Chest 123; There and back again

12 Jun
Chest 123 C

Chest 123; There and back again

The picture contains two X-rays from the same man after a severe car accident, one taken in the Emergency department immediately after the event, and another on the day of discharge from hospital several months later.

Encounters with people like this make one realise how precious life is and how it can be taken away in a single minute. One mistake when driving a car can result in extreme injury, or death. This man was lucky to have survived his ordeal.

Despite improvements in road conditions, vehicle safety and driver education, over 3 million people are injured in road accidents each year. In the period after an accident when someone is injured the focus is on saving life, preventing life-threatening complications, healing and physical rehabilitation. Later there can be psychological consequences most notably post-traumatic stress disorder (PTSD), frequently not recognised. These disorders cause extensive lifestyle restriction. Mental healing is essential for the injured person to pick up life again.

Whether the person involved is a driver, passenger, pedestrian or even just an observer some people  struggle mentally in the days and weeks following a crash. Up to 30 per cent will deal with a negative psychological response. Although most recover from the anxiety which is a natural reaction to a stressful incident, others develop PTSD symptoms that can become chronic. Some will have no symptoms, some just minor symptoms, but others run the full gamut with disabling flashback memories, anxiety related to the trauma, hyper-activity, irritability, confusion, sleeplessness, lassitude, difficulty concentrating, and feeling upset, angry, helpless or ‘out-of-control’.

It’s been shown that it is not so much the severity of the crash, or injury that is important, but more, how that person perceives it. Children seem to do better than adults. It is interesting that a single counselling and debriefing session after a motor vehicle accident results in a worse outcome than if there has been no intervention.

In this picture I’ve contrasted a wild chaotic pattern in the background with regular square shapes attempting to illustrate the mental journey from the out-of-body sensation of the motor vehicle accident experience (It is happening. But it feels like it’s not happening to YOU) through injury, physical recovery, returning to the person they used to be, or possibly even a new updated person.

Chest 122; Anorexia

15 May
Chest 122 Anorexia C

Chest 122; Anorexia

The X-ray study for this picture comes from a girl with anorexia nervosa. The subject of anorexia has been widely discussed and there is a well formed philosophy around this condition. General opinion is that the anorectic is a person with seemingly contradictory beliefs. They believe they are too thin, they also believe they are too fat. There is a view that anorexia is a self-destructive act; the sufferer has a self-imposed death wish arising from a complex perception of body image.

A contrary philosophy has, however been put forward, arising from the link between food and pleasure. This opposite view is based on the consideration that it is a condition not just of the body, but also of the mind.

The reason people pay so much attention to eating is that it is a pleasure. Like addiction this pleasure drives a person to want to eat more. It could be claimed similarly; 1, pleasure derived from food is self-defeating because eating does not completely satisfy, and from each meal less pleasure is derived and 2, pleasure obtained is illusory because it depends on the body being in a disordered state – in hunger – and in need of repair.

Hunger is a physical condition and the enjoyment derived from eating and drinking (and also from sex) is a base pleasure that employs none of the higher faculties enjoyed by humans; cognition, abstract reasoning, and judgement.

Arising from the opinion that eating is merely a base (animal) need, voluntary starvation can be interpreted as an opposite, possibly even a superior, (human)  act. Extreme dieting could be explained as reaching for the very core of the human nature and starvation construed neither as mental illness nor “eating disorder”. On the contrary, in this way of thinking anorexia is a symptom of ordinary mortality, a viewpoint taken more seriously than usual; taken to its logical conclusion.

I do not adhere to this philosophy myself. It is however an interesting contrary point of view. It does not undermine the position that when a person with anorexia dies, that death is entirely avoidable. It does not take away from the distress of loved ones who find the death literally unbearable.

The picture includes quite prominently the image of the girl with two contrasting patterns arising from within her pulling in opposite directions.

Chest 121 A and B; Talc

6 May
Chest 121 A C

Chest 121 A: Talc

Chest 121 B C

Chest 121 B; Talc

I try not to publish more than one version of an image, although whilst going through the production of the picture it is tempting to save different renderings. In this instance I present two versions because they are so different and both appeal for different reasons. The only technical difference between them is a change in application of filters, but the outcome is strikingly different.

The chest X-ray in this image is a museum case of a man who suffered for years with recurrent pneumothorax, which is leakage of air into the chest cavity, causing the underlying lung to collapse. After several emergency admissions to hospital, they performed a procedure to prevent the lung collapsing by encouraging the lung to adhere to the chest wall known as pleurodesis. The pleura is the membrane that lines the chest cavity and can be stripped off in a major surgical procedure to make the layers stick together. However there are several non-surgical techniques for pleurodesis, all require induction of pleural inflammation. The method of choice at the time was to introduce talc; that is to puff finely ground talcum powder, into the chest cavity. This sets up a reaction and the two inflamed layers of pleura stick together.

This picture taken during a thorascopic procedure gives an idea of the talc as it flies into the chest cavity.

Thorascopic insufflation

Insufflation of talc thoroscopically. Image acknowledgement: http://www.wabipacademy.com/webcast/clinicalstem2/step39

On an X-ray talc is visible as a white line, or plaque, around the lung. The radiologist only sees what appears to be pleural calcification that can have several possible causes including industrial lung diseases like asbestosis, previous bleeding, and infections like tuberculosis. It can be difficult to choose between them by appearance alone. It’s crucial to get the diagnosis right for on-going medical management, so to make a right diagnosis the radiologist relies heavily on a good medical history from the referring physician.

Both images show the X-ray and the talc can be seen over the right lung. I have tried to represent both the flying dusty talc and inflammatory reaction on the pleural surface artistically.

Chest 120: Etched in stone

1 May
Chest 120 Stone

Chest 120; Etched in Stone

The Chest X-ray in this picture was from a man, an ex-smoker, who was losing weight, with a cough and localised wheeze in his chest. An area of density in the lung on the X-ray was obscured by blood vessels and it was determined as normal. Because the test was described as normal, clinical signs and symptoms were disregarded, no further tests were done, and the man presented months later with a large inoperable cancer. A court case followed.
A radiological diagnosis is not etched in stone. Over a long career I have been involved with many cases of physical child abuse, and for many of these been called as an expert witness in a trial of the accused abuser. It was during these trials where I discovered that medical evidence and legal evidence are two entirely different things.
Medical evidence is often fuzzy relying on statistical likelihood of a diagnosis based on imperfect criteria – sounds heard through a stethoscope, lumps palpated with the hand for example. The art of medicine is about management of uncertainty. Legal requirements on the other hand are for precisely defined points. Lawyers, and many doctors, treat a radiological image as hard, clearly defined evidence; the experience of my career tells me it is anything but!
Paradoxically, as imaging becomes more sophisticated and sensitive the importance of clinical judgement in deciding both when to order a test and to assess the clinical relevance of an abnormal finding on that test becomes more important. Real but incidental sub-clinical anatomical disorders such as normal developmental variants and degenerative changes that are not symptomatic are frequently detected. These types of changes are present in a large proportion of people with no symptoms. It is therefore important to know that a test should not be ordered unless it is likely to influence or change the treatment of a patient (although there are a few exceptions even to that rule).
Many types of errors creep into diagnosis, and it can sometimes be difficult to trust one’s own judgement. This phenomenon has been extensively studied, but the following example will serve to illustrate just one type of error in which the context determines interpretation. In the top line most people read A B C. However, exactly the same letter B when inserted into another context now reads as 13. In this type of framework the image itself can be treacherous.

ABC

Adapted from: Kahneman D. Thinking, Fast and Slow. Farrar Straus & Giroux, 201

The Belgian surrealist painter, whom I greatly admire, René Magritte’s painting of a pipe “Ceci n’est pas une pipe” whose correct name is “The treachery of images” has fascinated me since I began studying radiology. It is about the relationship of an object and a representation of that object.

Pipe
The word is not the thing; the map is not the territory (Alfred Korzybski). And so, the X-ray is not the patient. It is a well-known, but poorly understood , medical aphorism; “Treat the patient, not the X-ray”. And so it should be.

Shadows Beyond Illusion

22 Apr

SBI 2

This animation is prepared for an exhibition later in 2015. I’ve been allocated a small space in a gallery, an old bank – in fact the old vault – and will project this animation on the back wall with prints of my work on the side walls.

The video can be found on YouTube at:

https://www.youtube.com/watch?v=zX9zZ4Lo4cw

Although there is some drawing in this, instead of sketching entire sequence as with a previous animation (Morphomitosis;   https://www.youtube.com/watch?v=BOIVjuX6cBU ) short videos were fused in a similar way to those used in my digital artworks, juxtaposed with rotoscoped drawings, and a photo of graffiti taken from tags on a wall.

Before describing the work, I pay tribute in this film to the inspiration of two brilliant artists to whom I’m indebted; Yayoi Kusama and Zilvinas Kempinas.

The overall composition is a simplified version of the Sonata form in classical music: Introduction, Exposition (with two contrasting themes), Development, Capitulation (with resolution of the themes) and a Coda similar to the introduction.

SBI 1

It begins with water, ends with water, and includes fluoroscopic X-ray examination of a pair of lungs in motion, simply breathing.  A circle with a dot, an ancient symbol for the sun, or the metallic element gold, in scout tracking signs also represents the end of the trail – “I have gone home”. Life is a trail with a beginning, an end, and twists, turns, changes and bends along the way. Although movement in the work is generally localised and controlled, the sense of time changing is enhanced by an additional unexpected element, travelling through a forest; an external environment; trees, earth, rock flashing by.

SBI 3 IBS 4

Swaying natural eucalyptus branches echo diaphragmatic movement and contrast with Kasuma’s motionless, highly geometric dots. Kempina’s shimmering, ever-shifting stripes and lines, moving but going nowhere. Tension develops as lines and dots are juxtaposed. It resolves as the fleeting introduction of a shadowy human figure heralds a recession into sparkling water, breathing lungs, and an exit. The high-pitched sound backing of playing children’s voices changes to the gentle sound of a babbling brook.

SBI 6

SBI 7

I hope you will enjoy this animation, it is only the second time I’ve attempted an ambitious project like this, and although there are errors in execution, these have a certain naive charm and I’ve allowed them to remain.

Chest 119; Absent lung

9 Apr
Chest 118 Absent lung C

Chest 119; Absent lung

Occasionally, unfortunate babies are born with organs missing from their body. The technical term for this is agenesis of the organ. A rare example is lung (pulmonary agenesis) which is often associated with other malformations. The baby whose X-ray appears in this picture was born with the right lung absent. The left lung grew slowly over time to fill the space of both lungs and fortunately functioned close to normal.

In the early phases after birth, care of a child with severe congenital abnormality needs to be intensive. Over time, as the alveoli of the lungs multiply, the need for intensive care declines. It may take up to four years to allow a child to leave the continuous care of a hospital to be managed in the home environment. A big problem with long term hospitalisation for children is lack of educational care and socialisation (these services are highly variable; excellent in some places and poor in others). Educational and health care services can be disconnected impacting negatively on health and development of the children.

Such children with complex congenital abnormalities raise highly controversial philosophical issues;
– Should they be subject to maximal treatment despite the severity of their condition?
– Should they not be treated at all, especially where the prospect of survival is poor? This situation is already complicated because when those infants who have not been treated on the assumption that they will die sometimes survive, their prognosis is bleak, quality of life much poorer than if they had been treated in the first instance.
– Further, if a determination is to be made whether to treat or not, who should take the responsibility? – –  The physician? The parents? Responsible legal bodies? These are some of the hard questions faced by carers every day.

The image contains three chest X-rays from this baby superimposed on three predominantly blue pictures; sky, sky reflections and water reflections to provide texture and colour. The filters interact to give a melange of colours to excite the eye. I have also tried to give an impression of movement and growth using swatches taken from reflections on the water.

Chest 118; Asbestosis

20 Mar
Chest 118 asbestosis C

Chest 118; Asbestosis

The original chest X-ray comes from a man with calcification of his pleura (the membrane that lines the inside of the chest and surrounds the lungs) due to long term exposure to asbestos dust in the mines of Western Australia.
All forms of asbestos cause lung disease but the type that is most harmful is Crocidolite – Blue asbestos. The disease is usually due to inhaling fine asbestos fibres over a long period of time. People exposed in their workplace are most at risk but occasional incidental exposure can lead to malignant change.
When asbestos fibres are inhaled the tiny sharp needle-like crystals penetrate deeply into the lungs causing slow, chronic inflammatory reaction leading to fibrosis of the lungs. This makes the tissues stiff and the total volume shrinks. The affected person gets slow onset of shortness of breath and eventually respiratory failure. The pleura may calcify and is at risk of developing malignant tumours known as mesothelioma.
As a child living on a copper-mine in Zambia I liked collecting geological specimens and treasured a large piece of Crocidolite that I was given. I would demonstrate the fibrous nature of the rock by pulling strands off to show my friends and kept it on a shelf with my other rocks in my bedroom. Even though concerns about the dangers of asbestos had been known since the early 1930s, they weren’t generally recognised even in a mining community like ours. Asbestos wasn’t removed from production in Australia until the 1980s.
In this picture I have used a spray-painted graffiti style and mixed blue colours with scarlet to symbolise blue asbestos and the malignant scarlet beast – mesothelioma: So he carried me away in the spirit into the wilderness: and I saw a woman sit upon a scarlet beast, full of names of blasphemy, having seven heads and ten horns (Revelation 17:3)

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