Need to vent

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tonem

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Disclaimer: This post is in no way intended to disparage the fine field of Radiology. It is merely a means to vent my frustration at certain radiology residents and hopefully gain some sympathy from my EM colleagues.

Me: Hello, I'd like to order a CT angiogram on one of my patients.

RR(radiology resident): What's the indication?

Me: I have a 35 yo woman that was involved in an MVC yesterday. Was seen and discharged from another hospital. She's coming back in today complaining of an occipital headache, neck pain, vertigo and nausea/vomiting.

RR: What are you looking for?

Me: Vertebral artery dissection.

RR: Laughing

Me: Why are you laughing?

RR: Did you look at her head?

Me: What do you mean? Did we get a head CT?

RR: No did you examine the patient...she has a concussion.

Me: How do you get a vertebral artery dissection?

RR: I don't have to answer that question!!! I'm trying to triage patients!!!

Me: Are you going to do the study or not?

RR: slams phone down...

10 minutes later after call from ED attending...and presumably mad scramble to look up vertebral artery dissection.

RR: Oh I didn't get that story (exact same description of patient)...sure we'll get it right away.

Me: I need to order a chest CT PE protocol.

RR2: Why?

Me: 32 y.o female smoker on OCPs returned to USA from Australia yesterday c/o SOB and CP.

RR2: Is she hypoxic?

Me: No.

RR2: Sigh..you guys are killing me...send her up.
 
Yes, radiology loves to diagnose patients from their dark little room. I just point out that it's my job to order the tests and their job to do them. 😉
 
Pulls up a chair and brews some coffee...
 
And what were the results of these studies?

I would have a smirk on my face if both came back positive.

Of course, even if the results were negative, your concerns about vertebral artery dissection and PE seemed to be legit and justified the scans.
 
See now me, I would just like a handy dandy box on the patient chart that we could check that reads:

"I (the Emergency Physician), having actually examined this patient, attest that this test, imaging, or scan ______________ (insert name of test, imaging, or scan here) is needed to reasonably exclude significant pathology and further attest that a delay in the discovery of this pathology may cause harm to the patient. The Radiologist, _______________ (insert name here) who has not examined the patient, does not feel this test, imaging, or scan is warranted and agrees to assume full legal responsibilty and financial liability for any untoward outcomes occurring as a direct or indirect result of not obtaining this test, imaging, or scan."​


Now, give me that and I bet that the number of attempted "blocks" by radiology drops dramatically, after all, have you ever met a radiologist that allows ANYTHING come between them and their paycheck?

- H
 
I also LOVE how they do their damndest to ignore you when you ask them to look over a study with you! One even posted a little article about how they need uninterrupted time with their "patient" (image) and how rude it is to be interrupted. I'm inturrupted when I'm with patients all the time! I try to be polite and patient, but it drives me nuts when they get mad when I ask
 
I'm glad you had the chance to vent. We all could use a little time to vent about other specialties including the ED. (Except we usually do it in private, amongst our own colleagues not on a public discussion board).
 
Voxel said:
I'm glad you had the chance to vent. We all could use a little time to vent about other specialties including the ED. (Except we usually do it in private, amongst our own colleagues not on a public discussion board).
Click to expand...

Except here:
http://forums.studentdoctor.net/showpost.php?p=1724622&postcount=2

and here:
http://forums.studentdoctor.net/showthread.php?t=173530&highlight=room

and I'm sure many other places. "ED", "ER", and "EM" are too small of strings to run in the forum search, and I didn't even bother to search AuntMinnie. I realize that you are a moderator and all but come on! Are you really suggesting that SDN is not the proper forum to vent? 👎

- H
 
Voxel said:
I'm glad you had the chance to vent. We all could use a little time to vent about other specialties including the ED. (Except we usually do it in private, amongst our own colleagues not on a public discussion board).
Click to expand...

If Emergency Residents aren't allowed to complain, it would take away 80% of what we would have to talk about! It'd be like telling you guys in Radiology to turn on the lights in your little rooms.
 
GeneralVeers said:
If Emergency Residents aren't allowed to complain, it would take away 80% of what we would have to talk about! It'd be like telling you guys in Radiology to turn on the lights in your little rooms.
Click to expand...

the rooms have lights? who'd've thunk it? d=)

-t
 
Daiphon said:
the rooms have lights? who'd've thunk it? d=)

-t
Click to expand...

Maybe not all the specialties require bright lights and the constant din of the ED to keep their slackjawed residents awake.
 
FoughtFyr said:
Except here:
http://forums.studentdoctor.net/showpost.php?p=1724622&postcount=2

and here:
http://forums.studentdoctor.net/showthread.php?t=173530&highlight=room


- H
Click to expand...

You missed the most infamous ED bashing thread of all. In fact it was the very first thread started by Kinetic on his infamous career of repeated bannings for trolling.

Tonem, Don't worry someday you'll be in private practice and then you can order any damn study you want just by writing it on the order slip. I still discuss cases with the radiologist but it is generally to ask which would be the best test to diagnose something I'm not so familiar with. It is not to get permission to run a study. On the down side it means I've seen some pretty stupid stuff get ordered. On the up side none of us waste time arguing about whether a study is going to get done. Of course if you go in to academics then 10 years from know you'll still be yelling at the R2 radiology resident to get a CT in the middle of the night.
 
Well, you could give them the stock answer for all grumbling consultants...

"Gee, I'm sorry to have disturbed your concentration with this patient so you would have to see them/their films/their slides and make a bunch of money."

Of course, this doesn't apply to residents, so they don't make that connection the way a private attending would.


'zilla
 
ERMudPhud said:
You missed the most infamous ED bashing thread of all. In fact it was the very first thread started by Kinetic on his infamous career of repeated bannings for trolling.
Click to expand...

Got a link? Should be worth a chuckle.

I mean really, is there any specialty in SDN that doesn't live in a glass house?

- H
 
ERMudPhud said:
Want to place bets now on how long it takes someone to feel compelled to answer the old troll and thus resurrect the thread? 😀
Click to expand...

Mission accomplished.
 
That was fast 🙄 (that was just wrong BTW)

Where's the popcorn?
 
fedor said:
Mission accomplished.
Click to expand...


That's lame. If you're going to revive the old thread you at least have to read the whole damn thing and add something that at least seems meaningful.

"Bump" is just weak 🙄
 
ERMudPhud said:
That's lame. If you're going to revive the old thread you at least have to read the whole damn thing and add something that at least seems meaningful.

"Bump" is just weak 🙄
Click to expand...

I'm working on it. Bump is just temporary. I don't read too fast so expect a reply more to your fancy by morning.
 
I know we all vent our frustrations but I think we should do them in private. I'm not saying any specialty or particular person is perfect or that they don't vent. I 'm just tired of people mudslinging each other. I think it's a waste of energy. But if you're here for troll inspiring mudslingin' entertainment.... at least pass the popcorn....
 
Voxel said:
I know we all vent our frustrations but I think we should do them in private. I'm not saying any specialty or particular person is perfect or that they don't vent. I 'm just tired of people mudslinging each other. I think it's a waste of energy. But if you're here for troll inspiring mudslingin' entertainment.... at least pass the popcorn....
Click to expand...


[Homer Simpson Voice] MMMMMM.......Popcorn.......
 
Voxel said:
I know we all vent our frustrations but I think we should do them in private. I'm not saying any specialty or particular person is perfect or that they don't vent. I 'm just tired of people mudslinging each other. I think it's a waste of energy. But if you're here for troll inspiring mudslingin' entertainment.... at least pass the popcorn....
Click to expand...

Wait, explain to me why other specialties are even looking in the EM area, and if you are looking to stop "mud slinging" can you pick a better post to start with I mean this is almost bread and butter.
 
Voxel said:
I know we all vent our frustrations but I think we should do them in private. I'm not saying any specialty or particular person is perfect or that they don't vent. I 'm just tired of people mudslinging each other. I think it's a waste of energy. But if you're here for troll inspiring mudslingin' entertainment.... at least pass the popcorn....
Click to expand...

I disagree and hence the posting of the thread. I think this is a healthy forum and a way to commiserate with other emergency medicine residents and attendings at various levels from all over the country. While I would certainly love to meet with each of them in private over a cold one to discuss the state of emergency medicine as it is practiced all over the country, it is not possible so this forum will have to do.

Like I said in my disclaimer, radiology is an honorable field filled with many intelligent people. I was just trying to express my frustration at certain individuals that sight unseen think they know more about the patient I just evaluated than I do. The reason I chose to air my frustration here was to see if it was just a local thing or if others shared the same experience. There was no mudslinging or generalizations about radiologists or radiology implied or intended.

To add some wood to the fire....as an example of the difference in mentality between EM and other specialties....

a specific radiology resident (who in no way is meant to reflect any implicit indictment on the field of radiology in its entirety or individuals engaged in said practice) once told a fellow EM resident in obvious frustration..."Do you guys realize that 90% of the testicular ultrasounds you order are negative?" Her response was, Oh my gawd! 10% are positive!!! Thats way more than I thought! So with that thought next time a kid comes in with testicular pain, tell his mom there's only a 10% chance his testicle will die so we dont need to get that annoying study and inconvenience that poor ultrasound tech who is getting paid extra to be on call. (Okay that was a little catty...but it was in no way intended to disparage the fine field of ultrasound technology nor those fine individuals who unselfishly give of themselves everyday in every way).

note: statistical data related to the incidence of testicular torsion was chosen at random and not a reflection of the actual occurrence of said disorder
 
tonem said:
I disagree and hence the posting of the thread. I think this is a healthy forum and a way to commiserate with other emergency medicine residents and attendings at various levels from all over the country.
Click to expand...

i tried some good-natured venting about pediatric patients in the ED, and was promptly shot down. 🙁

since then i have a few more amusing stories to add to my list, but i'm keeping them to myself because i like this forum and don't what people to hate me.

good luck with this, lol. it's just a matter of time before the radiology folks come out of their caves and defend themselves.

screw the popcorn. pass me some nachos and jalapenos and a large diet coke 👍

--your friendly neighborhood learned his lesson caveman
 
What about some m&m's as well?

I guilty of venting about other specialties, especially after a specific person has ticked me off. However, you can't solve problems without bringing them up. It helps to know if the problem is common or not.

With the radiology folks, I'd like to know what they want me to do when I urgently need to know about a study. Do I stand quitely out in the hall and hope they notice? Do I make a small amount of noise so they know someone is there? Do I knock and come right in? Phone call?????

If m&m's aren't available, how about snowcaps?
 
tonem said:
a specific radiology resident (who in no way is meant to reflect any implicit indictment on the field of radiology in its entirety or individuals engaged in said practice) once told a fellow EM resident in obvious frustration..."Do you guys realize that 90% of the testicular ultrasounds you order are negative?" Her response was, Oh my gawd! 10% are positive!!! Thats way more than I thought! So with that thought next time a kid comes in with testicular pain, tell his mom there's only a 10% chance his testicle will die so we dont need to get that annoying study and inconvenience that poor ultrasound tech who is getting paid extra to be on call. (Okay that was a little catty...but it was in no way intended to disparage the fine field of ultrasound technology nor those fine individuals who unselfishly give of themselves everyday in every way).
Click to expand...


10% is a lot. I have yet to ever see a positive study. At my institution overly conservative attenddings order an ultrasound on everyone who has epididymitis (based on physical exam, chronic history etc). When I ask why we are scanning Mr. Smith who obviously has epididymitis, they make some excuse about the testicle "torsing and untorsing". Does every center order ultrasounds on everyone, even when the entire history and physical points to infection?
 
GeneralVeers said:
Does every center order ultrasounds on everyone, even when the entire history and physical points to infection?
Click to expand...

No, but particularly when you're talking about epididymitis vs. torsion, even the "classic" findings in epididmytis like Prehn's sign are known to be unreliable. If it was your painful nut, I guarantee you'd be interested in a non-invasive study which could rule out a potentially correctable cause of testicular necrosis.

As far as a preponderance of negative tests go, if you're only order tests that come back positive that means you're incurious to a fault, as you're only studying people whose diagnosis is bloody obvious. If surgeons can come to terms with a negative laparotomy rate, so can radiologists.

As far as dealing with resident colleagues, rads or otherwise, there's no reason to "yell". If we can't behave like gentlemen and ladies to each other, then our profession will truly go down the pipes, times being how they are these days. If you're a resident in one of the situations mentioned above, offer to have your attending call and wake their attending up at 3am to discuss the situation.
 
GeneralVeers said:
10% is a lot. I have yet to ever see a positive study. At my institution overly conservative attenddings order an ultrasound on everyone who has epididymitis (based on physical exam, chronic history etc). When I ask why we are scanning Mr. Smith who obviously has epididymitis, they make some excuse about the testicle "torsing and untorsing". Does every center order ultrasounds on everyone, even when the entire history and physical points to infection?
Click to expand...
If he has a fever of 104 and a high white count I won't bother. If all he has is pain and sweling, then he's probably going to get the imaging. History is all well and good, but so many of my patients are miserable historians that it's dangerous to rely on only that sometimes.

"How bad is the pain on a scale from 1-10?"
"Oh, it's real bad, doc!"

After a few rounds of this I give up. Sometimes I don't wait that long if it's obvious that the answer isn't going to get any better. Getting a decent history out of some people is like trying to get orange juice out of a rock... or a testicle. I know you see some of the same people. That said, I also know of several of your attendings who are absurdly risk averse.

I had one case of testicular torsion where the guy only complained about diffuse abdominal pain of uncertain onset. He completely failed to mention that his nut was swollen and exquisitely tender.
 
I once had a guy with free air in the abdomen whose only complaint was testicle pain. I can't remember why the nurse ordered a CXR on this guy...but I was sure glad that she did.
 
Slightly different topic, but anyone else have issues with official reads being changed after the fact? Our studies end up dictated into the computer system. You would think rereads/addendums would be just be noted after the original read. However, we'll get an official (attending) read of a negative Head CT on a pt with HA that, after a positive LP, gets changed to a read of SAH. Its got to be illegal! Why in the hell would we tap a person with a positive HCT?

The truly funny part is that the last part of EVERY head CT read in our hospital explicitly states, "This study cannot rule out the diagnosis of subarachnoid hemorrhage or pseudotumor cerebri."
 
Scrubbs said:
Slightly different topic, but anyone else have issues with official reads being changed after the fact? Our studies end up dictated into the computer system. You would think rereads/addendums would be just be noted after the original read. However, we'll get an official (attending) read of a negative Head CT on a pt with HA that, after a positive LP, gets changed to a read of SAH. Its got to be illegal! Why in the hell would we tap a person with a positive HCT?

The truly funny part is that the last part of EVERY head CT read in our hospital explicitly states, "This study cannot rule out the diagnosis of subarachnoid hemorrhage or pseudotumor cerebri."
Click to expand...

We were having a MAJOR problem with that - and we said the same thing about it being illegal. However, now, the prelim reading that is released goes into our (separate) computer program that we chart in. The attending read that is different is a separate entry into our chart, while the prelim read gets overwritten in the hospital computer system. Although the radiology tab doesn't get added into the chart from our system that goes into the hospital system, still, that data is there, and, if/when a problem arises, the data isn't lost.

We were getting tired of looking like fools at 10am when the attendings read out, and the (formerly) big goombah is now a normal variant.
 
The problem of rads wet reads changing when the final is dictated is a HUGE liability issue for EPs. Since we act on info as it comes in real time but the finals are done next business day the damage will have been done. In all of my facilities we have fought hard to make the wet reads part of the permanent chart. This is how it should be everywhere.
 
ERMudPhud said:
Want to place bets now on how long it takes someone to feel compelled to answer the old troll and thus resurrect the thread? 😀
Click to expand...

Fedor's bump shouldn't count but it still took less than a week for someone to feel compelled to responded to a troll more than a year old. I'm just bitter because out of the whole 100 post thread they seem to have taken specific issue with one old post of mine. It seems ER docs shouldn't be allowed to complain because when we make mistakes its always some other service who has to bail us out but when they make mistakes they generally solve their own problems. I thought my post was full of examples of one service having to fix anothers mistake including the fire department putting out the fire started by general surgery but oh well. I guess I'm extra bitter because the poster appears to be an ENT resident and ENT is on my black list right now. All of our ENT's just went on strike and refused to take call which can make certain problems rather interesting. Even though they are no longer backing us up they still have no problems telling their patients to go the ED for any problem once their office closed. If I were as petty as Kinetic used to think I was maybe this would be the time to pull out the page that used to drive him crazy, "Dr. so-and-so your patient is in the ED waiting for you" but instead I'll just keep muddling along trying to help whomever they've sent in even if I can no longer count on their backup.
 
ERMudPhud said:
Want to place bets now on how long it takes someone to feel compelled to answer the old troll and thus resurrect the thread? 😀
Click to expand...


Oh No, one of our own,foughtfyr, just got sucked in! Shame on you.😀 I'm reminded of Brer Rabbit and the tarbaby.
 
ERMudPhud said:
Oh No, one of our own,foughtfyr, just got sucked in! Shame on you.😀 I'm reminded of Brer Rabbit and the tarbaby.
Click to expand...

And now Mikecwru gets sucked in too. That thread is like a cockroach, it will never die.
 
How are the ENTs getting away without taking call? Don't you have to take call in order to maintain your privileges at a hospital? I know that one of my past chiefs gave up privileges at one of the hospitals where he was working because he was getting tons of crap consults at all hours of the day and night from the Urgent Care Center that was associated with the ED. When he told the ED director that they needed to hire better staff to take care of the basic suturing needs. When they didn't do it, he left. But he couldn't just not take call anymore.
 
maxheadroom said:
How are the ENTs getting away without taking call? Don't you have to take call in order to maintain your privileges at a hospital?
Click to expand...
One thing about private hospitals is that the politics would shame the UN. None of my hospitals have ENT call but there are ENTs on staff (This puts us in a very bad position in terms of EMTALA by the way). Who has to take call and who doesn't is based on each hospital's bylaws and staff rules. If your department has enough leverage you can make things go your way. For example, the vast majority of ENT procedures are scheduled elective, read lotsa $$$. The ENTs can do many of these procedures at the hospital or at the shiny new surgi center. If they go to the surgi center the hospital gets less than squat. So, who thinks that the hospital admin is going to risk pissing off the ENTs? If your hand is up you're wrong. This same situation applys to Uro, Optho and others.
 
maxheadroom said:
How are the ENTs getting away without taking call? Don't you have to take call in order to maintain your privileges at a hospital? I know that one of my past chiefs gave up privileges at one of the hospitals where he was working because he was getting tons of crap consults at all hours of the day and night from the Urgent Care Center that was associated with the ED. When he told the ED director that they needed to hire better staff to take care of the basic suturing needs. When they didn't do it, he left. But he couldn't just not take call anymore.
Click to expand...

As docB said it is up to individual hospitals to decide call policies. EMTALA says something vague about each hospital can determine what sort of call system is most appropriate for their specialists and community. This has been interpreted by many hospitals to mean that if forcing a specialist to take call would cause you to have to go without that specialist all together than it better for the community to let them not take call. Many hospitals have resorted to paying specialists just to be on call. The ringleader of our ENT's is holding out for something like this. However, he is already getting paid to be on call for another local hospital and a friend of mine who works there says he still won't come in when paged. Makes me wonder what we would be paying for. Fortunately two of our ENT's have still agreed to take call. One guess who I am sending all the patients with good insurance to now. However, they can't take Q2 call so we go without coverage much of the time. I probably only ask an ENT to actually come in to the ED once every 25-50 shifts but when I do I usually really need them. Sometimes I just don't understand their responses. I had some L.A, bigwig in the ED one night who fell and exploded his nose. I mean hunks of meat and cartillage hanging out everywhere. I called everyone in our directory and the best I could find was a plastic surgeon who would agree to come in by noon the next day to work on the guy. The dude ended up calling his surgeon at home and then calling the airport to charter a flight home to L.A. I wrapped him up like the mummy and sent him on his way.
 
Sounds like a great deal for them. Still, in order to work at a Surgi-Center you have to have privileges at an acute care hospital in case the patient requires transfer (if the center is certified).
 
docB said:
The problem of rads wet reads changing when the final is dictated is a HUGE liability issue for EPs. Since we act on info as it comes in real time but the finals are done next business day the damage will have been done. In all of my facilities we have fought hard to make the wet reads part of the permanent chart. This is how it should be everywhere.
Click to expand...
Wet reads are definitely a problem, especially if you can't look at your own scans and are totally relying on a second year rads resident... but what I was talking about are supposed final reads getting changed. It'll be Monday morning, attending reading the scans, HCT report gets dictated into the computer as negative, and after our LP comes back positive, they'll reread the scan as (+) SAH. Has to be illegal, right?
 
Scrubbs said:
Wet reads are definitely a problem, especially if you can't look at your own scans and are totally relying on a second year rads resident... but what I was talking about are supposed final reads getting changed. It'll be Monday morning, attending reading the scans, HCT report gets dictated into the computer as negative, and after our LP comes back positive, they'll reread the scan as (+) SAH. Has to be illegal, right?
Click to expand...

Yes, because they've been signed. It's no different from changing a pen-and-ink written note.
 
docB said:
One thing about private hospitals is that the politics would shame the UN. None of my hospitals have ENT call but there are ENTs on staff (This puts us in a very bad position in terms of EMTALA by the way). Who has to take call and who doesn't is based on each hospital's bylaws and staff rules. If your department has enough leverage you can make things go your way. For example, the vast majority of ENT procedures are scheduled elective, read lotsa $$$. The ENTs can do many of these procedures at the hospital or at the shiny new surgi center. If they go to the surgi center the hospital gets less than squat. So, who thinks that the hospital admin is going to risk pissing off the ENTs? If your hand is up you're wrong. This same situation applys to Uro, Optho and others.
Click to expand...

Is this (ie, ENT, Uro, and Optho having political power) pretty much standard at hospitals across the country or just at your own program?

The only specialties I have heard having disproportionate power (so far) were rads and CT. Rads because they could always pack their bags and set up an imaging center across the street, and CT because it was non-stop CABG's bringing in ridiculous money for the hospital.
 
fedor said:
Is this (ie, ENT, Uro, and Optho having political power) pretty much standard at hospitals across the country or just at your own program?
Click to expand...
That's pretty typical. We're all having trouble because EMTALA demands that we take care of everything but they keep loosening the requirements for a call list placed on the hospital (for the reasons noted by ERMudPhud about "community service"). The result is that EPs are having to take more and more risk by seeing these cases with no specialty backup. This is the situation in the private hospital system where I work but dwindeling call lists are a national problem.
fedor said:
The only specialties I have heard having disproportionate power (so far) were rads and CT. Rads because they could always pack their bags and set up an imaging center across the street, and CT because it was non-stop CABG's bringing in ridiculous money for the hospital.
Click to expand...
"Disproportionate power" is a relative thing. In this instance we're just talking about having enough clout to avoid call. In my town the rads can't really play the imaging center card because we are already saturated with imaging centers. I don't wind up calling CT that much just due to our population so they don't fight the call.
 
ERMudPhud said:
Check it out. Foughtfyr gets trolled back into the old flame war by what I would bet is a reincarnation of Kinetic 😀

http://forums.studentdoctor.net/showthread.php?p=2977272#post2977272
Click to expand...

Actually, I am almost certain it is a reincarnation of Kinetic. Look at his word choice, typing style, etc. Although he has been lurking as a registered user since June, I think Kinetic actually stored a few user names up in anticipation of banning. Plus his only posts have been Kinetic-style trolling.

Some days I just like tilting at windmills 😛. I would guess that is a common disorder in EM.

BTW - Check it out ERMudPhud is still following the thread 😀!

I'm done now... I think... 😱

- H
 
FoughtFyr said:
Actually, I am almost certain it is a reincarnation of Kinetic. Look at his word choice, typing style, etc. Although he has been lurking as a registered user since June, I think Kinetic actually stored a few user names up in anticipation of banning. Plus his only posts have been Kinetic-style trolling.

Some days I just like tilting at windmills 😛. I would guess that is a common disorder in EM.

BTW - Check it out ERMudPhud is still following the thread 😀!

I'm done now... I think... 😱

- H
Click to expand...


If it is Kinetic I figured it would only be a matter of time before he starts posting at his old furious rate in the Lounge. Then I noticed the Lounge seems to be gone. Anybody know where it went?
 
ERMudPhud said:
If it is Kinetic I figured it would only be a matter of time before he starts posting at his old furious rate in the Lounge. Then I noticed the Lounge seems to be gone. Anybody know where it went?
Click to expand...

I don't know (where the lounge went - I think it is now it's own site), but someone called him (Kinetic) out on it in the thread.

EDIT: The lounge is at www.drslounge.com

- H
 
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