Cerebral Shunts and a Growing Cello Obsession

What I would give to be playing that cello in this current heatwave!

Stardate: 92179.63

This week is a mixed department week for me, due to the second years still being on their assessment. I've been in both general and screening. I'm actually welcoming the radiology department's low temperature! It's well-known I don't do well with heat or sunshine. I want Summer to hurry up and give way to Autumn; or at least for the sun and heat to give it a rest. Also, for those of you who can hear it, I've added an audio-player to my blog, not because it's important, but the song is that beautiful, I want everyone to hear it! If I could afford one, I'd buy a white cello right this minute... but alas, without including money for rent, travel and food, I have about £20 to my name. Such is the life of an NHS student!

Recently, I was witness to a type of examination I rarely get to see. It was an x-ray examination regarding a cerebral shunt. Cerebral shunts are commonly used to treat hydrocephalus, swelling of the brain due excess cerebrospinal fluid (CSF), but they can be used in cases of brain tumours, meningitis, head injury etc. These shunts are thin tubes placed into the brain's ventricle and tunnelled beneath the skin to the peritoneum (abdominal cavity membrane). The shunt reduces the intracranial pressure caused by the CSF by draining it into the peritonial cavity.

In Radiology departments 'shunt series' are simple sets of x-rays (skull, chest and abdomen) that may reveal any breaks in the shunting. In comparison, a 'shuntogram' uses CT and involves a radioisotope being placed into the shunt reservoir in the patient's head and measuring the speed it travels to the abdomen. Any delay implies a problem with the shunt. It was interesting to see, and also to help, as when you feel for the shunt locations, they feel like large lumps beneath the skin. I was worried I'd press a little too hard, but apparently they don't hurt! 

Aside from that, all I've been focusing on is just getting my case study done, but it's so laborious after a long day on placement! So far, I've managed to write 1,000 words, read it through, delete about 900 of them, and stare at the now rather blank Word document, hoping for either inspiration, or for the words to magically write themselves. So alongside making plans and drafts for my case study until the wee hours of the morning, I've been downloading sheet music for my violin, listening to The Piano Guys (the people who perform the song being played), scoured the internet drooling over cellos, and playing Pokémon while watching Star Wars. Because I'm ever so organised and practical, you see.

Next week, I'll be in general x-ray, so I'm sure there'll be plenty to do... including the dreaded 2,000 word case study! Maybe after the next two weeks, for the first time in nearly five years (possibly longer), I might sleep before one in the morning!

LLAP guys!

Cardiac, Cages and Conferences

An example of an Ilizarov apparatus on the tibia and fibula.

Stardate: 92138.26

So, this week I'm in Cardiac, Mobiles and Theatre. For a Monday, the cardiology department on the x-ray front was pretty slow. I helped out on some portable x-ray examinations in (surgical) recovery and also on the ICU. As the focus (funnily enough) in Cardiac is of course, the heart, you see chest x-rays in abundance here. 

But for the majority of the week, I have been placed on mobiles and theatre, and one thing I finally got to see, was a surgical procedure involving the fixing of an Ilizarov apparatus to a patient's lower leg, due to bone bowing caused by osteogenesis. After seeing so many in A&E clinics, it was interesting to see how they areactually done. 

Ilizarov cages (as I call them), are used to lengthen or reshape limb bones, to treat complex fractures, or non-unions of bone. They are named after the orthopaedic surgeon, Gavriil Abramovich Ilizarov.

The top rings are fixed to healthy bone by tensioned wire (Kirschner wires), allowing weight-bearing force to be transferred through the external frame, to bypass the fracture/injured site. The force is then transferred back to the healthy bone through the bottom ring. The structure therefore acts as a 'bridge', where the middle rings hold the bone fragments in place.

For bone lengthening/reshaping, the affected bone is surgically fractured, and the cage is attached. During recovery, the fractured bone will begin to heal. This process is slow, and the rings is adjusted using the network of nuts, increasing the spaces between rings. The adjustment is done four times a day, moving the fracture apart 1mm per day. This allows significant lengthening. 

The procedure I was present for was quite short (2 and a half hours in all), and the only thing that bothered me was probably seeing the wires about to come through, due to the wires pushing the skin outwards. The rest was fine. The sound of drills doesn't bother me, nor does blood or the sound of a mallet breaking a bone... on purpose (with good reason)!

Aside from that, mobiles has been quite quiet, so while surfing the internet, I came across an event that caught my eye: the International Association of Forensic Radiographers Annual Conference that's being held at Teeside University. Luckily for me, this event was open to students (with a student discount!), and after a long look at my funds, I decided I was definitely going. I've been told by friends on other courses who attend conferences that they're good for networking and experience, so how could I say no?! The topics that are going to be included on the day are:

• Update to the new Coroner & Justice act
• Post Mortem CT Angiography 
• The radiographer as researcher
• Pitfalls in NAI and follow-up imaging
• Radiological detection and interpretation of internally concealed illicit drugs
• and Ballistics

So on September 13th, watch this space! It might actually be interesting!

Next week is my guided study week, so unless something incredibly life-changing happens, I'll post again when I'm back on placement in screening. Due to me only having my case study to be getting on with now most of my portfolio is complete, I'm off to London for a few days to see my grandfather, and hopefully sit in on some cases at The Old Bailey. Murder trial anyone?

LLAP!

References

1. Ilizarov Apparatus, n.d. photograph, viewed 17 July 2014 <http://upload.wikimedia.org/wikipedia/commons/thumb/f/f6/Ilizarov2.jpg/640px-Ilizarov2.jpg>.

Post-Exams Placement... And Prescriptions?!

This is definitely how I'm feeling thus far into my placement due to lack of sleep....

Stardate: 92102.82

It's been a long while since I last wrote a post, but in all fairness, I've had a lot going on to actually really think about my blog! I've completed all my first year exams (and passed them all, and gained an overall high 2:1 grade; one shall work harder next year), moved into my new house for second year, undertaken and passed 4 out of my 5 clinical assessments (1 more to go), and have also been going back and forth to placement sites.

I'm six weeks into my 11-week long Summer placement, and I'm getting to that stage where my brain is on the verge of going on auto-pilot from early starts, input overload and circuit overuse. I've done lots of general x-ray, some in my base hospital site, and some in the 'satellite' hospitals. I've been on Mobiles & Theatre, next week I'm in A&E, and the week after that I'll be placed in Cardiac for the first time. I think Cardiac is like mobiles, but I'm actually not sure. I'll find out soon enough!

Although the exams are over, I've still got work for the portfolio to finish, which includes a 2,000 word case study and various forms. The case I've chosen is about atelectasis. But more about that to follow, as I am still researching into the condition... well, enough to sound coherent and knowledgeable on the subject, anyway. 

You'd think with all that's going on, my body would at least try to function on at a normal human standard. But no, mine has other ideas. Upon visiting a GP with some worsening thoracic (upper back) pain, I found out I am now possibly suffering with Myofascial Pain Syndrome. In other words, my back muscles have knotted up in a specific point to the right of my left scapula and are making life much less fun than before. I'm managing, but I've now been prescribed a tube of Ibuprofen gel, and the strong painkiller Codeine. Yesterday, I was fine, but today, the codeine made me feel completely drowsy and a little more mellow than usual. I didn't fall asleep at lunch... honest.

One other thing you have to get used to, and has finally made an impact, while being a student radiographer, is being almost completely poor for the majority of your degree course. With all the travelling to placement, secondary accommodation, paying for food, rent and bills, and then waiting for the NHS to pay the claim money back into your account, it's no wonder I hide in my room cuddled up with a book! Holiday to Middle-Earth anyone?

I've only one more assessment to go, which is my spine assessment. I'm prepared and ready to get it over and done with. It's just a shame there are never many spines to x-ray on a general x-ray department. There's always the odd one or two, but it figures that when they do come through, there's always at least 5 other examinations to do, and the assessors are too busy to actually assess you!

But once that's done, I will be able to have 5 glorious weeks of doing as little as possible to enjoy. Shall I re-watch all of Sherlock, or catch up on all the video games I haven't finished playing? Oh, choices, choices! What's that you say? Go outside and enjoy the sun? I don't even know what that is anymore...

LLAP!

'Just Another Mobiles Monday'...

"Have you seen what this examination here is called? A 'proctogram'... it sounds disgusting!"

Stardate: 92023.29

This week I'm placed in Mobiles and Theatre, and today was actually quite eventful for a Monday. I didn't do any portable x-rays, as none were requested, but I did get to assist in a urology theatre case in the afternoon.

In the morning, I had to give myself a celebratory clap. I was processing one of my x-rays, when I noticed the trabecular pattern was off on the AP (anterior-posterior) projection (the projection that shows the "front"), so once the lateral (the "side-on" view) had gone through, I saw a definite break on the radiograph. So, I grabbed my supervising radiographer to let them look, and pointed it out. We then tracked down a radiologist to see what they thought. Luckily, I was right. Turns out it was a 3-week old fracture that hadn't been seen to! Seems that commenting does come in handy sometimes...

Following that, I did some other general x-rays, as our morning urology case had been cancelled. I also produced an absolutely beautiful lateral horizontal beam knee (according to my supervisor; it's something to be proud of and show off all day on the screens) at some point during the day before lunch. I was also told to look up about 'proctogram' examinations... I'll leave Google to explain that one! 

When I got back from lunch, I filled out some commenting forms to pass the time until we were called to theatre. I managed to spot osteoarthritis, a comminuted fracture, and a lung abscess on the radiographs I'd chosen (don't worry, I checked against the radiologist reports, too! I did manage to completely miss a rib fracture on one.). Not bad for me, especially on a Monday! 

After eventually getting changed into scrubs, a hat and leads, I realised that I had picked the one pair of clogs that made me sound like a horse. Not only that, my scrub trousers kept falling down, as I apparently can't tie them up properly... Never mind!

Our case in theatre was a Bilateral Retrograde Stents Pyelogram. This is a urologic procedure where contrast is injected into the ureter to visualise the ureter and kidney. It requires cystoscopy, and a small tube (ureteral stent) being placed into the lower ureter. The 'retrograde' is due to the contrast flowing in the opposite direction to the usual flow of urine.

I watched my supervisor use the C-arm first (as it was a little different to the ones I'm used to), and then once I felt confident enough, I took over, and managed to get a good view of the guide wire and kidney slap bang in the middle of the image... just how they like it! To be honest, I was a little sketchy at first, but after a little while I'd gotten the hang of it.

So all in all, it wasn't so bad a day! I spotted a fracture, took a nice lateral knee, got to wear scrubs, and assisted in a case! I even had a nice lie in this morning for once, and got to watch Doctor Who!

Now to carry on it that same vein and enjoy some jelly babies...

LLAP guys!

First Year Commenting

Bone metastasis of a bronchial carcinoma in the tibia.

Stardate: 92012.11

Today was my spinal tutorial session with my lecturer practitioner/clinical tutor, which ended up turning into a general tutorial session, giving us the opportunity to ask questions on anything we need help with. In the first half we took some x-rays, mainly lumbar spines and pelvic examinations. In the second half, we talked about image commenting, which was one of our final exams, and also makes up part of our clinical portfolio.

Basically, we take an image, any image, and describe what we see. Easy, right? Well, not always, but the process seems simple enough, which goes a little something like this:

• Check the patient's clinical details - how old are they? What are their symptoms? 
• Is the image, abnormal, possibly abnormal or normal?
• Examine the general appearance of the bone
• Trace the bone's cortex and density for any irregularities
• Has the trabecular pattern been disturbed?
• Give a detailed account of the abnormality seen
• Examine the joint spaces and soft tissue
• Are there any artefacts on the image?

I'll use the above image as an example, although I don't know the clinical details. Let's say the patient is a 29 year-old male, with severe pain around the tibia, for 3 months.

- The above image is definitely abnormal.

- The bone's cortex has not been disrupted, and the bone density appears normal. The trabecular pattern has not been disrupted.

- There are two radiolucent (the dark patch within the bone) area on the proximal end of the tibial shaft, visible on both projections, on the posterior and anterior tibial aspects.

- The joint space appears within normal limits, and the there is no soft tissue swelling

- There are no artefacts on the image.

This is a basic "comment", and as I found out, this image displays bone metastases.

Bone metastases, is a class of cancer metastases that is the result of primary tumour invasion of bone. Metastasis is the spread of cancer from one organ or part to another. Bone-originating cancers like osteochondroma for example, are rare. These metastases form solid masses, and bone is one of the most common metastasis location. 

Bone metastases can cause severe pain, bone fractures, spinal cord compression, and other major clinical concerns. These symptoms are caused by:

• acidosis - increased acidity. Osteoclasts (bone cells that reabsorb bone tissue) generate extracellular protons, which lower the pH level.
• bone restructuring - the uncoupled regulation of osteoclasts and osteoblasts (bone cells that form bone tissue) leads to bone malformation. Malformed bones are unable to withstand normal day-to-day mechanical stresses (e.g. weight bearing), leading to fractures, spinal cord compression and instability.

Anyway, this is post is getting long enough, and I've got dinner to make for myself. I hope this post has given you some insight into how we "examine" an image, in it's most basic form, and it's actually one of the fun parts of being a radiographer. True, there is a lot of terminology to get your head around, but once you have, everything sort of clicks into place! Tomorrow's my half-day and I'm once more in general, so hopefully I'll get the rest of my unaided examinations signed off.

LLAP guys!

References

1. Bone Metastasis of a Bronchial Carcinoma in Tibia, n.d. photograph, viewed 29 May 2014 <http://www.mevis-research.de/~hhj/Lunge/imabc/BCKnMetb41_2.JPG>.

The 11-Week Stint

"How was your first day back in clinical?" "Great!"

Stardate: 92009.75

Heads up, True Believers! It's that time of term again.... placement! Bear in mind, this time round I'm here for 11 weeks, which followed on from our first year final exams (which I think went well, despite my original fears). What's that you say? I can relax now? Don't be ridiculous! I still have my portfolio, clinical assessments, an ALPS form, commenting forms, critique forms and a case study to produce yet! Does it make me miss Physics and Chemistry yet? A little...

This week (well, 2 and a half days), I'm placed in the General department, so I'll hopefully be seeing a good variety of examinations, get plenty signed off, and maybe, just maybe, get a chest assessment out of the way. It was strange going back into a clinical setting after being out for a while, especially seeing as I've been focusing so hard on revising for my exams. 

This morning happened to be a rather clunky one, (getting the 7:28 bus is too early), having stayed up late to iron all of my uniforms to save time. Getting ready with your eyes shut is never a good idea, by the way, even with my glasses on (there's a reason I keep my hair so short!) It also turns out, I forgot my placement notebook back in Leeds, which is what I attach my markers to (now jazzed up with Spider-Man stickers and polka dot patterns), so getting your images to the optimum standard, just isn't as easy. There's always something....

Once again, I felt like I'd forgotten everything, but after the first three pelvis x-rays, I was fine, considering the rest of my day consisted of... pelvis x-rays! Tomorrow is set to be my spinal tutorial, so I'll be practising spinal examinations (my favourite kind!) and critique. Finally, Friday is my half-day, so I'll be returning to Leeds for the weekend. A student radiographer's life is always busy!

I actually forgot how tiring placement is, no matter how much sleep you attempt to get beforehand. I got on the bus home and fell asleep! Luckily, I have the amazing knack to wake up just before my stop, and get off at the right one, so at least that's something. After forcing myself to make a healthy dinner, I traipsed into my room, I wrote this post, which will now be followed by a movie, a book and then bed!

Watch this space, it may get interesting...

The Finals Countdown!

"So Emily, do you feel you're ready for your final exams?"

Stardate: 91935.01

Well, I'm back in lectures again for two weeks, after returning from my short Easter break (I'd say holiday, but as I was mostly revising and working, I'll refrain from doing so!) My first-year final exams are now looming ever closer, and despite revising every day, passing all the mock exams, and even printing off an A3 skeleton, I still don't feel ready. 

We've only got four exams, the longest of which being Physics at two and a half hours, but luckily they're spread out over four days, so I don't have to cram for two subjects at once beforehand. We've got two exams for Musculoskeletal Anatomy, one for Imaging Technique and one for Physics. I'm feeling confident for the Anatomy exam, as this is the one that, for now, makes the most sense. Physics on the other hand (see above image), well... writing pages and pages of notes has helped, but as far as 12-pulse bridge circuitry and rectifiers are concerned, I'm done for! You cannae change the laws of physics Jim, unfortunately...

Thankfully, a good chunk of some exams are MCQs (Multiple Choice Questions), and as long as you've done some reading around and understood the basics of the module, you should get most of these right, which usually can get you to the 40% pass boundary. Following those are the long answer questions, which range from 10-20 marks. 10 mark questions apparently only need about a page of writing, and 20 is two pages (...Wha?) So, my aim is to write as much as possible (within the relevant parameters anyway), and hope for the best!

After the exams are done with, we're back off out on placement again, but this time it'll be for 11 weeks! How will I survive 11 weeks of no Taekwon-do, nor a constant internet connection?! Do I risk taking my PS3, or shall I take boxsets upon boxsets of DVDs? Oh, decisions, decisions...