Poor handwriting is a core deficit in Developmental Coordination Disorder (DCD). In a previous study, we compared the evolution of cursive letters handwriting in a girl with DCD throughout her second-grade year with that of typically developing (TD) children. We found that her handwriting evolved much less than that of TD children and remained similar to that of pre-schoolers at all stages, suggesting that her handwriting skills have reached a steady state level. We present here a continuation of this work, in which we focused on the velocity aspects of handwriting in another French child with DCD. Indeed, different velocity patterns have been observed in Chinese and English children with DCD. In the French cursive style of writing, consecutive letters are joined, a major difference with the English script style of writing. We thus analyzed the handwriting of a second-grade French girl with DCD, not only for isolated letters but also for syllables and words, in comparison to that of TD first-graders (6–7 years old; N = 85) and second-graders (7–8 years old; N = 88). Each written track was digitized, and nine kinematic parameters were measured to evaluate writing fluency. Results showed that the productions of the child with DCD were more similar to those of first-graders than to those of second-graders. In line with our previous study, the most discriminative parameters between the child with DCD and TD children were size and mean speed. Moreover, her handwriting was less fluent than that of TD children. In contrast to previous observations, we observed a higher writing velocity of the child with DCD when compared to TD children, whatever the complexity of the item, and no significant difference with TD children in the pausing time during writing. These differences may reflect linguistic specificities. For syllables and words, each letter was treated separately as a single unit, thus reflecting a problem in anticipation and automation.
Keywords: handwriting acquisition, developmental coordination disorder, single case study, comparison, typically developing children
Although it seems an easy task for adults, handwriting is in fact a very complex activity. For instance, handwriting requires not only perceptual-motor skills but also cognitive and linguistic skills (Blöte and Hamstra-Bletz, 1991; Viviani, 1994; Chartrel and Vinter, 2004; Vinter and Zesiger, 2007). The letter to be traced and the corresponding movements are intimately related in handwriting activity. Writing a letter requires to retrieve the letter stored in memory, to access the corresponding motor program associated to its tracing, and to execute this program (Ellis and Young, 1988; Van Galen, 1991). Handwriting learning begins in kindergarten, at the age of three, and takes several years before complete acquisition (Zesiger, 1995; Bara and Gentaz, 2007, 2010; Bara et al., 2011). At the beginning, handwriting exercises consist in copying tasks and are very similar to drawing. As learning progresses, writing and drawing activities dissociate, and children learn the visual representations of letters, which are used to guide their production, and the motor programs associated to each one. Handwriting is mastered once it is fully automated. At the cognitive level, the developmental changes in the product and the process of handwriting are associated with a shift from a retroactive control of movement based on feedbacks to a proactive control (Meulenbroek and van Galen, 1988; Zesiger, 1995; Palluel-Germain et al., 2007). Indeed, at the beginning of learning, movements are slow and essentially guided by visual and kinaesthetic feedbacks. With practice, writing becomes automatic and the control of movement is mostly based on an internal representation of motor acts.
Some children never master handwriting despite correct training. Handwriting difficulties in children can be evaluated and diagnosed by using standardized tests such as the BHK (Hamstra-Bletz and Blöte, 1993; Karlsdottir and Stefansson, 2002; Overvelde and Hulstijn, 2011). Handwriting difficulties can be of various origins. Among other possible causes, poor handwriting is a core deficit observed in Developmental Coordination Disorder (DCD) (Miller et al., 2001; Dewey et al., 2002; Smits-Engelsman et al., 2003; Bo et al., 2008; Rosenblum and Livneh-Zirinski, 2008; Cheng et al., 2011). Children with DCD display an atypical motor coordination development (Willoughby and Polatajko, 1995; Dewey and Wilson, 2001; Barnhart et al., 2003; Visser, 2003; Polatajko and Cantin, 2005; Huron, 2011). Five to eight percent of school-age children DCDs are affected by DCDs, with a higher incidence in boys than in girls (2:1) (Mæland, 1992; Wright and Sugden, 1996; Sugden and Chambers, 1998; American Psychiatric Association, 2000; Dewey and Wilson, 2001). The neuroanatomical origins of DCDs are not clear and may be various [for reviews, see Ahonen et al. (2004), Zwicker et al. (2009), Huron (2011)]. Children with DCD are affected in their everyday life and at school, in particular at the level of handwriting, a skill that they barely master (Miller et al., 2001; Geuze, 2005, 2007; Plumb et al., 2008; Chang and Yu, 2010; Huron, 2011). As they might have disorders in automatizing motor movements, each letter is produced by a succession of sequential movements (Mazeau, 1995). Since these movements are under voluntary control, this is extremely costly for the children in terms of attention, and it prevents them from performing higher order academic tasks such as composing or paying attention to the spelling or grammar. In addition, these children have difficulty with online control, i.e., adjusting the motor plan while executing the action, thereby preventing them to shift from a retro-active to a proactive control of handwriting.
Several research studies aiming at describing and understanding handwriting difficulties in children with DCD have been published in the past years. The written productions of children with DCD are of poor quality and usually display erroneous spatial organization (in particular a higher incidence of mirror letters). From a kinematic point of view, these children present a general writing slowness, a slow speed at initiation, an excessive number of unnecessary pen movements, an irregular pressure of the pen on the paper, and a greater variability in time taken and in the form of the letters (Rosenblum et al., 2003; Rosenblum and Livneh-Zirinski, 2008; Chang and Yu, 2010; Jolly et al., 2010; Cheng et al., 2011). It has been recently demonstrated that the general handwriting slowness observed in children with DCD is due to a higher percentage of time spent in pausing, rather than to slow movement execution (Prunty et al., 2013). Moreover, Chang and Yu (2010) showed that children with DCD used a faster stroke velocity than TD children when writing simple characters, but a lower velocity when writing complex characters. It emerges from these studies that children with DCD demonstrate a wide and various spectrum of handwriting difficulties. These inter-individual differences, which reflect the heterogeneity among children with DCD, add another level of complexity to the understanding of the neuro-anatomic bases of the disorder. In this context, an alternative and complementary approach to group studies to provide information relevant to the understanding of cognitive architecture is the single-case analysis (Caramazza, 1986; Caramazza and McCloskey, 1988). We recently provided a longitudinal analysis of the evolution of cursive letter handwriting in a girl with DCD throughout her second-grade year, in comparison with that of pre-school, first-grade and second-grade typically developing (TD) children. We showed that her handwriting only slightly evolved and remained similar to that of pre-schoolers, suggesting that the handwriting skills of this child with DCD have reached a steady state level (Jolly et al., in press). Moreover, we found that the most discriminative kinematic parameters between the child with DCD and TD children were letter size and velocity: She wrote bigger letters, but faster.
In the continuation of this work, we were interested in analyzing the handwriting of a girl with DCD not only of isolated letters, but also of syllables and words in comparison with TD children. More particularly, we were interested in addressing fluency and velocity aspects of her handwriting. Following the observations by Prunty et al. (2013) and Chang and Yu (2010) on velocity features of the handwriting of English and Chinese children with DCD respectively, we thus wondered if these findings could be extended to the Latin based alphabet, and more particularly to the French cursive style of writing in which consecutive letters are joined (Orliaguet et al., 1997; Kandel et al., 2000), a major difference with the English script style of writing. In the Latin alphabetic system, handwriting complexity relates to the length of the item to write rather than to the complexity of letters themselves. To address our question, we thus analyzed the cursive handwriting of a second-grade child with DCD in comparison to those of TD first-graders (6–7 years old; N = 85) and second-graders (7–8 years old; N = 88), in a task of random dictation of the 26 alphabetic letters, bigrams, trigrams, and small words. Each written track was monitored using a graphic tablet, and nine kinematic parameters were measured to evaluate writing fluency.
The present study was conducted in accordance with the Declaration of Helsinki. It was approved by the laboratory LPNC ethics committee. It was conducted with the understanding and written consent of each child's parent and in accordance with the ethics convention between the academic organization (LPNC-CNRS) and educational organizations. Concerning the child with DCD, her parents have given written informed consent to publish these case details.
Eighty-five first-grade children (34 girls) (mean age 6 years and 10 months at the time of the dictations), and 88 second-grade children (43 girls) (mean age 7 years and 11 months at the time of the dictations) participated in the study. None of the children included in the study presented known learning problems or neuromotor disorders. Since the two control groups are the same as those used in our previous study, their characteristics can be found in Jolly et al. (in press).
The child with DCD
The child with DCD (L.) is a little girl born in 2002. She was 8 years and 1 month old at the time of the dictations. Early childhood was normal. Graphic and praxic difficulties appeared at the age of four. L. is right-handed and presents a correct tripodic pen holding. She was diagnosed with visuo-spatial dyspraxia (DSM-IV) at the age of six (first-grade) by a neuropsychologist on the basis of a BHK test (Hamstra-Bletz et al., 1987; French version by Charles et al., 2004). Her mean writing speed (number of characters written in 5 min) was 66.6 and was not significantly different from the mean speed of TD first-grade children (48.9 ± 24.4) but L. had a large, irregular, and chaotic handwriting, and problems in spatial organization. Her total score was 30 and differed by 1.5 standard deviations from the mean score of TD first-grade children (13 ± 6.8). No associated disorders have been identified. Before diagnosis, L. has been receiving systematic remediation for graphic activities from the age of 3 to 6 by an occupational therapist (once a week). After diagnosis, she received systematic remediation for graphic activities (three times per week). The remediation that she received used a combination of techniques, including visual-motor training, handwriting practice and also explicit and supplemental handwriting instruction (i.e., a task-oriented approach).
Task and material for the analysis of written tracks
Children were asked to write, without time limit, the 26 dictated letters, the syllables “be,” “ble,” “bre,” “ch,” “ll,” and “ve,” and the words “cinq,” “dix,” “quinze.” Two dictations for the isolated letters and three dictations for the other items were performed at the end of the school year, in May, within a few days time interval. The items were dictated in four different random orders, and children were asked to write each item once, in cursive. We checked that the dictation order had no effect on children performances (data not shown). Dictations were performed on a sheet of paper placed on a Wacom© Intuos 3 A5 USB graphic tablet (sampling frequency = 5 MHz). All tracks were monitored using specific software (Hennion et al., 2005; Bluteau et al., 2008, 2010; Jolly et al., 2010), which extracts 9 different parameters for each track: (1) “nb strokes” corresponds to the number of pen strokes which constitute the letter; (2) “in-air time” corresponds to the total time (in seconds) during which the pen is not in contact with the tablet; (3) “length” corresponds to the total length of the track in cm; (4) “total time” corresponds to the total writing time in s; (5) “speed” is the mean speed in cm/s (length/time ratio); (6) “nb peaks” corresponds to the number of velocity peaks. The measure of this parameter requires prior filtration of raw data with an order 3 Butterworth filter at a seizure frequency of 8 Hz (Butterworth, 1930); (7) “nb slow mvts” corresponds to the number of slow movements, i.e., group of samples under 150 ms, between which the distance is less than 0.1 cm; (8) “nb pauses” corresponds to the number of pauses, i.e., periods during which the distance is null; (9) “pausing time” corresponds to the total time (in seconds) of pauses.
Mean values and standard deviations were calculated for each letter and each parameter for the two control groups. Comparisons between L. and the normative groups were then performed using an independent samples Student test. The only exception was for the letter “w,” for which only one unique value for each parameter was obtained for L. In this case, the unique value of each parameter was compared to the mean of the different control groups using the Singlims software, which was developed by Pr John Crawford's group for the comparison of single case values to a normative group (Crawford and Garthwaite, 2002, 2007; http://www.abdn.ac.uk/~psy086/dept/psychom.htm). In order to counteract the problem of multiple comparisons and to maintain the familywise error rate, a Bonferroni correction was applied for the analysis of isolated letters' tracks. Since 26 comparisons (one per letter) were performed for each parameter, an alpha-correction level of 0.05/26 = 0.0019 was used.
Qualitative analysis of the handwritten productions of the child with DCD
The cursive handwriting of the child with DCD (L.) was analyzed on the basis of a random dictation of the 26 alphabetic letters, 6 bigrams or trigrams, and three words. TD children of first-grade and second-grade performed the same task and served as control groups. Examples of the L's productions and of typical dictations for each control group are presented in Figure 1.
Samples of cursive handwriting by children. Examples of dictations performed by the child with DCD, first-graders and second-graders are displayed for isolated letters (top panel) and syllables and words (bottom panel).
Visually, L's handwriting letters appeared larger than those of both control groups. Moreover, the apparently random position of her productions on the paper sheet and the difficulties she had in following the paper lines suggest problems in spatial organization, a common characteristic of children with DCD (see Introduction).
To further investigate the fluency of L's handwriting from a kinematic point of view, we analyzed the velocity profiles of her written productions as well as those of TD children. Typical examples of a letter and a trigram are presented in Figures 2, 3, respectively. On the left part of the figures are shown the written tracks, on which are indicated the position of slow moves and velocity peaks. On the right are shown the corresponding velocity profiles and velocity peaks. For all items, the velocity profiles of L's productions appeared to be similar to those of second-graders. Likewise, the number and position of velocity peaks and slow moves on the tracks were equivalent to those of second-graders, suggesting a writing fluency similar to her peers. However, the major difference between L. and both first- and graders was the intensity of the velocity peaks on her tracks, which is always higher than that of both first- and second-graders.
Examples of the kinematic features of the letter “b” written by the child with DCD (L.) and a random first- and second-grader. The position of slow moves (red) and velocity peaks (purple circles) are shown on the letter tracks (right panels...
Examples of the kinematic features of the trigram “ble” written by the child with DCD (L.) and a random first- and second-grader. The position of slow moves (red) and velocity peaks (purple circles) are shown on the letter tracks (right...
Quantitative analysis of the handwritten productions of the child with DCD
Since we used the same control groups as in our previous study (Jolly et al., in press), we already showed that they all differed from each other.
For each item and each parameter, we compared the results of the child with DCD to those of the two control groups. Tables presenting the values obtained by L. for each item and each parameter, as well as the results of the statistical comparisons between L. and each control group, can be found online in the Supplementary Content. Significant results of these comparisons are presented as follows. Mean values and standard deviations were calculated for each parameter of each item, for the 2 control groups and for the child with DCD. We then compared L's results with those of each control group using a Student test. For isolated letters, due to the huge amount of data generated by our analysis, it was not possible to present a detailed analysis of each parameter, for each item and each group. To facilitate comprehension, we therefore chose to present the results for letters as follows. Firstly, we present a parameter-by-parameter analysis: For each parameter, the number of items for which this parameter was significantly different between L. and the control group (α = 0.0019) is scored. For example, a score of “0” means that no item displayed a different mean for this parameter, i.e., there was no difference between L. and the control group for this parameter. In contrast, a score of “26” for letters for example means that the mean for this parameter was significantly different between L. and the control group for all letters. The higher scores therefore reflect the biggest differences between L. and the group. The scores for the nine parameters are presented altogether in a single graph. Secondly, we performed a letter-by-letter analysis by calculating, for each letter, the number of parameters out of nine which were significantly different between L. and the control group (α = 0.0019). For example, higher scores in the categories “0 or 1 different parameter” mean that there was little to no difference. In contrast, higher scores in the categories “7 to 9 different parameters” reveal strong differences between L. and the group. The overall distribution of these results for the different items is presented in a second graph. To sum up, higher scores reflect a higher number of parameters or items different between L. and the group, and thus a poorer performance of L.
In Figure 4 are presented the results of the comparison between the cursive letters produced by L. and those of the control groups. For each parameter, there was a greater difference between L's letters and those of second-graders than those of first-graders (Figure 4A). L's letters displayed very little differences with those of first-graders (mean = 0.11 ± 0.33 parameters different) (Figure 4B). For instance, no difference between L. and first-graders was observed for 23 letters out of 26. In contrast, the overall number of parameters which differed between the child with DCD and the control group was greater for the second-graders' group (Figure 4B). For instance, 22 letters out of 26 displayed at least two different parameters (mean = 2.54 ± 1.36 parameters different). One important observation is that the parameters which were significantly different for the child with DCD always displayed a higher value than the mean of the control group. The most discriminative parameters between the child with DCD and second-graders were track length (25 letters out of 26) and speed (18 letters out of 26): The child with DCD produced larger letters, at a higher speed than TD children of the same age (Figure 4A).
Comparison between the DCD child's results for isolated letters and those of the 2 control groups. Results of the DCD child were compared to those of first-graders (black bars) and second-graders (white bars). (A) For each parameter, the bars indicate...
We next compared the results of the child with DCD for bigrams, trigrams and words to those of the two control groups. Tables presenting the values obtained by L. for each item and each parameter, as well as the results of the statistical comparisons between L. and each control group, can be found online in the Supplementary Content.
For each item and each parameter, we calculated the mean value and the SD for L. and for the two control groups. The means between L. and each control group were compared by using a Student test. Histograms presenting the results are displayed in Figure 5.
Comparison between the DCD child's results for syllables and words and those of the 2 control groups. For each parameter and each item, the mean values and SD were calculated for first-graders (black bars), second-graders (white bars), and for the DCD...
As shown in Figure 5, the productions of the child with DCD presented more significant differences with those of TD second-graders than with those of first-graders. For instance, differences with first-graders were only observed in mean speed (7 items), number of strokes (2 items out of 9), distance (1 item), and pausing time (1 item) (mean = 1 ± 0.71). In contrast, differences with second-graders were observed in distance (all items), speed (5 items), number of strokes (3 items out of 9), and in-air time (3 items) (mean = 2.22 ± 1.09). Same as for isolated letters, these results show that syllables and words produced by this second-grade child with DCD are more similar to those of first-graders than to those of second-graders. Again, the child with DCD produces larger items, but at a higher speed. Interestingly, her writing speed is even higher than that of first-graders.
To sum up, our results showed that the handwritten productions of this second-grade child with DCD are more comparable to those of first-graders than those of second-graders, for letters, syllables, and words. Interestingly, the lag between TD children and the child with DCD affected almost all items, even easy or familiar letters such as the “e.”
In the present study, we provide a comparison of the handwritten productions of a second-grade child with DCD with those of TD children of first- and second-grade. This work is a continuation of a recent study presenting a complete 1-year survey of cursive letters produced by a girl with DCD throughout her second-grade year, in comparison to those of TD children of the same age (Jolly et al., in press). In this previous work, we showed that in contrast to TD children, her handwritten productions evolved much less between the end of first-grade and the end of second-grade and remained more similar to those of pre-schoolers, thus showing that the lag between the child with DCD and TD children increased with time, even with remediation, suggesting that she may have reached a steady-state level reflecting his/her maximal writing skills.
In the present work, we were interested in the analysis of fluency and velocity aspects of the handwriting of another second-grade child with DCD. Indeed, Prunty et al. (2013) have showed recently that English children with DCD present a handwriting slowness which is due to an increased time spent in pausing and not to a decreased velocity. In addition, Chang and Yu (2010) reported different velocity profiles in the handwriting of children with DCD depending on the complexity of the Chinese characters to be written. We thus wondered if these findings could be extended to the Latin based alphabet, and more particularly to the French cursive style of writing in which consecutive letters are joined (Orliaguet et al., 1997; Kandel et al., 2000), a major difference with the English script style of writing. Since in the Latin alphabetic system handwriting complexity relates to the length of the item to write rather than to the complexity of letters themselves, we thus analyzed the handwriting of the child with DCD for isolated letters, bigrams, trigrams, and small words, and compared her productions with those of TD first- and second-graders. We found here that all productions of the second-grade child with DCD are more similar to those of first-graders than to those of second-graders. The delay between L. and TD children does not increase importantly with the complexity of the items to be written, suggesting that the treatment of the “letter” unit is the basis of her handwriting difficulties.
From a kinematic point of view, we found that the most discriminative writing parameters between the child with DCD and TD children of the same age were length and velocity: The child with DCD wrote larger but at a higher speed. These results, which are in line with our previous observations on another child with DCD (Jolly et al., 2010), are likely to be due to the principle of isochrony (Binet and Courtier, 1893; Lacquaniti et al., 1983; Wright, 1993). Indeed, it has been shown that there is a proportional and direct relationship between the trajectory length and movement velocity. This invariant feature of handwriting characterizes motor programs in adults. Other handwriting parameters which differentiate the child with DCD from TD children include the number of pen strokes and in-air time, in particular for syllables and words, and the number of velocity peaks for isolated letters. The increased number of pen strokes observed for syllables and words is perfectly illustrated in Figure 3, where it clearly appears that each letter of the trigram is treated separately as a single unit, with a pause in between, thus reflecting a problem in anticipation and automation. Altogether, these observations directly reflect the lesser fluency of the handwriting of the child with DCD. This particular pattern reflects hesitations during handwriting, which may be due to a deficit in procedural memory (Nicolson and Fawcett, 2011). This increased velocity of the child with DCD is likely due to the higher intensity of the velocity peaks during writing, as observed on the velocity profiles.
Our present findings as to the velocity pattern of this DCD child handwriting are distinct from those described by others. In particular, Prunty et al. (2013) observed a slowness in English children with DCD due to increased time spent in pausing, and Chang and Yu (2010) reported various velocity depending on the complexity of the Chinese character to write. In contrast, our results reveal a higher writing velocity of the child with DCD when compared to TD children, whatever the complexity of the item to be written, and no significant difference with TD children in the pausing time during writing. These differences between our results and previous observations may be due to the fact that our analysis is a single-case study while the other studies were group studies. Due to the high heterogeneity among children with DCD, group studies and single-case studies may lead to apparent discrepancies which actually reflect inter-individual differences. These two kinds of approaches are in fact complementary. Group studies reveal general tendencies, while single-case studies allow a detailed analysis of typical or atypical cases (Caramazza, 1986; Caramazza and McCloskey, 1988). Another possible explanation for the apparent discrepancy between our observations and previous ones may relate to the style of writing which was analyzed. Indeed, the French cursive style of writing is quite different from Chinese or Latin script. For instance, Chinese and to a lesser extent script writings require a higher number of strokes than French. Moreover, consecutive letters are joined in French cursive writing, while characters are separated in Chinese or script. Differences between the results of various studies may thus be due to linguistic specificities, as it is the case for example for the learning of reading (Gentaz et al., 2014).
Our present observation that the handwriting of the second-grade child with DCD is similar to that of first-graders is in line with our previous study on another second-grade child with DCD, whose handwriting was closer to that of preschoolers (Jolly et al., in press). Altogether our results support the hypothesis that each child with DCD may reach a steady-state level reflecting his/her own maximal skills on handwriting, and raise again the question of the necessity of handwriting intervention beyond this step.
Caroline Jolly and Edouard Gentaz designed the project. Caroline Jolly performed the experiments in schools and the statistical analyzes of the results. Caroline Jolly and Edouard Gentaz wrote the paper.
Conflict of interest statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We are grateful to the directors and teachers of schools, to the children and their parents, and to the child with DCD for participating in the study. We also thank Sébastien Boisard for developing the Scribble software used to analyze handwriting tracks. This work was supported by the French National Center for Scientific Research (CNRS) and by the University Pierre Mendès-France (Grenoble, France).
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HECS 2205: Professional Practice II Student ID: 200801503 Contents: Pages 1-3 Reflective Account: Analysis and reflection involving a difficult paediatric patient following the Gibbs Reflective Cycle (Gibbs, 1988) Pages 4-11 Case Study: Radiation protection, infection control and communication issues for a difficult patient undergoing an invasive vascular procedure. HECS 2205: Professional Practice II Student ID: 200801503 Analysis and reflection involving a difficult paediatric patient following the Gibbs Reflective Cycle (Gibbs, 1988) Description A 9 year old male patient was admitted to the department for a wrist radiograph from the accident and emergency department (A&E), accompanied by his mother. Clinical indications demonstrated a fall, querying a bony injury to that area. During the preexamination questions, including patient identification under Ionising Radiation (Medical Exposure) Regulations 2000 guidelines, it was discovered that the patient was severely autistic. This was not communicated to the department by the A&E staff, or on the examination request card. Unfortunately, due to a previously traumatic experience at another hospital, the patient was very reluctant to liaise with me and seemed very distressed by the environment. Because of this, I allowed the mother to accompany and position the patient under my instructions, whilst I stepped back and handled the equipment. The patient was largely unco-operative during the procedure and seemed very anxious about his surroundings. Feelings Whilst the procedure produced a successful and diagnostic result, it was very difficult due to the patient’s mental capacity and discomfort. It was necessary to gain a diagnosis from the patient, however it was very difficult dealing with and managing a patient who was reluctant to cooperate and showed significant anxiety throughout. I felt unhappy with the patient’s state, and the mother appeared to share this feeling. Evaluation I felt that the patient’s distress was unnecessarily increased as a result of his autism coupled with his length of time within the hospital environment; thus leading to his anxious behaviour. (NHS Protect. 2013). This incident highlighted the need to communicate the patient’s condition between departments, as this patient could have been examined earlier and his discomfort greatly reduced. Analysis Reflection on this incident demonstrated many negative aspects, however the examination result was positive, and the patient received a clinical diagnosis from 1|Page HECS 2205: Professional Practice II Student ID: 200801503 the radiographs produced. The breakdown in communication was acknowledged, and in response to this, a clear note of the patient’s condition was made on his request form. This will not only reduce patient waiting times in order to reduce anxiety, but to make the staff aware of the condition prior to the examination in order to tailor their care to the individual (NICE Guidelines. 2013). Conclusion Sometimes the examination and the difficulties with adapting technique can get in the way of what I am trying to achieve; taking a step back from the situation and viewing it objectively helps. Ensuring patient comfort is a main priority can often be side-lined as we focus solely on the diagnostic radiographs we are hoping to obtain. The mother clearly knew the patient much better than I did, and knew what to do and how to deal with the situation quickly and efficiently. By allowing someone who was familiar to the patient undertake the positioning gave the patient some familiarity and minimised patient discomfort in a new and frightening environment (Society of Radiographers. 2014). Action Plan Should this incident happen in the future, I am aware of the limitations of my clinical ability and will obtain advice from a supervising radiographer should I not feel comfortable with the situation. Observing the mother’s behaviours towards the patient, this could be replicated to produce a successful result. I must be mindful that each patient is an individual and my care towards them should be tailored accordingly. Word count: 500 ± 10% - 536 References: Her Majesty’s Stationery Office (HMSO). (2000). The Ionising Radiation (Medical Exposures) Regulations 2000. HMSO: London. Gibbs, G. (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Further Education Unit, Oxford Polytechnic. National Health Service Protect. (2013). Meeting needs and reducing distress: guidance on the prevention and management of clinically related challenging 2|Page HECS 2205: Professional Practice II Student ID: 200801503 behaviour in NHS settings. [Online]. [Accessed: 22/07/15]. Available from: http://www.nhsbsa.nhs.uk/Documents/SecurityManagement/Meeting_needs_and_re ducing_distress.pdf National Institute for Health and Care Excellence. (2013). Autism: The management and support of children and young people on the autistic spectrum. NICE clinical guideline 170. Society of Radiographers. (2014). SCoR Briefing Sheet: Autism. [Online]. [Accessed: 22/07/15]. Available from: https://www.sor.org/system/files/article/201402/2014.02.18autism_fact_sheet.docx#o verlay-context=practice/hot-topics/children 3|Page HECS 2205: Professional Practice II Student ID: 200801503 Radiation protection, infection control and communication issues for a difficult patient undergoing an invasive vascular procedure. A 45 year old female patient with end stage renal failure (ESRF) attended the Vascular Imaging Unit for a Tesio catheter insertion in order to provide vascular access for haemodialysis. This is a process which involves the transferral of blood from the patient’s body into a dialysis machine that filters out waste products and excess fluids (much like an artificial kidney). The filtered blood is then passed back into the body. It is a treatment that replicates the kidney’s functioning, where the patient’s kidneys have failed (NHS. 2013). A Tesio is a pair of hollow tubes (catheters) inserted into a central vein within the neck through the guidance of x-ray, either through the axillary or subclavian vein, in order to take and return blood for dialysis (Trust A (2), 2007). Wang et al (2006) suggest that the use of Tesio catheters has become increasingly popular as a result of a high technical success and low morbidity rates as a short-term method for haemodialysis. They argue however, that the use of catheters is ‘broadly discouraged’ due to inferior blood flow rates and a higher infection risk. For 10% of patients, including this patient, they are unable to maintain a permanent vascular access through surgical procedures and must rely on catheters for their dialysis (British Journal of Renal Medicine. 2007). The requested procedure was therefore justified under Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2000. The procedure was scheduled early in the morning and was the first that I had observed, as a result I was unable to research the procedure so I felt that I was unprepared for what I was about to see. A radiographer, radiologist and a team of nurses were present to perform the procedure; I introduced myself to some of the nursing team and the radiologist that I had not met before. I aided the nurses in their preparation of the sterile trolley using aseptic non-touch technique (ANTT) following the guidelines that relate to invasive procedures (Trust A, 2014). This differs greatly from my previous experiences within the general x-ray departments, which follow the protocol for ‘clean’ examinations; which involves a simple wipe-down of surfaces and equipment using disinfectant wipes before and after patient contact (NHS Professionals. 2010). 4|Page HECS 2205: Professional Practice II Student ID: 200801503 The following procedure, however, is deemed a ‘sterile’ examination as this is a procedure that bypasses the body’s natural defences through the invasion of the skin boundary (Chambers et al. 2006). This requires ANTT in order to prevent the contamination of the catheter insertion site from microorganisms that could cause infections. ANTT is employed by ensuring only uncontaminated equipment and fluids come into contact with sterile and susceptible sites during the entire clinical procedure (Trust A. 2014). This technique has become the de facto standard aseptic technique within the UK (Rowley et al. 2010), with poor performances of this technique clinically proven to be a fundamental cause of healthcare acquired infections (Department of Health. 2003). As I had not experienced this type of environment before, the nurses guided me in the correct preparation of the sterile trolley; ensuring that the aseptic field was not decontaminated when opened, and ensuring all equipment was opened from the middle of the sterile packet without any touch of its contents (Hunt. 2012). With the correct guidance from the nursing team, I felt confident that I would be able to carry out these principles of ANTT through future invasive examinations in order to work as part of their multi-disciplinary team (MDT). After the room was correctly prepared, I followed the radiographer to meet the patient for the first time. I aided the radiographer in gaining the patient’s consent for the examination (Trust A, 2008), ensuring that the patient was correctly identified under IR(ME)R 2000 guidelines and ensured that the patient’s last menstrual period (LMP) was recorded. As this patient was classed as being within child-bearing age (between 12-55 year of age), undergoing a procedure which was defined as a lowdose examination by The Royal College of Radiologists and the College of Radiographers (2009), as an examination which will result in a foetal dose of less than 10mGy, the 28-day rule was applied. Although this type of procedure demonstrates high doses of radiation, the primary beam did not directly irradiate the patient’s uterus, suggesting that the risk to the foetus within the first 3-4 weeks post-conception before the woman has missed her period (prior to 28 days), the risk of childhood cancer will be very small (below 1 in 10,000) It is therefore appropriate to use the 28 day-rule, as the cancer risk prior to 28-days is likely to be much lower than in the subsequent stages of pregnancy, although the risk within this time frame is still evident (International Commission on 5|Page HECS 2205: Professional Practice II Student ID: 200801503 Radiological Protection (ICRP). 2003). The patient declared that she was not pregnant and was post-menopausal, allowing the examination to be undertaken. During our first meeting with the patient, we discovered that the patient had a total laryngectomy (removal of the larynx) and was only able to communicate through an electrolarynx; a battery operated machine that produces voice and sound when pressed against the patient’s neck (Cancer Research UK. 2013). This was alarming as I had not experienced a patient with this type of communication and respiratory complication before. As a result of this, the MDT further discussed the implications of the procedure with the patient; which involved complications with the use of contrast media and local anaesthetics. As the procedure due to be undertaken was deemed as ‘sterile’, sterile drapes were required around the patient’s neck in order to ensure the puncture site was not contaminated, reducing the risk of infection (Trust A (1), 2007). As a result of this, however, the patient’s communication would be compromised as she was unable to use the electrolarynx throughout the procedure. This would mean that using iodinebased contrast agents throughout the examination to roadmap the patient’s vasculature would be cautioned, as they patient would not be able to communicate throughout the examination. Therefore, any evidence of an allergic reaction to the contrast agent would be difficult to determine, as she would not be able to communicate any symptomatic changes throughout the procedure (UK Drug Database. 2015). These symptoms included nausea, vomiting, dyspnoea (difficulty breathing), erythema (reddening), urticaria (hives) and hypotension; as well as a more severe anaphylactic shock (electronic Medicines Compendium. 2015). As this patient already had impaired respiratory functioning as a result of the laryngectomy, if any dyspnoea symptoms presented, their severity would be much greater than that of a patient with normal respiration. This made me nervous for the procedure, as I had not experienced a contrast media reaction previously, making me worried of how I would handle the situation should one occur. I was also aware that noticing any changes in the patient would be difficult from our position within the laboratory since we were at the patient’s feet, controlling the fluoroscopy C-arm and would be unable to see the patient underneath the sterile drapes. The examination was complicated further, as the patient 6|Page HECS 2205: Professional Practice II Student ID: 200801503 requested a local anaesthetic for the examination, 10mg/5ml intravenous Midazolam in accordance with Trust A’s nursing guidelines ((1), 2007) which was also cautioned due to the patient’s impaired respiratory function (British National Formulary. 2015), as this could potentially cause sedation induced respiratory failure (Trust A (1), 2007), providing a greater severity as a result of the patient’s current respiratory issues. After discussing the case, the MDT agreed that a trained nurse would remain by the patient’s head throughout the procedure to ensure that any symptomatic changes could be detected quickly. This compromised me as a student radiographer and the qualified radiographer’s role in radiation protection for the staff under Ionising Radiation Regulations (IRR) 1999 guidelines, as the x-ray tube of the fluoroscopic Carm would be located directly beside the patient’s head throughout the procedure, resulting in a large amount of scattered radiation from the patient irradiating the nurse within that proximity. It came to my concern that the inverse square law could not be adequately applied during the procedure, as the nurse would have to closely monitor the patient throughout. It was therefore my responsibility to ensure that the correct precautions were applied in order to reduce the radiation dose as much as possible to the nursing staff. This role gave me a sense of purpose within the MDT, and I felt that I could handle this situation well based on my previous experiences and knowledge in theatre and fluoroscopy settings. I issued everyone working within the vascular laboratory personal protective equipment (PPE); which according to the ICRP guidance (2010) defines as lead rubber aprons, thyroid shields and lead eyeglasses. It was ensured that in compliance with the publications by ICRP that the appropriate thickness of aprons were distributed to the staff members. These guidelines suggest that a lead equivalent apron of 0.35mm to be worn in areas where the x-ray tube has a set peak kilovoltage (kVp) value within the range of 70 to 100kVp, which are typical values within interventional procedures, alongside a 0.5mm lead equivalent thyroid shield providing additional protection to the radiosensitive thyroid (IRCP, 2010),. The ICRP recommends leaded eyeglasses with 0.5mm lead equivalence to be worn by the interventional radiologist performing the examination, in order to protect the lens of the eye. This organ is especially radiosensitive, and according to the ICRP, 7|Page HECS 2205: Professional Practice II Student ID: 200801503 the risk of cataract formation due to occupational radiation exposure is based on deterministic radiation-induced effects. Issued within a review article by Fish et al (2011) suggests that despite the ICRP stating the threshold for a single dose of radiation to the lens of the eye at 2 Gray for a single exposure which would pose a serious risk of cataract development, there is now evidence from several epidemiological studies to suggest that this threshold should be much lower (Miller et al. 2010). As a result of this evidence, it is recommended that the use of shielded eyewear should be maintained until further research has been conducted. I deemed it appropriate to also issue the nurse monitoring the patient during the examination with leaded eyeglasses, as a result of their close proximity to the x-ray tube. In order to reduce the dose to a single member of staff, I suggested that a rotation between the trained staff members would take place. Although the patient was physically distressed throughout the examination, the role of the supervising nurse worked well to not only ensure patient safety, but also as a comfort and supportive role to ensure the examination was effective. The MDT worked well to ensure that the patient was aware of each step within the procedure, with the use of tailored communication and picking up on non-verbal cues from the patient’s facial expressions as the examination continued. By building an effective relationship with the patient aided the team in explaining the procedure to a distressed patient and ensuring that they were aware of the examination taking place, aiding their compliance throughout (Ehrlich. Coakes. 2013). Although the patient was not able to communicate throughout the procedure, the team ensured that she was the primary focus of the examination, and were able to provide physical and psychological support for a very distressed patient, ensuring a positive result. The examination was successful and the MDT worked effectively in order to ensure that the patient’s safety was the focus of the procedure, with an action plan put into place should any potential problems became apparent, as well as adapting standardised techniques to the individual patient. I felt that, although I was unable to undertake all of the roles of a radiographer for this examination, I was still able to make a positive contribution to the MDT and their protection against radiation. I was able to reflect back on previous experiences within different settings which used high-dose radiation and observing the radiographers role within them to develop my 8|Page HECS 2205: Professional Practice II Student ID: 200801503 own experiences which I could demonstrate within this environment. I was able to successfully apply my radiation protection knowledge to ensure I was working alongside IRR 1999 guidelines, ensuring staff dose was kept to a minimum. Following the Gibbs reflective cycle (1988), I am able to reflect on my observations of how the team tackled a difficult situation, considering both the positive and negative aspects of the event. This will not only allow me to understand the entire aspect of a scenario, it will also allow me to adapt my actions and behaviours should I come across a similar examination in the future (Gibbs. 1988). Reflecting back, I am able to understand that I was not able to make a large contribution to the team, which did leave me feeling inadequate. However I feel that now I am able to play a bigger part within the MDT having observed the radiographer’s behaviours and actions in this event. I now feel confident that I can take a much more active role within the radiographic procedure given more time and experience, even those which are unfamiliar. I still feel worried about how to handle a situation where a contrast media reaction has occurred, however with appropriate training and updates I will feel better prepared for such an event should it ever arise (Morcos, 2014). Word Count: 2000 ± 10% - 2200 References: British Journal of Renal Medicine. (2007). 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