I was looking forward to sharing about myeloma this week but as fate would have it 10 – 16 March was ‘patient safety awareness week’ and I have to use this opportunity to educate on the measures we take for patient safety in the field of radiation oncology.
The Ethiopian Airlines crash marred the beginning of this week on 10 March. Ironically, Monday’s lunchtime education session at the hospital used airline safety as an example of safety standard. As the stories behind the victims come out it makes sad reading.
As in many medical fields, patient identification is the first safety precaution in cancer care. Much to the annoyance of people who come for help and are hoping to skip the line, the first point of entry should be the clerks desk so that a unique number is given to you and a patient file is opened. This file is your golden history and allows a lot of stories to be told about your disease with ease.
A common scenario is a patient who has been on treatment for a while, walking up to a doctor and asking for a refill for a prescription or sometimes an issue related to treatment or recovery. It can be quite disheartening when the doctor asks for the file as this looks like a delay tactic but it is all for the patient’s safety.
Having a file tells the health history well and provides a golden thread that the team can use to provide the best care. Careful history taking is valuable and providing that information as a patient or care giver should be taken seriously.
Recently I had a patient who came in after a sudden massive vaginal bleed. This place being what it is, within 2 days she had her lab confirmed diagnosis of cervical cancer. After I examined her, unfortunately it was quite advanced locally. Now even before the examination she had been unable to keep still on the chair and described a low backache and a feeling of faecal urgency so I was able to accurately estimate the extent the tumour. I empathised with this patient and she obviously needed a very strong analgesic. However she was also speaking a mile a minute and certain elements from her story were pointing to possible narcotic abuse. I did not feel it was safe to give her an opioid to relieve her pain as in most cases of pre treatment locally advanced cervix cancer. This presented a barrier to quality care but we had to choose safety first. As a result when you are coming to see an oncologist try to prepare yourself. Have a list of all your recent medication and know the medical conditions you are being treated for.
Treatment planning and treatment
One of the best parts of my work is the constant peer review that happens before a patient can start treatment. Irrespective of geographical location, radiation oncologists in a department sit together at least once a week to verify that a colleague’s plan is as safe as possible. In radiation there is a term called ALARA standing for As Low As Reasonably Achievable. This means that we aim to prescribe to a patient as little radiation for the maximum effect possible. It also means that we must try to avoid radiating the neighbouring organs without cancer.
One of the processes is having a planning scan, which allows us to mould the dose around the cancer and avoid the normal tissues. This can take up to two weeks for the images to go through the checks and balances.
Most radiotherapy courses involve multiple treatments and the patient has to be positioned in as close to the same position every day. To ensure this treatment rooms have infrared rays that are used to guide the patient positioning. Tattoos on the patient’s body help align the targeted area well. In recent times image guidance with on-board imaging on the treatment unit allows verification in 3D and internally matching the days images to the pre treatment plan. This is called cone beam CT. The advantage of this is it manipulates not only the external accuracy but takes into account the motion of organs like the bladder and the rectum which change position as they fill and empty.
Just two days ago we had a patient who was simulated with 900cc in the bladder. However, by day 8 on treatment the bladder was only filling with 200cc and this was causing a major shift in the tumour location. It is not unusual that patients are very nervous but by the end of the first week they are more relaxed and this allowed them to be more sensitive to the quantity of urine in their bladder!
Two very important cadres other than doctors are needed to ensure a seamless process. These are radiation therapy technicians and medical physicists.
The radiation therapy technicians are the actual drivers of the radiotherapy machines. They see the patient everyday of their treatment and actually form great bonds with patients in the process. Conversations with radiotherapy technicians sometimes help me bring out issues with a patient that I fail as a doctor alone.
If the radiation therapists are hidden away in the machine areas, the medical physicists who are an integral part of the whole process are even more obscured. Patients never really get to see the important work in safety that physicists do and I salute them. Their quality assurance processes on the machine makes sure it is delivering the dose the computer is telling us. They also counter check the prescription content by a radiation oncologist thus providing internal check and balances.
Chemotherapy administration also goes through quality assurance for patient identity, weight, height and dose. Oncology nurses and pharmacists verify this.
All in all just like in aviation we have put in place safe guards to make sure the right patient gets the right dose and treatment.Remember always – patient safety first!