, and in order to blog about them (which I really want to) I will have to indirectly out myself and my employer. This shouldn’t have a drastic effect on this blog but I will definitely be seeking advice on how to continue without jeopardising my career or my patients’ and colleagues’ privacy.
Watch this space.

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Differing Opinions

Uh oh,  it’s February and this is my first post of the year… Oops! I have a couple in my drafts but I need to let some time pass before publishing.

I just wanted to throw a quick question out there to my fellow health professionals as it’s an issue I’ve encountered a few times recently. What do you do when a patient says something you really disagree with, expecting a reply, and you know you’re going to be stuck in the examination room with them for an awkward few minutes?

I had to endure a patient’s hateful anti-cyclist diatribe shortly after attending a nasty cycling related trauma call. He even trotted out the ridiculous “they don’t even pay road tax” nonsense. I kept my mouth shut and refrained from providing my opinion because it wouldn’t have been appropriate, but it was a very uncomfortable experience for me.

How do you deal with these situations?

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“Superstition Ain’t The Way”

Medicine in this country is fairly evidence based, with a few exceptions usually presented in the name of “patient choice” (such as homoeopathy, chiropractic, and acupuncture being offered on the NHS). Healthcare professionals are expected as part of our ongoing clinical and academic development to keep informed on the best current practices within our field. Despite this general approach, hospitals (specifically A&E departments) can be incredibly superstitious places. In this post I’d like to cover (and maybe debunk) some of the superstitious behaviour that I have noticed.

Bark at the Moon
There’s a widely held belief that a full moon affects human behaviour, more specifically that it causes people to go crazy, thus making A&E departments (and police stations) busier than they would normally be at any other time of the month. People give various reasons for this, everything from the vaguely believeable (full moon = more light at night, therefore people stay out later and get up to mischief) to the completely bizarre (our bodies are made of 70% water, therefore if the moon has an effect on the seas, it must have an effect on us). This myth is so prevalent that it has been studied by academics to discover if there is any truth to it, and repeatedly it has been disproven. Nevertheless, once a month, a chaotic resus department will be blamed on the moon.

The “Q” Word
If they’re not pointing the finger at celestial bodies, A&E staff like to blame a sudden influx of patients on someone, somewhere uttering (or thinking about) the “Q word”. This one has got me in trouble a few times, as until recently I was wilfully ignorant of such superstition, so I once merrily wandered into majors and declared “corr it’s quiet in here tonight!” only to be practically mobbed by the nurses who were happily enjoying their rare minutes of downtime. On a recent night there were about four very drunk, quite rowdy patients in resus, and by 1am they had all either been discharged or fallen asleep; I went round to do a chest x-ray on a stroke patient and remarked to the doctor in charge that “it’s a lot quieter in here now!” referring to the volume rather than the workload. He shot me a look that pierced my soul and walked away. I was suitably embarassed.

The funny thing with this particular superstition is that it is a self-fulfilling prophecy; if it’s got to the point that it is so quiet that it’s worth remarking on, regression to the mean dictates that the situation will probably change soon, regardless of the language used in the department. I’m desperate to ask one of the A&E consultants if they genuinely believe that words uttered in resus can cause a major trauma 4 miles away… I’m not that brave though.

Lucky Number 12b
This isn’t a universal thing by any means, not every hospital adheres to this superstition, in fact, not every ward within a hospital observes it, but in Trogdor’s Majors A&E there is no cubicle 13. There’s 11, 12, 12b, and 14. However most of the actual inpatient wards do have a bed 13, so maybe it’s just an A&E thing. On a related but separate note, clinicians have been known to close an A&E bay if it appears particularly unlucky; on a recent night shift, 4 consecutive patients who were admitted to resus bay 2 died. The first was a cardiac arrest (who was unlikely to have survived as they had had multiple arrests before the paramedics arrived), one was a major trauma who had severe blood loss, another was a stroke, and the last was admitted with sepsis and neurological instability. Plainly, there was nothing wrong with the bay itself to cause these deaths (that would trigger a profoundly serious investigation) but such was the bad feeling about it that it went unused for a couple of hours until the other bays were all full. I don’t think anyone else passed away for the rest of that shift- maybe the trauma gods were satisfied? Who knows.

“Bad Nights” and “Good Nights”
I think that in the US these are called “black clouds” and “white clouds”, but they mean the same thing; certain people get branded as having “bad” night shifts, or “good” night shifts. I’ll be looking at the rota, and someone will say something like “oooh, you’re with Dave, he has really bad night shifts”, which is always helpful. Some people will even go to the extremes of swapping shifts to avoid working with certain people (although they might be using it as an excuse!). I can’t help thinking that this has more to do with how much the person moans about how horrible their shift was, as the people I know that have a reputation for “good” shifts have actually had some hideous ones, they just keep their mouths shut about it.

That’s all I can think of for now, but if you’ve encountered any peculiar superstitions within the medical field, feel free to share them in the comments!

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Oh What A Night!

NB: This isn’t meant to be a rant at other healthcare workers in particular, just me venting about some of the issues relating to working in a “multidisciplinary team”. I completely appreciate that every aspect of healthcare presents its own unique challenges, and that the two overriding factors which affect and unite us all are the public’s high expectations of us, and the government’s “bare-minimum” approach to both funding and staffing.

So. Here goes. Last night was easily one of the worst night shifts I’ve had, if not the worst. Nothing especially awful happened, it was just a never ending stream of constant difficulties. Firstly, when I arrived at the department there were already three patients on trolleys lined up in the corridor and two wheelchairs in the waiting area. The day crew handed over and explained the chaos, and then I went to resus to do an urgent chest and pelvis which absolutely had to be done round there as the patient was too unwell to come round to us. Fair enough, it was a trauma call after all. So I get round to resus and my trauma patient wasn’t collared or boarded, and wasn’t even hooked up to any monitors. When I asked why he couldn’t come to the department the nurse replied “He’s too unwell.” When I asked the patient how he was feeling he shrugged his shoulders and said “Not too bad, foot hurts though.” In the end I did the x-rays in resus, as they asked, because yes, it was a trauma call, yes he did have bruises on his pelvis, and we didn’t have room for him in the department anyway.

It’s exceptionally annoying when our colleagues lie to us in order to make life easier for themselves though, and we always find out, so it’s pretty bloody insulting. Most of the times I get a crappy reason for doing a mobile x-ray I take the time to explain to the referrer why we prefer patients to come to the department; it’s not because we’re lazy (although some radiographers are), it’s not because it’s easier (that’s not always the case), it’s because we actually give a shit about the radiation that we’re exposing ourselves and others to. When we trundle up to the ward with our trusty AMX (other models are available) we’re putting ourselves, other staff, and patients at risk. A radiographer’s best friend is the inverse square law (the further you are from the source of radiation, the better) but not all wards are set up to accommodate us. Hospitals are encouraged to squeeze as many beds as possible into every available space (as a side note, one of Trogdor’s board rooms is actually being turned into a patient area and having beds put in it) meaning that there isn’t always the minimum recommended 2 metres between patients. I’ve occasionally refused to perform a mobile x-ray purely because of the logistics of the ward- in one case the wall separating the patients’ bays was so thin that I would have been directing the primary beam at the back of another patient’s head. Nope.

So when I’m told “Mrs Smith is desaturating rapidly and is too unwell to leave the ward”, and I close the department (because I’m the only one there) only to find Mrs Smith sitting up in bed with a cup of tea and no oxygen mask in sight, it’s more than a little frustrating. Add to this the sheer unpleasantness for the other patients being woken up at 3am because mobile x-ray units don’t have a silent mode. This is a point I try to make regardless of whether the request is for a mobile x-ray; I know the medical registrar said that the chest x-ray was urgent, but it’s for a PICC line placement and you don’t plan on using the PICC before 8am so how about letting the patient sleep?

I think that “bullying” might be too strong a word in this context, but I honestly think that sometimes junior doctors aren’t allowed to use common sense as the pressure from their superiors is too high. A while ago I was chatting with a junior doc in resus while waiting to do an x-ray. She’d just had to abandon an attempt to get blood gasses because the patient was squirming in pain, so I asked if there was a reason why no one here tends to use local anaesthetic for the procedure. Apparently a friend of hers had asked the same question a while back and was told that if you can’t do it without local you can’t do it at all, or words to that effect. Apparently the patient’s comfort is irrelevant.

While the Daily Fail loves to scream about “Killing Season” every August, there isn’t a huge amount of truth behind the scare stories about junior doctors causing loads of extra deaths in their first few weeks. Sure there’s a statistically significant rise of about 6% in death rates in early August, but mortality and morbidity figures fluctuate all over the place throughout the year for a variety of reasons, and this is something which requires a lot more research before wildly labelling all F1s as Harold Shipman. Not that the Daily Fail gives a shit about the truth, of course.

One thing which does increase in August though, is crappy x-ray requests, and while it’s frustrating and annoying, it’s our job as radiographers to vet these requests rather than blindly performing them. I know it must be hugely difficult to be an A&E doctor, especially early on in one’s career, but it’s almost comical how the requests pile in. So far I have seen two perforated bowels (colloquially called a perf) but I have probably done a few hundred x-rays with “?perf” on the form. This is basically like a cheat code for a chest x-ray, write “?perf” on the form, get  a chest x-ray. Write “?obstruction ?perf” and you’ll have an abdomen thrown in as well. And you can tell when the new doctors learn about this, because the requests come flooding in shortly after. Instead of properly examining the patient to give us a real reason for doing the chest x-ray (and there is usually a real reason) we get loads of these cheat-codes. A tip for spotting when this has happened: a genuine perforated bowel does not present with the patient strolling in to the x-ray room and making small talk. A real perf is generally accompanied by a patient curled into the foetal position, screaming in agony. Not always, but most times.

So as well as crappy requests we also had loads of patients turning up without wristbands, who we were unable to positively identify. Patients suffering from stroke, dementia, acute confusion (due to LRTI etc), and narcotic or alcohol abuse need to have wristbands on so that we can categorically confirm that we are about to x-ray the correct person for the correct body part. This is beyond essential, yet some of the nurses on shift last night didn’t seem to think so, and the worrying thing was that a few of these patients had clearly been administered drugs before coming to x-ray, something which really shouldn’t be done unless you can be 100% certain of their identity.

Then there was the abuse, a constant factor in this job, but it was particularly noteworthy last night. The first was from a group of “lads” who came along at about midnight with their friend who had banged his wrist earlier that evening: I was processing the x-rays of the patient I had just examined, and standing at the computer annotating the images. One of the “lads” loudly exclaimed that “she needs to get off Facebook and sort your wrist out cos I’m sick of waiting here”, a comment I had no choice but to ignore for the sake of professionalism. I helped my current patient put his shoe back on, and pushed his wheelchair out of the room, and was met with another “hilarious” quip from the group, which I won’t repeat. Then when I called in the injured boy for his x-ray, all of his mates tried to come into the examination room and didn’t like it when I told them that they couldn’t, so I said that he could have one companion to hold his hand if he was really that scared and that seemed to shut them up. The patient was actually alright when the door was closed, but then reverted to making obscene comments about me when he left the room. What a gent.

Not long after there was a middle aged man with a laceration to his arm, he wasn’t drunk (a usual factor in abusive patients) but he was really grumpy. I only had one image to do as we were just looking for broken glass in the wound rather than a fracture, but he was determined to make it a difficult one. First off he refused to let me remove the bandage, but his wife talked him round. Then he wouldn’t put his arm where it needed to be because he didn’t want me to touch it, and when his wife came to the rescue again, he got really arsey with me. I demonstrated with my own arm what I wanted him to do, but he wasn’t getting it, so I lightly tapped his (uninjured) elbow to show where it needed to be and he said “touch me again and you’ll regret it”. No swearing, no bravado, just a plain threat. At this point I figured that his position was good enough for what I needed so I set up the x-ray tube, ushered his wife behind the screen and took the image. Walking back towards him I gestured for him to lift his arm off the x-ray cassette so I could remove it for processing, he did so, but when I reached to pick it up he grabbed my wrist very tightly and said “put the bandage back on now”. I stood my ground and said that I’d like to make sure that the x-ray was ok before doing that, and he hissed something derogatory as I wriggled out of his grip and walked to the processor. His wife looked so embarrassed, I really felt for her. I only had to spend a few minutes with him, she was married to the guy.

Then at about 3am I had a patient growl at me when I asked his name. I phoned majors to ask if there was anything I should be aware of: “Yeah, he spits and will try to bite if you go anywhere near his head”. Thanks for putting that on the form, guys. I nearly found that out the hard way.

I also had a lady call me a stupid cow when I told her I couldn’t confirm whether her ankle was broken or not (it wasn’t), but she actually came back to apologise on her way out, which surprised me. Apparently the nurses in minors explained why I wasn’t able to tell her and she felt shitty about it so she wanted to make it right. That was nice.

So that was my night. Busy, but not the busiest. Just generally unpleasant even though I was working with fantastic colleagues (one with me, and one in CT), I dread to think how it would have been with others!

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She Likes Surprises

I’m frequently surprised in this line of work, usually in a good way; for example seeing a very unwell patient drag themselves back from the brink in resus, or seeing a young trauma victim recover from their horrific injuries and carry on with their life. One in particular was a teenage girl who had been knocked off her bike and had broken every limb as well as a severe head injury; I first saw her in the operating theatre where one of her femurs was fixed with metal rods, her ankle was manipulated back into place and casted, and the following day her wrists were fixed. Then, a couple of weeks ago I was covering the paeds room over lunch and she walked in for her 6 month checkup. I recognised the name instantly and was genuinely blown away when I saw her walking without even a limp after such a short time. She’s got a fair way to go until she’s fully recovered, but the fact that she’s outwardly fixed is incredible.

There are some unfortunately common nasty surprises too; abuse and violence is something that many health care workers have come to accept as a part of the job, regardless of the NHS’s policies on unacceptable behaviour. It just wouldn’t be practical to dismiss every patient who shouts at or hits you, so you judge each individual situation as it occurs and decide whether it’s worth continuing. In the case of dementia patients there’s usually a way of continuing with the examination without risk to the patient or the staff, and it would be idiotic to take these incidents personally as the patient is absolutely not to blame. Drunk patients can usually be reasoned with, or at least sent back to A&E to sober up for a bit, after which they tend to become slightly more amenable and occasionally even apologetic.

My scariest incident (so far at least) didn’t even involve a patient though; I had just been to NNU to do an abdomen x-ray on a very unwell preterm baby who had rapidly deteriorated despite the efforts of the intensive care team. As I walked out of the secure neonatal unit I could hear shouting from further up the corridor but couldn’t see anyone, so I continued walking. I got to the nearby stairwell and contemplated changing floors to avoid the commotion, but it was then that I noticed it wasn’t an actual fight, but a lone man getting angry with the world. I gave him a wide berth and continued on my way (it’s a fairly long walk from one end of the hospital to the other) keeping an eye out for the nearest phone so I could call security and report the issue. Normally it wouldn’t be necessary, but it was 8.30pm and he was directly outside the neonatal unit and the delivery suite so not only were staffing levels reduced, but also vulnerable people were in the vicinity. As I stopped to reach for the phone I heard running footsteps behind me and it was at this point I freely admit that I panicked; clutching the imaging cassette to my chest I ran as fast as my flat, tired feet would allow. He screamed some rather vulgar comments aimed at me (even more vulgar than my usual tone, which should give you an idea as to the nature) and then just started shouting swear words whilst occasionally kicking the wall or throwing the folder that he was carrying, all the while running (chasing?) behind me.

Did I mention it’s a long way back to x-ray?

I got to the stairwell outside theatres and ducked in to phone security. As I hung up a porter walked up the stairs, about to walk straight into scary-man’s path so I advised him against it, told him security was coming, and ran away like a scared girl.

I had never been so happy to get back through the secure doors and into x-ray. I told my colleagues what had just happened and waited for the NNU x-ray to process whilst my pulse rate settled. Barry pointed at the security monitor which shows us the corridor outside x-ray and said “is that him?” and I glanced up to see scary-man tussling with a security guard outside the lifts on his way out of the building. Phew!

And then there are the really unexpected surprises like today’s trauma patient who came in for a chest and T&L spines. I did the lateral T-spine and saw a metal artefact covering one of his vertebrae; it was a similar shape to an ECG clamp so I removed the one that I thought it was, checked for anything else in the way and took another image. The artefact was still there so I completely searched his chest looking for the culprit, at which point he casually mentioned that he had been shot some years ago, as if it were a normal predicament for someone to find themselves in. The bullet fragment was huge and had migrated over the years from his upper shoulder to below the scapula, not that it was relevant to this particular hospital visit. Other than that he had no injuries.

People eh? A rather surprising species.

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Anything and Everything

I’ve spent quite a lot of time working in A&E recently as I’ve had a few night shifts and even a whole week of regular days there.  It’s one of my favourite places (along with theatre) and I really enjoy the challenges it throws at me. I’m also constantly amazed by what some people class as an “emergency” though (and yes, A&E stands for Accident and Emergency not Anything and Everything) and this can be incredibly frustrating.

The other weekend we had a paediatric trauma call; when a paeds trauma bleep goes out you can see the dread on the team’s faces while we wait nervously in resus for their arrival. Apparently a young girl had fallen quite a height from a tree and landed face down, where she remained unresponsive for a while. These were the only details we had at this point so it was hard not to worry about the state she might be in. The ambulance crew wheeled her in, neck brace, head blocks, parents alongside, and we were all quite relieved to see her conscious; at first glance it was obvious that she had broken at least one wrist so I knew that she’d definitely be coming round to x-ray very soon, and upon further investigation it turned out that she had not been unresponsive or unconscious for any amount of time. Due to this and the lack of any head injury she ended up coming round to x-ray for a full trauma series as well as some extremities.

Our A&E x-ray department has two examination rooms, and therefore we are only able to see two patients at a time; normally this is fine, and people only have to wait a short while, but this particular day was quite busy. Several patients were waiting to be seen when the trauma patient arrived and I heard a few tuts as we whisked her straight in to the examination room. I was honestly quite shocked, as one of the men who tutted was there for an x-ray of his ankle which he injured two weeks ago and had been walking around on ever since; how he got through triage I’ll never understand. Luckily the girl’s parents were too worried about consoling their child to hear such an inconsiderate man making his feelings known, but myself and my colleagues definitely heard him. One of them decided to make things clear by announcing that: “A paediatric trauma patient has arrived so there may be a delay in getting to you- I’m sure you all understand the urgency of the situation, thanks for your patience.” Hurty-ankle man tutted some more and looked at his watch dramatically, and then rolled his eyes when the patient in front of him was called in. I wasn’t there when he was eventually seen, but I do now know that he hadn’t broken anything (what a surprise!) and he was very rude to the radiographer who saw him. Meanwhile I was next door attempting to get some decent radiographs of a terrified child; we had to take x-rays of her neck, chest, pelvis, and both forearms, one of which was visibly deformed. She had never had an x-ray before so was understandably terrified to be strapped down flat to a stretcher and wheeled into a dark room while I shone a bright light at her and made her move her badly bruised arms.

In the end she “only” had a couple of fractures to one arm which was fixed in theatre that afternoon, so all in all a fairly good outcome.

So back to Hurty-ankle man. Someone in the triage stage should have explained to him that better care options are available (it’s possible that they did but he insisted on being seen- that happens too) but for whatever reason he ended up being seen through A&E. Apparently he had twisted his ankle two weeks before but hadn’t been to see his GP because apparently A&E is more convenient to get to.

You may think I’m being overly judgemental (and it’s likely that I am) but the NHS, and emergency departments in particular, are currently experiencing workloads which are simply unmanageable. The government’s answer to this is to add more targets and blame GPs and junior doctors for failing to meet them. The real solution isn’t that simple, but patients can help by choosing their care provider wisely; A&E is for acute illness and injury- things which cannot wait. Unfortunately it’s difficult to get this message across without risking scaring those away who genuinely need help. The elderly are especially at risk- “oh I didn’t want to be a bother” they say, having revealed that yes, they have been walking on a broken hip for a week, while the woman with cystitis calls an ambulance to rush herself to hospital.

NHS Choices is a good starting point for finding out who is best suited to look after you in your hour of need, but you should also familiarise yourself with which services are available in your area before you desperately need them. Some cities and towns have urgent care centres which are essentially diet A&E departments. These are a touchy subject politically, as they have sprung up in recent years, replacing real A&Es. They’re perfect for when you sprain your wrist, or cut your knee, but if you’re having chest pain, call an ambulance or go straight to a proper A&E. Some A&E departments are even able to book same day GP appointments for patients that are deemed suitable, so if your sprained ankle isn’t improving and you can’t get an appointment for a week, there might be other options available to you.

All I’m asking, as a healthcare worker and supporter of the NHS, is that you consider your options before going to (or not going to) A&E.

Thanks.

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What a PAIN!

I haven’t written a lot recently, although I’ve had more than enough material for a book already. The problem is, after a particularly heavy day at work (and those are the ones I’d be more inclined to write about) I usually just want to zone out when I get home so I usually do.

Anyway, so I’m now about 6 months into my first job and already my eyes have been opened more than I expected. I always knew that “how things should be” and “how things are” rarely follow the exact same tracks, but it’s disappointing, and I try to keep my standards as high as practically possible.

Nowadays some patients expect to be treated like customers (they’re even referred to as “clients” in some NHS literature) and therefore if they don’t get what they want, regardless of what they need, they get upset. This is something of a common theme; when a patient goes to see a GP they expect an intervention, whether it’s anti-biotics, an x-ray, blood tests, whatever. What they don’t want to be told is that their low back pain can be helped with exercise and posture improvement, or that their cold is not swine flu and doesn’t require medication. What this means for the radiology department is that we’re constantly getting x-ray requests for things that are just completely unjustified, and our job as radiographers is to weed these crappy requests out. Unfortunately a lot of people find it easier to just do it. I’m not one of those people; radiology referrals have fairly clear guidelines and they’re not difficult to find. I’d rather take the time to get the full story from the patient and determine whether the x-ray is needed instead of exposing a patient to unnecessary radiation. A lot of the time these crappy requests are actually fine, they’re just missing information- not surprising when GPs are only given 10 minutes per patient.

This is a difficult problem to tackle, as when you hand the request form back to the patient they are completely within their rights to take it to another hospital where they may not be questioned, and thus the fee for that examination goes onto someone else’s books. I have absolutely no doubt that this has happened to patients that I have refused to irradiate, even after explaining my reasons to them. But what can I do?

Recently I picked up a form for a 29 year old female patient which had only three letters in the Clinical Information section: LBP. This section is meant to contain relevant information so that we can justify the examination- things like fell onto outstretched hand or ?osteoarthritis are enough for the radiographer to understand why the examination can go ahead and which images they need to produce.

LBP means low back pain, an affliction suffered by many due to things like poor posture or years of manual labour. It’s unfortunately a sad fact of life, and the guidelines clearly state that there’s no need for x-rays except in certain very particular circumstances, none of which were applicable to this patient. She was young, otherwise fit and well, had no family history of osteoporosis or spine pathologies, and had suffered no trauma. Her only problem was that she was unable to sit in her office chair for more than a couple of hours at a time without feeling pain in her lower back. And this had been going on for two weeks. I explained why I wasn’t going to do the x-ray, and that even if I did it would have absolutely no effect on her future treatment; the GP would give her exercises to strengthen her back muscles and probably recommend a better office chair. She seemed annoyed and didn’t like my quick explanation of the ALARA principle, instead choosing to assume that I was being lazy because I couldn’t be bothered to do her x-ray. Sure, my laziness lead me to speak to her to find out more information about her pain, then phone the GP (7 minutes on hold after navigating their hideous phone menu) to ask if he was looking for anything in particular in this patient’s spine (I also took the opportunity to direct him to the Royal College of Radiologists’ guidelines which are freely available online), and then to explain the concept of risk vs benefit to a woman who just wanted to know why her back hurts.

I can’t say I made any friends in that particular encounter, and I’m pretty certain I was branded a jobsworth by all parties involved… I can see why the just do it attitude is so popular! Can’t say I’ll be adhering to it any time soon though.

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Reading, Riting, and Radiology

It’s been a while since my last update; my rota has been hectic recently, but for the first time in ages I have two free weekends in a row! Not that I’m complaining of course; it’s very tiring but I really need the money for my birthday holiday.

One thing I seem to be doing a lot of at the moment is teaching, which is really really weird. Trogdor’s is a large teaching hospital and there are only a few weeks of the year when we don’t have students in the department. When I first started there were a handful of third years dotted around, some of whom were extremely competent (which was quite intimidating actually!) so it was nice for me as I was still finding my way around. I wasn’t “given” a student until a few months in which was even better, but the first time I had to “teach” I was super nervous. I was a student myself only recently, so memories of good (and bad) teaching experiences are still fresh in my mind and while I know what kind of teacher I would like to be, it is very dependent on the student. A genuinely enthusiastic student is a pleasure to teach, regardless of current knowledge or ability, but I dread working with someone who would rather be somewhere else as it’s a constant uphill struggle.

The students that I have worked with so far have been a mixed bunch ranging from absolutely excellent, to worryingly deficient, but I think that’s the most I shall say as I know some of them read this blog!

We’ve also had some first year medical students shadowing us this week which has been an interesting experience! Being first years their medical knowledge is very limited so some of them struggled to even point out some basic radiographic anatomy, which is fair enough I guess, but it made their time in radiology somewhat baffling! The department has been fairly quiet as well recently so I couldn’t even show “my student” how to x-ray a patient, so I x-rayed a box of gloves instead! After that I opened the teaching file on PACS and showed them some of the interesting images that the department has accumulated over the years. When that got boring I resorted to showing them things like this:

To infinity and beyond!

Aside from educational endeavours, it’s been an interesting few months; five months to be exact! How time flies… I’ve finished my training rotation (when new people start they are rotated through the different areas such as A&E, fluoroscopy, theatre etc as a shadow so they can become familiar with protocols and equipment before being expected to cope alone) and am well into my shifts. My night shifts so far have been pleasant- busy, but not horrible. I’ve imaged a fair amount of trauma too, which is exactly what was lacking in my student years; down south it’s mostly broken hips and strokes, but here we get more things like stabbings, shootings, car collisons and industrial accidents. Resus can be a very exciting place for someone like me! I’ve seen everything from degloved feet to abdominal stabbings, and one thing that always amazes me is the different reactions from the patients.

One which really sticks in my mind is the lady who had ripped a huge flap of skin about the size of her foot off of her shin. It was down to the bone (hence the x-ray to rule out bony injury) and there was adipose tissue all over the place, but she was so calm and composed. She didn’t even flinch when I removed the dressing that was obscuring her wound, and while I would have screamed the place down if someone lifted my leg to put an imaging cassette beneath it, she laughed and apologised for making a mess! Certainly makes a change from the usual tirade of abuse A&E patients send our way!

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