Introduction
Handling an angry or uncooperative patient can be a challenge to any healthcare professional trying to perform a medical procedure on the patient’s behalf. When a patient is faced with a sudden illness, he or she may experience overwhelming fear about the outcome of any testing or procedures that have to be performed. For many patients with no medical knowledge, testing brings with it more fear about what is going to happen during the tests. The role of the radiology professional is to maintain compassion while educating the patient about the procedure that is to be performed. In doing so, the patient will have a better understanding of what is going to happen during the procedure which may have a calming effect on him or her. The radiologist should also take into consideration the physical and emotional status that the patient presents with. Any evidence of acute injury should be evaluated immediately. In this case, the patient is presenting with acute chest and abdominal pain while appearing inebriated and uncooperative. An accident of some type with trauma to the chest and abdomen should be considered at this time, especially since the patient seems to be under the influence. Because of the patient’s condition both physically and emotionally, there are many ethical considerations to be acknowledged. The question of getting an informed consent form signed is the major issue. The patient’s rights have to be protected, no matter his current state of sobriety and level of care needed. This is important to protect the radiologist and the hospital legally, also. No patient can be forced to have a treatment performed against his will, except under certain circumstances. This paper explores the relationship of the radiologist professional and his or her role in treating all patients, both cooperative and not, and the responsibilities that go along with the profession.
Consent
Informed consent is a procedure where a clinician presents medical information to a competent patient so that he or she can make a decision regarding whether or not to accept treatment at that time (De Bord, 2014). This legal document originates from the right of the patient to assert what happens to his or her body, and the ethical responsibilities of the healthcare provider to involve the patient in his treatment. The following aspects need to be discussed with the patient for informed consent: the type of the procedure being performed, reasonable alternatives to those being discussed, the risks, benefits and uncertainties, assessment of patient’s comprehension, and acceptance by the patient of the intervention (De Bord, 2014). The patient must be considered competent and his consent voluntary in order for the document to be valid. There are three approaches to keep in mind when attaining an informed consent from a patient. The first is reasonable physician standard or how an average physician would describe the procedure. Secondly, what is the reasonable patient standard or to be informed, how much information would the average patient need to know. Finally, is a subjective standard or for this individual patient, what does he need to know to make an informed consent (De Bord, 2014). Sometimes it is not so clear when a patient is capable of making his own decisions regarding consent. Many patients experience a great deal of fear, anxiety, depression, and stress during illness which can affect decision making, but it should not preclude that patient from being involved in his own care. The patient should be assessed to ensure that he understands his situation, understands the risks of the procedure, and is able to verbalize a decision based on this understanding (De Bord, 2014). Refusal of a treatment does not mean that the patient is incompetent, however, and further avenues may have to be pursued to explain or discuss the patient’s options. If a patient is uncooperative or disturbed, it may be helpful to have a psychiatric consultation to aid in treatment. If a patient is completely incompetent or incapacitated, then a surrogate should be assigned to make decisions of the physician is expected to take over that role until a surrogate can be found.
Communication
Verbal
Verbal communication is the ability to present ideas in a clear, concise language that a patient is able to understand completely. This can range from a simple, polite introduction to the explanation of a complex medical procedure. Verbal communication involves the use of the skills of presentation, patient awareness, critical listening, and body language. Good communication skills between the practitioner and the patient are essential for his successful treatment and a beneficial outcome, and it is a vital element in all areas of healthcare in all types of interventions. The therapeutic practice of verbal communication is a two-way process involving both the practitioner and the patient where the clinician communicates to the patient the procedure or test or diagnosis in a language the patient will understand, and the patient then expresses his feelings regarding this information (Kourkouta and Papathanasiou, 2014). Effective communication involves an understanding of the patient and the feelings they express, whether it is in a cooperative or uncooperative manner. It also involves the ability to compassionately and actively listen to the patient and hear his concerns, fears, and anxieties about his situation.
Non-verbal
Communication occurs without words, also. It happens through facial expressions, gestures, posture, and physical characteristics such as distance located from the person communicating. Non-verbal cues can provide more information about a patient than his verbal ones. A patient in pain will present with different non-verbal messages than one who is calm and relaxed. Each patient also has his own characteristics that the clinician has to recognize in order to effectively communicate. In addition to picking up on the non-verbal cues of the patient, the practitioner also has to be aware of his own cues that he is presenting to the patient. These can include making eye contact, facial expressions and gestures, posture, touching such as a handshake, distance placed between him and the patient, arrangement of the room such as privacy, and listening (Centers for Disease Control, 2014). Any distress on the patient’s part needs to be addressed immediately or the communication will not be effective.
Care and Compassion
Compassion is a personal and deep emotion and is defined as the ability to put oneself in another’s position, to be able to understand the emotional state of another person. Having compassion conveys the message of kindness being extended, but while most people can show kindness and generosity, not everyone is compassionate (Crowther, Wilson, Horton, and Lloyd-Williams, 2013). The care of patients in a healthcare setting requires the effective use of compassion in all areas of the treatment process. Compassionate care of patients is important and relevant to all healthcare and social sectors. While the practitioner’s level of knowledge about the procedure or test that is being explained is their expertise, this is not always a requirement in order to give compassionate care and to act in a humane manner. Sometimes, however, in a healthcare setting where diagnostic testing is a routine occurrence, professionals become accustomed to performing the procedures without thought to the fears they may cause the patient. Trauma becomes the norm rather than the exception. In order to protect themselves from the emotional aspects of the job, the clinician may distance themselves and compassion may be lacking when dealing with their patients. With a patient who is in pain and who seems uncooperative, this may present a challenge to providing compassionate care to the patient for the healthcare worker. Another aspect to compassion is the toll it takes on the clinician caring for patients full-time. Compassion burnout among workers should be identified and addressed immediately for it compromises the ability of the professional to provide effective patient care and support should be offered to him or her to work through the feelings causing the stress in the work environment. The hard work and compassionate nature of healthcare providers is not always recognized which can be a problem.
Understanding the Patient’s Illness/Presentation
The patient’s condition at the time he presents for a procedure or treatment is of utmost concern and should be the priority when considering how to handle the situation. In order to understand the patient’s illness, it is vital to understand his story. The assignment of explanation and meaning is just as important as is the physical presentation. According to Toombs (1992):
Just as illness without a cough is different from an illness with this symptom, so an illness in which the patient suspects or is afraid of, say, kidney involvement is different from an illness without this fear. Only the patient’s narrative can disclose such meanings (p. 104).
In order to fully understand the patient’s story, the practitioner must gauge his perspective and be sure about what he wants from the care. In this case study, this means asking the patient to elaborate on his condition, the events that led up to his arrival in the department, and what is causing the acute pain. At this time, the patient’s fears about his condition should be addressed and his concerns about his prognosis. In allowing the patient to convey information about his condition, the clinician is gaining an understanding of what brought the patient in for treatment and what, if any, emergency situation exists that needs to be attended to. It may be difficult to empathically understand or “imagine” what the patient is going through, but through his description of the pain and discomfort, a greater understanding of what it is like to feel these things is gained and compassion can take over in his care. Even though this patient is inebriated and perturbed, he deserves the same respect, compassion, and unequivocal care as any other patient. Dealing with an uncooperative patient can be a challenge, but with caring and compassion and an understanding of the patient’s situation he presents with, the situation can be diffused, and the patient successfully treated.
Justification of Examination and Correct Imaging Modality
The radiologic examination should be considered justified in a situation where the risks of exposure to the radiation from the procedure are minimal compared to the benefit from providing a diagnosis to the patient’s condition. In the case study, the patient is clearly in distress from some sort of trauma, and even if he cannot articulate the happenings of the event clearly, the radiologist should take into account the acuteness of his condition and the level of his pain. This should justify the necessary testing that has been ordered by his attending physician. Once the procedure has been justified, the correct imaging modality needs to be ascertained and decided upon. For the chest and abdomen, there are several studies that can be ordered. Computed tomography (CT) can be performed to check for issues involving the organs in the chest and abdomen, vascular condition and blood flow, bone injuries, traumatic injuries, and pulmonary embolism (Medical Imaging and Technology Alliance, 2016). Magnetic resonance imaging can be utilized also for the organs in the chest and abdomen, blood vessels, bones and joints, and spinal injuries. Ultrasound may be considered for the heart and organs in the abdomen. Finally, a conventional x-ray can be performed to detect broken bones such as ribs or the sternum and to assess the lungs and blood vessels. Since this patient is not cooperative and if techniques to assuage him are not working, there are several options available. An x-ray is a simple, quick procedure that can be performed if getting him to remain still for a period of time is an issue. He may be more likely to consent to an x-ray taking only a few minutes over a CT scan or MRI. However, the more detailed CT scan or MRI may be necessary due to his injuries to rule out all possibilities of injury and illness.
Use of Immobilization
The use of immobilization should be considered if there is a risk of movement during the procedure and having to repeat the film increasing exposure to the patient. Simple aids such as tape, wedges, and sand bags can be used to aid in the process of keeping the patient still. Care has to be taken, however, in the immobilization aid used so that it does not interfere with the image produced. The main goal is to keep the patient centered, aligned, and still during the entire procedure in order to get the best result and to avoid having to repeat it. In the case study, if a CT scan or MRI is required, immobilization will probably be required in order to get the necessary films. Explaining to him that it is for his own safety in order to assess his condition and allowing him to still remain in control of the situation will prevent the situation from escalating.
Manual Handling Issues
The manual handling of patients in radiology is one of the highest risk factors for injury in healthcare workers as reported by the Health and Safety Authority (Health and Safety Authority, 2011). According to the Health and Safety Authority (2011), 35% of the total number of incidents reported by the healthcare sector was for manual handling issues. They concern both the handling of patients and the handling of inanimate loads with the most common being that of lifting or carrying. This can be a concern in radiology because of the manipulation of patients who are unable to fully move and cooperate or those who are immobilized who need to be adjusted in order to obtain the correct positioning. In a patient who is uncooperative, this can be exacerbated making it difficult for the radiologist to center the patient. This is also an issue with patients who are overweight or obese.
Radiographer Interpretation
The radiographer is the first healthcare professional to view each diagnostic image taken of the patient. They are in a unique position to communicate their professional observations directly with the attending physician, and thereby, having a significant influence on the care of the patient. Interpretation of a radiograph takes place in three steps: detection, interpretation, and evaluation. Each of these steps takes advantage of the radiographer’s visual acuity which is the ability to resolve a spatial pattern in an image. The diagnostic imaging examination has three critical elements which include: it must be the appropriate investigation that is justified in the context of the patient’s presenting signs and symptoms and history, the procedure needs to be timely and accurate to increase the diagnostic ability of the investigation, and a report of the findings of the examination must be the endpoint which must be timely and communicated effectively so that it affects the patient’s clinical management (Paterson, 2010). A radiographer’s scope of practice covers all three of these elements. Medical imaging interpretation by a radiographer is done so within a well-defined scope of practice for which they have been educated, assessed, trained, and deemed proficient in their area of expertise. Radiographers make a sizable contribution to the workload of a radiology department. Reporting by radiographers has led to improved patient care and better services for clinicians. Because of their work, the volume of unreported images has decreased and the turn-around time increased thereby improving the care of patients. The growth of the profession has grown over the past four decades and remains essential to providing quality radiology imaging results for patients. The availability of radiographers to interpret images is growing and is vital to the healthcare system. As a regulated allied health profession, radiographers are accountable for their practice, including reporting.
Conclusion
There are many different variables to consider when a patient presents to the radiology department for diagnostic imaging studies. The most important factor to remember is that the patient comes with both a physical and emotional history that may or may not be related to the reason for the exam. First and foremost, he needs to be treated with caring, compassion, respect, and understanding in order to be able to proceed effectively with the treatment ordered by his attending physician. Once a rapport has been developed, the patient needs to be made aware of the test that is to be performed and the reasons it was ordered. Without this basic understanding, informed consent cannot be obtained. Informed consent is necessary to protect the patient’s right to understand and be aware of what is happening to his body during the procedure or test. If a patient is non-compliant or incompetent, a surrogate can be assigned who can give consent on behalf of the patient. Once consent is received, the testing can begin. Having an understanding of the patient’s condition, both physically and mentally, such as the events that brought him to the department, will help the clinician derail any touchy situations and will give the patient reassurance that things are alright to proceed. The radiographer should pay attention to any verbal and non-verbal cues the patient is giving in order to assess him accurately. When dealing with an uncooperative patient, all of these factors come into play and even more so. It takes a great deal more compassion and caring to handle a patient who is belligerent than one who is calm and accommodating. For all patients, however, every possible effort should be made to evaluate and examine humanely and with dignity no matter the physical or emotional state they present with.
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