It is impossible to imagine the work of a modern district or city hospital without the service of radiation diagnostics, including computer ultrasound, magnetic resonance imaging (MRI), and many new and expensive research methods in addition to classical x-ray . The content of the article
X-ray diffraction. However, despite all the novelties, conventional radiography continues to lead both in the number of studies and at their relatively low price. For almost a century and a half of the existence of our service, an original structural unit has been formed, from the relationships of its members, the quality of both the X-ray diffraction patterns and their descriptions largely depends. This is a kind of team, which includes one radiologist, one or two radiologists, a nurse. Each of them knows its functional responsibilities and seems to be quite autonomous, but failures in any part of this cell inevitably affect the quality of research and, consequently, the health of the patient.
Communication and work with the teams of various X-ray rooms led to an unequivocal conclusion: patients are served quickly and qualitatively only where there is mutual understanding among members of the X-ray brigade, and conflicts are minimized. Conversely, if a roentgenologist and an X-ray lab technician can not find a common language, if the doctor, in the presence of patients, scolds the attendant for a minute’s delay, then the reputation of the doctor and the quality of the descriptions that are done hastily, by conveyor method, inevitably fall.
We must not forget that we are primarily clinicians, not “ancillary services”, as some doctors try to “put in place” the treating physicians, so before you describe the pictures or perform fluoroscopy, you always need to look at the medical history, and sometimes talk directly with the patient. In no case can you obey the claims of veterinarians: “You are told to take it off – here and do what they told you, and do not go into someone else’s work!” Sorry … This work is not someone else’s, but ours, and how each of the us and all of us together do it, the patient will get better, or someone will have to fill in the direction for VTEK or the death certificate form again.
Qualification of a specialist
Nobody argues that the level of a specialist’s qualification largely depends not only on the quality of his work, but also on prestige. Romance is romantic, but health is also a branch of production, wholly subject to both the laws of a market economy and the objective laws of the producers of goods (in this case, health), otherwise why would we be paid our beggarly wages? And we, like all specialists, must perfectly know their profession. “The word heals”, but this is not a reason for familiarity with the patient for the sake of cheap self-promotion. Do not go out and the other extreme, when the doctor builds himself from the impregnable, all-knowing professor. Just need to know your place and do your thing.
In the last ten years to go to a one-and-a-half, two-month out-of-town improvement courses has become too expensive a pleasure. But this can not be avoided: a man can not forget, and the courses make one not only remember the things he learned many years ago, but also learn something new, which before did not have any free time, and also learn what can not be written now in results of research, so that the doctors who have just received a diploma do not giggle. And if someone says that the courses are a waste of time and money, I categorically disagree: they are needed. That’s just would be cheaper …
Quality of equipment
The weakest place in the service of radiation diagnosis is equipment. Done can be dilapidated, which continues to function only because in Soviet times everything was done with a multiple safety margin, and even thanks to the masters from Medtekhniki, miraculously (that is, expensive repairs) that make the X-ray machines ” write-off 10-15 years ago.
In many respects, the dynamics of the structure of X-ray studies is determined not only by innovations, but also by simple wear and tear on the equipment, which allows only the most primitive research to be carried out, if only the level of staff training makes it possible to conduct much more complex and informative studies: after all They did the same before and without a computer tomography, and without ultrasound.
Modern X-ray room Never once I believe in a fairy tale that the general refusal in district hospitals of cholecystography and urography is caused by higher informativeness of ultrasound. No, everything is much simpler: these very effective types of research are not done only because of the high cost of contrast preparations and X-ray films: 2 ampoules urographine + 4 sheets of film – this is already 360 rubles (in 2004), and ultrasound can be done for fifty . And do not try to convince anyone that the patient will go to any expenses for the sake of health.
Comparing the figures from the analyzes of the annual reports on radiology for 1981 and 1999 by regions of our region, we see that the percentage of fluoroscopy has decreased fivefold and the percentage of images among the total number of studies has decreased almost threefold in 10 years, and in 9 years it has decreased 9.4 times, and the number of fluorographs decreased by 3 times. This can be interpreted from different perspectives, however, from the point of view of the radiologist, it is the extreme reluctance of the radiologists themselves to do fluoroscopy, especially if the X-ray apparatus is not equipped with URI (X-ray image intensifier), due to very biased radiation safety propaganda, and those studies that were “Unfinished”, offset by stamping pictures instead of “live” viewing of organs. This same propaganda of harm, which allegedly can cause X-rays to the body, as well as the lack of the possibility to attract a large number of working people (as was done before) in the mandatory order to a compulsory and organized medical examination, caused a decrease in the number of fluorescopes and inevitably a sharp jump in the incidence of pulmonary tuberculosis. And the fact that the total number of shots per year has been reduced almost ten times is due to a single factor – the illness of the entire health care system: there is no money to buy new equipment and X-ray film.
Since the 90’s, i.e. from the beginning of “perestroika”, and until now almost all annual reports with despair repeat the phrase about the shortage of supplies (films, reagents, contrast preparations), the lack of tanks in X-ray rooms, drying cupboards for films, protective equipment from leaded materials, about insufficient and untimely maintenance and repair of equipment by “Medtechnika”. For example, I will say that only in my office of six X-ray machines five were issued in the early eighties of the last century, i.е. all of them serve for a third term instead of the prescribed write-off. But on what to buy new? We are trying to help the advice of the staff of the Department of Radiology, X-ray and radiological department of the OKB, even TSGSEN – and he understands our problems, but only people who manage finances,
In the same 80-ies were widely introduced, but for some reason the ERGA devices were used in practice, very cheap, unpretentious and convenient to use (as they were, and their development was army), which do not require processing in a darkened laboratory and chemical reagents for fixing, if to use (as I did in 1986 and proposed for introduction) a simple electric oven. In the end, as far as I could find out, they are not being used anywhere. But in vain. By the way, the copying machine is a miniature ERGA, only instead of X-rays it uses light from the visible part of the spectrum. In our time ERGA could almost completely remove the problem of consumables, drying cabinets, the organization of archives in the departments of radiation diagnostics.
X-ray defects in the overwhelming majority of cases (with minor exceptions – for example, exposure of the film during transportation, its adhesion from the bay with boiling water from the burst heating battery, under-or over-manifestation due to a sudden power outage) are due only to insufficient qualification or laziness of the X-ray lab assistant. All defects in the radiograph can be divided into 6 groups:
- Rough chemical and mechanical damage (dust, mold in case of improper storage, sticking of sheets or drip from dripping due to improper drying, whitish coating, yellowing and fading of the image with insufficient fixing and washing).
- Incorrect exposure (artifacts on the image due to careless gluing of reinforcing shields or contamination, scratches on them, un-removed clothing or a bandage in the patient in the shooting area).
- Incorrect storage of the film (black spots and points when storing the film in damp areas, different types of veils due to storage of unexposed film flat, not enough darkened room).
- The negligence of the X-ray lab assistant (fingerprints, intermittent strips along the edges of the image due to unwashed after hand reagents, black “twigs” due to electrostatic discharges when the sheet of film is pulled out of the package, the developer spray splashes trapped in the cassette, sickle-shaped black strips in places inflection of the film before its manifestation, exposure of the edges of the frame due to incomplete closure of the cassettes or the edge of the film falling into the cassette shroud).
- Light veil due to falling on the film of extraneous light (carrying the cassette without additional packaging in the sunlight, prolonged exposure of the unpacked film to the light of the laboratory “non-tactical” flashlight, cracks in the faulty cassette, the under-closed door of the photo lab).
- Other causes (incorrect exposure or appearance, transparent specks, if the film does not move in the developer in the first seconds of development, the fixer is depleted or contaminated by the developer, the failure to develop due to the adhesion of the film sheets in the developer).
Recommendations for X-ray labs
You do not need to have an excessive intellect to understand: any of these defects might not have been if the X-ray lab handled their work seriously.
Such excuses of the X-ray lab assistant as “developer is exhausted”, “fixation is not dead” only testify to the fact that he forgot to apply in time for obtaining fresh reagents or was too lazy to dilute fresh solutions in time. Never believe, if you are told that a defective developer package or fixation was caught: the times of adjustment, when this was still possible, were long gone.
Worthy of surprise is the fact that sometimes you can even see something in pictures that do not fit into the standards and, most surprisingly, put the right diagnosis at the same time. But we are just accustomed to work like this: if something is not visible in the picture due to the negligence of the radiologist, we prefer to guess, like Sherlock Holmes, according to the principle of “induction and deduction” and to guess the diagnosis (risking a finger in the sky), only would not once again irritate the X-ray labager with the requirement to remake the picture, do not spend the last sheets of “en-zesny” remnants of the film, saved only for urgent shots, do not try to explain to the patient that an additional dose of radiation does not harm his health at all. Thus, when examining the skull, it is easy to miss a fracture of the middle cranial pit, if not done,
During the cycles of improvement of radiologists, dispatching them for a month at home to their place of work does not bring anything to improve their qualification, except for an additional monthly paid vacation, especially since they do not require it from ordinary trainees, nurses and paramedics, written a report on this “practice”, certified by the radiologist, and not by any of the familiar administrators. Of course, knowing the theoretical basis for the propagation of electromagnetic waves is fine. But it is better if, in addition to this, there would also be knowledge of such practical bases as:
- Impeccable stacking of all types in radiography, taken not on the theoretical, namely practical examination: on an operating X-ray apparatus, a real patient, on the quality made in the presence of a snapshot commission, and not on the answer to the examination ticket;
- Selection of the modes of radiography (current, kilovolt, time) on the X-ray apparatus after changing the tube, changing the adjustments by the master, using a film with a different photosensitivity – depending on how the first few pictures look, i.e. on the principle: “Here are the bad pictures. Approach the X-ray machine and establish the correct modes “;
- Knowledge of specific orders (and exams on them) that regulate their work, in addition to our “constitution of radiation diagnosis” – the order of the Ministry of Health of the RSFSR №132 of 02.08.1991, also such as:
- The order of the Ministry of Health of the RSFSR No. 249 of 19.08.1997 “On the nomenclature of specialties of the average medical staff”, p.4.1 and p.20 in annexes 1-3 (very detailed list of the functional responsibilities of the X-ray lab assistant)
- Order of the Ministry of Health of the USSR No. 1030 of 04.10.1980 (on samples of documentation)
- Order GUZAO № 203/188 of 26.10.1998 “On the regulation of preventive fluorography studies” (no comment)
- Resolution of the Legislative Assembly of the Omsk Region No. 148 “On the Territorial Program for Medical Insurance of the Population of the Omsk Region” (on the Correctness of Designation of Paid Studies to Patients)
- Orders of the Ministry of Health of the USSR No. 79 of 1978, No. 408 of 1989, No. 2780-80 of 1980, No. 12 / 3-4 of 1980 (they explain in detail all those methods of maintaining the sanitary and epidemiological regime, TSGSEN)
- The Order of the Ministry of Health of the Russian Federation No.90 of 14.03.1996 “On the procedure for conducting … medical examinations …” (all about the requirements of the “Radiation Commission” to the personnel of the departments of radiation diagnostics)
- “Collection of technologies and rules for the organization and conduct of work …” GUZAA from 1992 (maintenance of accounting and reporting documentation).
Recommendations for X-ray doctors
The doctor-radiologist with the patient The doctor-radiologist should not be “a little acquainted” with the work of the radiologist. No, he must know this work better than the technician himself. Only in this case he will be able to help the lab technician to make the patient’s correct packing – exactly the one that he needs to describe a particular picture of a particular patient, and not the one that is drawn in the directory; only then he will not allow himself to be deceived by the assertion that, for example, “the raster did not work”, when a lab technician who forgot to switch a workstation button brings a striped image or, stuck in a dark laboratory, a roll of a fluorophone film with three dozen pictures in a fixer instead of a developer, tries to explain , that it’s “just a developer too old,” and he has nothing to do with it.
Defects in the description of radiographs
Unlike image defects, defects in describing images can not be attributed to equipment in any way: in any case, such defects are due only to the incompetence of the doctor.
In something you can forgive a radiologist, working in the specialty of the first or second years, when the “standard template” has not yet been formed in the subconscious, but it is completely unforgivable for a doctor to miss with a large “radiation” experience. It’s silly to describe the pictures “on the run”, looking at them against the window or chandelier, without first having been acquainted with the minimum information about the patient’s complaints and clinical data: too high a chance to simply not see anything, do not take into account the factor that requires additional research. We should not forget that when describing raw pictures, we can see on them something that no one else ever sees on dry – this is the peculiarity of the film structure, where the crystals of silver halides are interspersed in a layer of gelatin, the thickness of which after drying considerably decreases . And no prosecutor will take into account the excuse, that there was no time to wait for the pictures to dry out, that the administration did not buy a new tube in exchange for the burned in the negatoscope. By the way, instead of very scarce and expensive drying cabinets, we successfully use the usual stationary hairdresser’s hair dryer, long ago written off from the House of Life. It dries faster and better than a drying cabinet.
Poverty of health is often caused by errors in the diagnosis of respiratory diseases: well, it’s just a pity to spend a whole leaf of the film (30-40 cm) on the side shot! Of course, it’s a pity and ridiculous to spend it when there are indisputable signs of bronchitis on the survey. And if somewhere in the bone-diaphragmatic sinus is a tiny, diffuse shadow? And if the shadow is roundish, and settled near the root? What if …
That’s why they invented the second projection in the 19th century – so that there were not any “ifs”: thanks to it, we suddenly see that this shadow in the sinus is not at all the vessels of the breast, but the whole half-liter of exudate in the pleural cavity, and the shadow the root does not “seal and darken the lung root, which corresponds to chronic bronchitis,” but a real cancerous node growing from the 6th segment of the lung, and therefore just almost invisible in the survey image due to the lung root. And any radiologist can bring dozens of such examples.
So, the reasons for all errors and the radiologist, and the X-ray laboratory are:
- unwillingness from time to time, even not to read, but at least to look at the manuals on the specialty of at least the most basic level, institute textbooks, abstracts left after the improvement courses or internships. The result is incompetence, caused only by laziness and nothing else.
Summarizing all of the above, the question “Is it difficult to take a picture?” You can answer: “Very easy”, but only if the following conditions are met:
- if the health care is again financed, based on the needs of the industry, and not from the whims of the power structures that determine the budget;
- if both the radiologist and the X-ray lab not only have, but also constantly update, a sufficiently high level of qualification with periodic testing;
- if the departments of radiation diagnosis will be staffed with new equipment.