Calling radiology for reads

[GadRads]

Recently an ER physician called and was pretty condescending when requesting CT reads on his patients, apparently because he wanted to keep things moving. If he/she had been in the reading room, he/she would have observed me reading a high volume of cases for 10+ hrs with no breaks to even drink water or barely use the restroom. We are usually working against the clock, sometimes reading at break neck speeds. We read several studies with inadequate or sometimes painfully misleading histories or indications, leading to chart reviews for simple pieces of clinical information that could have been provided. These calls are not helpful, they slow us down, are distracting and can lead to higher miss rates. We don't mind calls to provide more history as these help to improve the sensitivity, specificity, and overall quality of the read.

Of course if a patient is crashing or especially critical, we appreciate calls to prioritize that patient's read. For example calling about a patient with Hgb of 6, who we then prioritize and find an aortic transection. Unfortunately, these days, referrers stamp too many imaging requests as "STAT", for example, a tumor staging study, so this delays care for the truly urgent cases.

In summary, we are usually not sipping coffee and taking leisure strolls. Give us the time to properly read the study. It's better for everyone, especially the patient. And please provide a good history or indication, assuming of course you have seen the patient. Not uncommonly these days, the approach is to scan first and examine later.

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[docB]

I understand your frustration. Emergency physicians, more than most other specialties, have to deal with condescending colleagues. Sometimes the angst and irritation slips out when we don't even mean it to, as with your jab saying we don't see the patient before ordering tests. We certainly understand being under the clock. Sometimes watching what's unfolding in the ED heightens tension and makes us start reaching out to try to make sure everyone on the team understands the situation. When we're just ranting in the ED it's contained. Once that goes out over the phone it does get others wound up. Like going into another specialty forum to complain about that specialty. Some things are probably better kept within a like minded group. As far as the systems issues you mentioned like not getting enough history in the study requests and non urgent floor studies being ordered as STAT I suggest working with your admin to find solutions. In my shop we've fixed some of those problems by tweaking the EMR/Ordering system or just changing policy.
Good luck and I hope you feel better.

 

[VA Hopeful Dr]

I understand your frustration. Emergency physicians, more than most other specialties, have to deal with condescending colleagues. Sometimes the angst and irritation slips out when we don't even mean it to, as with your jab saying we don't see the patient before ordering tests. We certainly understand being under the clock. Sometimes watching what's unfolding in the ED heightens tension and makes us start reaching out to try to make sure everyone on the team understands the situation. When we're just ranting in the ED it's contained. Once that goes out over the phone it does get others wound up. Like going into another specialty forum to complain about that specialty. Some things are probably better kept within a like minded group. As far as the systems issues you mentioned like not getting enough history in the study requests and non urgent floor studies being ordered as STAT I suggest working with your admin to find solutions. In my shop we've fixed some of those problems by tweaking the EMR/Ordering system or just changing policy.
Good luck and I hope you feel better.

 

[maxxor]

A rads rotation or at least two weeks or something should be required in med school. My last rotation of med school was rads and it's no joke and how busy you can be with essentially zero pertinent clinical information. Essentially every CT that just says "pain" or "sob" or CT/CTA/MRI head/neck without any localizing info, etc. I have colleague that orders almost all his rads stat because he wants to go home. I physically confront them all the time about this, so I understand your frustration.

Agree with DocB, I would approach the ED medical director so they can remind EM docs and the NPPs on what's appropriate. Something our rads has been doing often is making a quick call to me and finding out more about their presentation, which I reallly enjoy and appreciate. Obviously uncommon, but it's helpful for both of us.

When I cover the ER, I use the Epic secure chat system heavily for this.

its super hard to call a specific ER doc and ain’t nobody got time to wait for the secretary to find you.

 

[Groove]

Recently an ER physician called and was pretty condescending when requesting CT reads on his patients, apparently because he wanted to keep things moving. If he/she had been in the reading room, he/she would have observed me reading a high volume of cases for 10+ hrs with no breaks to even drink water or barely use the restroom. We are usually working against the clock, sometimes reading at break neck speeds. We read several studies with inadequate or sometimes painfully misleading histories or indications, leading to chart reviews for simple pieces of clinical information that could have been provided. These calls are not helpful, they slow us down, are distracting and can lead to higher miss rates. We don't mind calls to provide more history as these help to improve the sensitivity, specificity, and overall quality of the read.

Of course if a patient is crashing or especially critical, we appreciate calls to prioritize that patient's read. For example calling about a patient with Hgb of 6, who we then prioritize and find an aortic transection. Unfortunately, these days, referrers stamp too many imaging requests as "STAT", for example, a tumor staging study, so this delays care for the truly urgent cases.

In summary, we are usually not sipping coffee and taking leisure strolls. Give us the time to properly read the study. It's better for everyone, especially the patient. And please provide a good history or indication, assuming of course you have seen the patient. Not uncommonly these days, the approach is to scan first and examine later.

Weird. I almost never see EPs routinely calling up a radiologist to rant, berate or condescend. Hospital specialty hierarchy just doesn't support that type of routine behavior. If anything, most of us are calling your CT tech to "pass along" or "remind you" about a CT that's taking forever. It's just incredibly rare for me to get on the phone with a radiologist directly and berate them about something. I can't ever think of that happening in my career or witnessing it for that matter. I suspect there was more to this case than you might be telling us. Are you a resident? It appears you were a senior resident last year. Is it your first year out? If so, are you taking longer to read than your more experienced colleagues? There would have to be some egregious delays for me to demand to speak with you over the phone in a manner in which you describe. It almost never happens in my experience.

If it's your first year out, don't worry about it. You'll probably get faster with time. Almost all of you guys that are newly graduated are a bit on the slow side for the first couple of years. You do make a good point about not enough context in the comments section regarding imaging orders that's worth passing along to your director to pass along in turn to the ED docs. I always try to provide adequate context in my order comments. I had a grizzled old radiologist tell me one time "Listen...you want poop? Just order the study with no comments. Poop in, poop out!"

 

[emergentmd]

The ER doc and what happened is just that one docs stressed/personality disorder. Just tell the guy that you are busy and just bug you if there is an emergency read needed and you would be glad to DROP EVERYTHING if patient care would be affected.

There are only two times I would ever call/go to radiology for a quick read.

#1 - I suspect something bad is happening and need a quick read to affect outcome.

And More importantly

#2 - I am about to go off shift and need a read to go home which I do respectfully which always comes across very well.

 

[southerndoc]

@docB summed it up well. The ER docs also are frequently running around thirsty and overworked. Heck, half the time I wait until my bladder is about to explode and I'm forced to go to the bathroom before I actually go. I sometimes feel like I need an IV of NS infusing and a Foley catheter for every shift.

On another note, I had to get the president of our radiology group involved to stop the stupid calls we were receiving for our new STATRAD designation for trauma alerts, super STAT CT's, etc. The clerks were calling for normal reports. One called and said she was required to read me the impression (as I was supervising a resident running a cardiac arrest). After she refused to listen to me that I didn't need her to read me the normal report with incidental findings, I finally just hung up on her.

Luckily we have a great relationship with our radiologists. We usually don't bother them unless we're worried about a patient. I agree that it distracts them from their methodical ways of reading a study, and if you take someone out of their routine, things get missed. I try to tell the residents not to bother them unless it's something that's urgent. Just because you're 30 minutes from going home doesn't mean you have a right to bug the radiologist for a quicker read.

The point about clinical history is a valid one. All physicians need to put in adequate history (right lower quadrant abdominal pain instead of just abdominal pain, right flank pain r/o stone, etc.).

Ultimately, we all want to do what is best for the patient.

 

[Kuratz]

From a Rad perspective in defense of the ED when the list is piling up and I’m cranking through studies I try to empathize that it also means the ED is getting destroyed, and frankly I think that’s a much more stressful job.

It can feel like the volume of work required of ED and Rad alike is not proportionate to our other colleagues and that can lead to frustration on both ends when **** hits the fan (spoken as a former surgery resident). We truly are a team and should try to help each other out accordingly.

I was incredibly impressed when an ED attending came to the reading room the other night to go over a case that was still in progress. Gave a quick wet read that there was a PE with heart strain and called IR together to get them to the angio suite asap. It was a nice gesture to physically come to the room that I greatly appreciated and gave me a bit more satisfaction that I played a small role in the patients care. I’m bummed that even the 10 minutes it takes to do that is not realistic for referring clinicians because it builds some “in the trenches together” mentality at 2am.

ED isn’t the problem. Even the extremely low pre-test probability studies that everyone knows will be negative serve a role to get the patient out the door. I try to keep that in mind.

 

[The Knife & Gun Club]

I’m sorry you got treated poorly by one of our ED colleagues. I’ve worked with people who hammer call rads and I think it’s a really bad look to not play nice in the sandbox with the other kids. Most of us our immensely appreciative of what y’all do and personally am consistently impressed with what you all are able to pick up on a read that I would’ve missed every time, or worse not even considered.

Personally I think a call to rads is appropriate if there’s a critical patient who needs one aspect of their scan quickly interpreted to help me determine what the heck I need to do to start the process of making them not die. Like making sure there’s not a dissection flap I’m missing or something.

On the flip side - what sort of thing is particularly helpful to you all in the comment box? Sometimes I have no idea what I’m looking for, just know they’re sick...but that’s bad form to write that in the comments.

 

[Rekt]

I’m sorry you got treated poorly by one of our ED colleagues. I’ve worked with people who hammer call rads and I think it’s a really bad look to not play nice in the sandbox with the other kids. Most of us our immensely appreciative of what y’all do and personally am consistently impressed with what you all are able to pick up on a read that I would’ve missed every time, or worse not even considered.

Personally I think a call to rads is appropriate if there’s a critical patient who needs one aspect of their scan quickly interpreted to help me determine what the heck I need to do to start the process of making them not die. Like making sure there’s not a dissection flap I’m missing or something.

On the flip side - what sort of thing is particularly helpful to you all in the comment box? Sometimes I have no idea what I’m looking for, just know they’re sick...but that’s bad form to write that in the comments.

I mean, you should at least have some idea? If I have a sick sepsis without a clear source, I don't send them upstairs without a CT a/p and I write that.

 

[dadaddadaBATMAN]

Only reason I call on studies that take a while is that sometimes the study got shunted to a purgatory between the techs cpu system and pacs. Or someone opened the read, got distracted by the clink of gold doubloons in the dark, and then started reading other studies without picking it back up. I’m usually polite about this, I just wanna know it’s in the queue.

As to the resident mention of what to write when you’re ordering a ct ap on a sick undifferentiated person:

Ams, fever, no obvious source based on limited hx. Eval for atypical presentation of appendicitis, cholecystitis, colitis, or other source of infection/abscess. It’s a somewhat crappy indication but that’s probably the question you’re asking.

Or hypotension, ams, limited collateral with diaphoresis. Eval for perforation, aaa, ischemia or obvious source of infection. Again vague but at least clue someone in for the type of thing you want them to look at closely rather than let it get lost in a sea of bull**** abdominal cts. It also says “hey look at this one close something ain’t right”.

Disclaimer: Ed doc, scourge of radiologists, caller of phones

 

[Tenk]

I’m pretty good friends with one of our radiologists so I just text him memes instead.

 

[gutonc]

I am not in EM, or Rads, but have a very similar approach to both when I need to call them, or they call me....

"Here's what I know, here's what I don't. Thanks for your help, call me if you need more/I'll call you if I need more."

It's incredibly common sense and basic human kindness. And it makes it easier for me to sleep at night, while you all are looking out for my folks who decided not to call at 11am when things went pear shaped, but showed up in the ER at 2am because they felt bad.

 

[GeneralVeers]

I only call the radiologist when they've missed something.
For anything ultra-stat I read my own. Any ICH, Aortic problem, or acute stroke I look at my own images and make decisions. Even clear-cut appendicitis I have the surgeon paged before the radiologist calls back.

 

[The Knife & Gun Club]

I mean, you should at least have some idea? If I have a sick sepsis without a clear source, I don't send them upstairs without a CT a/p and I write that.

Yea it’s rare but comes up. It’s not uncommon for us to wait 3-4 hours for Med reads at our county site if we’re slammed with traumas. And eventually you need an idea of what’s up to appropriately dispo the patient.

Came up the other day with a dude who was spiking fevers, looked like crap, pan positive on HPI, and was just the tiniest bit altered.

I wanted to know if there was an intrabdominal focus of infection I was missing or if this was someone I was gonna have to break out my big boy meningitis antibiotics + LP. Because one goes to MICU and the other goes to surgery.

Well in the end it turned out he had COVID but you get my point.

 

[GadRads]

Nice to see the positive comments. I understand that ERs are busy and you guys have to see a lot of patients per shift. Just wanted to emphasize that we are also busy as well. If you guys are slammed, then we are also slammed, so there might be a delay in turn around times.

Also I’m not slow by any means. I would say I’m average in reading speed. I could probably read faster, but the fear of missing something significant tempers that tendency.

Also appreciate when I’m able to talk to an ER attending about a patient The MDs usually understand the significance of a finding, but not infrequently I have to explain some rather basic things to PAs/NPs. Seems I’m talking to more midlevels than is typical.

 

[Apollyon]

I only call the radiologist when they've missed something.

"There's a fine line between balls and stupidity". You really think you're as good as a radiologist all the time? Your risk tolerance is much more robust than mine.

 

[GeneralVeers]

"There's a fine line between balls and stupidity". You really think you're as good as a radiologist all the time? Your risk tolerance is much more robust than mine.

I'm not sure what you mean.....if the patient clearly has something emergent like a ruptured AAA, or SDH, why wait for the radiologist read to call the specialist? If an EP can't pick up these critical diagnoses on their own, then there's a problem.

Also about once a month I pick up a fracture, PTX, or something else the radiologist missed. I call and politely ask them to take another look at it.

 

[Apollyon]

I'm not sure what you mean.....if the patient clearly has something emergent like a ruptured AAA, or SDH, why wait for the radiologist read to call the specialist? If an EP can't pick up these critical diagnoses on their own, then there's a problem.

Also about once a month I pick up a fracture, PTX, or something else the radiologist missed. I call and politely ask them to take another look at it.

You make it sound like you are superior to radiologists - you find things they miss, and you find things on CT, for stroke, for example, when the rads (who are trained experts) don't find things, what is it, half the time?

And, if your rads folks are missing those findings monthly, then, you have some really weak rads.

I can't find the appt on a CT. I freely admit that. Stranding, edema? I was never trained on that, and I've never picked up seeing them. If you are that good, quite frankly and honestly, you can monetize that, and forget working in the pit.

I recall a rads resident during conference who said, about a CT, when pointing out free air, "that's big enough to get sued for". The best mistake is the one I don't make.

Edit: I'm not hammering on you. I just do NOT have your skill, or confidence.

 

[GeneralVeers]

You make it sound like you are superior to radiologists - you find things they miss, and you find things on CT, for stroke, for example, when the rads (who are trained experts) don't find things, what is it, half the time?

And, if your rads folks are missing those findings monthly, then, you have some really weak rads.

I can't find the appt on a CT. I freely admit that. Stranding, edema? I was never trained on that, and I've never picked up seeing them. If you are that good, quite frankly and honestly, you can monetize that, and forget working in the pit.

I recall a rads resident during conference who said, about a CT, when pointing out free air, "that's big enough to get sued for". The best mistake is the one I don't make.

Edit: I'm not hammering on you. I just do NOT have your skill, or confidence.

I look at every CT and X-ray that is done on my patients, then correlate with the radiologist read. The vast majority are negative studies, I have to wait for the radiologist to confirm a negative study. I never act on a NEGATIVE study because there are subtleties to be missed. You don't look at your own CT scans when you suspect life-threating ICH, traumatic injury or aortic rupture? I'm not comfortable waiting the 45 min - 1 hour for these studies to be read to diagnose a life-threatening injury.

There are a lot of more rural EDs out there where you don't get radiologists reading real time X-rays and have to do all of your own wet reads. I've worked in many of these.

 

[Apollyon]

I look at every CT and X-ray that is done on my patients, then correlate with the radiologist read. The vast majority are negative studies, I have to wait for the radiologist to confirm a negative study. I never act on a NEGATIVE study because there are subtleties to be missed. You don't look at your own CT scans when you suspect life-threating ICH, traumatic injury or aortic rupture? I'm not comfortable waiting the 45 min - 1 hour for these studies to be read to diagnose a life-threatening injury.

There are a lot of more rural EDs out there where you don't get radiologists reading real time X-rays and have to do all of your own wet reads. I've worked in many of these.

I look at them, but, I'm leery about calling them negative.

The black and white are obvious. The grey in between, that's the thing.

Again, not hammering on you.

 

[GeneralVeers]

I look at them, but, I'm leery about calling them negative.

The black and white are obvious. The grey in between, that's the thing.

Again, not hammering on you.

You misunderstand me. I don't call them negative. I call them positive and act on those. Exception is for CT head when giving TPA.

 

[SirGecko]

As to the resident mention of what to write when you’re ordering a ct ap on a sick undifferentiated person:

Ams, fever, no obvious source based on limited hx. Eval for atypical presentation of appendicitis, cholecystitis, colitis, or other source of infection/abscess. It’s a somewhat crappy indication but that’s probably the question you’re asking.

Or hypotension, ams, limited collateral with diaphoresis. Eval for perforation, aaa, ischemia or obvious source of infection. Again vague but at least clue someone in for the type of thing you want them to look at closely rather than let it get lost in a sea of bull**** abdominal cts. It also says “hey look at this one close something ain’t right”.

Actually I would say you can curtail the order even more than that. Vague indications are OK as long as they aren't so vague that you can't tell if its vague because the clinical scenario is nonspecific or if its vague because someone along the line didn't want to (or couldn't) put in an actual indication. The important part is saying what is making you order the study. So for example your first indication is great (way better than most) but if you truly don't have anything pointing you in a specific direction you probably don't even need the list of possible etiologies there because we look for that on everyone. So instead it could just say "AMS, fever without obvious source." That's actually enough to be an OK indication, particularly if you have already written something in the EMR and this is easily accessible. It says why you are ordering the study and is obviously not just some filler put in by a clerk.

Unfortunately though I think *most* doctors (I'd say all but I still sometimes see people express surprise that this is such a big issue to us) know that actual indications are important but a lot of the time its more systemic issues that prevent good transfer of information. For example my hospital has a terrible system for ordering in the ED where the ED doc puts an order in one EMR, a clerk then orders it in a second EMR. This results in most indications not actually getting transferred over because the clerk just types the "reason for visit" that they see on the status board instead of the actual indication given by the ordering physician.

 

[southerndoc]

I also review nearly all of my CT's and x-rays. I won't say all, because sometimes our radiologists are very quick. If there is even a decent amount of clinical suspicion, I'll look. If radiology has read it before I get the time to look at something I ordered for defensive medicine (low back pain x-ray for some weird reason), then I may not look at it. Of course, there are times when it's busy and you don't have the chance to look at something.

I frequently have already discussed with neurosurgery for the SDH before the radiologist even calls.

 

[docB]

I try to look at all my studies too but I admit when I get backed up I don't get to all of them. I do sometimes find stuff the rads miss but only because I know exactly where to look and what to look for based on the H&P.

 

[Groove]

Nice to see the positive comments. I understand that ERs are busy and you guys have to see a lot of patients per shift. Just wanted to emphasize that we are also busy as well. If you guys are slammed, then we are also slammed, so there might be a delay in turn around times.

Also I’m not slow by any means. I would say I’m average in reading speed. I could probably read faster, but the fear of missing something significant tempers that tendency.

Also appreciate when I’m able to talk to an ER attending about a patient The MDs usually understand the significance of a finding, but not infrequently I have to explain some rather basic things to PAs/NPs. Seems I’m talking to more midlevels than is typical.

Well, trust me when I say we appreciate all you do. After all, we couldn't do our job without you. Feel free to call us up to discuss a pt as long as it doesn't slow you down too much. I had an old radiologist that loved to call me up and discuss cases. I learned quite a bit and still remember him showing me hypoattentuation in globus pallidus on a head CT that was characteristic for carbon monoxide poisoning. Another one was thyroid associated orbitopathy. I loved that guy, lol.

 

[johnohn]

I only call the radiologist when they've missed something.
For anything ultra-stat I read my own. Any ICH, Aortic problem, or acute stroke I look at my own images and make decisions. Even clear-cut appendicitis I have the surgeon paged before the radiologist calls back.

Humble brag

 

[GeneralVeers]

Humble brag

As I said they have to be clear cut. I can see some appendicitis, but not all. ED physicians should be able to see any significant SDH or SAH on a head CT.

 

[Siggy]

"There's a fine line between balls and stupidity". You really think you're as good as a radiologist all the time? Your risk tolerance is much more robust than mine.

I generally only call if they missed something, there's something that just looks odd that I need clarified, or if I caught a critical finding before them (they're going to call anyways, so I might as well beat them to the punch).

I mean... do you routinely call to chit chat about normal findings? If they missed something then they should amend their report to include it. If I'm missing something on one of my patients and the hospitalist or other specialist calls to clarify treatment plans, I don't think that they're thinking they pulled one over on the intensivist. Same way I doubt that the ID guys think I'm flexing on them when I text about a culture result and antibiotic clarification that came in after they rounded.

 

[GadRads]

Radiologists read a high volume of cases routinely, and even more on call. The volume, pace, and inadequate/misleading history can lead to misses. This doesn’t happen often. That said, most radiologists appreciate the feedback. No one is infallible.

 

[CoolDoc1729]

Over the weekend I called because they said a male patient had a normal uterus and ovaries. Who knows nowadays, so I looked at the scan to make sure “he” didn’t before I called the teleradiology service. I truly only called to make sure they had looked at the right persons CT... then got a kind of snide re-read “asked to re report on CT due to report of uterus and ovaries, patient is male, uterus and ovaries not present”. You can’t make it up.

 

[docB]

Over the weekend I called because they said a male patient had a normal uterus and ovaries. Who knows nowadays, so I looked at the scan to make sure “he” didn’t before I called the teleradiology service. I truly only called to make sure they had looked at the right persons CT... then got a kind of snide re-read “asked to re report on CT due to report of uterus and ovaries, patient is male, uterus and ovaries not present”. You can’t make it up.

I've gotten "No central PE, no pulmonary infiltrates" on a CT head before. While technically correct I'm gonna call.

This raises an interesting issue in terms of trans patients. My system's policy, and most systems to my understanding, is that the patient's identified gender is what goes in the chart. This can clearly cause some issues, for example a patient who identifies as male but is pregnant and is scanned without a pregnancy test. My EMR places a small icon (ℹ️) next to the gender when the biological gender is not the same. I don't think any of that crosses over to PACS or the radiology ordering system. That means the radiologist is in the dark 😉 as to the patient's biological gender.

 

[The Knife & Gun Club]

I've gotten "No central PE, no pulmonary infiltrates" on a CT head before. While technically correct I'm gonna call.

This raises an interesting issue in terms of trans patients. My system's policy, and most systems to my understanding, is that the patient's identified gender is what goes in the chart. This can clearly cause some issues, for example a patient who identifies as male but is pregnant and is scanned without a pregnancy test. My EMR places a small icon (ℹ️) next to the gender when the biological gender is not the same. I don't think any of that crosses over to PACS or the radiology ordering system. That means the radiologist is in the dark 😉 as to the patient's biological gender.

Had a guy/lady the other day who was born male, transitioned to female, and then transitioned back to male, and was now at age 65 was transitioning back to female for the second time, however had already had the M—>F surgery, and then an attempted revision back from F—>M.

Rads resident called me to ask “Hey um, what’s like, going on with their pelvic anatomy?”

 

[SirGecko]

Over the weekend I called because they said a male patient had a normal uterus and ovaries. Who knows nowadays, so I looked at the scan to make sure “he” didn’t before I called the teleradiology service. I truly only called to make sure they had looked at the right persons CT... then got a kind of snide re-read “asked to re report on CT due to report of uterus and ovaries, patient is male, uterus and ovaries not present”. You can’t make it up.

I mean it’s obviously a templating error (I always use gender neutral templates for this specific reason) so appropriate to let them know the error got through. However why do you think that addendum is “snide”? I can’t think of how I would word it differently. They said that it was brought to their attention by you, that there was an error and they corrected it. Where in there are you getting a snide tone? How would you have worded it differently? (Honest question, I’d hate to think if I wrote that addendum that I was coming across as snide and would like to avoid that)

 

[CoolDoc1729]

I mean it’s obviously a templating error (I always use gender neutral templates for this specific reason) so appropriate to let them know the error got through. However why do you think that addendum is “snide”? I can’t think of how I would word it differently. They said that it was brought to their attention by you, that there was an error and they corrected it. Where in there are you getting a snide tone? How would you have worded it differently? (Honest question, I’d hate to think if I wrote that addendum that I was coming across as snide and would like to avoid that)

I don’t know .. maybe it wasn’t and I was just frustrated ... it took me like 8 minutes on the phone to get the telerad receptionist to understand the problem and then that radiologist had stopped reading for the night so the receptionist said the later one “wouldn’t want to read it” and we went back and forth a bit before she agreed to at least ask him, and then it was fine. I’ve talked to that particular telerad guy a million times and he’s super nice and professional. I would have settled for speaking to the original radiologist as I truly just wanted to make sure he’d looked at the right person’s images. But now there’s this ridiculous oddity in the patients chart forever ..

 

[thegenius]

I look at them, but, I'm leery about calling them negative.

The black and white are obvious. The grey in between, that's the thing.

Again, not hammering on you.

I'll say it's pretty rare that I look at an xray or CT, and possibly even an MRI, and I think it's negative...and I've missed a life threatening problem. I think you're making a big deal here Apollyon.

I miss things all the time on imaging but it's no biggie as the radiologist will say there is an appy, or pneumonia, or a broken bone, or whatever. Nobody is going to die from an appy that's been sitting around for 1 hr waiting for the rads read.

 

[thegenius]

Had a guy/lady the other day who was born male, transitioned to female, and then transitioned back to male, and was now at age 65 was transitioning back to female for the second time, however had already had the M—>F surgery, and then an attempted revision back from F—>M.

Rads resident called me to ask “Hey um, what’s like, going on with their pelvic anatomy?”

LMAO

 

[GeneralVeers]

I just don't think the medical chart is the place to be hashing out the Trans Identity War. It's irrelevant to me what they identify as. I still need to know if they are biologically male or female so I can get a pregnancy test, or order the appropriate US for the right genitalia.

 

[Tipsy McStagger]

One thing that really opened my eyes to the reality of Radiology on the overnights was our joint conferences. In residency we had a monthly conference with the Radiology residency that was a lot of fun. EM would present a few cases, discuss the clinical aspects and our challenges. Radiology would go over the images, talk about imaging options and important critical findings, and go a bit more in-depth in the reads for our education as well. They learned more about what it was actually like in the ED, and we learned the same for them in turn.

What I learned once I became closer with the Radiology residents, was that overnight they were just as busy as we were, just in a different way. They had to do the reads for 4-5 hospital systems including ours, it was 1 resident and 1 staff (and the resident was expected to read everything - just as we as EM residents were expected to see everyone). They also had to do any procedures that came up. So if I'm asking them to do a hip aspiration, intussusception reduction etc, then they have to stop reading and do the procedure. Analogous to me having to take time to repair a complicated pediatric facial laceration. I have to manage the sedation and do the repair. When I'm finished there's 20 more patients that have checked in. It's the same for them, the readings pile up while they're doing these procedures. I go into a room where a patient is yelling at me for waiting so long, they're getting calls from physicians demanding to know why it's taking so long to get reads. We're not so different.

The actual work is obviously different, but I think we have a lot more in common than we realize. Ultimately everyone is stressed, and instead of channeling our feelings towards management for more appropriate staffing, we target each other. We are all peasants, kept in servitude by our lords' ability to keep us from learning to read and organize against them. We keep ourselves in check by constantly belittling each other, when really we have far more in common with each other than we do with anyone else in healthcare. If physicians ever learned to put ego aside, be willing to understand that everyone else is just as busy and stressed as you are, and empathize with each other instead of criticizing each other, we'd really be able to change health care in this country. I'm not holding my breath...

 

[lucid_leprechaun]

One thing that really opened my eyes to the reality of Radiology on the overnights was our joint conferences. In residency we had a monthly conference with the Radiology residency that was a lot of fun. EM would present a few cases, discuss the clinical aspects and our challenges. Radiology would go over the images, talk about imaging options and important critical findings, and go a bit more in-depth in the reads for our education as well. They learned more about what it was actually like in the ED, and we learned the same for them in turn.

What I learned once I became closer with the Radiology residents, was that overnight they were just as busy as we were, just in a different way. They had to do the reads for 4-5 hospital systems including ours, it was 1 resident and 1 staff (and the resident was expected to read everything - just as we as EM residents were expected to see everyone). They also had to do any procedures that came up. So if I'm asking them to do a hip aspiration, intussusception reduction etc, then they have to stop reading and do the procedure. Analogous to me having to take time to repair a complicated pediatric facial laceration. I have to manage the sedation and do the repair. When I'm finished there's 20 more patients that have checked in. It's the same for them, the readings pile up while they're doing these procedures. I go into a room where a patient is yelling at me for waiting so long, they're getting calls from physicians demanding to know why it's taking so long to get reads. We're not so different.

The actual work is obviously different, but I think we have a lot more in common than we realize. Ultimately everyone is stressed, and instead of channeling our feelings towards management for more appropriate staffing, we target each other. We are all peasants, kept in servitude by our lords' ability to keep us from learning to read and organize against them. We keep ourselves in check by constantly belittling each other, when really we have far more in common with each other than we do with anyone else in healthcare. If physicians ever learned to put ego aside, be willing to understand that everyone else is just as busy and stressed as you are, and empathize with each other instead of criticizing each other, we'd really be able to change health care in this country. I'm not holding my breath...

It’s always tough, and anyone who’s been doing this long knows we all miss stuff. More reason to look at your own imaging, you know what you’re looking for. All the emergency things you spot sooner.

 

[qwerty89]

Over the weekend I called because they said a male patient had a normal uterus and ovaries. Who knows nowadays, so I looked at the scan to make sure “he” didn’t before I called the teleradiology service. I truly only called to make sure they had looked at the right persons CT... then got a kind of snide re-read “asked to re report on CT due to report of uterus and ovaries, patient is male, uterus and ovaries not present”. You can’t make it up.

Probably a template with structured reporting.

 

[n2b8me]

My number one consultant from the ER without doubt is the Radiologist. I'm consulting them on like every other patient in the ER. I have to interpret all my lab results, but the Radiologist interprets all these crazy x-rays I'm ordering. Thank you Radiology! You do god's work in my book!

 

[DoctwoB]

Yea it’s rare but comes up. It’s not uncommon for us to wait 3-4 hours for Med reads at our county site if we’re slammed with traumas. And eventually you need an idea of what’s up to appropriately dispo the patient.

Came up the other day with a dude who was spiking fevers, looked like crap, pan positive on HPI, and was just the tiniest bit altered.

I wanted to know if there was an intrabdominal focus of infection I was missing or if this was someone I was gonna have to break out my big boy meningitis antibiotics + LP. Because one goes to MICU and the other goes to surgery.

Well in the end it turned out he had COVID but you get my point.

Random aside. As a Uro one of my pet peeves is patients admitted for presumed. urosepsis with no imaging. Because urosepsis plus hydro or stone = emergent stent or neph tube. Urosepsis without hydro = Antibiotics and supportive care.

 

[southerndoc]

Random aside. As a Uro one of my pet peeves is patients admitted for presumed. urosepsis with no imaging. Because urosepsis plus hydro or stone = emergent stent or neph tube. Urosepsis without hydro = Antibiotics and supportive care.

If they have unilateral pain with UTI, yea, I agree they need imaging. If they have bilateral pain with a UTI, then it's pyelo 99% of the time. It's a waste of CT utilization to routinely image every pyelonephritis.

On another note, it took radiology 90 minutes to read the CTA with runoffs yesterday. 10 minutes after CT, I looked through it, saw the right popliteal aneurysm with thrombosis, started heparin and texted vascular surgery. It always helps to look at your images when you have a concerning patient because radiology can get backed up during all the crazy volume fluctuations.

 

[turkeyjerky]

Random aside. As a Uro one of my pet peeves is patients admitted for presumed. urosepsis with no imaging. Because urosepsis plus hydro or stone = emergent stent or neph tube. Urosepsis without hydro = Antibiotics and supportive care.

A decent number of patient's w/ pyelo have some mild hydronephrosis on imaging, without a stone visualized, do these patients require decompression as well?

If they have unilateral pain with UTI, yea, I agree they need imaging. If they have bilateral pain with a UTI, then it's pyelo 99% of the time. It's a waste of CT utilization to routinely image every pyelonephritis.

How about sick or old patients with pyelo merit imaging? (this will represent most patients admitted). I don't image young patients with pyelo who are going home.

 

[DoctwoB]

If they have unilateral pain with UTI, yea, I agree they need imaging. If they have bilateral pain with a UTI, then it's pyelo 99% of the time. It's a waste of CT utilization to routinely image every pyelonephritis.

On another note, it took radiology 90 minutes to read the CTA with runoffs yesterday. 10 minutes after CT, I looked through it, saw the right popliteal aneurysm with thrombosis, started heparin and texted vascular surgery. It always helps to look at your images when you have a concerning patient because radiology can get backed up during all the crazy volume fluctuations.

If it is uncomplicated pyelo then sure, no imaging. But in a truly septic patients, 1/3 will have an actionable upper tract problem (stone, hydro, mass, etc). 1/3 chance of missing a surgical issue is far too high to omit imaging

The role of imaging of the urinary tract in patients with urosepsis

The aim of this study was to provide recommendations for imaging of patients with urosepsis in order to detect urological complications that need inte…

www.sciencedirect.com

 

[DoctwoB]

A decent number of patient's w/ pyelo have some mild hydronephrosis on imaging, without a stone visualized, do these patients require decompression as well?


How about sick or old patients with pyelo merit imaging? (this will represent most patients admitted). I don't image young patients with pyelo who are going home.

It would depend. Mild hydronephrosis is actually relatively uncommon. Many of those are actually an extra-renal pelvis, not hydronephrosis (differentiated by whether the calyxes are dilated or just a big renal pelvis). Other times it can be due to reflux in the setting of a distended bladder. But if someone has pyelo and mild true hydronephrosis, I would consider decompression based on the clinical parameters. If they are actually sick then I would, since a stent has almost no risk and lack of adequate source control has a lot of risk.

The frail old patient with pyelo I would have a low threshold to image. If they just have fever or UTI with flank pain (or the ubiquitous change in mental state with fall that is instantly blamed on UTI) without other vital sign derangement then I would let it be. But the tachycardic/hypotensive (even if responding to resuscitation) patient I would image. You can also incorporate the patient into it, if they're a frequent flyer with no stone history who has gotten a dozen CTs in the past couple years then I think the yield is very low. If they're unknown to you or have a stone history definitely image.

 

[southerndoc]

If it is uncomplicated pyelo then sure, no imaging. But in a truly septic patients, 1/3 will have an actionable upper tract problem (stone, hydro, mass, etc). 1/3 chance of missing a surgical issue is far too high to omit imaging

The role of imaging of the urinary tract in patients with urosepsis

The aim of this study was to provide recommendations for imaging of patients with urosepsis in order to detect urological complications that need inte…

www.sciencedirect.com

If they have severe sepsis/septic shock, then sure. Just sepsis? No. 2 SIRS + infection = sepsis. They have to have a lactate >2 or hypotension before I start imaging pyelo without unilateral pain.

The abstract you quote doesn't say a 1/3 will have an actionable upper tract problem. A 1/3 aren't getting procedures. They might have hydro, but how many are going to IR to get a nephrostomy tube? Sounds like only 6% had stones. That's way less than 33%.

 

[dadaddadaBATMAN]

It would depend. Mild hydronephrosis is actually relatively uncommon. Many of those are actually an extra-renal pelvis, not hydronephrosis (differentiated by whether the calyxes are dilated or just a big renal pelvis). Other times it can be due to reflux in the setting of a distended bladder. But if someone has pyelo and mild true hydronephrosis, I would consider decompression based on the clinical parameters. If they are actually sick then I would, since a stent has almost no risk and lack of adequate source control has a lot of risk.

The frail old patient with pyelo I would have a low threshold to image. If they just have fever or UTI with flank pain (or the ubiquitous change in mental state with fall that is instantly blamed on UTI) without other vital sign derangement then I would let it be. But the tachycardic/hypotensive (even if responding to resuscitation) patient I would image. You can also incorporate the patient into it, if they're a frequent flyer with no stone history who has gotten a dozen CTs in the past couple years then I think the yield is very low. If they're unknown to you or have a stone history definitely image.

I think that in general the population you’re describing (old, altered, +\-“septic”, no clear source) should be imaged because the physical exam is useless on them.

Altered old people without a clear source of infection merit a ct a/p in my mind, because a significant portion of them will have ischemic bowel, gangrenous cholecystitis, bowel obstruction from metastatic cancer, etc.

I guess I can add obstructive stones to that list, but it’s one of like twenty other things I’m looking for in my scan.

It seems ubiquitous to order a ct head on these folks even without trauma or blood thinner use (I don’t disagree with this, but I think I’ve only seen a sdh in like 1/100 of these scans and something that actually changes definitive management in like 1/1000), but I agree it’s frustrating how often the abdomen is skipped

 

[DoctwoB]

If they have severe sepsis/septic shock, then sure. Just sepsis? No. 2 SIRS + infection = sepsis. They have to have a lactate >2 or hypotension before I start imaging pyelo without unilateral pain.

The abstract you quote doesn't say a 1/3 will have an actionable upper tract problem. A 1/3 aren't getting procedures. They might have hydro, but how many are going to IR to get a nephrostomy tube? Sounds like only 6% had stones. That's way less than 33%.

Hydro in the setting of sepsis is quite concerning and not always due to a stone. UPJ obstructions, ureteral stricture, obstructive mass are some of the other causes, and all would require decompression in the setting of acute illness. But whether is 10% or 30%, what is an acceptable rate of failed source control for you? Especially since an ultrasound has 0 risk and if they're ill enough to require admission won't affect your dispo.

I agree that using 2 SIRS criteria + UTI is overly stringent, but thats where your clinical judgement comes into play. 20 year old female with fever and HR of 105 (while febrile) is technically septic but I wouldn't image. 60 year old with tachycardia and hypotension of suspected urinary origin should be imaged. Basically if you're considering the unit they should have abdominal imaging. I've seen patients basically dying in the unit from urosepsis with no imaging. Step 1 is source control, and without imaging you're just assuming you have that with antibiotics alone.