Best Practice Case Study Medical Imaging Medical Presentation

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Published on : May 03, 2019 | Views : 1702 | Downloads : 9

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Assessment 2 Best Practice Case Study (Medical Imaging)
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Patient Demographics Patient (Cindy Pike) 39 year old female (12/02/1980), rural location, with symptoms of neck pain (niggling) from a 1.5m fall early morning. Chiropractor ordered c-spine series for adjustment. Routine chiropractic flexion-extension views contraindicated in the case of Cindy Pike.2
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Errors of Performing Flexion-Extension Views Dependent on assessment of her history and images requested by referrer. Cindy Pike’s history (evidence of trauma) was unacknowledged and a chiropractor c-spine series was completed. Series is inappropriate as history is indicative of trauma. 2 C-spine trauma series protocol should be utilized, ruling out flexion-extension views. 2 Determination of the Correct Imaging Protocol for Cindy Pike
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Khan et al3 demonstrates the minimal clinical use of flexion-extension views. Difficult to obtain and time consuming.4 Minimally helpful for c-spine clearance.4 Promote muscle spasm/strain (painful to the patient).4 Dangerous (cause neurological deficits).4 Additional radiation exposure to Cindy Pike, jeopardizing MRPBA Code of Conduct and ALARA principle.1,6 Errors of Performing Flexion-Extension Views Considering the Contraindications of Performing Flexion-extension views
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Errors of Performing Flexion-Extension Views Assess dynamic ligamentous stability.4 Increase sensitivity (99%) and specificity (93%).5 Exclude diskoligamentous injuries.5 Evidence base literature states definitively, flexion-extension views are still only adequate in 20-30% of cases, and rarely change patient management.4 Considering the Indications of Performing Flexion-extension views
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Errors of Performing Flexion-Extension Views Guarnieri et al8 states provide minimal information for cases of acute trauma (condition of Cindy Pike). Utilized in detection of potential sites of nerve compression in cases of radiculopathy suspicion and to assess patency of intervertebral foramina – irrelevant to case of Cindy Pike. 9 Increases time of examination Extra radiographs contribute to additional radiation exposure, jeopardizing MRPBA Code of Conduct and ALARA principle.1,6 Considering the Contraindications of Performing Oblique views
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Three projections: lateral, anteroposterior (AP) and open-mouth odontoid.5,8,10 Lateral performed first: 70% detectable abnormalities visualized.10 Lateral: T1 visualized (Swimmers view appropriate?), assessment of arcuate lines, vertebral bodies below C2 and intervertebral disc spaces.10 Errors of Performing Flexion-Extension Views Evaluating the Importance of Performing Trauma C-spine series Protocol In rural settings, it is imperative I am trained in radiographical abnormality detection techniques, reducing probabilities of missing pathology.11
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Errors of Performing Flexion-Extension Views AP performed second: spinous process in straight line, equal distances apart.10 Open mouth odontoid third: C1/2 lateral margins aligned, distance between lateral masses of C2 and each side of odontoid peg equal.10 Three views: Cindy Pike at less risk of additional induced symptoms, adequate assessment of cervical spinal injury, ALARA principle upheld, MRPBA guidelines are adhered.1,5,6,8,10 Evaluating the Importance of Performing Trauma C-spine series Protocol
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Questioning a Radiologist’s Report Radiologist report states normal c-spine, reduced flexion – however clear C2 fracture is visualized (Employment of radiographical abnormality detection techniques) .10,11 Legal obligation (MRPBA Code of Conduct) and moral obligation to question report so Cindy Pike receives suitable diagnosis for treatment.1 If report is not questioned the reputation of myself, chiropractor and radiologist is threatened.1 If report is not questioned the quality of life for Cindy Pike is endangered.1
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Alert reporting radiologist of C2 fracture while Cindy Pike remains in hospital. Firstly: investigate if images were sent to PACS, Rural site may have experienced Wifi issue – if so, contact IT to repair connection. Then upload images to PACS and alert radiologist. Alert radiologist through I-TeleRAD (DayRAD), however most likely call radiologist. Questioning a Radiologist’s Report A Discussion of the Appropriate Steps to Question a Radiology Report
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The next step: constructing a professional message to the radiologist. Utilize appropriate social techniques: start positive.12 Begin the message positively: Prevents being blunt.13 Prevents accusing radiologist of being wrong.13 Radiologist is primarily praised for hard work.13 Questioning a Radiologist’s Report A Discussion of the Appropriate Steps to Question a Radiology Report ‘Good evening. Thank-you for reporting on Cindy Pike’s examination. It is evident you dedicated time and effort toward the betterment of hear health’
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Self-aware of difference in authority between myself and radiologist.14,15 Be respectful while indicating reports issue and opening for discussion.16 A component of empathy is paramount.17,18 Utilization of question prevents being demanding (bullying).15 ‘something looked a little out of ordinary’ – employs empathy. 17,18 Questioning a Radiologist’s Report A Discussion of the Appropriate Steps to Question a Radiology Report ‘I reviewed the flexion-extension views, and I thought something looked a little out of the ordinary around the posterior section of C2 Could you please reinspect this area?’
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Radiologist may submit a complaint to my employer or MRPBA I must uphold a degree of professionalism, providing an open, prompt and constructive explanation An apology may be necessary Complaint may have implications on my reputation I must save messages and record of Cindy Pike’s c-spine images for evidence to dispute complaint I may need to converse with my employer about the situation Questioning a Radiologist’s Report Implications of Questioning a Radiology Report
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ED Doctor/nurse inspect flexion-extension views – should stabilization of C-spine (hard brace/supine on bed stabilized with two towels) occur? Cindy Pike should be supervised Neutral lateral x-ray for completeness CT contains high sensitivity and specificity for vertebral fractures, is commonly readily available, is quick to perform Questioning a Radiologist’s Report Further Investigations to Confirm Diagnosis
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Neutral lateral x-ray for completeness (low probability) CT surpass x-rays in detecting vertebral pathology Readily available Swift study Unmatched sensitivity and specificity Defines morphology, pattern and mechanism of fracture Aids in determining appropriate treatment plan May not be available in rural clinic Questioning a Radiologist’s Report Further Investigations to Confirm Diagnosis: CT
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Excludes diskoligamentous injuries Must be performed within 48 hours Evaluate spinal cord parenchyma Increased spatial resolution Limitations include: time required to obtain evaluation, not readily available, cost heavy, contraindicated in presence of metal implants MRI is not superior to CT for evaluating c-spine trauma Questioning a Radiologist’s Report Further Investigations to Confirm Diagnosis: MRI
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Considering Aspects of Patient Care for Further Action Issues surrounding semi-rigid cervical collar: Unnecessary movement during sizing/fitting, causes pain and discomfort, compromises the airways, hides life-threatening conditions (anzcor too) ANZCOR recommends: head immobilized in neutral position However given rural setting, lack of radiologist: trained ED doctor should fit brace for transport to major hospital CT has not yet ruled out other possible c-spine pathology Is Cervical Immobilization Required?
Slide 18-

MRPBA states it is my legal obligation to uphold aspects of patent care Importance of effective communication Cindy Pike understands condition Immobilization can be emotional/traumatic – Cindy Pike must be understood, acknowledged and respected Treatment plans/further actions communicated – Cindy Pike has obligation to question/refuse Considering Aspects of Patient Care for Further Action Relevant Fundamental Aspects of Patient Care
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Nearest major Hospital 2 hour drive away Van: supinated and immobilized, accompanied by nurse/carer trained in c-spine precautions Accompanied by family member/close friend: ensures is comfortable and relaxed Royal Flying Doctors service: Doctors can supervise/immobilize –faster means of transport, reduces delayed diagnosis and treatment Studies state transport movements generating additional injury is unlikely Considering Aspects of Patient Care for Further Action A Discussion of Appropriate Methods for Transportation
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Incident occurred early morning, assumed x-ray examination performed 1pm and second report produced around 3pm ~ 10 hours Increased time Cindy Pike endures neck pain – could have been managed through medication Delayed c-sine diagnosis: 9.5% patients result in longer hospital stays, ¼ experience severe disabilities neurological deficit in 44% of patients, with 11.1% developing permanent deficit Minimal permanent complications with delayed diagnosis Risk of Inadequate/delayed immobilization causing neurological injury overestimated Considering Aspects of Patient Care for Further Action The Implications of Delayed Diagnosis
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Cindy Pike must spend increased time at rural hospital – generates management issues Notify family, formulate management plan – Cindy Pike’s privacy/confidentiality must be acknowledged Cindy Pike may display negative motions – level of trust reduced due to inadequate radiology report Must rebuild trust: maintain good communication, uphold degree of respect, treat as individual, be courteous, honest, compassionate about her healthcare Considering Aspects of Patient Care for Further Action The Implications of Delayed Diagnosis
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Initially stabilize c-spine in neutral supine position in trolley, with padding under head Trained in C-spine precautions Monitor BP, cardiovascular and lung function, reduce movement of c-spine Respiratory management (protect airways), maintain adequate respiration Dermatologic management: risk of skin ulcers and sores increases by 66% each day of additional immobilization ED nurse accompany patient to ensure c-spine immobilization during transport Trained in spinal boards and log rolls Health Professionals Utilized in the Case of Cindy Pike The importance of the ED nurse
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Decide if early immobilization required through interpreting flexion-extension projections Trained in C-spine precautions Fit and size collared brace Trained in spinal boards and log rolls Outline c-spine management and further actions to patient Delegate case information to royal flying doctors service Produce referral for CT scan Health Professionals Utilized in the Case of Cindy Pike The importance of the ED Doctor
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Radiologist not on site: provided expertise and support is minimized Enhanced understanding of cervical anatomy – generate report for elaborate analysis of pathology Analysis provides evaluation of findings to myself, ED doctor, ED nurse and health professionals at nearest major hospital Report functions as a determiner for further investigations Health Professionals Utilized in the Case of Cindy Pike The importance of the Radiologist
Slide 25-

Probability health professional is not present on site – tasks will be delegated to myself and other health professionals Assist in paper work/decision making for Cindy Pike - benefits of travelling to nearest major hospital to receive treatment Advocate for the patient rights of Cindy Pike Produce dialogue regarding inefficiencies in radiology report, building relationship to rebuild trust to ensure comfort and cooperation Health Professionals Utilized in the Case of Cindy Pike The importance of the Medical Social Worker
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References Medical Radiation Practice Board of Australia - Professional capabilities for medical radiation practice [Internet]. Medicalradiationpracticeboard.gov.au. 2019 [cited 2 May 2019]. Available from: http://www.medicalradiationpracticeboard.gov.au/Registration/Professional-Capabilities.aspx The Royal Australian and New Zealand College of Radiologists – Adult Cervical Spine Trauma [Internet]. https://www.ranzcr.com. 2019 [cited 2 May 2019]. Available from: https://www.ranzcr.com/college/document-library/overview-adult-cervical-spine-trauma Khan S, Erickson G, Sena M, Gupta M. Use of Flexion and Extension Radiographs of the Cervical Spine to Rule Out Acute Instability in Patients With Negative Computed Tomography Scans. Journal of Orthopaedic Trauma. 2011;25(1):51-56. McCracken B, Klineberg E, Pickard B, Wisner D. Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients. European Spine Journal. 2013;22(7):1467-1473. Vialle LRG. AOSpine Masters Series, Volume 5: Cervical Spine Trauma. Stuttgart: Thieme Medical Publishers, Incorporated; 2015. Hansson S. ALARA: What is Reasonably Achievable?. Radioactivity in the Environment. 2013;:143-155. White A, Biswas D, Smart L, Haims A, Grauer J. Utility of Flexion-Extension Radiographs in Evaluating the Degenerative Cervical Spine. Spine. 2007;32(9):975-979. Guarnieri G, Izzo R, Muto M. The role of emergency radiology in spinal trauma. The British Journal of Radiology. 2016;89(1061):20150833. Simpson A, Sabino J, Whang P, Emerson J, Grauer J. The Assessment of Cervical Foramina With Oblique Radiographs: The Effect of Film Angle on Foraminal Area. Journal of Spinal Disorders & Techniques. 2009;22(1):21-25. Raby N. Accident and Emergency Radiology. Elsevier ClinicalKey Books; 2015. Murphy A, Neep M. An investigation into the use of radiographer abnormality detection systems by Queensland public hospitals. Journal of Medical Radiation Sciences. 2018;65(2):80-85. HUTCHINSON M, HURLEY J. Exploring leadership capability and emotional intelligence as moderators of workplace bullying. Journal of Nursing Management. 2012;21(3):553-562. Salin D. The prevention of workplace bullying as a question of human resource management: Measures adopted and underlying organizational factors. Scandinavian Journal of Management. 2008;24(3):221-231. Chrobot-Mason D, Gerbasi A, Cullen-Lester K. Predicting leadership relationships: The importance of collective identity. The Leadership Quarterly. 2016;27(2):298-311. Barsky A, Kaplan S. If you feel bad, it's unfair: A quantitative synthesis of affect and organizational justice perceptions. Journal of Applied Psychology. 2007;92(1):286-295. Jameson J, Bodtker A, Linker T. Facilitating Conflict Transformation: Mediator Strategies for Eliciting Emotional Communication in a Workplace Conflict. Negotiation Journal. 2010;26(1):25-48. Burks D, Kobus A. The legacy of altruism in health care: the promotion of empathy, prosociality and humanism. Medical Education. 2012;46(3):317-325. Gerdes K, Segal E. Importance of Empathy for Social Work Practice: Integrating New Science. Social Work. 2011;56(2):141-148.