Calling radiology for reads

[southerndoc]

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.

I agree with some of your points, but this can also be done in the ICU and not necessarily in the ER especially if you're talking about ultrasound which is portable.

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[Avalanche19]

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.

Thank you. I appreciate you saying that.

 

[docB]

This is an interesting discussion. I've been scratching my head lately because whenever I admit a pyelo the IM residents ask "Is it verified on imaging?" I keep asking them if they've been taught that pyelo has some specific imaging findings and then they don't really know. It sounds like what they're really trying to ask is "Has hydro or obstruction been ruled out by imaging?" That would be a more rigorously correct question.

I'll be honest, I don't image every elderly female pyelo I admit. I generally do with men because of the likelihood of retention due to BPH. But as someone who trained in the era of 16 slice scanners (better than holding the patient up to a bright light, but not much), I'm willing to start.

 

[GeneralVeers]

This is an interesting discussion. I've been scratching my head lately because whenever I admit a pyelo the IM residents ask "Is it verified on imaging?" I keep asking them if they've been taught that pyelo has some specific imaging findings and then they don't really know. It sounds like what they're really trying to ask is "Has hydro or obstruction been ruled out by imaging?" That would be a more rigorously correct question.

I'll be honest, I don't image every elderly female pyelo I admit. I generally do with men because of the likelihood of retention due to BPH. But as someone who trained in the era of 16 slice scanners (better than holding the patient up to a bright light, but not much), I'm willing to start.

Agreed, I don't usually image if pyelonephritis and pain is bilateral, or mild. Severe pain gets a stone to rule out a scan.

 

[SirGecko]

This is an interesting discussion. I've been scratching my head lately because whenever I admit a pyelo the IM residents ask "Is it verified on imaging?" I keep asking them if they've been taught that pyelo has some specific imaging findings and then they don't really know. It sounds like what they're really trying to ask is "Has hydro or obstruction been ruled out by imaging?" That would be a more rigorously correct question.

I'll be honest, I don't image every elderly female pyelo I admit. I generally do with men because of the likelihood of retention due to BPH. But as someone who trained in the era of 16 slice scanners (better than holding the patient up to a bright light, but not much), I'm willing to start.

I actually think the residents you are asking might not know why they are questioning if a ct has been ordered. A lot of people just get into a default of thinking everything needs imaging, especially when they are busy or aren’t confident. The junior medicine resident managing the floor on his own for the first time would rather be not be yelled at for not having a study done and most of the time he’s not going to get yelled at for a patient having an unnecessary test in the ER.

Honestly I think appropriate use of imaging is probably one of the greatest arguments for people always looking at the scans they order. (I think this is a great practice as long as you are also always following up on the read) If you actually try to interpret the imaging you get a better picture of what you can and cannot reasonably expect us to say about a study.

 

[maxxor]

I actually think the residents you are asking might not know why they are questioning if a ct has been ordered. A lot of people just get into a default of thinking everything needs imaging, especially when they are busy or aren’t confident. The junior medicine resident managing the floor on his own for the first time would rather be not be yelled at for not having a study done and most of the time he’s not going to get yelled at for a patient having an unnecessary test in the ER.

Honestly I think appropriate use of imaging is probably one of the greatest arguments for people always looking at the scans they order. (I think this is a great practice as long as you are also always following up on the read) If you actually try to interpret the imaging you get a better picture of what you can and cannot reasonably expect us to say about a study.

It’s also possible some IM qbank or ward handbook has out of date information on pyelonephritis, which is why they are all asking this question.

Before I started in Radiology, I too asked some nonsensical imaging questions because it was in either the UCSF house staff manual or MGH handbook of internal medicine.

 

[SirGecko]

It’s also possible some IM qbank or ward handbook has out of date information on pyelonephritis, which is why they are all asking this question.

Before I started in Radiology, I too asked some nonsensical imaging questions because it was in either the UCSF house staff manual or MGH handbook of internal medicine.

Oh yeah, definitely. Out of date information is also how we get stuff like shellfish allergy listed as allergy to contrast (can’t believe there are still people that learn that one in school but they do) or people insisting on the “spiral” ct for a PE protocol.

edit: oh and to be clear I’m sure I have said things that are wrong due to outdated information as well. It’s something that plagues everyone. When I encounter it I try to be as nonjudgmental as I can if I attempt to correct someone. (Glass houses and all)

 

[southerndoc]

CT in most pyelonephritis is about as useful as a CT in syncope without neurologic deficits.

 

[deleted836128]

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.

Does #2 really go over well? I would think they wouldn’t find that a valid excuse to be bugged but at the same time they’d feel the same way if in our shoes. When I am dealing with #2, I don’t outright say it, I just say something like, “Hey, would you mind taking a look at ——-?” I also do call if a study is taking an extraordinary amount of time because sometimes they’ll say “oops! That is not on my list!”

I do appreciate this post. I think I am going to be calling radiology a lot less often.

 

[emergentmd]

Does #2 really go over well? I would think they wouldn’t find that a valid excuse to be bugged but at the same time they’d feel the same way if in our shoes. When I am dealing with #2, I don’t outright say it, I just say something like, “Hey, would you mind taking a look at ——-?” I also do call if a study is taking an extraordinary amount of time because sometimes they’ll say “oops! That is not on my list!”

I do appreciate this post. I think I am going to be calling radiology a lot less often.

#2 goes well when you are a doc but not sure if it would with a PA. Plus I knew all the radiologist and chit chat with them often. All docs hate to wait to go home so we all are understandable about this and would do the same for each other. Truth is they don't care if they read a CT next or pull up my CT next to read. It is the same amount of work. Plus they appreciate me coming over and asking vs having the nurse call over

Same thing when a police officer brings in a pt, I expedite things to get them back to work.

 

[nikolaite]

I got a referral from a colleague for a case in a mechanical thrombectomy study I’m running the archives on. Pt was AIS, NIHSS 15+ to my recollection. Rural ER sent CT at routine priority. Reason I’m mentioning this is the rad apparently called the ER doc to clarify some thing or other and about lost his head when doc mentioned she was still waiting on a CT review for a suspected AIS. Apparently the history attached to the CT was “altered mental status” and “aphagia “ (literally spelled like that in the order). No mention of AIS suspicion. SMH.

 

[Siggy]

I got a referral from a colleague for a case in a mechanical thrombectomy study I’m running the archives on. Pt was AIS, NIHSS 15+ to my recollection. Rural ER sent CT at routine priority. Reason I’m mentioning this is the rad apparently called the ER doc to clarify some thing or other and about lost his head when doc mentioned she was still waiting on a CT review for a suspected AIS. Apparently the history attached to the CT was “altered mental status” and “aphagia “ (literally spelled like that in the order). No mention of AIS suspicion. SMH.

To add to this, at every hospital I've been at stroke CT orders are a different order than CT brain. Normally it's something along the lines of "CT brain stroke protocol" for the actual order (not the indication). One thing this does is help sorts the scan into a separate pile that will get read before other STAT studies. It generally also triggers an automatic call to report the findings, even if the findings are normal. I believe that "scan to read" time is a tracked metric for stroke centers.

 

[nikolaite]

To add to this, at every hospital I've been at stroke CT orders are a different order than CT brain. Normally it's something along the lines of "CT brain stroke protocol" for the actual order (not the indication). One thing this does is help sorts the scan into a separate pile that will get read before other STAT studies. It generally also triggers an automatic call to report the findings, even if the findings are normal. I believe that "scan to read" time is a tracked metric for stroke centers.

I just pulled the chart to check the accuracy of my memory and found another little gem: that pt arrived at the ER with 3/3 CSS from EMS, but “routine“ CT wasn’t ordered until 61 mins after pt admission, and pt wasn’t actually in rad dept until 81 mins after admission.... Wow. I bet if rad knew that little bit he’d have called legal while reviewing the images. This one makes my TMJ hurt to read from all the cringe.