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'Exactly what kind of a force Professor Röntgen has discovered he does not know. As will be seen below, he declines to call it a new kind of light, or a new form of electricity. He has given it the name of the X rays. Others speak of it as the Röntgen rays'
'The New Marvel in Photography'
Almost all ED docs have missed a fracture.
Nope, all ED docs have missed a fracture. Doesn't mean they should all be clasped in irons and thrown in the hold. It does mean though that X-rays are always an area of risk, error.... and learning.
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| As it was, not that long ago |
So you would have thought that digital imaging was a great step forward.
Well of course it is, but errors still occur, sometimes because of the nature of digital media......and sometimes because you can never under estimate the ability for a human to muppet something up.
Here are three X-ray related cases. All real films. all real patients. all with real harm..... But also all with learning
All of the Films, All of the Time
A lady in her 50's, 'AB' presented with a several month history of non traumatic right hip and thigh pain, with extensive swelling and bruising of the thigh.
She was having great difficulty walking. The ED doctor sent AB for X-rays and then handed her over to another ED junior, leaving a clear plan in the notes. ' If X-rays abnormal- admit. If normal- home'
The second doctor reviewed the films......
............declared them normal and sent her home with GP follow up.
In the following days she had a torrid time. She became entirely immobile, bed bound and unable to get to the toilet in time. Her GP, reassured by the recent ED visit prescribed her morphine and arranged urgent Musculoskeletal out patient review.
Hey, the X-rays are normal right? What could go wrong?
After ten days an Intermediate Care Team visit lead to an ambulance being called. On arrival at the ED for the second time her right leg was now externally rotated and short. An ED Reg saw her and sent her for repeat films which unsurprisingly showed a proximal femur fracture.
When the Reg reviewed AB's previous films taken 10 days before, he saw that the pelvic film had been red dotted by the radiographers and clearly showed a hip abnormality. This turned out to be a pathological fracture related to a disseminated malignancy. Bony Mets on X-rays
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| erosion of the cortex of the lesser torchanter |
Sadly AB died 4 months later.
Whilst the eventual outcome for AB would not have been changed by the diagnosis being made ten days earlier the letter of complaint makes it clear how terrible those extra days at home were
the pain was intolerable…she could do nothing but sit for hours on her landing until her neighbour could attend and carry her back to the bedroom. Her bed had to be changed due to incontinence, her leg had rotated and this was very frightening
The quote is included not to sensationalise, but to remind us of how 'simple' decisions we make day to day can have hugely significant effects on lives
Learning Bite
The doctor who reviewed AB’s initial films missed the abnormality even though it was red dotted because they ONLY looked at the shaft of femur and knee films, which are indeed normal. They did not look at the pelvis films.
PACS is a very useful tool BUT it can make it easy to miss all the films, or look at the wrong date or even the wrong patient’s images.
So Triple Check- Is it the right patient? Is it the right date? Have I seen all the films?…..and finally if the films don’t seem to make sense for the patient in front of you. Double check the films and double check the patient.
Too obvious?
LM a 20 something year old man, attended four days after an accident sustained on holiday. He had dived into a swimming pool and struck his head on the bottom. He had immediate neck and arm pain, and felt his arms were weak. He managed to climb out the pool after a few minutes.
A local doctor advised him that he had a muscular sprain. On return home he initially attended a MIU, who immobilised him and sent him to the local ED. On arrival he was log rolled off the board by a senior doctor who noted normal neurology and sent him for an x-ray of his neck.
On his return he was fully assessed by a different doctor who clearly documents the history and some possible right upper limb weakness. The doctor reviewed his x-rays including a swimmer’s view before making a diagnosis of neck sprain and discharging him without further senior review.
Six days later a radiologist contacted the ED to advise that LM had a fracture of C6 and the swimmer’s view did not show the C7-T1 junction.
Unfortunately the ED had no patient contact phone number so attempts to recall him immediately proved futile. A letter was sent out to LM’s home address, but he did not receive that for a further four days.
Ten days after his first ED visit LM re-attended and was sent for CT, then MRI. This showed further minor fractures of C7 & T1 with evidence of ligamentous instability. He was admitted and underwent surgical repair the following day.
Learning Bite
LM had ‘the’
classic history for a forced flexion neck fracture. This should always make you
raise your index of suspicion. i.e ‘It’s
such a good story that I am expecting a fracture but can’t see one- I had
better talk to a senior.’
How do you know your contact details are correct in the event f recall?
How do you ensure radiology can feedback in real time?
Too likely?
A man in his 70's fell down some stairs and hurt his back. He had suffered back pain for many years so was used to being sore but he thought this was worse than normal.
An ambulance was called and he ended up being seen in an ED. He was deemed to have no significant injury and discharged back home without imaging but with painkillers.
Two weeks later he was still struggling. His analgesia requirement had increased and he was not able to mobilise as well as before the fall.
Another ambulance was called and he ended up in a different ED. They decided that X-rays of his lumbar spine were indicated. Theses were reviewed and declared as showing no fracture. So...... he was sent home with a further change in his analgesia.
Ten days later the X-Ray department at hospital two contacted the ED and said that they thought there might be a fracture on the patients lumbar films but weren't sure. The ED phoned the patient who was still struggling away and sent out an ambulance.
On review he was sore throughout his spine but most notably in his lumbar region where he said he could feel some grinding, clicking and movement..... Movement ? So?...
Well the 'killer' fact missing from this review is that thus chap had a well established history of Ankylosing Spondylitis and had been fixed in the classical 'question mark' position for the past 15 years at least. Ankylosing Spondylitis
His lumbar films do show a fracture.....
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| What fracture? |
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| there it is - right through L4 and all the posterior calcification |
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| Question Mark Spine |
The whole spine CT showed just how abnormal his whole spine is, and also clearly showed the fracture
Learning Bite
'Ank Spond' patients fall over.When they do they usually break something..... Assume, until you can be SURE that they don't, that they have a spinal fracture
Plain films in this group are abnormal before they have a fracture.
Their plains films are notoriously hard to get right. Consider CT as the investigation of choice
Finally, if an AS patient does have a fracture, then the long sections of fused vertebrae either side of the fracture mean that there is lot of leverage at the fracture site and neurological deficit is common.
Final Comment
When we send people home they trust what we say (amazing, but true)
This can mean that folk stay at home in the face of quite dire symptoms
It's really important to give them advice about when, where and how to re-access care.... and then document these 'triggers to return'
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