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WESTERN INFIRMARY

By Leon Spencer,2014-06-05 19:07
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WESTERN INFIRMARY

ELECTIVE REPORT

Elizabeth Florey

020419930

WESTERN INFIRMARY, GLASGOW

My Elective in Hospital Radiology

WHERE

    The Western Infirmary is situated in the west end of Glasgow, and is joined with Grtnavel General Hospital, also in the west end of Glasgow, to form 1200 beds. It is a teaching hospital used by the University of Glasgow, and its main specialties are:

    ; Medicine

    ; Surgery

    ; Pathology

    ; Biochemistry

    ; Dermatology

    ; Orthopaedics

    ; Opthalmology

    ; Immunology

    ; And the Renal Transplant Service

THE RADIOLOGY DEPARTMENT

    There are 14 Consultants in radiology, who work between the Western Infirmary and Gartnavel general Hospital. There are also 12 Specialist registrars, who were all at various stages of a 5 year training post in Radiology, which sees them going through the transition of becoming a consultant. Whilst in their 5 year rotation, they see all aspects of radiology including interventional, accident and emergency, MRI, CT, ultrasonic, fluoroscopy and much more.

My two supervisors for my 6 week elective were:

    Dr Desmond Alcorn A consultant who trained in Glasgow, who had previously been a General surgeon, but had been working in Radiology.

    Dr Grant Baxter A consultant in radiology, who also held a teaching role within the department, and was involved with the management of Foundation doctors at the Western Infirmary. His specialist interests were renal radiology, and he had delevoped a new form of contrast for looking for blockages in the urinary tract.

WHY

    Throughout the first 4 years of medical school I always loved the teaching sessions we had on radiology at various stages of the course. However, I felt that a lot of the teaching was very rushed, and as the topic had always seemed very interesting, and I had found myself looking through patient’s radiological investigations and reports whilst taking

    histories on the ward, so I decided to organise an elective in radiology.

    I had initially arranged an elective in Houston, Texas, but due to a family matter, I chose to be closer to home for my elective, so arranged my elective in Glasgow. I hope to apply to Glasgow for my Foundation Year posts, so it was a good idea to get used to the hospital and some of the staff before I hopefully start working there next year.

WHAT I WANTED TO GET OUT OF THE ELECTIVE

    I wanted to form a good base of knowledge on all the principles of radiology, and be able to examine and interpret most radiological studies, and have an understanding of the completed reports.

    My starting knowledge in radiology was quite meagre, having only ever really seen a few chest xrays. However, I had done some reading prior to starting my elective, and had seen some orthopaedic studies, some abdominal films, and a few CT scans and MRI scans.

    My main interests in the radiology elective, were Accident and Emergency medicine, CT scanning with and without contrast studies, and Ultrasonic investigations.

    During my six weeks, I saw many aspects of radiology, including Basic radiology reporting, both inpatient and out, CT, MRI, Ultrasonic investigations, Accident and Emergency radiology, Interventional radiology, and I also spent some time on the wards with the foundation doctors seeing why certain investigations were ordered,

Basic Reporting

    Basic reporting was done every day on all types of xrays within the western. It was done by all members of the department, and was on both inpatients, and outpatients.

    The reporting was done in the main reporting room of the Western, which was usually a hub of activity with many radiologists present, usually with at least one cup of coffee per doctor, if not two! There were always junior doctors around, either seeking a second opinion, or requesting further investigations for the patients up on the wards.

    The reporting room was always very dark, which at first took a lot of getting used to, as I had never set in a darkened room staring at radiological studies for such a long period of time. It was very relaxing after having spent so much time in a busy bright ward environment, but I, and a lot of the other doctors felt the strain to our eyes after a hectic morning, especially when you were looking for minor changes in routine studies requested by outpatient oncology clinics!

The types of reporting that occurred within the basic studies were:

Chest Xrays from septic patients on the wards,

     Patient in clinics, or on the wards with chest pathology found on

     examination and history.

     Routine screening xrays on patients seen in outpatient oncology clinics

     Follow-up Xrays on patients with known chest pathology

Abdominal Xrays Films on patients with sepsis of unknown origin

     Studies to rule out volvolus and obstruction on patients with

     abdominal pain etc

    Skeletal Xrays from outpatient orthopaedic clinics to check for joint position, fracture

     healing, and foreign bodies.

Breast Mammograms These were reported by radiologists with special interests in

    breast pathology, and were mainly studies from outpatient breast clinics.

Typical Pathologies seen:

    Pneumonia, Tuberculosis changes, Pleural Effusion, Congestive Cardiac Failure, Cardiomegaly, Bronchial Carcinoma, Abdominal free fluid/gas, Abdominal obstruction,

    Bowel perforation, Metastatic disease, Old/new fractures, Breast Carcinoma, Breast cysts etc etc

Interesting Reports

    One report which sticks in my mind is an abdominal x-ray of a patient who had perforated his bowel. He had been using a rolling pin in a way that rolling pins really shouldn’t be used, and suffice to say, his xray was rather interesting, as the offending object had become lodged in an unfortunate place!

Ultrasonic

    I attended many ultrasound clinics during my elective, as I had initially found this to be my favourite aspect of radiology, and after working closely with one of the registrars, he let me perform my own ultrasonic investigations, and I even managed to find 3 deep vein thromboses on my own! This very quickly became a passion of mine during the elective, and I undertook every opportunity I could to attend clinics when I wasn’t busy in other departments.

I saw ultrasonic investigations of the:

    Liver to look for cysts, metastases, and other abnormal pathology including free fluid Kidneys to check for hydronephrosis, and cysts

    Bladder to look for enlargement and retention

    Legs to exclude deep vein thrombosis

    Ovaries and Uterus To exclude polycystic ovaries and other pathology

Interesting things seen

    Whilst examining the leg of a patient who was an intravenous drug-abuser, I discovered that she had a sinus which had formed between the skin surface of her femoral area, and went directly into her femoral vein. She had been using this spot to inject so frequently, that she now had a direct link. However, she had presented with limb pain, and I therefore performed ultrasonic investigation of her upper and lower limb main veins to rule out a deep vein thrombosis. There was no thrombosis present that I could find.

CT Scanning

    I saw many many Ct scans whilst on my elective, mainly CTPA (Chest, Abdomen and Pelvis CT scans), used for staging various cancers, but I also saw a lot of head CTs to rule out reasons for neurological symptoms.

CTPA I saw these with contrast and without.

     These are used to look for pathology within the body that cannot be easily seen on normal plain films. They are performed on most patients with cancer to stage their disease, and to provide options should a surgical opinion be considered. CTPAs are also performed on patients with sepsis of unknown origin, patients with pyelonephritis, patients with kidney problems.

    CTPAs are very large investigations, and therefore it is sometimes necessary to only select part of a patients torso to scan to save the poor radiologists eyes when it comes to examining the scans and reporting them! For example if a patient presented with signs of a renal calculi, a very low quality scan is usually performed using contrast, and only the renal pathways are scanned (i.e. kidneys to bladder), so avoiding the use of a lot of radiation, and also the contrast would show up any calculi present despite the low quality scanning.

    Head Cts these are performed on patients presenting with symptoms of stroke, and are uslaly done to differentiate between a haemorrhagic stroke, or a thrombo-embolic stroke, as these are managed differently.

MRI

    I did not spent that much time in MRI scanning, as neither of my supervisors worked within this department, but I did spend a couple of afternoons there, comparing the use of MRIs with CT scanning, and what scan was better for showing up different areas of the body.

    MRI scans are mainly done to look at the bones, and soft tissues in more detail than is required from a CT scan. However, there are many more complications with MRi scanning, including the size of the patient, and the inability of the machine to work if the patient is wearing anything metallic.

    The MRI machine is used a lot for viewing the brain and circulatory system, as these are far clearer than conventional Ct scans.

Fluoroscopy

    I saw a lot of fluoroscopy whilst on my elective, both investigational, and interventional.

    I worked with speech therapists to look at patients with swallowing problems, who were given some contrast to swallow when asked, and their upper GI tract was then visualised in real-time whilst the effort of swallowing occurred. There showed up pharyngeal pouches, and oesophageal strictures etc.

    I also performed some fluoroscopy with my consultants, and got to manipulate the x-ray machine myself so as to get the best view possible of the patient’s GI tract for the investigation.

    I also saw some angiography in theatre for the treatment and investigation of patient’s with suspected clots of their arterial systems.

Accident and Emergency

    Most mornings on my elective, I would join the first or second year Specialist registrars to go over all the accident and emergency cases from the day before.

    These ranged greatly for patients requiring chest x-rays for suspected pneumonias, to patients with broken fingers, dislocated shoulders, and even the occasional foreign body!

    I really enjoyed this aspect of my elective, as initially I found it much easier to spot abnormal signs on plain films of orthopaedic cases, then anything else! I got to grips with the terminology used when describing certain fractures, and enjoyed showing off my knowledge when it came to departmental meetings!

    I learnt all about the differences between epiphyseal plates, and fractures, and how these can look very similar on plain films. I was taught many tricks of the trade for examining certain films, for example cervical spine x-rays.

    This was one of the most enjoyable aspects of my elective, as I got to work with the younger staff, and if there was a film where the registrar was not convinced, then it became a team effort between me, them and the consultant to try to come up with a diagnosis.

Interventional Radiology

    When I started my elective, I had no idea that radiology involved so many minor surgical procedures! Whilst on my elective, I got to scrub and help for many small operations, including:

    ; Oesophageal stents

    ; Nephrostomies

    ; Ultrasound guided drainage of knee effusions in ITU

    ; Drainage of Pleural Effusions

    ; Angiograms

    ; Tenckhoff catheter placement for peritoneal dialysis

    ; Any many more.

    I loved this hands on approach to the patients, as having spent quite a few days just purely reporting plain films, without much patient contact, I missed the skills required in talking to patient’s and performing minor procedures.

Shadowing of FY1s

    Whilst in the Western, I spent a couple of days shadowing new Foundation doctors, and observing when and why they requested plain films, Ct scans or any other radiological investigation. I saw how much detail was needed when requesting a study, as the request forms were frequently sent back, as the consultant had refused to agree the investigation due to lack of detail.

    This gave me a good grasp of what would be required of me in a years time, when it was my own turn to be an FY1.

Elective Project

    During my elective period, I self reported 20 different investigations which were being placed in a national library at the Royal College of Radiologists. These varied between fluoroscopic studies, plain films, and Ct scans. This took up quite a lot of time, as unlike normal hospital reporting, this required me to write a short summary of the patient’s presenting complaint, their symptoms, the differential diagnoses, and then my findings, and further management of the patient.

    I have attached a few of these forms that I completed as an example of my work.

Conclusion

    I thoroughly loved my elective in Glasgow, and would recommend it to anyone thinking about a career in radiology, or just someone interested in knowing more about the subject like myself.

    The Western Infirmary was a lovely place to work, and the staff were all very friendly, and willing to let me help out in any way possible.

    I felt that I got a much better grasp of reporting plain films and more complicated investigations, and although I fully admit, my knowledge of the physics behind all the investigations is somewhat limited, I still thoroughly enjoyed reporting films on my own, and performing the minor procedures as detailed above!

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