Years ago when I was a radiology trainee I was fortunate to spend a day a week for several months with an aged but very eminent radiologist, Dr Ronald O. Murray.
He was one of the pioneers of skeletal radiology and co-authored with an American radiologist, Dr Harold Jacobson, their magnum opus Radiology of Skeletal Disorders: Exercises in Diagnosis. As might be expected Ron had many stories and anecdotes and the lunchtime trips to the pub (the best ham sandwiches I have ever tasted) were highly entertaining.
One story which sticks in my memory concerned a lady at the highest level of society (one must maintain patient confidentiality). Ron was in his shared rooms in Harley Street one day when the door opened and a plain clothes policemen entered. “She’s arrived!” he declared. Ron was bewildered until it was realised that the appointment date had inexplicably been confused, and the lady was booked to see a different radiologist the following day. But obviously the receptionist was not going to say, “Sorry Dear, you’ve got the wrong day. Come back tomorrow”.
The patient was due a chest X-ray and, on completion, asked if “one could get dressed”. After about ten minutes a very panicky radiographer rushed in to tell Ron that the film had got stuck in the processor and needed to be repeated. He then had the embarrassing job of confessing to the “patient” that, unfortunately, she needed to get undressed again.
His moral was simple: no matter how eminent the patient keep them in the gown until the film has been checked!
Of course modern young doctors will not have a clue what I am talking about! Today the digital image will appear on the screen seconds after the exposure, and even if the image is not perfect it can generally be “windowed” to improve it. The clinicians then dial up their patient’s images on the PACS system or probably before long on their mobile phone. However things were very different in the olden days.
In 1966, while still a sixth former, I took a summer job as a porter in the X-ray department of Charing Cross Hospital, and I mean the original hospital just off the Strand built in 1831. I remember that the department was very small and cramped. The radiologists (such as there were) would wear red goggles to get them “dark adapted” before using the fluoroscopy unit which was a much more basic bit of kit than we have today.
In those days the radiographs were still processed in dark-rooms containing large tanks of developer and fixer fluid. They would then be hung up on a rack to dry in warm air unless clinical urgency demanded the “wet film” – a term which survived for many years after wet processing ceased.
But by the time I started as a medical student in 1967 the tanks were being replaced by mechanical processors – large smelly machines which automatically rolled the films through the developer and spat them out dry at the other end after about four minutes. But they were forever going wrong and chewing up the films so that they had to be taken apart to retrieve the crumpled mess. Obviously it was this type of equipment which was used in Ron’s rooms down “the Street”.
But accepting that all of medicine has progressed hugely in the last forty years I would argue that it is probably the developments in radiology which have had the greatest impact on patient management.
When I was House Surgeon to Sir Alan Parkes in 1974 a very common operation was the laparotomy – that is open them up to take a look and find out what is going on in the abdomen. Today no one would dream of operating on a patient without knowing exactly what is going on thanks to our high quality ultrasound and CT scanners.
Major trauma patients can be on the scanner within minutes of arriving in the ED and imaged from top to toe in seconds. 3D reconstructions of complex fractures will demonstrate for the orthopaedic surgeons exactly what they need to do in terms of repair. Cancers may be diagnosed and accurately staged with extraordinary accuracy.
But perhaps the greatest advance has been in the area of interventional radiology, or “surgery down the tubes” as a past President of the RCR called it.
As an FRCS who became an FRCR I was well placed, with many others, to start developing these techniques, especially image-guided interventions. And we are now able to do what was unimaginable when I started forty years ago.
A few weeks ago a twenty-two year old lad was admitted to my hospital with abdominal pain. He was generally very fit, gym three times a week! A CT scan demonstrated a huge pelvic abscess almost certainly from a missed pelvic appendicitis.
In the olden days he would have had a full laparotomy with a stormy post-operative recovery probably involving wound sepsis and the risk of adhesions. He would have been off work for weeks and probably would not get back to the gym for months. He would also have a large lower abdominal scar.
But under ultrasound guidance I was, without difficulty, able to drain a litre of pus trans-rectally and he was discharged well two days later.
In a few days I will retire from clinical work. I have had a full, interesting and enjoyable career. But as I look back it will be this case, and many others like it, which will give me the most satisfaction. We are now able to diagnose, treat and cure many patients using minimally invasive radiological techniques. A new generation of radiologists are building on this type of work and much of it is very impressive.
But I am quietly pleased that I was there at the beginning.