Intermediate examinations

Table 6b. Summary of the data codes arranged by complexity-intermediate Intermediate cases

M SO SOD L C P I F AP LAT

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Table 6b provides figures to indicate the summary of number of times the data codes were observed during intermediate examinations.

Half of the intermediate cases were included in this section as a result of uncertainty about the patients’ ability to comply; the majority of these cases being children. This uncertainty influenced the behaviour of the radiographer they were less inclined to demonstrate positioning to patients (SOD) who may be unable to understand and opted to manually position the patients (M). The remainder of patients in this classification were included as a result of the complexity of the imaging examination or their presentation and the move to manual positioning (M) was also evident for these patients with only one case relying on demonstration (SOD) alone for positioning. This may be attributed to the level of injury as assessed by the radiographer. Interpretation of this behaviour might suggest that the severity of the injury indicated that the patient might need support in attaining the appropriate position required rather than relying on demonstration alone. Table 6 intermediate cases (see appendix 2c page 185) demonstrates this change in practice between classifications of examination. Communication for comfort checks (C) was seldom used in intermediate cases but there was an increase in the use of pads to position the patient (P) with half the patients in this category having their limb supported in position with a pad. This also suggests that the radiographers feel the need to provide the patient with an additional level of support. All but one of the cases (where the information was recorded) were commenced with the AP projection with the exception of the first examination conducted by radiographer 21 where the patient presented in a sling with the arm flexed in the lateral position and the radiographer intentionally left the patient in this position then reviewed the first image produced before moving the patient (see appendix 2d page 188 for Radiographer 21 patient 1 transcription). Choice of room was to some degree influenced by this category of patients as nearly half of the patients in this group were children and site two used a dedicated DR room for paediatric examinations and would intentionally move across the site to use the paediatric room (see appendix 2e page 190 for site 2 map). This in turn influenced the review of the images which was conducted immediately (I) as they are instantly available with DR equipment but there was also a rise in immediate review of the images produced in CR rooms. At site one there was no demonstrable influence of examination complexity on room choice.

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Assessment of the patient was key in intermediate examinations and radiographers made conscious efforts to assess the patient.

“…I would be constantly assessing the patient from the moment you meet them and using, using all of those cues I guess you would say to inform it”

Radiographer 1 patient 4

“…so (they) was calm, (they) was sensible (they) understood what was going to happen, and (they) was ok like I mean I made a judgement call I did make a judgement call that (they) would be fine…”

Radiographer 1 patient 4 Assessment of the patient in intermediate cases influenced the radiographers’ approach to the examination in terms of problem solving.

“…I made a decision that the child was capable and competent…”

Radiographer 1 patient 9 For many patients in this group, despite the potential for intermediate complexity at information review, assessment of the patient on introduction indicated that the examination was routine, and intuitive, “automatic” problem solving was employed.

“…apart from that it was a quite routine protocol…”

Radiographer 1 patient 9 This happened primarily with the patients who were children. When assessed they were deemed capable of compliance as such it became a routine examination requiring little active cognitive input.

“…there was no requirement for any adapted technique, the patient was quite fit, erm (they) understood what I was saying to (them)… …a straight forward AP and lateral wrist…”

Radiographer 2 patient 3 Some of the cases proved to be more complex than a routine examination when the patient was assessed at introduction.

“Because (they) was, looked like (they) was guarding it a lot and it looked it more or less was the wrist as opposed to the elbow and I thought about, and that’s the way (they) put (their) hand down first and I thought well rather than moving (them)…”

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Few of these examinations required some thoughtful effort. This was sometimes planning the order of the examination.

“I thought you are better off getting proper projections of the wrist in its, well PA really then getting (them) to flip (their) hand around and make (them) in pain when it is not really

needed, really, plus its, for then the lateral, I was doing it in, I know on the computers it’s like turning off turning on in terms of switching around the exposures and everything but in terms of the patient it is more fluent…” Radiographer 18 patient 4 As previously noted when patient 6 complained about pain radiographer 1 drew on their experience to help them decide how to position the patient. The radiographer in this observation suggests that with experience their perception of how much pain the patient is experiencing has changed. They now perceive that patients can tolerate the pain associated with positioning the patient to the required standard. It is not clear whether this is as a result of desensitising the radiographer to pain experienced by patients or because patients’ report less pain than expected.

“when I was a student and didn’t have much experience I would have been hesitant to actually have continued on with say doing the axial because (they) was in pain, I maybe would have gone to an alternate view quicker like I would have on fewer patients whereas with experience I think ‘oh no (they) can move that little bit extra it’s not that difficult for (them)’ so I will persevere” Radiographer 1 patient 6