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When There are Events Invisible to the Radiologist’s Eye
While seemingly extraneous imaging requests may lead to annoyance and frustration, there are some common contributing factors that may be at the root of these requests.
Once or twice in this blog, I have reminisced about bits of nonsense from call shifts during my radiology residency. After a certain hour of the evening, sono and MR techs didn’t remain in-house. If the ER or any other clinician claimed they had an emergent case that simply could not wait till the next morning, the on-call rad resident was supposedly gatekeeper for determining whether to summon the on-call tech to do the case.
The nonsense was that we had no real authority, and pretty much everyone knew it. We were just there to apply social friction to the situation. Anybody who really wanted their “emergency” done in the middle of the night knew that they could steamroll us by ringing up the attending rad. If the attending held the line, they could go to his or her section head, the department chair, etc.
For both rezzies and attendings, the calculus was simple: agree to whatever, and you immediately resumed work (or sleep). Put up a fight, and you would waste time and trouble with an argument, followed by losing face when the other party got you overruled by going up the chain of command. At worst, caving in would get you sassed by the justifiably grumpy tech, or a token next-morning quarterbacking from your attending saying “You probably shouldn’t have called the tech in for that,” even though he or she would totally have sold you out over the issue at 2 a.m.
Aside from the hassle, even a young rad rez knew what a waste of resources it was to call in a tech for a needless study. The justification of the not-really-emergent ultrasound was always something like “If it’s positive, we’re taking the patient straight to the OR!” Then, regardless of what the sono showed, they were demanding a STAT CT. It didn’t take many iterations of this before even the greenest of rads would want to scream: If the sono never has an impact, why are you insisting on it, and why do I have to be a part of your farce?
Some of us would try asking the clinicians about it, in part because we figured there had to be a reasonable explanation and we wanted to understand. Another less noble motivation was because we had already concluded that there was no reasonable explanation, and we just wanted to watch them squirm, which was pretty much what happened every time we asked.
Although we were obviously entangled in the situation, we were relative outsiders. The insiders were the patient (duh!), maybe accompanying family, ER and/or surgical staff, etc. Our understanding of what was going on was relatively indirect. That didn’t get in the way of our forming the following conclusions.
* They have no idea what they are doing, or what they want.
* The surgeon (or other specialist) is dragging his or her feet, trying to put off having to come in to see the patient and/or intervene. Saying that he or she “needs” more imaging to be done before getting involved is just playing for time.
We could have been entirely correct. Nothing about the situation, played out time and again, suggested any alternatives. Further, it seemed like any self-respecting clinician would want to appear wise and competent and might bend over backwards to explain his or her reasoning. Not doing so seemed as good an admission of guilt as one could get.
Once residency ended, I never worked in quite the same environment again. The “we need a pointless exam” charade, however, continued finding its way to my doorstep over the years including this past week.
Shades of residency, I got a “R/O appendicitis” sono on a kid. It was one of those vanishingly rare, unequivocally positive cases, and they proceeded to get the CT anyway two hours later. (This also showed an appy, no complications or other new details.)
At some point in the 20-plus years between this case and those from my residency, I was introduced to a notion: If you don’t know everything about a situation but what you do know leads you to one and only one conclusion about it (the ER is clueless for doing things this way, etc.), you have probably overlooked some possibilities.
Under such circumstances, I try to exercise my mind a bit. Realistic or not, can I come up with any other explanation for what I am seeing? Thinking of more possibilities feels like racking up a higher score and, as a side effect, gives me excuses to think less better of other folks. If, for instance, I spend time thinking of ways the ER, surgeons, etc. might not be behaving poorly, it can only help me have fewer sour notions in their general direction.
Here are some ideas I have had in scenarios like the (maybe not) wasted appendiceal ultrasound.
• Perhaps someone in the ER, surgery department, etc. is doing a bit of research on the sensitivity/specificity of sono vs. CT. They need case volume for their study. Yes, it has been done before, but contrary to a trite expression, science is never really “settled.”
* Maybe the pediatric patient’s parents are being very hesitant about whether to consent to surgery. Adding more pieces of evidence as to why the OR is warranted might just nudge them in the right direction. Perhaps the parents started off vehemently against radiation dosage, but when the sono turned out positive, they experienced some denial about its bad news results.
* Sometime between the ultrasound and the CT, there was a change in clinical status. Perhaps the patient improved, and no longer seemed to need intervention. Alternatively, maybe there was an episode of crashing with concern for perforation or something beyond a simple hot appendix. Either way, CT becomes reasonable to see what might be different.
* CT was overwhelmed with other cases, suffering technical problems, etc., and ultrasound was the only option for a while. But then, before surgery could happen, CT became available, and nobody remembered to cancel the order. The patient got whisked away to the scanner and the case was done, unbeknownst to the referring clinician.
