How much diagnosing does radiology do in the ED?

[Maybedoc1]

Forgive my complete lack of knowledge on anything, but how much diagnosing does radiology do for you guys? I shadowed for the first time in an ER last week and it was a super cool experience. However it did kind of seem like the ER doctor ordered some scans and then X amount of time later the radiologist issued his report and we went from there. Seeing how I only spent 3 hours shadowing I'm certain my understanding of the process is faulty, but still I thought I'd ask you guys.

Also I read somewhere on here that some ER doctors will read their own MRI's and such and begin treatment for things before the official report comes through. Is that a common practice?

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[Tenk]

At most shops, ED docs will read X-rays at night with radiology overreads in the morning but CTs and MRIs and USs will be read 24/7 with most places doing radiology reads of X-rays during the day.

A lot of times I will read and act on imaging I order before the radiologist calls me. I had an attending in residency who I really respect told me I should read every study I order myself, so I do. As a result I can read almost anything pretty dang well. Practice makes perfect.

 

[EM Junkie]

They’re a helpful member of the team, to be sure - but I also read the vast majority of my own studies. It is not uncommon to have the radiologist call to inform me of the emergent surgical finding on imaging, only for me to tell them the patient is already on the way to the OR.

 

[BJJVP]

Forgive my complete lack of knowledge on anything, but how much diagnosing does radiology do for you guys? I shadowed for the first time in an ER last week and it was a super cool experience. However it did kind of seem like the ER doctor ordered some scans and then X amount of time later the radiologist issued his report and we went from there. Seeing how I only spent 3 hours shadowing I'm certain my understanding of the process is faulty, but still I thought I'd ask you guys.

Also I read somewhere on here that some ER doctors will read their own MRI's and such and begin treatment for things before the official report comes through. Is that a common practice?

If I am pretty sure that clinically, a pt has a fracture or a dislocation, I will look at the x-ray and act on my own interpretation. I also usually put in chest tubes without the radiology read. If I am pretty sure the xray will be negative, I may tell the pt that all looks well before the radiology report, but I will usually wait until the formal report before discharging the patient. For severe conditions (intracranial hemorrhage, rupture AAAs, etc), I will usually get the surgeon on the phone before the radiology reads. When it comes to CT scans, I will NEVER discharge a pt based on my interpretation. I rarely order MRIs and when I do, I will look at it, but I definitely wait for the radiologist and/or specialist to look at it before any decisions are made.

Radiologists, in my opinion, do A LOT of diagnosing for us. I think they have a very important & tough job. I can say this and still insist that most ER doctors don't just turn off our brains and order a bunch of scans. Although I can see how it appears that way at times.

 

[enalli]

Forgive my complete lack of knowledge on anything, but how much diagnosing does radiology do for you guys? I shadowed for the first time in an ER last week and it was a super cool experience. However it did kind of seem like the ER doctor ordered some scans and then X amount of time later the radiologist issued his report and we went from there. Seeing how I only spent 3 hours shadowing I'm certain my understanding of the process is faulty, but still I thought I'd ask you guys.

Also I read somewhere on here that some ER doctors will read their own MRI's and such and begin treatment for things before the official report comes through. Is that a common practice?

A pretty good amount. Sometimes all you need is the history, sometimes the physical exam, sometimes the labs, and other times imaging. You could just as well ask "how much diagnosing does the lab do for you guys?"

 

[EMDOC17]

How much does my physical exam diagnose? How about my history? Out all specialists I rely on my radiologists way more than any other. Do they “make the diagnoses”. Well I’m not sure. I think we both do. If I have a high index of suspecion for appendicitis and radiology reads inflammation around the appendix then it’s appendicitis. Who made the diagnosis? Me or the radiologist? If I didn’t order the CT it wouldn’t have been made. If the radiologist didn’t read it as acute appendicitis the diagnosis wouldn’t have been made either.

It’s semantics. In a way I consult radiology way more than any other specialty. Simply because they read my imaging studies. I am also in the group that they don’t read x-rays last 6 on unless I request it.

 

[turkeyjerky]

A good corrallary to this is the number of studies that come back with "clinical correlation advised"

 

[VeitVat]

A good corrallary to this is the number of studies that come back with "clinical correlation advised"

And a good collorary to THAT is the number of clinical histories supplied to radiologists as “Pain.”

Or “R/O Pathology”
Etc ...

 

[Angry Birds]

Forgive my complete lack of knowledge on anything, but how much diagnosing does radiology do for you guys?

A lot.

Also I read somewhere on here that some ER doctors will read their own MRI's and such and begin treatment for things before the official report comes through. Is that a common practice?

No.

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Labs and radiology are a huge part of diagnosis for any physician, working in any setting, anywhere.

 

[scummie]

They’re a helpful member of the team, to be sure - but I also read the vast majority of my own studies. It is not uncommon to have the radiologist call to inform me of the emergent surgical finding on imaging, only for me to tell them there already on the way to the OR.

"Doctor, I have the radiologist on the line, they have some critical findings for you."

"Yes, this is Dr. Scummie. Yes, I am aware that my patient has a massive head bleed with midline shift. Good thing neurosurgery is going to do something about it. K thx, bye."

Not quite exactly like that, but you get the point.

 

[Groove]

Forgive my complete lack of knowledge on anything, but how much diagnosing does radiology do for you guys? I shadowed for the first time in an ER last week and it was a super cool experience. However it did kind of seem like the ER doctor ordered some scans and then X amount of time later the radiologist issued his report and we went from there. Seeing how I only spent 3 hours shadowing I'm certain my understanding of the process is faulty, but still I thought I'd ask you guys.

Also I read somewhere on here that some ER doctors will read their own MRI's and such and begin treatment for things before the official report comes through. Is that a common practice?

We have wet reads at night which are technically preliminary CT reads which are then overread in the a.m. by the 7a.m. radiologist. XRays are interpreted by the ER doc overnight and are also then overread in the morning by the radiologist. I personally hate the system and we continually push for 24/7 formal reads and although we have made significant progress by pushing them to read later and later at night, we haven't gotten there yet and it's a constant source of frustration for us.

If I have time, I try to look at most of my CTs where I have a high clinical pre-test suspicion of acute path. I've gotten pretty good at PE studies, recognizing appendicitis, pyelo, obstructive uropathies, abscesses, head bleeds, dissection, etc.. Sometimes, I'll see a PE and initiate treatment before the radiologist confirms but I always try to call them and see if they can confirm as quickly as possible. I have a few radiology texts that I read a few years back that helped out my diagnostic skills tremendously. I always recommend for residents to try to read their own CTs first, then check the report, then go back and see what you missed. If you get in the habit of this practice and carry it forward to when you're an attending (if you have time), you'll get remarkably good at basic interpretation.

If I ever have an iffy Xray, I do have the option of telling the tech to "push" it to the night radiologist for a wet read and I have been known to do that on occasion, but I think most EPs are pretty good, or should be, at Xray interpretation. It just comes with practice.

 

[JAFERD]

If I see something that’s obviously positive, I act on it, whether that be CT or XR. If it’s during the day and I have radiology reading xrays, I’ll typically wait on their report before discharging a patient with normal findings, although not always. At night, we don’t get our X-rays read, so I make decisions based on what I see. Not going to lie, definitely order more CTs at night for that reason. I try to always look at CTs and XRs before they’re read to continually improve my skills. While I will glance at MRI’s, I almost entirely rely on radiology for those. Even the general radiologists typically refer them to neuro rads, or whatever else might be appropriate.

 

[Vandalia]

A few thoughts:

1) This is becoming less of an issue for EM as radiology groups in most places - although certainly not all - are forced to provide 24/7 coverage to keep their contracts. As mentioned, this varies from complete coverage to just cross-sectional imaging. Again, as mentioned most places that typically exclude plain films are willing to read one on occasion. Either they want to keep the "nighthawk" contract as well or they are part of the group and don't want to deal with a bad miss by EM in the morning.

2) Radiology is vastly easier if you have access to the patient. It is also far easier if you are asking a single, relatively simple question. Example: we generally are acceptable at seeing blood on a head ct, but I am probably not going to look for or care about a small pineal cyst. I might be able to see concerning signs about the appendix, but I am definitely not going to see subtle, chronic lung pathology on a scout image.

3) Some things are subtle: my last month I didn't see a subtle spiral wrist fracture in a 9 year old that radiology found. I also knew that there was a relatively good chance that would happen. There are also things that a 10 year old can see, literally. Once we had a head ct of someone with a GBM on a monitor, a kid passing by in the hall said "that's bad!" Yeah kid, radiology, and a half-dozen specialties aren't going to end up adding much more, even thought they will add a lot more technical phrases

4) Even with radiology most physicians look at the imaging. It is rare, but switching left/right is still one of the more common of those errors, and perception errors (that even we catch) do occur. It also gives you a general sense of things: if someone comes in with abdominal pain and nothing seems too concerning on exam, and the ct looks textbook-normal to me, it is unlikely that they will crash due to abdominal pathology in the next hour.

5) A lot depends on your radiology coverage. We have very good coverage w/ very good turnaround times. So it doesn't depend that much on what we see; on the other hand if you are at a place w/ 2 hour turnaround times, a lot more will depend on you.