Charing Cross Interview - Stage 2

Tell me about yourself

• I am a newly qualified Diagnostic Radiographer, having graduated from St George’s, University of London with the undergraduate programme prize + clinical prize

• Clinical training at both FPH and CWH has allowed me to adapt to different protocol, working environments and patient groups

• Exposure to all modalities, especially enjoyed A&E due to the combination of patient interaction + problem-solving

• I have developed a very kind, compassionate approach towards patients, prioritising their care and comfort by adapting to their individual needs

• I am a strong communicator when working with a variety of patinets from paediatrics to th8ose with dementia, adapting my methods to ensure their understanding and safety

• I am now looking forward to progressing into a rotational band 5 role to develop my clinical skills, contributing both within the Charing Cross team and patients

• Drawn to Charing Cross Hospital due to heavy focus on teaching and exposure to a diverse patient population, I hope to bring my enthusiasm for learning and comitment to patient care to the team

Why did you apply for this role?

• Rotational role will help me to develop into a well-rounded radiographer with strong foundations in involving plain-film, fluoroscopy and CT

• I feel as though the Trust values well-reflect the type of radiographer I aspire to develop

• For example, I really prioritise being kind and approachable for patients, so not only do they receive timely diagnostic imaging, but have a positive imaging experience

• This year while on placement at CWH, I attended a Preliminary Image Interpretation study day that was co-hosted by your colleague Anthony

• As a student, I found his teaching style to be very concise, memorable and approachable

• Knowing that Charing Cross Hospital advocates for research and learning, this firsthand teaching experience has given me confidence that Charing Cross creates a positive learning environment, where I will be able to continually learn, and continue this cycle of teaching for students who are also on placement

• I hope that I can bring my enthusiasm and adaptability to both the Charing Cross MDT and patients

What are the 4 Trust values?

1. Kind

2. Collaborative

3. Expert

4. Aspirational

Scenario 1 - Kind

Kind = going above and beyond for patients, to ensure patients feel respected, included and heard

• During training, had an outpatient who presented in a wheelchair with incredibly limited mobility and pain

• Required DP and oblique foot X-rays

• Rather than asking the patient to stand up unnecessarily, I considered their mobility and comfort

• I used a sponge underneath the detector to adapt to the angle at which their foot was naturally resting at to acquire the X-rays without contributing to their pain

• This way I acquired the diagnostic images while adapting to their situation, placing the patient’s comfort first

• This demonstrates ‘Kind’ as I adapted away from standard textbook positioning and went above and beyond to prioritise the patient’s needs and dignity, while still acquiring a diagnostic image

Scenario 2 - Collaborative

Collaborative = working as a team and sharing knowledge, all with the united goal of providing quality patinet care

• As a third-year student, I was completing a DHS case independently under direct supervision of the theatres radiographer

• I understand that theatres can be quite a stressful environment, especially as the operating surgeon adviced me prior to the case that the patient was unstable

• I ensured to maintain effective communication with all MDT members when it came to radiation safety, for example, ensuring all staff members were wearing appropriate shielding before exposing

• I also maintained clear communication with the scrub nurse team to ensure that my C-arm movements weren’t breaking the sterile field

• The case was successful and I was commended by the theatres radiographer for my professional and clear communication with all team members

• Taught me the value of teamwork, and how through having a common goal and practising collaboration, the patient recieves timely care and faces the best possible outcomes

Scenario 3 - Expert

Expert = expanding your skillset so patients always recieve up-to-date quality care - not about what you already know, but being committed to learning through CPD

• For example, I have a great interest in furthering my clinical competence in both anatomy and ability to recognise and describe abnormalities

• I have completed the Norwich Red Dot course, NHS appendicular and axial course and attended a preliminary image interpretation course

• These CPD opportunities have improved my ability to spot and describe red-dots, which will help me to work within my scope as a Band 5 radiographer and escalate findings especially in ED

• For example, as a student I identified an area of callouf formation on a patient’s ankle X-ray that had been overlooked, and after being escalated to the radiologist, they confirmed it was a previously healing fracture - the patient confirmed they had a previously unchecked injury of their ankle

• I have learnt many techniques to identify and describe abnormalities and improved my attention to detail, which is important to spot to ensure a patient’s timely management

• On reflection, lifelong learning ensures you can offer your patients with up-to-date, quality care

Scenario 4 - Aspirational

Aspirational = not becoming complacent, being receptive to new ideas and lifelong learning to improve the services provided to patients

• During my third-year, I had encountered my first ever Rosenburg veiw request at CWH

• Rather than stepping back, I ensured to let my supervising radiographer that I had never performed this view before, and asked if they could teach me through their technique of patient positioning and tube set-up

• After discussing the theory, I attempted it with the help of my supervisor and achieved a clear view of the joint space

• I ensured to go home and study the view, preparing me for the next Rosenburg view

• Since then, I have completed many more and now feel confident to take them on independently due to my supervisor’s teaching and my research

• On reflection, it taught me the value of being proactive in my learning, and how it is okay to not know everything - but how taking the right steps to learn a skill is important

What are the 6 NHS values?

1. Working together for patients

2. Respect and dignity

3. Comittment to quality of care

4. Compassion

5. Improving lives

6. Everyone counts

What skills, experiences or traits make you uniquely qualified for this role?

Tell us about a time you have gone above and beyond

• Completing a CXR for GP patient with SOB 

• She suddenly became very clammy and complained of a sharp headache 

• However, the radiographer I was with needed to go for an urgent portable in NICU

• Quickly printed ID sticker, helped her change and safely tranported her into a wheelchair to ED 

• Monitored pt behaviour throughout transport, checked her in at ED, where the nurses quickly triaged her 

• Learned importance of staying calm, acting quickly and prioritising patient safety 

How do you work both as part of a team and independently?

Teamwork:

Independent:

How do you ensure safety in your practice?

1. Patient identification and checking procedures

2. Justification and optimisation

3. Radiation protection - IRMER, ALARA

4. QA - equipment safety checks

5. Incident reporting

6. Recognising and responding to patient deterioration - cardiac arrest

What is Duty of Candour?

• Requirement for healthcare professionals to be open, honest and transparent with patients and their families if something goes wrong

• Duty to report any incident, regardless of size

• Important to ensure relevant training, and that mistakes don’t occur again

What would you do on a night shift if a patient has a cardiac arrest?

What is your biggest strength?

• Attention to detail

• E.G: patient came in with ankle pain, and on the X-ray I had noticed an area that looked like callous formation that was initially missed

• The radiographer and I checked with the radiologist, who confirmed it was a healing old fracture, to which the pt confirmed she had had a fall the previous year but never got it checked

• Reinforced the importance of PCE and reviewing an image before sending a patient home

Alternative:

• Adaptability

• During training, had an outpatient who presented in a wheelchair with incredibly limited mobility and pain

• Required DP and oblique foot X-rays

• Rather than asking the patient to stand up unnecessarily, I considered their mobility and comfort

• I used a sponge underneath the detector to adapt to the angle at which their foot was naturally resting at to acquire the X-rays without contributing to their pain

• This way I acquired the diagnostic images while adapting to their situation, placing the patient’s comfort first

• I adapted away from standard textbook positioning and went above and beyond to prioritise the patient’s needs and dignity, while still acquiring a diagnostic image

What is your biggest weakness?

• Spending too much time speaking to patients as I want them to feel heard and supported

• While empathy is essential, I’ve noticed it can slow workflow 

• Solution: I stay conscious of time during the X-ray and try to find a way to gently end the conversation without the patient feeling rushed 

Scenarios

Can you tell us about a time where you noticed something was not being done as well as it could have been?

• Noticed a pt was referred for a left shoulder, but their pain was in the right one

• Confirmed symptoms and correct side with pt

• Explained the situation kindly, apologised for the delay, asked pt to wait outside please

• With the supervising radiographer, contacted referrer who correct the request

• Outcome: prevented unnecessary exposure and ensured accurate care - following IR(ME)R-17 by limiting dose and only expsing when the request was justified

• Highlighted importance of carefully checking requests and confirming details with patients before imaging

You must X-ray patients in resus, mobile in ITU and a theatre case. How would you prioritise your workload?

• Assess clinical urgency and requests

• Must prioritise workload while ensuring patient safety and timely care

• Resus patient first → likely life-threatening, requires immediate imaging to guide management 

• ITU mobile → critically unwell but stable enough to wait for 5 minutes 

• Theatre case → if non-urgent, safe to slightly delay, but communicate with MDT of an estimated wait time

What would you do if a surgeon refused to wear a lead gown?

• Stay calm and politely remind the surgeon of radiation safety requirements - minimise unnecessary exposures 

• If the surgeon refuses, stop the procedure and notify RPS immediately 

• Record what happened and how you complied with IRR-17 

• Reflect on the incident and if I handled it to the best of my ability, and what I could improve on next time

What would you do if the wrong patient was X-rayed?

• Unlikely as you always do 3-point ID check

• Stop the procedure immediately

• Duty of Candour - be honest and calmly inform the patient of the error

• Inform the superintendent and RPS - legal requirement under IR(ME)R-17

• Document the indicent in the patient record

• Complete a DATIX report

• Reflect on the incident and why this happened, and what will prevent this from happening in the future again

A child comes in with bruising and you suspect abuse. What would you do?

• My duty is to ensure the child’s safety and follow safeguarding protocol

• Remain calm and not make assumptions that incriminate their guardian - show no judgement

• Document any visible injuries objectively 

• Immediately inform the superintendent radiographer 

• Escalate to SPA team and ensure the child is in a safe environment until reviewed 

If a mobile machine stops working while exposing, what do you do?

• Immediate terminate any imaging

• Try to identify the fault immediately - whether it is related to any technical factors that I chose

• If I cannot resolve the issue, I would take it out of action, placing a clear sign on it and letting the superintendent know, so they can communicate this to the rest of the team

• Involve the engineers during this to fix the issue

• Use a different mobile machine in the meantime

What would you do if your image intensifier went out during a case?

• Remain calm and immediately alert the lead surgeon and MDT that there is an issue with the II

• Ensure the patient is safe and avoid continuing the procedure if imaging is required

• Try troubleshooting the II (check cable connections, power supply etc)

• Note the last imaging view the patient had taken

• Alert the lead radiographer that there is an issue with the current II, and consider using an alternative II nearby if available

• Be honest and communicate with the MDT about the status of the II and any expected wait times for switching out machinery

• Document the equipment fault and label the II with a note of date and issue for fellow radiographers to be aware - aware that the images may be locally saved on the faulty II

• Once another II is back in the room, pick up where you left off by entering at the same positioning / angulation for the view the surgeon requires

• Reflection - did I handle the situation well? How can I ensure smooth switching of II in the future?

Out of a mother, father and grandmother, who would you choose to hold a kid for an X-ray?

• I would first ask the child if they would be comfortable for an X-ray by themselves, assuring them their family member of choice would be visible from behind the lead screen during the short exposure

• This is to limit unnecessary radiation exposure to family members if the child feels capable of independence

• If not, I would directly ask the child who they would prefer to be accmodating them - it is important to provide the paediatric with the dignity to choose so they feel most comfortable

• Then I will ask the chosen family member if they are comfortable with the radiation exposure, explaining the risks and benefits

• I will ensure to ask whoever accompanies the child if there is chance of pregnancy, and supply them with appropriate lead shielding

• This will reduce the chance of motion artefact and the need for repeats, increasing efficiency and improving radiation safety

• Overall, my priority is to ensure the child feels comfortable and has freedom of choice

What is your step-by-step process in taking a mobile X-ray?

1. Preparation: check the request on RIS (correct patient details, hospital location, clinical indication, justification, pmh)

2. Prepare mobile: exposure factors, lead gown

3. Enter ward: introduce myself, confirm 3-point ID check, explain examination and gain consent, assess patient condition and positioning

4. Patient preparation: ensure no artefacts, position the detector appropriately, asking fellow ward colleagues for help if needed, set up the mobile X-ray with appropriate collimation, ensure the patient is comfortable at all times and uphold their dignity e.g. covered up

5. Instructions: ensure patient is aware of any additional instructions e.g. breathing

6. Radiation safety: ask staff and visitors to leave the local area, follow inverse square law and distance myself at least 2m from source to limit radiation exposure, ensure all staff are aware of X-ray by loudly saying X-ray before exposure

7. Check the diagnostic image quality (anatomy included, positioning, rotation, exposure) and assess if a repeat or additional view is required to answer the clinical question

8. If not, remove the detector from the patient and ask if they are comfortable, remembering to give all their belongings back and adjust their positioning to how they would like it

9. Clean the detector and mobile machine

10. Post-processing: note the dose, add all relevant labels to the X-ray taken e.g. dose, location, positioning and send image to PACS

11. After returning to department, ensure to log on RIS and record the dose, number of exposures and check if the image is on PACS ready to report on

Clinical guidelines

What is clinical governance?

• Healthcare framework to maintain and continuously improve quality and safety of patient care

• Involves clinical audit, evidence-based practice, incident reporting, CPD

• E.G: if there was an incident in the imaging department, I would report it appropriately, reflect on what happened and contribute to any learning to prevent it from happening again

• Always work in my scope of practice and keep my skills up to date to ensure patients’ safety

What is the NHS longterm plan?

• A plan to redefine healthcare in England

• One method is moving care from hospitals to communities

• E.G: introduction of CDC’s in local communities improves accessibility to care and allows patients to receive elective and routine imaging

• Improves accessibility to care, reduces pressure on acute hospital and reduces wait times for diagnoses

• Aims to reduce the healthcare inequalities patients from deprived areas may face

What is DAP?

• Dose area product

• Total radiation delivered to patient during examination - how intense the beam is and how large of anatomy area is exposed

What is a DRL?

• Diagnostic reference level - help to optimise dose

• National DRL’s allow you to compare the trust’s radiation dose to the rest of the country 

• If doses are too low or too high, the protocol is re-evaluated E.G: radiographic technique or equipment performance 

What are the 4 IR(ME)R 2017 duty holders?

1. Employer - the organisation who runs the medical practice E.G. NHS

2. Referrer - registered medical professional who must supply the practitioner with enough clinical history to justify the imaging

3. Practitioner - responsible for justifying the radiation exposure, benefits outweigh the risks

4. Operator - the radiographer who carries out the imaging, follow ALARA principles

What is ALARA?

‘As low as reasonably practicable’ radiation doses

What is the importance of justification and optimisation?

Justification:

• Ensure the X-ray is clinically indicated as per ROI and reason

• Benefit must outweigh risk

Optimisation:

• Use the lowest dose possible to produce a diagnostic image

• ALARA principles

What is the difference between IR(ME)R-2017 and IRR-2017?

IR(ME)R-17:

• Ionising Radiation (Medical Exposure) Regulations 2017

• Protects patients during medical exposures

• Ensure every exposure is justified (benefit > risk)

• Exposures are optimised - ALARA (as low as reasonably possible) 

• Responsibilities fall on referrer, practitioner, operator 

• Regulated by CQC

• E.G: adjusting EF for paed, pregnancy status before pelvic X-ray

IRR-17: 

• Ionising Radiations Regulations 2017

• Protects staff and public from workplace radiation 

• Use lead aprons, shields and dose monitoring badges

• Responsibility falls on employer and employee

• Regulated by HSE (Health and Safety Executive)

• E.G: behind a barrier for a mobile X-ray

What is the difference between a controlled and supervised area?

Controlled area:

• E.G: CT room 

• High radiation dose, so stricter safety measures

• Restricted areas to trained staff only 

• Requires dosimeters, shielding and warning signs 

Supervised area: 

• E.G: waiting area outisde X-ray room 

• Lower radiation exposure

• Open access, but staff must understand risks 

• Requires basic warning signs 

What is the difference between the 10-day and 28-day rule?

10-day rule:

• Can only scan within the first 10 days of the menstrual cycle

• Ensures fertilisation has not occured

• For high-dose examinations E.G. barium enemas

28-day rule:

• First day of the last menstrual period must fall within last 28 days

• For ages 12-55 + examinations between the diaphragm and knees

What is QA?

• Quality assurance

• Range of tests to ensure each machine produces high quality diagnostic imaging to a safe departmental standard

• E.G: TOR CDR tool to check for spatial resolution and contrast-detectability… place phantom on detector and expose it under standard beam conditions… count the visible greyscale groups and number of low contrast circles and compare it to the baseline

• E.G: beam alignment test tool (clear plastic cylinder with beads) is used to check the collimation area actually matches the area that becomes exposed, compare against standard tolerance limit

Physics

What is the relationship between kV and mAs?

kV: penetration power → image contrast 

mAs: number of photons → image density 

• Increasing kV increases penetration, and so you reduce the mAs to maintain the same image density → reduced dose 

• Decreasing the kV means you need a higher mAs (more photons) to make up for the lower penetration power 

• For every 4cm increase in tissue thickness, mAs must be doubled to maintain same image density

What is the inverse square law?

• I ∝ 1/d²

• Radiation intensity is inversely proportional to the distance squared from the source

• If you double the distance from the source, radiation intensity decreases to ¼

• Important in radiation protection - increasing distance from the source reduces staff radiation exposure

• E.G. during mobile X-rays

What is the purpose of a grid?

• Device placed between patient and IR 

• Made of alternating lead strips and low attenuating material interspaces

• Bigger and denser areas of anatomy produce more scatter

• Lead absorbs the scatter radiation produced by Compton scatter + PEE

• Low attenuation interspaces allow the primary beam through (characteristic and Bremsstralung)

• Improves image contrast and diagnostic quality in larger areas of anatomy 

• Two types: stationary and moving 

Stationary: 

• Fixed in place and doesn’t move during exposure 

• Can produce grid lines on image

Moving: 

• Oscillates during exposure to blur grid lines 

• Produces a clearer image with less mottle 

What is an AEC?

• Automatic exposure control

• Combination of 3 chambers selected depending on AOI

• E.G: AXR would activate all 3 chambers

• Terminates the exposure when a preset number of photons pass into the chamber and are detected by casette 

• Provides consistent image density, regardless of patient size / density 

How is an X-ray produced?

• Filament is heated, causing thermionic emission where electrons are released at the cathode

• A high potential difference between the cathode and anode accelerates the elctrons to the anode

• Electrons high the tungsten target, where Ek is converted to X-ray photons and heat

• X-ray beam exits the tube and are directed toward the patient

What are the two mechanisms of X-ray production?

1. Bremsstrahlung

• Electron slows down near tungsten nucleus

• Energy released as an X-ray photon

• Produces majority of diagnostic X-rays

2. Characteristic

• Electron knocks out an inner-shell electron

• Outer electron drops down to fill in this gap

• Energy difference released as an X-ray photon