Sunday, August 14, 2011
Saturday, August 13, 2011
Pacemaker Insertion
One of the things I wish I had better training on prior to my first Technologist position is OR procedures. Sure, most Radiography Programs give you some exposure to them, but it is unrealistic to place the expectation on a clinical rotation in your x-ray program to make you a certified guru on these procedures... and just because you can operate a majority of the features on a c-arm, it doesn't mean that you understand HOW the procedure goes, WHAT to look for, -WHEN to move the c-arm in, WHERE to center, WHO all the people are in the room and WHY they are there.
Let's break it down for a pacer insertion. Examine the pre-op film taken the day of the procedure:
You can tell that this patient has had a history of cardiac pathology. They have had a CABG - often referred to as a "cabbage" and stands for Coronary Artery Bypass Graft. This means that one of the blood vessels supplying the heart (coronary arteries) had once become occluded severely enough to block blood flow to the heart causing a heart attach (Myocardial Infarction - MI). The visual giveaway is the metal wiring that looks like twist-ties. These are placed around the sternum after open-heart surgery to mend the sternum that must be sawed through to access the mediastinum... but that's not what this post is about.
You will be asked for live fluoro during pacer insertions to assist the Cardiologist with positioning of the pacer leads. Remember the electrical conduction system in the heart? Conduction between the AV (atrioventricular) node and the SA (sinoatrial) node can sometimes fail, causing an abnormal heart rhythm, hence the need for an artificial device to assist with providing the heart with a normal "pace" for beating.
So why does the Physician need you? Without fluoro, they cannot see where the leads are being placed. It is imperative that one lead be placed in the right atrium and the other be placed in the right ventricle. Here's what you need to do:
Before the Doctor asks for fluoroscopy, you will know which side he is going to place the pacer (right or left). You will most likely come in the opposite side with the c-arm. In this occasion, the Physician inserted a pacer on the patient's left side. So when prompted, go ahead and center over the subclavian vein on the side the MD is working:
The Physician will need to insert each of the two leads separately, and there should also be a Sales Representative in the room from the device company that manufactures the pacemaker. The Physician and the Sales Rep will always be in constant communication about which lead is being inserted first because what they do requires active monitoring of heart function and good communication. Just listen to their conversation in order to find out which lead is going in first. This will have an impact on where your centering should be with the fluoroscope.
So why are we centering at the subclavian? Well, you know that the body's vasculature has many branches, and without fluoro, the Physician could take a "wrong turn" with the lead, which could potentially be life-threatening if inserted too far through the wrong vessel. This is why it is imperative to be ready to bring the c-arm in when he begins running the leads. Where could they go? Here's a picture of possible routes; green means that's where the Physician SHOULD be going, and red is where he SHOULDN'T go:
The most serious of these directions is toward the head. The blood vessels get small really fast once the lead starts travelling north. It would be easy to perforate a vessel if pushed too far. Pay attention to your image as the Cardiologist is advancing the lead. If the lead starts going up the neck, make sure to tell him because he may not be looking at the monitor in that split second that the lead turns (and you might be the only one in the room looking at it). Keep in mind that everyone in the room is multi-tasking, so don't assume that 100% of anyone's attention is on your fluoro screen.
You shouldn't really have to move the c-arm too much until the lead turns the corner to the south and heads down the IVC (inferior vena cava) and into its appropriate chamber. Anticipate this movement because the Cardiologist NEEDS to see where the lead is going. If you have let the lead go below your field of view, you are not doing your job well. This is important because as soon as the lead enters the heart, it can cause variations in sinus rhythm as it rubs the inner wall of the heart muscle. Once the first lead is anchored, or "screwed" into the heart muscle, re-center as before and follow the same procedure. Here's the final saved image from the c-arm:
Notice the outline of the heart, as well as the Atrail and Ventricular Lead positions. During live fluoro, these may blur due to the heart motion, so make sure to fluoro for at least a second when the Doctor wants to see placement. If you simply "spot" check, it might be so blurry that you can't see the tips. Here is a portable chest x-ray done after the procedure and insertion of the pacer device under the skin (but outside the ribs):
Sometimes the Physician will require an image in PACU (Post-Anesthesia Care Unit), and sometimes not. But equally important is if a 2-view chest x-ray is ordered within the next few days of the procedure. Remember how I mentioned that the leads are "screwed" into the heart muscle? The Physician will typically place a sling around the patient's neck holding the arm in place (on the side of the pacer insertion - left in this case). This is because any extreme motion of that arm may dislodge the screws in the leads. This is bad news - the surgery will have to be performed again if this happens and until it's completed, the lead may impair heart rhythm. This is why it is important to AVOID raising the arms for a lateral chest x-ray after a pacer insertion. Check with your facility's protocols to see if you are required to wait a certain number of hours or days before doing so, and encourage the patient not to raise their arms, even if they feel like they can. A 45 degree wedge sponge may be used under the patient's affected elbow to move the arm out of the way if a 2-view is absolutely required, but no lifting should occur.
Let's break it down for a pacer insertion. Examine the pre-op film taken the day of the procedure:
You can tell that this patient has had a history of cardiac pathology. They have had a CABG - often referred to as a "cabbage" and stands for Coronary Artery Bypass Graft. This means that one of the blood vessels supplying the heart (coronary arteries) had once become occluded severely enough to block blood flow to the heart causing a heart attach (Myocardial Infarction - MI). The visual giveaway is the metal wiring that looks like twist-ties. These are placed around the sternum after open-heart surgery to mend the sternum that must be sawed through to access the mediastinum... but that's not what this post is about.
You will be asked for live fluoro during pacer insertions to assist the Cardiologist with positioning of the pacer leads. Remember the electrical conduction system in the heart? Conduction between the AV (atrioventricular) node and the SA (sinoatrial) node can sometimes fail, causing an abnormal heart rhythm, hence the need for an artificial device to assist with providing the heart with a normal "pace" for beating.
So why does the Physician need you? Without fluoro, they cannot see where the leads are being placed. It is imperative that one lead be placed in the right atrium and the other be placed in the right ventricle. Here's what you need to do:
Before the Doctor asks for fluoroscopy, you will know which side he is going to place the pacer (right or left). You will most likely come in the opposite side with the c-arm. In this occasion, the Physician inserted a pacer on the patient's left side. So when prompted, go ahead and center over the subclavian vein on the side the MD is working:
The Physician will need to insert each of the two leads separately, and there should also be a Sales Representative in the room from the device company that manufactures the pacemaker. The Physician and the Sales Rep will always be in constant communication about which lead is being inserted first because what they do requires active monitoring of heart function and good communication. Just listen to their conversation in order to find out which lead is going in first. This will have an impact on where your centering should be with the fluoroscope.
So why are we centering at the subclavian? Well, you know that the body's vasculature has many branches, and without fluoro, the Physician could take a "wrong turn" with the lead, which could potentially be life-threatening if inserted too far through the wrong vessel. This is why it is imperative to be ready to bring the c-arm in when he begins running the leads. Where could they go? Here's a picture of possible routes; green means that's where the Physician SHOULD be going, and red is where he SHOULDN'T go:
The most serious of these directions is toward the head. The blood vessels get small really fast once the lead starts travelling north. It would be easy to perforate a vessel if pushed too far. Pay attention to your image as the Cardiologist is advancing the lead. If the lead starts going up the neck, make sure to tell him because he may not be looking at the monitor in that split second that the lead turns (and you might be the only one in the room looking at it). Keep in mind that everyone in the room is multi-tasking, so don't assume that 100% of anyone's attention is on your fluoro screen.
You shouldn't really have to move the c-arm too much until the lead turns the corner to the south and heads down the IVC (inferior vena cava) and into its appropriate chamber. Anticipate this movement because the Cardiologist NEEDS to see where the lead is going. If you have let the lead go below your field of view, you are not doing your job well. This is important because as soon as the lead enters the heart, it can cause variations in sinus rhythm as it rubs the inner wall of the heart muscle. Once the first lead is anchored, or "screwed" into the heart muscle, re-center as before and follow the same procedure. Here's the final saved image from the c-arm:
Notice the outline of the heart, as well as the Atrail and Ventricular Lead positions. During live fluoro, these may blur due to the heart motion, so make sure to fluoro for at least a second when the Doctor wants to see placement. If you simply "spot" check, it might be so blurry that you can't see the tips. Here is a portable chest x-ray done after the procedure and insertion of the pacer device under the skin (but outside the ribs):
Sometimes the Physician will require an image in PACU (Post-Anesthesia Care Unit), and sometimes not. But equally important is if a 2-view chest x-ray is ordered within the next few days of the procedure. Remember how I mentioned that the leads are "screwed" into the heart muscle? The Physician will typically place a sling around the patient's neck holding the arm in place (on the side of the pacer insertion - left in this case). This is because any extreme motion of that arm may dislodge the screws in the leads. This is bad news - the surgery will have to be performed again if this happens and until it's completed, the lead may impair heart rhythm. This is why it is important to AVOID raising the arms for a lateral chest x-ray after a pacer insertion. Check with your facility's protocols to see if you are required to wait a certain number of hours or days before doing so, and encourage the patient not to raise their arms, even if they feel like they can. A 45 degree wedge sponge may be used under the patient's affected elbow to move the arm out of the way if a 2-view is absolutely required, but no lifting should occur.
Friday, August 12, 2011
How to Improve Relationships with your Coworkers
You are Super-Tech. Your ability to obtain those difficult trauma views is unmatched and your savvy knowledge of every feature of every c-arm in the hospital has made you the go-to guy for surgical procedures. You are efficient, accurate, the Radiologists love your films, and you have arrived!
A Radiologic Technologist can have all the technical skills in the world, but even someone with the attributes listed above can be someone that you absolutely dread working with. Here are 10 things you can do to improve your relationships with your coworkers.
- Process your coworkers' images - nothing helps reduce patient exam time like being able to focus on performing the views (especially during multiple exams), and being able to view your images immediately after shooting the last image.
- Relieve someone for a break - most departments have scheduled break times for their employees to ensure that everyone gets to eat/rest in a timely manner. Being aware of your own stomach grumbling is easy, but being aware of your fellow techs' is often overlooked.
- Clean up your mess - Clean up your exam room after your procedures. Wipe down surfaces, throw away trash, dispose of contrast containers, get rid of dirty linens and replace with clean linen. Your mother didn't even like leaning up your messes and your coworkers most definitely are not being paid to baby you.
- Do your job - don't mysteriously go missing or decide to take a break whenever an exam needs to be done that you don't partiularly like doing. Oh yes... this happens.
- Talk up your coworkers - when handing over patient care to a coworker, make sure to reassure the patients that they are in good hands. Also see #6
- Don't talk down your coworkers - you may have a negative opinion of something a coworker did, but letting everyone know about it makes you and the department you represent look bad.
- Restock supplies - nobody likes to be in need of supplies, especially in an urgent situation, and open the cabinet to find that it hasn't been stocked in the department. I bet you can think of one or two techs who do most of the stocking in your department. What happens when they're on vacation?
- Stay until your shift is over - if your shift is over in 15 minutes, don't avoid exams because you "want to leave on time." This is just bad patient care, you're still getting paid, and if your relief staff notices this becoming a pattern, you are sure to make enemies.
- Be flexible - be available for shift coverage, sick calls, holidays, weekends, call. Anyone doing this for a while without a break is sure to burn out. Besides, you may need someone else to do this favor for you one day.
- Be a trainer - contribute to the training of new staff and students; they may just be your supervisor some day. Take some accountability for their improvement in skills - a student is only as good as his teacher.
It all boils down to treating your coworkers how you would like to be treated. I'm quite sure you already know people who don't exacly live up to these simple guidelines, but don't let that keep you from abiding by them yourself. People do notice when others go out of their way for their fellow coworkers and it can inspire them to do the same. Pretty soon the people who don't do these things will be the minority, and you will have contributed to your department and health care system in a way that supercedes technical skill and know-how.
How to Improve Relationships with your Coworkers
You are Super-Tech. Your ability to obtain those difficult trauma views is unmatched and your savvy knowledge of every feature of every c-arm in the hospital has made you the go-to guy for surgical procedures. You are efficient, accurate, the Radiologists love your films, and you have arrived!
A Radiologic Technologist can have all the technical skills in the world, but even someone with the attributes listed above can be someone that you absolutely dread working with. Here are 10 things you can do to improve your relationships with your coworkers.
- Process your coworkers' images - nothing helps reduce patient exam time like being able to focus on performing the views (especially during multiple exams), and being able to view your images immediately after shooting the last image.
- Relieve someone for a break - most departments have scheduled break times for their employees to ensure that everyone gets to eat/rest in a timely manner. Being aware of your own stomach grumbling is easy, but being aware of your fellow techs' is often overlooked.
- Clean up your mess - Clean up your exam room after your procedures. Wipe down surfaces, throw away trash, dispose of contrast containers, get rid of dirty linens and replace with clean linen. Your mother didn't even like leaning up your messes and your coworkers most definitely are not being paid to baby you.
- Do your job - don't mysteriously go missing or decide to take a break whenever an exam needs to be done that you don't partiularly like doing. Oh yes... this happens.
- Talk up your coworkers - when handing over patient care to a coworker, make sure to reassure the patients that they are in good hands. Also see #6
- Don't talk down your coworkers - you may have a negative opinion of something a coworker did, but letting everyone know about it makes you and the department you represent look bad.
- Restock supplies - nobody likes to be in need of supplies, especially in an urgent situation, and open the cabinet to find that it hasn't been stocked in the department. I bet you can think of one or two techs who do most of the stocking in your department. What happens when they're on vacation?
- Stay until your shift is over - if your shift is over in 15 minutes, don't avoid exams because you "want to leave on time." This is just bad patient care, you're still getting paid, and if your relief staff notices this becoming a pattern, you are sure to make enemies.
- Be flexible - be available for shift coverage, sick calls, holidays, weekends, call. Anyone doing this for a while without a break is sure to burn out. Besides, you may need someone else to do this favor for you one day.
- Be a trainer - contribute to the training of new staff and students; they may just be your supervisor some day. Take some accountability for their improvement in skills - a student is only as good as his teacher.
It all boils down to treating your coworkers how you would like to be treated. I'm quite sure you already know people who don't exacly live up to these simple guidelines, but don't let that keep you from abiding by them yourself. People do notice when others go out of their way for their fellow coworkers and it can inspire them to do the same. Pretty soon the people who don't do these things will be the minority, and you will have contributed to your department and health care system in a way that supercedes technical skill and know-how.
Monday, August 8, 2011
The Walk of Shame
No matter how many years of experience we gain as technologists, we all know what it's like to do the "Walk of Shame." You know, the slothful downtrodden shuffle you do when you do perform an exam, go to check your films, and you realize you need to repeat. These come with the job and serve to keep us humble.
Every once in a while, it's tempting to get a little bit cocky about your skills after a streak of not having any repeats. I've heard techs say things like "ooooh, that's textbook quality" among coworkers and students. I've also heard "check out that collimation" or "you could drive a truck through that joint space" accompanied by a self-pat-on-the-back. I've been guilty of doing that myself on occasion, all in good fun of course.
But then some days you just don't have it together. I find that everyone has their particular view like a Y-view shoulder or an open-mouth odontoid that a lot of techs struggle with, but you're the go-to person if someone else is struggling with that particular view. But there are some days when you repeat that view that you are typically awesome at, and then another patient comes in for the same exam, and you end up doing a repeat on that patient. This could happen several times in one shift, and can even last for multiple days. I don't know if anyone reading is superstitious, but I equate this to a losing streak experienced by professional sports players.
This happened to me today. It wasn't with a specific exam that I can normally do better than other exams... this was worse. I had to repeat on a patient that was already upset about something. I don't know what they were upset about, but they made it very clear during my first portable chest x-ray that the did NOT want my company. After explaining what I was going to do for the first exam, a comment was made like, "let's just get this over with." Even after offering to help with anything to make the patient's experience better, I was certain that the patient just wanted me to do my job and leave.
I was writing a patient history on my requisition when out of the corner of my eye, the image slowly began to scroll across the monitor. I could already tell... clipped costophrenic angles!!! The sinking feeling set in that I was going to need to face this patient who made me feel so unwelcome once again. We've all been there. I've seen techs stand in front of the image and just stare at it for a few minutes. I can see the gears cranking in their minds; trying to rationalize a reason for not repeating the exam. But we all eventually face the fact that no matter how long we stare at the monitor, it simply won't fix it. We're just delaying the inevitable... walk of shame.
So I returned to the patient with my portable x-ray machine, and as soon as I made eye contact with him, he rolled his eyes. I knew I was in for it. He said, "what happened? Did you screw up?" I said "I missed the bottom of your lungs on the first x-ray, and the Doctor really needs to see the rest of the lungs in order to be able to provide a thorough evaluation. In other words... yes." Admitting your mistakes is one of the more difficult things to do in life, let alone to disgruntled patients. This actually payed off. His response: "that's the first straight answer I've received since I came through the doors." I opened up a dialogue with the patient leading to the explanation about why he was upset. A bunch of tests had been ordered and performed, and he wasn't really kept in the loop. I was able to chat with the Doctor and told him what the patient had expressed and he began speaking with the patient as I was wheeling out the door with my x-ray machine. Thankfully, the repeat image included the missing anatomy from the first film, and I did not need to return.
Don't get me wrong... admitting your mistakes not typically a good experience, and rarely will it result in a positive outcome, but mistakes do happen. They remind us that we're human, as well as our patients in this case. The best thing we can do when confronted with them is to act with integrity.
Every once in a while, it's tempting to get a little bit cocky about your skills after a streak of not having any repeats. I've heard techs say things like "ooooh, that's textbook quality" among coworkers and students. I've also heard "check out that collimation" or "you could drive a truck through that joint space" accompanied by a self-pat-on-the-back. I've been guilty of doing that myself on occasion, all in good fun of course.
But then some days you just don't have it together. I find that everyone has their particular view like a Y-view shoulder or an open-mouth odontoid that a lot of techs struggle with, but you're the go-to person if someone else is struggling with that particular view. But there are some days when you repeat that view that you are typically awesome at, and then another patient comes in for the same exam, and you end up doing a repeat on that patient. This could happen several times in one shift, and can even last for multiple days. I don't know if anyone reading is superstitious, but I equate this to a losing streak experienced by professional sports players.
This happened to me today. It wasn't with a specific exam that I can normally do better than other exams... this was worse. I had to repeat on a patient that was already upset about something. I don't know what they were upset about, but they made it very clear during my first portable chest x-ray that the did NOT want my company. After explaining what I was going to do for the first exam, a comment was made like, "let's just get this over with." Even after offering to help with anything to make the patient's experience better, I was certain that the patient just wanted me to do my job and leave.
I was writing a patient history on my requisition when out of the corner of my eye, the image slowly began to scroll across the monitor. I could already tell... clipped costophrenic angles!!! The sinking feeling set in that I was going to need to face this patient who made me feel so unwelcome once again. We've all been there. I've seen techs stand in front of the image and just stare at it for a few minutes. I can see the gears cranking in their minds; trying to rationalize a reason for not repeating the exam. But we all eventually face the fact that no matter how long we stare at the monitor, it simply won't fix it. We're just delaying the inevitable... walk of shame.
So I returned to the patient with my portable x-ray machine, and as soon as I made eye contact with him, he rolled his eyes. I knew I was in for it. He said, "what happened? Did you screw up?" I said "I missed the bottom of your lungs on the first x-ray, and the Doctor really needs to see the rest of the lungs in order to be able to provide a thorough evaluation. In other words... yes." Admitting your mistakes is one of the more difficult things to do in life, let alone to disgruntled patients. This actually payed off. His response: "that's the first straight answer I've received since I came through the doors." I opened up a dialogue with the patient leading to the explanation about why he was upset. A bunch of tests had been ordered and performed, and he wasn't really kept in the loop. I was able to chat with the Doctor and told him what the patient had expressed and he began speaking with the patient as I was wheeling out the door with my x-ray machine. Thankfully, the repeat image included the missing anatomy from the first film, and I did not need to return.
Don't get me wrong... admitting your mistakes not typically a good experience, and rarely will it result in a positive outcome, but mistakes do happen. They remind us that we're human, as well as our patients in this case. The best thing we can do when confronted with them is to act with integrity.
Sunday, August 7, 2011
Equipment Review: FUJI FCR Go 2
I recently had the opportunity to demo a FUJI FCR Go 2 as our facility is in the market for some new equipment. I have been primarily using GE’s AMX4 series for the last 10 years, so that is the kind of perspective I am writing from while telling you what I think about the Go 2.
On first appearance, the Go 2 is visually pleasing to the eye. It has a slim design left to right, and you can’t tell until you drive it, but it is slightly longer than the AMX series. It feels light-weight because of the drive-assist, and it can go pretty fast with less noise than I am used to. I have to say that it took a few minutes to get used to the feel of driving it. I started out lunging forward and slowing down like when I was 16 and learning to drive a manual transmission. That feeling quickly left though after driving down to our ICU a couple of times. The boom for the x-ray tube also resides in a much lower vertical position than most portable machines I have used, so I can imagine it would be ergonomically easier to use for people who aren’t as tall as me at 6 feet. Even with that feature, the push-bar seemed to be located higher than what I am used to, preventing me from having to hunch over in an uncomfortable position while I drive.
One thing that I noticed when aligning my central ray is the increased length of the telescopic boom. I could park the base pretty far away from the bed and still pull the tube head past the center of the bed if needed. The x-ray tube controls feel natural when aligning the central ray, and the tube swings horizontally 360 degrees around to the cradle position. The collimation and exposure controls are easy to use, and anyone who has ever operated a portable x-ray machine would feel comfortable operating these.
There is an on-board CR reader that functions with the same software as the stationary IIP, so that felt very familiar as I was processing my Image Plate. There is a line of FUJI DR receptors that I did not demo, but I did try out the “gridded” CR cassette. It was very light and I probably wouldn’t have even noticed that it was gridded unless the sales rep informed me that I didn’t need a grid-cap when we were heading out for an exam. There is a touch-screen interface that is spill-resistant above the push-bar which allows you to wirelessly pull up the work list and select your patient. The images appear with what seemed like the same speed as the stationary processors as well.
Here is one major drawback to the post-image production: In order to annotate, there is a stylus pen attached to the unit used on a small keyboard that pops up on the touch-screen when prompted. The keys are small and I found the calibration of our demo unit to be inaccurate. The angle of the screen compared to where my eyes were when viewing the screen seemed like I was pushing the letter “P” and the letter “O” would be typed.
The other major drawback was one I learned the hard way. I went to the ER to perform a portable chest on a code blue patient. One the Physician waved me in to take the exposure, he noticed that I had a sales rep with me and inspected the Go 2 saying “can I see the image now?” I was excited to show off this feature and told him he could. He waited patiently for me to clean the cassette and load it into the reader. Right after I loaded the cassette into the slot and my raw data image began to populate the screen, a nurse told me she needed to get where the machine was. I reached for the push-bar handle and was asked to wait by the sales rep. I was informed that if I moved the machine while the plate was being scanned, that it could produce an image artifact and it was not recommended. Luckily, the Physician told the nurse to hang on while the image came up. Note for future use: pull the machine out of the work area before processing the image plate.
The only other consideration from a usage standpoint is the speed of workflow. I would highly suggest analyzing what types of patient flow you have before you decide on a purchase. If you’re leaving your department once every 30-60 minutes for a STAT portable, or if you are using this in the OR, this might be the equipment for you, especially if you don’t have the budget for a Direct DR machine. However, if you are performing 30 ICU portables in every morning, this might not be the unit you want to take. You may want to make a comparison on efficiency for your facility taking note of how long it takes you to lug CR cassettes back and forth from your closest reader to taking one cassette with the Go 2 and having to wait for processing time of each cassette between exposures. Include in your estimations possible repeats, time and effort spent annotating, and how many cassettes you would be able to carry back and forth (and how many times you would need to do so) without the Go 2.
Appearance:
Practicality:
Versatility:
User-friendliness:
Portability:
Overall Grade: B+
Advertisers: Products that I review on this blog are reviewed based on my own personal opinion. If contacted by an advertiser with offers to review a product, I will be publishing my honest personal opinion regardless of any compensation offered by the advertiser.
Saturday, August 6, 2011
Density Maintenance Formula
I just didn't feel like that last video was complete after reading the original blog post it was meant to supplement, so I just had to go ahead and record the second example problem solution here:
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