Saturday, December 12, 2009

The screening x-ray on the dementia patient

Two weeks of work down, four to go. I'm still enjoying catching up with other people, although there are parts to the job that I find painful and mind-numbing.

Medical imaging is a lot harder physically than medicine. You have to move patients around all of the time - pulling them across the imaging tables, moving them into position, lifting them, pushing heavy equipment, pushing the imaging cassettes under 10+ intubated people in ICU rounds, as well as doing a lot of walking all day. It is quite hard work, and takes me about a week to get used to it again after I return.

I also find that I get a little angry when asked to do examinations on extremely demented elderly patients when the exam is pretty much for screening purposes. I understand that the doctors want to check for things, but I think that sometimes they send these patients to imaging because they can't talk to them and they just run as many "simple" tests as possible to get a profile of the patient's health.

My main issue with this is that a "simple" examination can turn into an ordeal when the patient is unable to comply or move. We have to force them into positions that are uncomfortable, push and pull them around and cause them quite a bit of pain and upset them, all for an exam that is effectively for screening.

A normal patient who can move onto the imaging table and stand up can have an abdominal and chest series finished in under five minutes - and most of this is paperwork time. (Yes, I know you are supposed to wait to take the erect abdomen - I do it first, after the patient has been sitting up in their chair for at least 10 minutes on the way to the department/waiting, and then do the supine. This saves time.) They walk over to the erect bucky (the upright thing that you use for chest x-rays and erect abdomens) for two/three shots, then lie down on the table for the last one. Easy. Fast. Painless. We have a little chat while I take the images (generally the highlight of the exam for me - I get to meet some truly interesting people), then they move on.

An elderly patient with severe dementia or severe illness who is unable to remove or respond, and who gets sent to the x-ray department on a trolley or bed is quite a different matter. We have to force them into the upright position by having a radiographer/wardsperson sit them forwards, jam a heavy block behind their back, force a cassette behind them on top of this, lean the back against it, and then run out of the room to take the image before their hands move across their chest fields or they slide off the cassette. Similar thing for the lateral chest, if we can do it - we turn the bed sideways and try to use the erect bucky. We often have to do it more than once, because they are quite difficult to take.

For a supine abdomen (you really aren't going to get an erect abdomen on a patient like this, unless you REALLY need it and can manage a decubitus), you have to force the patient to lie down flat, get them flat on their bed, then wedge a hard, thick block of plastic (the x-ray cassette) directly underneath their back, make sure it is in place, then run back out of the room again to take the image. If you are lucky and have trauma trolleys and your patient happens to be on one, this is much easier.

And this is if you ask for a simple abdomen/chest series. I have taken full spines on patients like this - for trauma, so it needed to be done, but it takes a lot of time and energy and is a challenge and a half.

I am gentle and patient. I always address the patient by name, regardless of whether they can respond or not. Other people aren't, but that isn't a topic for this post. The process is a lot more uncomfortable for the patient than I can get across in writing. They don't understand why somebody is hurting them, or telling them to do things that they don't want to do.

To top it all off, most of these x-rays are normal. It was a screening exam for a patient, and may have been much more acceptable if the patient would have a better outcome and prognosis with treatment. Extraordinary measures for patients who are not going to understand what is happening and have bad prognosis - well, that is just cruel. I have heard it referred to as "atrocities" in medical circles, moreso when talking about extreme medical intervention for patients who won't recover and should be make comfortable, but it is a similar principle.

I often wonder whether the doctors who order these would think more carefully about whether or not they needed them if they knew what we have to put the patient through in order to get the images. One of my favourite physician teachers told us that you should know (or at least suspect)the results of the test before you order it, and you should always be able to give strong reasons for every test you order.

Obviously the doctor is the person responsible, which is why I do the best images I can for them, so that they can decide where to go from there. I just can't wait for the day when all I do it the physical exam - it is a breeze compared to the imaging, particularly for the patient. It would also be nice if the doctors had any idea about what they were asking us to do to their patient. Not all chest x-rays are equal.

At the start, I found it really hard to get back into imaging because you have to make people uncomfortable to get diagnostic images. I shied away from making patients experience pain. It isn't pleasant, and I won't be upset when I don't have to do it any more.


*C said...

Funny thing, my uncle has been an RN working with geriatrics forever in nursing homes and hospitals. He (finally) finished his radiography degree and has just finished his first year. It should've been good, except his employers know his background and he's convinced he ONLY gets elderly patients with dementia.

It must be hard. Your post resonated with the complaints I hear from him.

The Girl said...

Wow, he has my sympathies (and congratulations on finishing his PDY!). It must be frustrating after working with the patients with dementia for so long, and knowing just how futile much of it is. Treating them to a certain level is worthwhile, but the concepts of futility of treatment and not doing any harm really need to be looked at a lot more closely.

If you auscultate their chest as normal, their sats are normal and if they appear to not have any cardiac or respiratory problems, do they REALLY need a chest x-ray, even if they can't give you a history?

This is why I really loved emergency radiography - your images actually make a difference.

In the end, it isn't so hard for us, I just feel bad for the patient. I wish more doctors actually knew what was involved in taking an x-ray. We learn what happens in just about every other test.

Dragonfly said...

Fishing expeditions...grrr.