Jlaw

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I am rapidly heading towards the second half of residency and realizing that I am really deficient in reading my own CT's. Anyone have a recommendation for a good book or website for self teaching?
 

brk81144

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I started scrolling through all of my CTs just for the experience and then would take a second look after the rads report to see what was identified. Now I can pick up most head bleeds, PEs, stones, etc. Thankfully though out rads group is great about getting quick reads even overnight
 

swamprat

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As a resident this should be one of the last things on your list of things to learn. Just saying..

I am a new attending and I couldn't care less about reading CTs. I'm not going to act on any information without a radiologist report (unlike xrays which I think you should learn well). Anyway just my opinion.
 

startupquick

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As a resident this should be one of the last things on your list of things to learn. Just saying..

I am a new attending and I couldn't care less about reading CTs. I'm not going to act on any information without a radiologist report (unlike xrays which I think you should learn well). Anyway just my opinion.

Disagree. Well worth it to look at your own cts and x rays. I'm okay, not good, but have caught missed head bleed, stones, diverticulitis etc... Def agree about x rays, caught several missed fractures, pna, shoulder separation etc

Remember, you know where your patient is having pain, radiologists don't.

A missed head bleed is on you too. Not just rads.
 

southerndoc

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Disagree. Well worth it to look at your own cts and x rays. I'm okay, not good, but have caught missed head bleed, stones, diverticulitis etc... Def agree about x rays, caught several missed fractures, pna, shoulder separation etc

Remember, you know where your patient is having pain, radiologists don't.

A missed head bleed is on you too. Not just rads.
Many state medical boards have the assumption that if you order it, it's your responsibility for interpretation. Yes, the radiologist is an expert and can guide you on his/her opinion of what it shows, but it's ultimately the ordering physician's responsibility to interpret the scan.

Like startupquick, I also have caught some missed things.
 

flasheroonie

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You really need to always, and I mean ALWAYS look at the image first, make your own interpretation, THEN look at what the radiologist's read shows. That's the best way to learn. Every image, every time.
 

e30ftw

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I read this book as a PGY-2 and recommend it:

Emergency Radiology: Case Studies (Medical/Denistry)

Like any medical studying endeavor, the critical point is committing the knowledge to memory then repetitively applying it in practice. Learn what to look for in common emergency scans (brain, abd, thorax being most common) and apply that knowledge by consistently reviewing your own imaging and comparing it to the radiology report.

We order enough imaging that it doesn't take much effort in residency to become "adequate" at interpreting relevant CT findings.

In addition to the book above I would make a special effort in learning what "fat stranding" and other signs of soft tissue inflammation and injury, as this is the easiest way to pick up on more subtle findings in abd/soft-tissue studies. This is how you can call diverticulitis based on a 5 sec scroll through an abd series or pick up a punctate or recently passed kidney stone that radiology may miss.

CT interpretation is important for emergency physicians. I routinely call consultants on CT findings prior to formal interpretation to provide definitive care and speed up dispo.
 

e30ftw

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A few weeks ago had a young guy come in with reproducible pleuritic chest pain. Normal vital signs and exam consistent with costochondritis.

CXR on my review shows evidence of a small-moderate R pneumo.

Radiology formally interprets imaging as normal.

I call radiology and advise the patient has a right pneumothorax. Radiologist assures me he is looking at the image and that there is no pneumo.

So I order a CT which shows a large pneumothorax.

Pneumodart was already in by the time he called to inform me of the "critical CT finding".

This is not a situation that occurs frequently, thankfully, but every once in a while due to the sheer volume of unusual presentations we see in the ER you will be in this situation and it's important to be confident in your ability to interpret imaging.
 

Groove

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I really support getting proficient at reading your own XR and CTs. In residency, I would try to read it, then read the radiology read, then try to see what I had missed. I still try to do that to this day unless the ED is really busy and/or the read doesn't jive with the clinical presentation. In my case, there's a bit of an incentive since I don't have "formal" reads at night on CTs. They do prelim reads and then a full formal read in the morning at 7am by a different radiologist. (Don't get me started.) We have to read our own XRs at night though I can get him to read it with a phone call. I probably think I'm better at reading CTs than I actually am, but I can read all the easy stuff. 90% of my PEs, I've usually already spotted and initiated therapy on or am calling the radiologist to confirm. Radiologists def miss stuff and don't have the luxury of the clinical correlation so I've been surprised at some of the addendums after I've called them to question a particular read. (gallbladder looks fine to ....early cholecystitis, etc..) Our radiologists have missed head bleeds, PEs, one time I called them on a very obvious L5 burst fx that he had missed. The list goes on, they aren't perfect. Anyway, I enjoy radiology and am always pestering our radiologists to show me what they are talking about. (Recently one was showing me the hypoattenuation in globus pallidus seen in CO poisoning, I had never heard of it...it was very cool.)

I've got the following texts. Most are good but not great. My main complaint with radiology books is the fact that the images are so tiny and low quality on paper. However, there are probably high resolution images you can download for all of theses and I just don't know it.

The first two, I "think" I read them in residency and are several years old but probably have updated versions. I can't remember if they were part of our curriculum or not (I think I got one from ACEP?). I bought the third one a few months ago and have only had time to read a couple of chapters...pretty good so far. That's probably the only one I would recommend. There may be better ones out there. It's a pretty hefty text and def not a light read.

Radiology 101 - Erkonen
Imaging Atlas of Human Anatomy - Weir
Diagnostic Imaging for the Emergency Physician - Broder
 
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Jlaw

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In addition to the book above I would make a special effort in learning what "fat stranding" and other signs of soft tissue inflammation and injury, as this is the easiest way to pick up on more subtle findings in abd/soft-tissue studies. This is how you can call diverticulitis based on a 5 sec scroll through an abd series or pick up a punctate or recently passed kidney stone that radiology may miss.
Yes! Fat stranding...a term I hear all the time but no idea how to find it!
 
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Jlaw

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Thanks all, very helpful, going to check out some of the references and try to get better. I do look at all my own studies and I think I'm fairly adept at CXR, some msk plain films, CT head, stones on CT, etc but need to work on PE and abdominal/pelvic CT a lot. Please keep the references coming...
 

DrBowtie

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Thanks all, very helpful, going to check out some of the references and try to get better. I do look at all my own studies and I think I'm fairly adept at CXR, some msk plain films, CT head, stones on CT, etc but need to work on PE and abdominal/pelvic CT a lot. Please keep the references coming...
Fundamentals of Body CT by Webb is THE body CT book for all first year Radiology residents. Should be level appropriate and covers both emergent and non emergent pathology.

For working on PEs, key is to put it on vascular windows and systematically work through each lobar branch vessel.
 
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DrDrummer

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Have you guys seen this? Definitely along with radiopaedia my favorite online radiology teaching resource. Also agree with everything said above about looking at all your own images -- much faster and helps develop your gestalt for abnormalities on imaging. As someone said, you get to clinically correlate, which helps a lot.

One Night in the ED: Proceed to Instructions and Cases

You can scroll through the CTs by clicking/dragging.

He also has an iPad / iPhone app. I think it's so cool that this guy is continuing to make this available for free. He could be charging for it and probably making a lot. He also has a whole app dedicated to pregnant appendicitis -- haven't gotten to that level yet myself. :)
 

VeitVat

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Reading some posts here brings a necessary piece of advice: Poop goes in, poop goes out.
Give poop Hx, don't be shocked at the increased chances of getting a poop report.

If you give a good clinical Hx there's a better chance to get a good diagnostic read. Here are some Histories provided by ER on imaging studies THIS MORNING :

- R/O 47 yo female

- Pain

- AMS

- R/O pathology

- SOB

- CT C/A/P r/o PNA

This is where you get a million and one misses and irrelevant reports.

Contrast those to:

- h/a, dizziness for 7 hours

- CP right substernal after MVA

- SOB since am, (+) fevers

- Abd pain, N/V, periumbilical since 12pm

- tenderness 2nd toe, foot vs nightstand.

- ulcer 5th toe, oozing, osteo?

Doesn't take much to provide even borderline useful quality clinical information to the radiologist.
 

Apollyon

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Reading some posts here brings a necessary piece of advice: Poop goes in, poop goes out.
Give poop Hx, don't be shocked at the increased chances of getting a poop report.

If you give a good clinical Hx there's a better chance to get a good diagnostic read. Here are some Histories provided by ER on imaging studies THIS MORNING :

- R/O 47 yo female

- Pain

- AMS

- R/O pathology

- SOB

- CT C/A/P r/o PNA

This is where you get a million and one misses and irrelevant reports.

Contrast those to:

- h/a, dizziness for 7 hours

- CP right substernal after MVA

- SOB since am, (+) fevers

- Abd pain, N/V, periumbilical since 12pm

- tenderness 2nd toe, foot vs nightstand.

- ulcer 5th toe, oozing, osteo?

Doesn't take much to provide even borderline useful quality clinical information to the radiologist.
When our system allowed more than 28 characters, I was able to stop my creative abbreviations. When there are only a finite number of spaces, I had to really cram it in. I try to give as much detail as possible, for the reasons you outlined above.
 

The White Coat Investor

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Remember, you know where your patient is having pain, radiologists don't.
Why would you make your radiologist read blind? I tell mine where my patient hurts when I order the study.
 
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brk81144

Attending
Apr 10, 2014
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Reading some posts here brings a necessary piece of advice: Poop goes in, poop goes out.
Give poop Hx, don't be shocked at the increased chances of getting a poop report.

If you give a good clinical Hx there's a better chance to get a good diagnostic read. Here are some Histories provided by ER on imaging studies THIS MORNING :

- R/O 47 yo female

- Pain

- AMS

- R/O pathology

- SOB

- CT C/A/P r/o PNA

This is where you get a million and one misses and irrelevant reports.

Contrast those to:

- h/a, dizziness for 7 hours

- CP right substernal after MVA

- SOB since am, (+) fevers

- Abd pain, N/V, periumbilical since 12pm

- tenderness 2nd toe, foot vs nightstand.

- ulcer 5th toe, oozing, osteo?

Doesn't take much to provide even borderline useful quality clinical information to the radiologist.
Unfortunately I have to select from a drop down list which makes it hard to give great history or even come close sometimes
 

VeitVat

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Oct 20, 2014
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Unfortunately I have to select from a drop down list which makes it hard to give great history or even come close sometimes
You can take this to management to address this problem: it's obviously a systems problem that impacts quality of patient care. If you frame it like that (which it is) I'm sure it'll make everyone's job - and the patients care - more effective.
 
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Jlaw

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Reading some posts here brings a necessary piece of advice: Poop goes in, poop goes out.
Give poop Hx, don't be shocked at the increased chances of getting a poop report.
Doesn't take much to provide even borderline useful quality clinical information to the radiologist.
This was the most useful thing I learned on my radiology rotation. One of the radiologists basically told me that without an HPI or short clinical correlate its basically impossible to provide a diagnosis on a lot of the scans we order. Since then I've always tried to complete my HPI and PE immediately on patients I order imaging for.
 

Trail Blazer

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+1 for one night in the ED. Both online and on iPad. Awesome stuff, better than a book since you can scroll through a real ct, decide what's up, then click and scroll through for arrow signs

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