A recent article in the Independent caught my eye, as it was on the subject of healthcare workers and night shifts. I assumed that it would be about how difficult they can be and how they have a proven negative effect on the worker but I assumed incorrectly.
Instead it appeared to be quite a venomous piece on the audacity of hospital staff daring to have a twenty minute nap during a twelve hour night shift, and how some are even brazen enough to use hospital linen when they do so. There were frequent quotes from King’s College about how unacceptable this is, including this particular gem:
At King’s, emergency situations are now said to be more common than ever before, and staff have been told to be “alert and able to respond should these occur during their break time”.
To me this is an utterly disgraceful stance for a hospital to have; I don’t believe for a second that any healthcare professional would deliberately ignore a medical emergency, regardless of whether they’re currently on duty, on a break, or even on holiday in a foreign country. A nurse I once worked with performed CPR on the first day of her honeymoon, before even reaching the hotel. She could have carried on walking and enjoyed the first day of her holiday, but instead she spent it exhaustingly and ultimately fruitlessly trying to save a stranger’s life.
Most breaks in this context are unpaid, and a lot of the time they’re taken very late, if at all. It’s very common for junior doctors to work a 12+ hour shift overnight, covering an entire hospital, attending crash calls and sudden deteriorations, as well as monitoring patients who were already on their lists, without eating or drinking anything, and breaks can be as mythical as an early handover.
So KCH is expecting staff stay awake during breaks, but if this is so they can be around for emergencies, does it also mean they can’t leave the department? Can’t go to the vending machine (often the only source of nourishment out of hours) or outside away from the fluorescent lights? What about the staff who spend five minutes hiding in a store cupboard during their break because they don’t want their colleagues to see them crying about something they’re struggling with? Why not just force all staff to live on site so they can be nearby at all times, on duty or not?
My advice to healthcare staff working night shifts is this:
If you get the chance to take a break, then do it. Even if you don’t need to eat or sleep, just take the opportunity to get away from things, if only for a couple of minutes. Use your own judgement, and bear your own safety in mind, as well as that of your patients’. Driving home? Don’t take the risk of ending up back in resus as a patient, it would be embarrassing at the very least. Gone 15 hours without water? That back pain you’re having could either be from muscle ache, or your kidneys shutting down. Dizzy? Lightheaded? I wonder what state your blood sugar is in.
The key message from this is to look after yourself, because you’re no good to your patients if you’re suffering. How you do this is up to you. Some people like a proper sleep if they can get it, others prefer a short catnap instead.
The Royal College of Physicians put out their own guidance for surviving night shifts, and I found it really useful, but when you’re first starting out it can be a case of trial and error.
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?
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!
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!
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.
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.
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.
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:
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!
I haven’t blogged in a while, partly because I’ve been busy / exhausted, but also because I worry that if I blog about specific events, even with details removed, patients and colleagues may potentially be able to identify themselves if I write about it straight away, and that would be unfair and unprofessional. But mostly, I’m lazy and can’t motivate myself to write after a day at work.
So I’ve been working for 2 and a half months now, and honestly, I’ve really been enjoying it. There are some stark differences between working in Hampshire and London; most noticeably, budget. I’d mentioned before that the imaging equipment was different to what I’m used to, but it extends beyond that. The rooms in general could do with a refurb; the paediatric room is quite an intimidating place for an adult, let alone a 5 year old with a broken leg. There’s also a dearth of basic accessories such as positioning pads and cassette holders; this doesn’t necessarily affect patient safety or the diagnostic quality of the resulting radiograph (assuming that the radiographer is determined and caring enough) but it can affect patient comfort, and it can also make the task for the radiographer much more laborious and require some significant creativity.
That said though, having the newest fanciest kit doesn’t solve everything; our fancy DR system in Resus decided to stop working on the morning of the Vauxhall helicopter crash, when we were on standby for some of the casualties. It turned out to be a very quiet morning in the end, but nerves were certainly frayed when one of the A&E rooms packed in at the same time! This all happened during my fortnight’s “training” in A&E (I’m still rotating through the various modalities so I can get a basic understanding of equipment, protocols, and working practices). Unsurprisingly, this was my favourite time period so far, and I can’t wait to get back round there.
So far, my shifts have been nice and easy; 9-5 every day, no weekends, but that all changes this month. Luckily I’ve only got one evening shift, one weekend long day, and two weekday long days in February, but it steps up further in March with night shifts thrown into the mix too.
So… what other news? Well I received a dose badge, but then that expired and I wasn’t on the list for a replacement so now I’ve got a temporary one; my markers finally arrived from the USA but apart from my A&E fortnight I’ve hardly used them; and I’ve received half of my uniform (the trousers) and when I collected them my colleague, who accompanied me to find out about hers, demanded that they give me a plain white tunic to tide me over til my proper ones arrive. Hopefully this will mean fewer incidences of being called “The Student” by consultants.
After all this behind-the-scenes waffle you may be surprised to hear that I have actually encountered some patients in my 10 weeks of employment, so here are some anonymised excerpts of the ones who have, for various reasons, stuck in my memory:
The 6 year old who barely even winced when I moved his obviously fractured arm to a more lateral position- brave kids like this just make me even more annoyed at perfectly well yet uncooperative adults who scream the place down over a slight sprain or bruise.
The elderly lady with multiple myeloma who had been booked in for a skeletal survey (a long list of x-rays covering basically the whole body, to assess the formation of any lesions in the bones) who not only repeatedly apologised for taking so much time (!) but also told me about the horrible experience she’d had at another hospital. Apparently the radiographer there shouted at her when she misunderstood his instructions and she cried on the bus home. I hope I’ve managed to show her that those types of radiographers are in the minority.
The young teenager who came into Resus following a collision with a vehicle; she sustained several injuries (luckily none were life threatening) including losing all of her front teeth only a day after having her braces removed. She was understandably devastated and kept apologising to the trauma team for crying. I think she made a lasting impression on all of us.
The gentleman who refused to take his necklace off for his chest x-ray and got very aggressive at the mere suggestion of doing so, telling me that if he takes it off “and something bad happens, it’ll be your fault” whilst standing 6 inches away from my face. More on this in a future post.
The father of the tiny baby on NICU who was born so premature that her lungs had barely formed. I felt awful asking him to step out of the room while I x-rayed his daughter, especially as he cleared his throat and tried to hide the fact that he’d been crying when he returned.
I’ll try to be more regular with my updates in future; I’ve got a few radiology related posts to write on a number of different subjects which have been on my mind recently.
Just over three years ago, in a lecture shortly before our first clinical placement, we were given three vital radiographical items: our uniforms, a dose badge, and a set of markers. Three weeks into my first post, and I’m now devoid of all three.
My uniform is currently on order, and may not arrive for a few months (some staff members have been waiting since August) so I’m still mooching around in my student tunics; luckily there are no Portsmouth students at Trogdor’s so it doesn’t look too awful. My dose badge (this measures the amount of radiation we’re exposed to) is also on its way. And yesterday, I made a terrible mistake which has led to a painful loss…
An essential part of any radiographer’s inventory is a set of markers. X-ray images are 2D representations of 3D structures, and as such it isn’t always possible to be 100% certain what orientation the image is supposed to be in; looking at a chest x-ray you could be fairly sure that the heart is on the left hand side, but conditions such as dextrocardia remove any certainty. Extremity images (such as knees, hands, feet etc) can be very easily flipped by the processing software, making distinguishing left and right nearly impossible. This has huge medical and legal implications (you may have heard horror stories about surgeons amputating the wrong leg; improperly reported x-rays can contribute to these disasters) and as such, it is a legal requirement to physically denote which side of the body is which. We do this using markers: a simple L and R made out of metal which can be placed on the patient or the imaging cassette.
My markers and I went through a lot together, and as such we were parted several times, but until yesterday we were always reunited. My R frequently visited many a ward after being taped to an in-patient, and I once had a patient return to the department after discovering my L stuck to her hip whilst getting into her car. For these reasons (and others) I stopped using tape to secure my markers, and instead I chose to attach them to each end of a disposable tournequet; some people use ribbon but I personally find this a bit grim as it’s difficult to clean and ribbon is quite slippery, a problem when you’re hanging it over a wall stand. The tournequet is rubbery so it stays put, can be wiped down in between patients, and can be easily replaced when it gets soiled.
But yesterday I made a mistake. It was my first day in theatre so I wore scrubs instead of my tunic; and at the end of the day I was tired and had broken my routine so I put the scrubs into the laundry bin and went home, forgetting that my precious markers were in the pocket. This morning upon opening my locker the terrible realisation dawned on me… But it was too late.