Trauma patient injured in a motor vehicle accident - Essay Example

Running Head: Reflective Work Journal REFELECTIVE WORK JOURNAL Reflective Work Journal Introduction: Since there are so many sophisticated radiographic techniques available for use in the present day, the question that a radiology practitioner needs to consider while evaluating patients is the relative efficacy of these other methods as compared to plain films. Certain films are taken as a matter of course in treatment of a variety of ailments ranging from complaints of pain to serious injury and trauma. The following discussion centers upon three specific cases and the use of plain films to evaluate whether it is indeed the best option that is available and preferable for use in each particular situation. Trauma patient injured in a motor vehicle accident: The patient is a 9 year old male, who has been injured in a motor vehicle accident. He has sustained injuries to the thoracic and lumbar regions and is admitted as a trauma patient. The patient exhibited all the signs and symptoms of acute trauma, such as elevated heart rate, low blood pressure and a tendency to slip into unconsciousness. Plain radiographs of the chest and lumbar regions were taken, in order to assess the extent of injury to the internal organs. The plain radiographs were used as the gold standard and a CT (computed tomographic) scan had already been taken on this patient immediately on admission, as a matter of course, in view of the mechanism of injury. Since the patient was unconscious, it was necessary to ascertain whether there had been any internal injury to the head, which was facilitated through a normal CT scan. While the external injuries to the chest could be seen, evaluated and treated, the possibility of internal injuries became an imminent threat in this case for the following reasons: (a) His level of consciousness vacillated between being alert and being unable to arouse. (b) The initial imaging appeared to suggest that Daniel’s CNS was not the cause of his problems and the CT scan revealed no abnormalities or fractures in the brain. The CT scans of the chest and spine area also did not give any indication of any internal injuries in the thoracic and spinal region. (c) The level of trauma that the patient had experienced was the patient was indicative of internal injury, since in spite of the fact that there was no respiratory distress that could be noted, the patient demonstrated a consistently increased heart beat and low blood pressure, coupled with spells of unconsciousness, which was alarming and indicative of stress due to shock. (d) He appeared receptive to intravenous drips, and demonstrated continued acidosis further enhancing the possibility of internal injury that was not showing up on the CT scans. The chest x-ray showed no fractured ribs, and plain films obtained on expanded lung fields showed no evidence of contusions in the thoracic region. However, as compared to the CT scans, the sensitivity of the plain films was actually better and specificity and accuracy of the plain films were 96 and 86% in the case of the thoracic examination, with sensitivity of 55%. The plain films showed no fractured ribs, however they were able to detect a mildly increased heart size and in view of the fact that the patient was responsive to intravenous drips and his bouts of unconsciousness showed continued evidence of shock, a sonogram of the abdomen was undertaken, which led to the diagnosis of cardiac tamponade in this child’s case and surgery was undertaken for right atrial rupture. According to Hazinski (1999) low ECG voltage and an enlarged heart size showing up on x-rays are significant indications of pericardial tamponade, therefore in this case it was the plain films that aided in the initial diagnosis. In general, plain films have been found to be more useful as compared to CT scans and other diagnostic methods in thoracic and spinal injuries sustained as a result of trauma, especially in vehicular accidents (Bielman et al, No date). Therefore, for such patients, plain films may be quite adequate to determine internal injuries and fractures and there may not be a need to go in for more sophisticated procedures. A case of nausea and low back pain: In this case, the patient is a 56 year old female who complains of nausea, flushing and low back pain. Although there is no history of hypertension, nevertheless blood tests show up the presence of the dopamine receptor as well as increased levels of norepinehprine and epinephrine. Preliminary investigation included the collection of several plain films, after the patient had been injected and hydration was maintained both before and after the injection. The films taken consist of views taken within four hours of being admitted and regions surveyed were the planar, posterior and anterior abdomen at 15 minute intervals. Further films were taken after twenty four hours of the same regions, including views of the chest and the abdomen. The films showed a large suprarenal lesion, which demonstrated peripheral uptake. Although CT scans were also taken and this lesion showed up on the CT scans as well, they were not strictly necessary, since it is possible to detect the presence of the lesion merely through the administration of diagnostic procedures using plain films. These films also showed that there was an intense level of activity in the kidneys and bladder with less uptakes in the liver and the spleen. The presence of the suprarenal lesion was further confirmed through the use of outside ultrasound and a diagnosis of right adrenal pheochromocytoma was made in this case. The renal lesion was identified as the primary lesion and those in the kidney, liver and spleen identified as the secondary lesions. In this case also, the efficacy of plain films is demonstrated amply. There is no need to use more sophisticated imaging techniques such as MRI or CT scans, which are also relatively more expensive and do not yield any significant improvements on the results that have been obtained through the use of plain films in this case. The technique of octreotide imagine is likely to be both beneficial and applicable in this case as a viable alternative option, however for preliminary diagnosis purposes, plain films will be found to be more than adequate. Frostbite of the digits: This is a 59 year old patient who has suffered from exposure to the biting cold while stranded out in the cold and being forced to repair his car. Diagnostic imaging is also useful in this case, to determine the extent and nature of the damage due to frostbite. The value of the plain film is in detecting fractures and other abnormalities. While frostbite tends to cause more tissue damage, nevertheless there is also the possibility of identifying significant damage to the interior phalanges which will necessitate amputation of the digit in question. The nature of the imaging that was done in the case of the patient with frostbite helped to determine which parts of the fingers would recover, which parts were in a critical condition and which parts could be salvaged. However, in this instance, since the nature of the damage is likely to be to the tissues rather than the bones, vascular phase images and tissue phase images are more useful, together with delayed phase images obtained at four hours with cobalt markers at the tips of the digits. The preliminary plain film radiograph that was performed was helpful in ascertaining that there were no damages to the bones in the swollen, painful fingers. Such a bone scan is particularly critical in the initial critical phase of the injury from two days to 2 weeks. Periodic bone scans help to ascertain the degree of sepsis and hence provide the indication of whether or not amputation of the digit will be deemed necessary in order to avoid spread of the infection (Cauchy et al, 2000). In this case, the phase images reveal frostbite injury to the tissues in the mid and distal 2nd through 5th phalanges. The delayed phase images that were obtained with cobalt markers were helpful in determining that there was no significant critical infection that would mandate amputation. Only the distal phalanx of the left hand was considered to be at risk and a possible candidate for amputation. There are some parts of the digits that appear in a critical condition, however the fact that uptake is relatively increased in the delayed phase tests indicates that there will be a recovery of function in those parts that demonstrate increased uptake, while the significantly decreased uptakes would be predictive of a critical condition that mandates further observation. In this patient’s case, increasing age was also a factor to be taken into consideration since it could have affected the results. Therefore this is case where the efficacy of plain films may not be as high as desired. It may be necessary to use alternative methods to determine the nature and extent of the injuries. The major problem with diagnostic imaging is that most of these procedures are expensive with limited availability, especially MRI (Khan and Macdonald, 2004). Another problem that arises is the fact that in certain areas of the body, it is difficult to distinguish a benign sarcoma form a malignant one. But planar tomography is still a proven, effective method to focus on bone details in complex skeletal areas (Khan and Macdonald, 2004). Moreover, it is also cost effective as compared to other methods of imaging such as MRI. Therefore, in terms of its sensitivity, planar X-rays are invaluable in picking up details that are not visible in an ordinary scan, especially in areas where there is a complex differentiation of bones and it becomes difficult to distinguish between ordinary bone growth and irregular growth of potentially dangerous lesions and sarcomas. However, as a practitioner, I have focused on identifying which particular diagnostic technique would be appropriate in a particular situation. For example, while bone scans are useful in the case of frost bite and potential damage to the bone cartilage in the digits, nevertheless, the preliminary diagnostic scan is the one that is useful in determining what kinds of future tests are necessary. It is only in the event that bone damage is suspected, that the need to use further bone scans and sophisticated imaging techniques arises. Otherwise, the vascular and tissue phases are more useful in first determining the extent of the injury and in ascertaining which part of the digits are likely to be significantly affected and may need amputation. In the case of the child who suffered thoracic injury, the plain films were extremely useful in identifying the enlarged heart which led to the diagnosis and helped to ensure timely treatment. For the patient who had intrarenal lesions, plain film was more than adequate to reveal the existence of lesions. There may be a need to use more sophisticated techniques if additional complications are identified later. Role of the practitioner: It is to be noted that in the case of diagnostic imaging, the practitioner is administering a scan that most often comprises radioactive rays and it is the responsibility of the practitioner to make his or her patients aware of the attendant risks associated with exposure to even minimal levels of radiation, so that the patient can make an informed decision about whether or not the degree of risk is acceptable. There is an element of risk involved in the administration of diagnostic techniques by inexperienced clinicians, which can also produce possible complications (Ladas, 2001), especially in the case of techniques such as endoscopy. But the value of diagnostic imaging as a exploratory tool is considerable, since most of these techniques are non invasive methods with a high level of accuracy in the results. A practitioner must be skilled in the proper implementation of these techniques and it is necessary for practitioners to use these tools only as and when necessary. The doses administered intravenously of the appropriate therapeutic preparation that will enhance the diagnostic image is of vital importance, since a too large dose could be potentially destructive in its effect and cause serious and long term radioactive complications. Not he other hand, an insufficient dose will prove to be ineffective and produce an unclear image which may render the diagnostic tool inadequate to meet the requirements. The use of filtration techniques to reduce patient exposure to radiation doses is also being actively explored in recent times. (www.ipem.org.uk). There has been much debate on the use of Kedge filters to reduce radiation dose and practitioners need to be fully conversant with the appropriate use of these filters to ensure patient safety. Another aspect of using imaging techniques is the fact that it is a relatively new technique and results are often used as teaching tools in medical schools. This raises issues of privacy and confidentiality of patient records in public and a practitioner need sot very careful in making such information available to unauthorized sources who may misuse the information and cause the issue of medical malpractice suits, for violating patient-doctor confidentiality. Treatment is being administered online on an increasing basis. This poses ethical issues of patient confidentiality that do not arise within a private hospital or clinical setting. While physicians are increasingly using online tools to observe and treat their patients, practitioners need to be aware of the ethical issues in professional online practice(www.ethicscode.com). For example, client’s identity must be clearly established and the limits of the practitioner’s liabilities must be set out upfront in order to avoid confusion later. There is also the threat of confidential medical information leaking out to unauthorized sources via the Internet which is increasingly subject to the actions of hackers. Provision must be made for insurance protection by the practitioner in order to limit liability since online treatment moves into a realm where the degree of control becomes less and it is more difficult to retain patient confidentiality. References cited: * Beilman, Greg J, Peltola, Tom, Schultz, Scott, Relos, Rene P, Grim, Mark and Croston, Kevin. (No Date). “The effectiveness of CT Scan vs. Plain radiographs for detection of thoracic and lumbar spine injuries in trauma patients”. Retrieved 09/11/2005 from URL: http://www.aast.org/00abstracts/00absPoster_006.html * Cauchy, E, et al (2000). “The Value of Technetium 99 Scintigraphy in the Prognosis of Amputation in Severe Frostbite Injuries of the Extremities: A Retrospective Study of 92 Severe Frostbite Injuries.” Journal of Hand Surgery ;25A:969-978. * Childs, Andrew F and Cunningham, Scott Britz.(2004). “Frostbite of the digits”. Harvard Medical School. Joint Program of Nuclear medicice. Retrieved 09/07/2005 from URL: http://www.jpnm.org/elr.html * Hazinski, M.F. (1999). Cardiovascular disorders. In Manual of pediatric critical care (p. 211). Baltimore: Mosby, Inc. * Julius, Barry and Cunningham, Scott Britz (2004) “Diamox imaging of the brain” Harvard Medical School. Joint Program of Nuclear medicine. Retrieved 09/07/2005 from URL: http://www.jpnm.org/elr.html * “Kedge filters”: Retrieved 09/07/2005 from URL: http://www.ipem.org.uk/meetings/17feb.PDF * Lahas, Spiros D. (2001). “Ethical issues on ERCP in the era of MRCP”. Accessed 09/07/2005 from URL: http://www.omge.org/publications/archive/2001_1/d-ercp/d- ercp.htm * Khan, Ali Nawaz and Macdonald, Sumaira. (2004). “Osteochondroma and Osteochondromatosis.” E-medicine. Retrieved 9/7/2005 from URL: http://www.emedicine.com/radio/topic496.htm * “Professional practice online”. Retrieved 09/-7/2005 from URL: http://www.ethicscode.com/pages/698182/index.htm Read More