What a field day for the heat
A thousand people in the street
Singing songs and carrying signs
Mostly saying, "hooray for our side"

Saturday, September 6, 2014

Thing I've learned in the reboot, part 4

"Why do you need to hurt me?" Well, that's not the actual question we get, it more like, "Ow! F#$kers, why did you do that?" or "I can't move that way."

Let me just say to that last one, yea, you probably can. I've seen people all stiff and immovable while on the table. Then once I say we're done, suddenly get all flexible and lose while they walk out of the room (yes, we call you names after you leave). I should also point out there are patients I try not to move at all (especially if I can see that they have a broken hip/femur before I even x-ray them). But mostly people can do what we ask.

By why do I need to move you, touch you, get you at just the right angle? Because I need to demonstrate your anatomy in the proper position with the proper relationships of parts so the Radiologist can diagnose you correctly.

Okay, first there's such a thing as anatomical position. Everything relates to anatomical positions. Why, when your hip is hurting, why do I need you to go pigeon-toed? Because the neck and head of your femur are at specific angles entering the acetabulum and I need you to be in that correct anatomical position for the x-ray. Is it important? Well, if say your hip is broken (I can tell by how your foot is laying on the table, even if I can't see a clear dislocation in the leg) I won't make you (warning FEMORAL ARTERY!), but for everything else, yea, I need you to do that.

In general, we will probably take at least two x-rays of you (with some notable exceptions). And we may take up to six for any one study (like a cervical spine). If you have multiple studies that number can really add up. For one patient I had to do C-Spine, T-Spine, and L-Spine (that's at least 12 x-rays, if not more for repeats or to get specific cone down views). For everything we x-ray we need at least two views to determine exact location of anything that might show up. Also, not all problems show up in all views. Even broken bones. You'd be surprised how many breaks we see in one x-ray in a study and don't see in any of the others. For any bone we need two views, hopefully at 90° to each other. For any joint we need three views (sometimes only two, but that's depending on if you just have pain or if there was a recent injury). Your bones (and soft tissues) are complex. Nobody is exactly the same. I've taken AP (straight on views, beam enters Anteriorly, exits Posteriorly) views of forearms that look like Laterals (side view, typically lateral to medial sides). It's freaky. Then there's your spine. Sure, you may think it's just a bone, but we have to show the intervertebral joint spaces (either an oblique or lateral depending on where we are in your spine, these are where your nerves exit the spinal column) and the zygapophyseal joints (this is where the vertebra articulate against each other, either the oblique or lateral, not the same plane as for the intervertebral spaces). I need to show all of those, hence the numerous x-rays for what you think is a simple pain.

Why don't I focus in on exactly where your pain is? Well, I need certain studies for the doctors to diagnose you correctly, and where you think the pain is may not be where the problem is. Also I need to show the x-rays in specific order to the doctor. Every x-ray has distortion in it. This is because the x-rays come from a point source (5mm) and angle outward from there. I need to show the x-ray with the distortion the doctor has come to expect. If, however, I'm x-raying the wrong side, let me know (you wouldn't believe just how often doctors put the wrong side on their orders - heck, even we get it wrong because we're thinking about the last order we did, or mix up our anatomic positioning). Also, if we're x-raying the "wrong part", ask about it. I've had to (have the full tech) call the doctor's office to get them to change the order. For example, PT had obvious forearm fracture, doctor ordered a wrist thinking it would also show where the fracture was. Um, no. Would you like a forearm instead?

Why can't I just do the wrist and get the forearm (or vice versa)? Okay, one a wrist is typically 4 views for injury, and a forearm is always just 2 views. With a wrist I will get the distal quarter of your radius and ulna (the bones that make up your forearm), but I'm demonstrating the spaces between your carpels (wrist bones), so the radius and ulna will be distorted. While the forearm shows the elbow and wrist, because I'm centering on the forearm, those joint spaces won't be open. One is not the other (even if the doctor asks us to cheat - which we won't do).

And because of how your anatomy is put together I need to get you at specific angles to demonstrate the proper anatomy. Take your shoulder. For an injury we will get a view called a Grashey (named after the doctor who specified it). This is typically an AP (your back against the plate) and rotating the patient by about 45° (again, everybody is slightly different) onto the injured side (especially if you're lying on the table, this can be quite painful). I need to get this view to show the Glenoid Fossa (this is the "socket" on the scapula where the head of your humorous articulates) in profile (it's a cup, but I need it as flat as possible) and the humeral head and the space in-between them. There are a lot of injuries that can only be diagnosed with this view, and it needs to be done properly. So, yes, even if you're in real pain, I need you to do this. I may be able to get away without the Lawrence/Superior-Inferior Axillary (your armpit), for an injury (and that's the only time we take it) it's a very difficult position to hold. But I can't argue away not having the Grashey.

So, yes, I know you think we should only need one x-ray to see what's going on. But we need more. And we need you to hold in exact, specific positions. I know it's painful to hold your legs pigeon-toed on the table (yes, we have to do it ourselves for training) or to rotate your hand palm up and then palm down (AP and internal rotation for elbow and shoulder routines), but the doctor needs to see the bones and tissues in the relationship they're expecting. And know if I'm too far off, I get written up. So not only is it your health on the line, it's my ass and job on the line too.

Also, we will ask you if you've had a recent injury and exactly where the pain is. Be honest with us. If you've had an injury that may mean I need to get different views and your really don't want us calling you back to redo the study (yes, it's happened more than once). If you have a question, like "why are you x-raying my right shoulder when it's my left knee I twisted" ask away. I want to get the right study done (because I don't want to ask you back for another study) and the doctor may have ordered the wrong study (or I may think I'm x-raying someone else, this is why we always ask you to say your name and birthdate). Also, I should be able to explain why I'm doing all those x-rays or why I'm looking at your C-spine instead of your hand where you have the pain (probably looking for pinched nerves). It's your right to know.

But if you ask me not to do something because of the pain, I may be able to take the same image a different way, but I may need you to be at a certain angle, holding you hand a certain way, leaning on the bad side because I need that exact view to show the Radiologist so they can diagnose you properly.

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