I don't think that the junior needs to be "dealt with" as I don't think that they made an error. Enough of us did not spot the abnormalities (or made up others!)for you to say that it is perfectly reasonable for the ED junior miss the abnormality. I would not call this an error - simply the inevitable consequence of medical practice.
I would use the case as the start of a discussion with the junior on how to handle the situation and how to talk to patients and their relatives when things do not go right.
Tim.
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of Rowley Cottingham
Sent: 04 January 2006 10:11
To: [log in to unmask]
Subject: The cervical spine xray - my answer.
Thank you all for erudite and interesting comments.
This is why this is SUCH a good Xray to discuss. Those who criticised the
image are quite right - it isn't a very good image, and is inadequate in
the technical sense as it does not show all the cervical spine. But that
is real; that is what we have to cope with day in, day out. As I pointed
out, the original picture is rather better - but I was careful not to
damage what I perceived as the abnormalities.
My question was only - is this a normal Xray?
I believe there are three abnormalities; two easy to see and in my view
incontrovertible and one difficult to see and arguable.
The first and to my eye most obvious abnormality is the posterior step if
you run your eye down the vertebral bodies. Look at the magnified images
of the C4/5 region on http://www.emergencyunit.com/images/close.htm.
You will see that if you run your eye down the front of the vertebral
bodies they are in alignment. However, if you look down the BACK, there is
a step at C4/5. Definite, no argument. That should lead you to look at
the curvature of the lines once more back at
http://www.emergencyunit.com/images/cspine.jpg.
Remember, in a young fit person artificial lines running down front and
back of the bodies should curve gently and smoothly. Look again at the
front of the vertebral bodies, and you will see a quite clear smooth line
- to C4/5 when you will see a change and a second sinuous line down to the
haze at C7. It is like a sail constrained by rigging.
The third abnormality I see is that there is something awry with the facet
joints. Again, looking at the closeup, I think that there is a
discontinuity which represents a unifacetal fracture and that this film
demonstrates a displacement. I have tried to outline this on the right
side film. Furthermore, this insignificant little lesion
is unstable.
I'm not sure if there is an associated soft-tissue abnormality as Jean has
suggested, as this is the difficult zone where the laryngeal
apparatus starts. He may very well be right.
I'm not saying my interpretation is right. I have looked at an awful lot
of cervical spine films and I am prepared to defend my opinion. What I
will say is that I have DELIBERATELY not yet reviewed his CT scans,
although I am told that he has a unifacet fracture dislocation which had
to be fixed.
I think this is a fabulous film. It has demonstrated that a very ordinary
film which many eminent and skilled colleagues of mine have stated is
normal can hide a significant abnormality to the expert as well as the
tyro. It also demonstrates that a structured and pedantic review of the
film ATLS style does spot the problem.
As Tim Coats has said, the very fact I have invited comment means that I
think it is abnormal and this will have swayed everyone's judgement in
this forum. Many people fixed on the dens because it was difficult to see
- but the real abnormalities are plain to see, I contend. More than that,
there is a lesson here. In the event of an altered sensorium (in the
wonderful speak of ATLS) fail to CT the neck and the whole neck at your
peril.
Now, a further question. How would you deal with a junior who missed this
abnormality?
/Rowley./
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