You’ve clapped for us. You’ve sent us Nando’s. You’ve put up “yup the frontline” outside your windows (10/10 sign). And that has all been stunning, and warmed my cold, dead heart. But it hasn’t been all sunshine and delicious carby goodness. A pandemic is still a pandemic. The impact this crisis has had on radiographers has been profound.

The world is ending, and whilst some are working from home, some are working on the frontline. It is not easy for anyone in the midst of the apocalypse, and radiography is no different. In this article, I will discuss the role of the radiographer in imaging COVID-19 patients, the impact it has had on Irish radiographers and some potential considerations for us.

The Role of Imaging in COVID-19

One of the main roles of radiographers is to provide diagnostic images across a variety of modalities, to aid in the clinical pathway of a variety of patients. As of 2019, there are currently some 2,301 radiographers practicing in Ireland^[1]. Our nice easy life of button pushing was thrown by the wayside when some bat decided to wreck the buzz and inflict a pandemic upon the world in the form of COVID-19.

Diagnostic imaging is a key part of the COVID-19 patient care pathway. By default, this places radiographers right in the firing line. Typically, the suspected COVID-19 patient with respiratory complaints will undergo a chest x-ray (CXR). CXRs are also performed in addition to a swab, as swabs (great and all as they are) do not provide information on the severity of the disease and can provide false negatives^[2]. A CXR will allow the clinician to assess the lung fields, and help separate COVID-19 from an upper respiratory tract infection (read: sore throat)^[3].

Computed tomography (CT) scans are also part of the pathway for some COVID-19 patients. CT is advantageous in that it is more sensitive to detecting the disease^[4]. It offers the capacity to view the anatomy in multiple planes (an x-ray is only a single image). CT is also useful in monitoring the progression of the disease, and is more sensitive for subtle changes in lung fields^[5]. CT is not as prevalent as CXR, as it is a higher radiation dose, and is too time-consuming for the patient load.

The accuracy of these imaging modalities is disputed in literature^[6], but regardless, their use in the clinical setting is widespread. And who provides said imaging? The lowly radiographer.

The Radiographer in COVID-19: Then & Now

As with almost everything in life, COVID has drastically changed the way radiographers practice. Contrary to the preaching of anti-mask fuckwits, COVID-19 is a highly contagious respiratory disease, so extreme care is taken when carrying out examinations. The examination time is increased, owing to the need for donning/doffing personal protective equipment (PPE) and increased infection control protocols.

The organisation and imaging protocols were also changed in a number of departments. Some departments have moved to performing x-ray examinations of COVID-19 patients portably, requiring the radiographer to use a mobile x-ray machine to acquire images of these patients in different locations throughout the hospital. This helps reduce the spread of the disease, by keeping the patients in a single location^[7].

As a result, the radiology service is placed under increased demand, in terms of service provision and workload. Whilst the numbers of examinations required may decrease (certain outpatient services reduced etc.), the intensity of the work has increased. This has had several implications for the radiographer, and this will be discussed in the next section.

Stress, Burnout & Fatigue

Stress/anxiety has been the most marked complaint from radiographers, reported in the recent Foley et al study^[8]. This study sampled 16% of all radiographers in Ireland (what a stunning sample size). In the initial 6 weeks of the crisis, 97% of radiographers reported feelings of anxiety in work (as I’m sure everyone all over the country was!). This did reduce vastly after the initial six week period. This supports another study of UK radiographers, whereby 63% of radiographers experienced workplace-related stress during the crisis^[9].

This change in routine and workload intensity has likely contributed to the increase of work-related stress, with radiographers fearing contracting the infection and spreading it at home, concern over infection control policies and PPE^[8],[9]. Alarmingly, some of the interviewees reported huge concerns for their safety and well-being with some quoted as saying:

“I feel so vulnerable right now. I feel genuinely afraid my life and my family members at work right now.”

“This has been the hardest and darkest part of my career”^[8].

A study of all healthcare workers during the pandemic found they are at high risk of suffering mental health issues such as anxiety and depression following working in healthcare during the pandemic^[10]. From looking at the responses from radiographers it is clear that we are no different.

Antidotes to Workplace Chaos: Eat, Move, Mind Yourself & Talk

Exercise

Exercise is well-documented in literature as an effective intervention to combat workplace burnout and stress^[11]. Cardiovascular exercise (running etc.) has been found to decrease perceived stress and emotional exhaustion. Resistance training has been effective at increasing well-being and stress reduction.

It can be helpful for us to move and get active (in our own rescue, as the great Marcus Aurelius once said). It doesn’t have to be anything spectacular. A walk with a podcast, a short weight session or a light jog. The act of moving alone has huge benefits for the mental health of everyone, and radiographers are no different.

Nutrition

Workplace stress is attributed to a rise in harmful eating patterns and obesity^[12]. Stress can lead to disordered eating, which in turn can lead to the development of eating disorders (anorexia, binge-eating disorder etc.)^[13]. It can be challenging to avoid using food as a crutch to carry you through the harder days (can confirm from personal experience!). Keeping a structured routine of eating can be helpful, and give you some form of “control” over some aspects of your life.

Eating a balanced diet with the occasional bar of salted pretzel chocolate can be instrumental in reducing stress and improve health outcomes.

Mind Yourself

Burnout is real, and you need to look out for yourself. Taking time for yourself, doing nice things for yourself when you can and being kind to yourself is invaluable. This can be hard to do, especially at work. But it is SO important you make time for it. It can be a coffee with a friend, watching your favourite TV show, reading or anything that makes you feel safe and cared for.

Some of these can be done during work. The one caveat to this I would say is reading. Be careful what you read. I read Man’s Search for Meaning one night on call, and mother of divine jaysus I was in ribbons after it. Unless you want to be discovered by a porter almost sobbing, be careful!

Mental Health Services

The psychological burden placed on all of us is quite heavy, and some of us struggle under the weight more than others. We are all handling the situation differently, with our own unique circumstances.

Establishing good nutrition, exercise patterns and self-care strategies is great. But sometimes it isn’t enough. There is absolutely no shame whatsoever in talking to someone. You only get one head, and you best look after it. As the great Marcus Aurelius said:

“Don’t be ashamed of needing help. You have a duty to fulfil just like a solider on the wall of battle. So what if you are injured and can’t climb up without another soldier’s help?”

The pandemic has lead to some dark days for us all, and workplace-related dark days are all too real. With this said, only 10% of radiographers have utilised mental health resources available to them at work^[8]. We have discussed at length the impact of radiography on the mental health of the individual, and it bears repeating. These are some of the hardest and darkest days. So, if you can benefit from talking to someone, do it. Most hospitals have more resources and services in place for staff. Don’t do yourself a disservice by neglecting your mental health.

Use the resources that are available to you. Talk. Don’t keep it all inside.

Conclusion

This article is not intended to say “radiographers have it harder than everyone else”. Not at all. It is a load of shit for everyone at the moment. But I know from speaking to my colleagues and friends who work in radiography, we are notoriously awful at speaking about how it has affected us. Because it is just “our job”. But it is SO important to look out for yourself, and as today is World Mental Health Day, I thought I would highlight just how important it is to look after yourself.

Furthermore, this article is not intended to be a panacea for everything that ails you. It is a broad suggestion of ways you can look after yourself. Please talk to someone if you are struggling.

References

1. CORU (2019) CORU Registration Statistics. Available at: https://coru.ie/news/news-for-health-social-care-professionals/coru-registration-statistics-july-2019.html.  
2. Orsi, M.A., Oliva, A.G., Cellina, M. (2020) ‘Radiology Department Preparedness for COVID-19: Facing an Unexpected Outbreak of the Disease’, Radiology. Available at: https://pubs.rsna.org/doi/full/10.1148/radiol.2020201214.
3. Hui, T.C., Khoo, H.W., Young, B.E., Mohideen, S. M., Lee, Y.S., Lim, C.J., Leo, Y.S., Kaw, G.J., Lye, D.C., Tan, C.H. (2020) ‘Clinical utility of chest radiography for severe COVID-19’, Quantitative Imaging in Medicine and Surgery. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358410/.
4. Cellina, M., Orsi, M., Toluian, T., Pittino, C.V., Oliva, G. (2020) ‘False negative chest x-rays in patients affected by COVID-19 pneumonia and corresponding chest CT findings’, Radiography. Available at: https://www.sciencedirect.com/science/article/pii/S1078817420300699#bib1.
5. Zanardo, M., Martini, C., Monti, C.B., Cattaneo, F., Ciaralli, C., Cornacchione, P., Durante, S. (2020) ‘Management of patients with suspected or confirmed COVID-19, in the radiology department’, Radiography. Available at: https://reader.elsevier.com/reader/sd/pii/S1078817420300626?token=579E3396FF9C91272B99C101DF02D8DD4911AB79CFAF6CC56821ABFEB0FBF55B5D93D2741167035EA33A5F505F545CDA.
6. Wong, H.Y., Lam, H.Y., Fong, A.H., Leung, S.T., Wing-Yan Chin, T., Lo, C.S., Lui, M.M., Lee, J.C., Chiu, K.W., Chung, T.W., Lee, E.Y., Wan, E.Y., Hung, I. (2020) ‘Frequency and Distribution of Chest Radiographic Findings in Patients Positive for COVID 19’, Radiology. Available at: https://pubs.rsna.org/doi/full/10.1148/radiol.2020201160.
7. Stogiannos, N., Fotopoulos, D., Woznitza, N., Malamatenious, C. (2020) ‘COVID-
   19 in the radiology department: What radiographers need to know’, Radiography. Available at: https://www.sciencedirect.com/science/article/pii/S1078817420300845.
8. Foley, S.J., O’Loughlin, A., Creedon, J. (2020) ‘Early experiences of radiographers in Ireland during the COVID-19 crisis’, Insights into Imaging. Available at : https://insightsimaging.springeropen.com/articles/10.1186/s13244-020-00910-6.
9. Akudjedu, T.N., Lawal, O., Sharma, M., Elliot, J., Stewart, S., Gilleece, T., McFadden, S., Franklin, J.M. (2020) ‘Impact of the COVID-19 pandemic on radiography practice: findings from a UK radiography workforce survey’, British Journal of Radiology. Available at: https://www.birpublications.org/doi/full/10.1259/bjro.20200023.
10. Lai, J., Ma, S., Wang, Y. (2020) ‘Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019’, JAMA Network Open. Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763229.
11. Bretland, R.J., Thorsteinsson, E.B. (2015) ‘Reducing workplace burnout: the relative benefits of cardiovascular and resistance exercise’, Peer Journal. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393815/.
12. Nishitani, N., Sakakibara, H. (2005) ‘Relationship of obesity to job stress and eating behaviour in male Japanese workers’, International Journal of Obesity. Available at: https://www.nature.com/articles/0803153.
13. Gluck, M.E. (2006) ‘Stress response and binge eating disorder’, Appetite. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0195666305001133.