Read your CTs, folks.

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RustedFox

RustedFox

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Twice in three shifts now I have had to call the radiologist to point out their mistakes, and it has changed patient care radically.

1. 55 year old fatman. "Its gawtta be muh diverticalosis again, doc." LLQ tenderness. Rebound+. I'm worried about perf. Radiology reads "acute diverticulitis at rectosigmoid junction; no abscess or free air."

*RING RING!*

"Hello? Dr. Mouthbreather? This is Dr. RustedFox. Take a look at Jack Sprat's CT again. You see all that free air around the spleen? Might wanna look again.

Report amended.

2. Just admitted this gal to the ICU. 41 year old female. Thoracic back pain for 10 days. Seen twice by Jenny McJennyson in the outpatient world. "Musculoskeletal pain". "Back muscle spasm". She comes in with 4 lidoderm patches on her posterior thorax. HR = 146. BP = 97/66 (or close). "It hurts when I breathe!" Radiology reads "mild inflammatory lymphadenopathy; likely infectious/inflammatory in nature. No pulmonary embolism or aortic pathology."

*RING RING!*

"Hello? Dr. Scaredofthelight This is Dr. RustedFox. Take a look at this CT angio again. Images 40-52. Large PE in the left side. Might wanna look again."

No joke, guys and girls: learn to read your own CTs. Not comprehensively, but learn to look for the things that you're worried about.
 
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RustedFox said:
Twice in three shifts now I have had to call the radiologist to point out their mistakes, and it has changed patient care radically.

1. 55 year old fatman. "Its gawtta be muh diverticalosis again, doc." LLQ tenderness. Rebound+. I'm worried about perf. Radiology reads "acute diverticulitis at rectosigmoid junction; no abscess or free air."

*RING RING!*

"Hello? Dr. Mouthbreather? This is Dr. RustedFox. Take a look at Jack Sprat's CT again. You see all that free air around the spleen? Might wanna look again.

Report amended.

2. Just admitted this gal to the ICU. 41 year old female. Thoracic back pain for 10 days. Seen twice by Jenny McJennyson in the outpatient world. "Musculoskeletal pain". "Back muscle spasm". She comes in with 4 lidoderm patches on her posterior thorax. HR = 146. BP = 97/66 (or close). "It hurts when I breathe!" Radiology reads "mild inflammatory lymphadenopathy; likely infectious/inflammatory in nature. No pulmonary embolism or aortic pathology."

*RING RING!*

"Hello? Dr. Oujaybatharamalamadingdongndovu? This is Dr. RustedFox. Take a look at this CT angio again. Images 40-52. Large PE in the left side. Might wanna look again."

No joke, guys and girls: learn to read your own CTs. Not comprehensively, but learn to look for the things that you're worried about.
Click to expand...

You need a better radiology group...
 
is it vrad by any chance? Saw a large splenic bleed missed by Vrad that got taken to angio. It appears that sometimes those people are reading so fast they simply ignored to look at all the images (like different phases).
 
RustedFox said:
Yeah.
We ER docs know that when Dr. Mouthbreather and Dr. Scaredofthelight are reading that we need to be vigilant.
Click to expand...

We had a Night rads that always found something that “couldn’t be ruled out” on normal scans. But missed major things on positive scans.

we used “clinical correlation” and brought all these to the rads chair. He is now searching for work elsewhere
 
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Count me among those who have had radiologists miss early appendicitis, free air, PE, etc, and were quite appreciative of the phone call (though interestingly never word the amendment as it happened, but rather, "on further review...").

Hey, radiologists that got lost on their way to their forum and are reading this: I love you guys and happen to enjoy radiology. You have a hard job. So do we. We generate a lot of work (and thus productivity) for you because that's the nature of the beast, and we know we do, so your signal to noise ratio sucks sometimes. We can all see how it happens.
 
Veil said:
Count me among those who have had radiologists miss early appendicitis, free air, PE, etc, and were quite appreciative of the phone call (though interestingly never word the amendment as it happened, but rather, "on further review...").

Hey, radiologists that got lost on their way to their forum and are reading this: I love you guys and happen to enjoy radiology. You have a hard job. So do we. We generate a lot of work (and thus productivity) for you because that's the nature of the beast, and we know we do, so your signal to noise ratio sucks sometimes. We can all see how it happens.
Click to expand...

Also having the clinical correlation is a big deal. You’ve seen the pt and know where they are tender. We see the indication that a lot of the time just says “pain” or “trauma”

honestly some rads throw a fit about that but personally I think you guys are busy as it is so it’s whatever.
 
Our generally put it as an addendum on the top of the report (unless it's a basic dictation error). I appreciate their transparency... since the EMR records all time stamps anyway might as well just be honest.
Veil said:
Count me among those who have had radiologists miss early appendicitis, free air, PE, etc, and were quite appreciative of the phone call (though interestingly never word the amendment as it happened, but rather, "on further review...").

Hey, radiologists that got lost on their way to their forum and are reading this: I love you guys and happen to enjoy radiology. You have a hard job. So do we. We generate a lot of work (and thus productivity) for you because that's the nature of the beast, and we know we do, so your signal to noise ratio sucks sometimes. We can all see how it happens.
Click to expand...
 
And for the residents or Med students who think that they won’t need to do this because they are going somewhere with a good group:

1) you may moonlight
2) sometimes radiology gets destroyed. 8. traumas come in and get panscanned plus all the usual stuff. You’re CT-PE or CT-AP for appy is gonna take a minute.
 
I always look at my own CTs especially when there is high suspicion for badness. One night I looked at the CT and clearly saw acute appendicitis with a huge fat appendix and bubbles of air. Then Dr. Bozo read it as normal. I called up Dr. Bozo and she seemed embarrassed and amended the report. Scary to think that an EP who doesn't look at the CT (most of the ones I work with) would possibly send that person home.
 
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meister said:
Always appreciate a phone call about a boneheaded miss or typo, though I like to think I keep them to a minimum.

It sounds like your radiology group kinda sucks.
Click to expand...

Our good ones left because admin pissed them off.

Also, you have the best avatar pic.
 
doctorsdatdo said:
Also having the clinical correlation is a big deal. You’ve seen the pt and know where they are tender. We see the indication that a lot of the time just says “pain” or “trauma”

honestly some rads throw a fit about that but personally I think you guys are busy as it is so it’s whatever.
Click to expand...
... aren’t you the med student who pretended to be IR faculty on the crit care forum? Back at it again I see...

forums.studentdoctor.net

What’s one thing you wish your IR guys/gal know?

As title. IRs deal with a lot of ICU pts. Are there one or more things you wish to have us know about critical care?
forums.studentdoctor.net forums.studentdoctor.net
 
So many times I have found missed things on CT. Vrad reads are bad, but I've seen missed things from good employed radiologists as well. We aren't perfect ourselves with what we do, neither are radiologists. I've seen missed subdurals, missed appys, pneumos, tons of missed rib fractures on pan-scan patients, etc. You have to remember, we have a clinical context they don't always have. When you work in a place that is doing a ton of trauma pan-scans, and rads is getting indication "Trauma" for 4 CTs, and has no idea where someone is hurting, its easy to miss things. Whereas we can focus in because we know the patient is tender in their left lower ribs for instance. Clinical context is super important.
 
doctorsdatdo said:
Also having the clinical correlation is a big deal. You’ve seen the pt and know where they are tender. We see the indication that a lot of the time just says “pain” or “trauma”

honestly some rads throw a fit about that but personally I think you guys are busy as it is so it’s whatever.
Click to expand...

Everyone agrees on that.

But your misappropriation of words like "we" and "us" when you are a med student speaking to people board certified and many, many years ahead of you, because you vaguely stated in the earlier-quoted post that you "know more than the average med student" and have a IR physician family member, makes people not take you seriously. So if you're trying to be taken seriously, stop doing that.
 
Ok, I had to change a few of the names. It doesn't change the general message, but there were complaints about xenophobia and racism due to foreign sounding names, which is a fair complaint. We need to be careful the message we are portraying to the readers, and do not want to become an echo chamber.

That being said, yes, radiology is full of people, and people are fallible. We could have a thread on "I caught this miss from ________________ specialty" for every specialty out there, simply because of our job descriptions. Similarly, almost every specialty can dump on EM for missing something before admission. We can be a team AND recognize that sometimes people screw up. This is a venting thread, about a few people in one specialty. It's not painting an entire specialty with a bad light.
 
I once argued about a large PTX on a pCXR with a new radiologist who'd interpreted the film as normal and he told me he was looking at the film in real-time and there was no PTX.

Not at all upset by the miss but by the fact he was obviously lying to me as anyone could see the PTX from across the room.

He no longer works with our hospital rads group.
 
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Our rads group is usually pretty good. I don't think they miss much. They do sometimes make some funny mistakes like putting a head scan macro in an abdominal scan.

The biggest actual problem with have with them is a few guys who won't take a stand on anything:

Chest Xray essentially unremarkable. Can't r/o pneumonia, can't r/o CHF, can't r/o PTX, can't r/o gout, lymphoma, St. Vitus Dance. Possibly not a CXR, possibly a painting, maybe a giraffe. Recommend clinical correlation and every other study available.
 
RustedFox said:
Twice in three shifts now I have had to call the radiologist to point out their mistakes, and it has changed patient care radically.

1. 55 year old fatman. "Its gawtta be muh diverticalosis again, doc." LLQ tenderness. Rebound+. I'm worried about perf. Radiology reads "acute diverticulitis at rectosigmoid junction; no abscess or free air."

*RING RING!*

"Hello? Dr. Mouthbreather? This is Dr. RustedFox. Take a look at Jack Sprat's CT again. You see all that free air around the spleen? Might wanna look again.

Report amended.

2. Just admitted this gal to the ICU. 41 year old female. Thoracic back pain for 10 days. Seen twice by Jenny McJennyson in the outpatient world. "Musculoskeletal pain". "Back muscle spasm". She comes in with 4 lidoderm patches on her posterior thorax. HR = 146. BP = 97/66 (or close). "It hurts when I breathe!" Radiology reads "mild inflammatory lymphadenopathy; likely infectious/inflammatory in nature. No pulmonary embolism or aortic pathology."

*RING RING!*

"Hello? Dr. Scaredofthelight This is Dr. RustedFox. Take a look at this CT angio again. Images 40-52. Large PE in the left side. Might wanna look again."

No joke, guys and girls: learn to read your own CTs. Not comprehensively, but learn to look for the things that you're worried about.
Click to expand...

We had one radiology group at our hospital and i would pick up on a bad read about 1/month. I would report them on occasion. Now we contracted with a different group and they seem to get CTs and other stuff right.

Missing “all that free air around the spleen” seems like a no-brainer, that was odd.
 
Veil said:
Count me among those who have had radiologists miss early appendicitis, free air, PE, etc, and were quite appreciative of the phone call (though interestingly never word the amendment as it happened, but rather, "on further review...").

Hey, radiologists that got lost on their way to their forum and are reading this: I love you guys and happen to enjoy radiology. You have a hard job. So do we. We generate a lot of work (and thus productivity) for you because that's the nature of the beast, and we know we do, so your signal to noise ratio sucks sometimes. We can all see how it happens.
Click to expand...

Agreed, and ER docs miss stuff too. I have, you have, RustedFox has, we all have missed stuff.

If we angrily call Rads and say how did you miss this obvious finding...you know you are not gonna get far in life and will have few friends.

We should be nicer to each other. And if one finds a radiologist who regularly misses stuff over and over, then report them
 
the other problem is that to err is human and there is a specific amount of error rate that is unavoidable in medicine.

While error in medicine and ER are often not discovered, surgical mishaps corrected on the spot in the ED or rationalized as unavoidable complications in the form of abscess formation etc, error in radiology are often magnified by the fact that PACS images are saved forever and can be manipulated and magnified after the fact.
Retrospectoscope is real.
 
One of our residency program radiologists (he generally read from our hospital but it's a larger private group) told us he gets irritated when some of his colleagues [sic] "don't have the balls to put it out there even if they're not 100% sure."

On the plus side we have all subspecialty reads so I've never seen a wrong body area template.


.
docB said:
Our rads group is usually pretty good. I don't think they miss much. They do sometimes make some funny mistakes like putting a head scan macro in an abdominal scan.

The biggest actual problem with have with them is a few guys who won't take a stand on anything:

Chest Xray essentially unremarkable. Can't r/o pneumonia, can't r/o CHF, can't r/o PTX, can't r/o gout, lymphoma, St. Vitus Dance. Possibly not a CXR, possibly a painting, maybe a giraffe. Recommend clinical correlation and every other study available.
Click to expand...
 
D*ckheads in medicine is a problem. Luckily we don't have many of them, and it's almost always a specialist we have limited interaction with.
thegenius said:
Agreed, and ER docs miss stuff too. I have, you have, RustedFox has, we all have missed stuff.

If we angrily call Rads and say how did you miss this obvious finding...you know you are not gonna get far in life and will have few friends.

We should be nicer to each other. And if one finds a radiologist who regularly misses stuff over and over, then report them
Click to expand...
 
Radiologists miss things just like we do. So yea, it's good to always read your own studies. Some state medical boards hold you liable for reading/interpreting the study even if it's advanced imaging like an MRI or CT.

I agree you need a better radiology group.
 
Everyone misses stuff, but the best Radiologist are the ones that when you call them about something they may have missed and ask them to re-look at it, they relook at it, acknowledge the miss if you are right and thank you for pointing it out. The worst ones are the ones that get angry that you are questioning them. I’ve had radiologists who missed small subdurals and appys be over the top greatful when called about it. But I’ve also had radiologists act high and mighty.

Case in point. Had a preschool age child with a C1 burst fracture. Axial load injury, wouldnt move their neck. Cspine CT read as negative. There was clearly a C1 burst fracture, I had already consulted trauma when I initially saw the CT waiting for the read. Trauma reviewed the CT as well and was like “Yeah, that’s a C1 burst fracture”. I called the Vrad radiologist, who was angry we questioned him and told me immediately (clearly didn’t relook at it) that it was normal. Transfered the kid to the PICU where he got an MRI that showed.... a C1 burst fracture.
 
TooMuchResearch said:
What is a vrad?
Click to expand...

big telerad company that covers a lot of practices for after hour.

honestly rad practices need to start hiring their own ED partners rather than rely on telerad read. I’ve seen some extremely baffling vrad read myself (and some extremely good ones).

Another big miss that often occur for those folks are cancers, say things like the double duct signs/pancreatic duct enlargement that could suggest presence of pancreatic CA, or pelvic lymphadenopathy, or subtle lytic lesions or lung masses. Granted those can be more difficult to pick up for those who did not have rad training.
 
TooMuchResearch said:
Oh, yuck. I'll keep counting my blessings, great 24/7 subspecialty radiology coverage by a local group being among them.
Click to expand...

I'm in the same boat. I'm very fortunate to have 24/7 attending radiologists read everything (including plain films) very timely. Even have 24/7 neuroradiology reading our neuro stuff. Out of a large group (30-50 radiologists), maybe 2-3 aren't fellowship trained.
 
thegenius said:
Agreed, and ER docs miss stuff too. I have, you have, RustedFox has, we all have missed stuff.

If we angrily call Rads and say how did you miss this obvious finding...you know you are not gonna get far in life and will have few friends.

We should be nicer to each other. And if one finds a radiologist who regularly misses stuff over and over, then report them
Click to expand...


Totally, let he who is without a clinical miss cast the first stone. I've picked up a couple things on CTs that the rads miss, mostly rib fractures and once an appy (to be fair it was a borderline CT call but the patient's presentation was out of a textbook), but like Gamer said, that's because they're reading the whole CT and I'm hyper focused on the right anterior chest wall where the patient has tenderness and ecchymosis. But to be fair I blow by the 4 incidental pulmonary nodules that are actually probably medico-legally the highest risk thing on the CT. But yeah, free air seems especially egregious.
 
Had our Neuro guys miss a pontine glioma recently on a 18 y/o. Called them up and asked him to take another look at the brainstem. He changed his read immediately. MRI noted 8x4x4cm pontine mass. Being a radiologist isn't easy. Glad I didn't go that route.
 
I think even a good radiologist will miss the occasional free air if they have no idea what they're supposed to look for other than "rule out intra-abdominal pathology."
SamtheWise said:
Totally, let he who is without a clinical miss cast the first stone. I've picked up a couple things on CTs that the rads miss, mostly rib fractures and once an appy (to be fair it was a borderline CT call but the patient's presentation was out of a textbook), but like Gamer said, that's because they're reading the whole CT and I'm hyper focused on the right anterior chest wall where the patient has tenderness and ecchymosis. But to be fair I blow by the 4 incidental pulmonary nodules that are actually probably medico-legally the highest risk thing on the CT. But yeah, free air seems especially egregious.
Click to expand...
 
TooMuchResearch said:
I think even a good radiologist will miss the occasional free air if they have no idea what they're supposed to look for other than "rule out intra-abdominal pathology."
Click to expand...
So much this. If you want an accurate read give an accurate indication. It’s funny reading people saying that the radiologist was obviously disadvantaged because they didn’t know to look where the patient was hurting. They only don’t know that because your ordering system somehow doesn’t give them that information.

That said anyone that doesn’t actually look at the study again when alerted to a potential miss is crazy. Interactions between different medical specialists having an adversarial tone makes no sense. Just be polite about it, don’t lie and admit when you don’t know something and ask questions.
 
I think a radiologist missing free air in the abdomen is akin to an ER doctor missing a STEMI.

Shouldn't happen.

Missing an occasional rib fracture, or colitis or something is no big deal though.
 
doctorsdatdo said:
big telerad company that covers a lot of practices for after hour.

honestly rad practices need to start hiring their own ED partners rather than rely on telerad read. I’ve seen some extremely baffling vrad read myself (and some extremely good ones).

Another big miss that often occur for those folks are cancers, say things like the double duct signs/pancreatic duct enlargement that could suggest presence of pancreatic CA, or pelvic lymphadenopathy, or subtle lytic lesions or lung masses. Granted those can be more difficult to pick up for those who did not have rad training.
Click to expand...

Dude. Why do you keep holding yourself out to be an expert on radiology as a Med student. Why are you talking about what can be difficult to pick up for those who don’t have radiology training when you don’t have radiology training. I don’t care if your Dad is an IR doc - your opinion on how a hospital contracts for PM radiology is of no consequence.
 
thegenius said:
I think a radiologist missing free air in the abdomen is akin to an ER doctor missing a STEMI.

Shouldn't happen.

Missing an occasional rib fracture, or colitis or something is no big deal though.
Click to expand...

Yea. But not all STEMI a are tombstones and not all free air is massive.
 
TimesNewRoman said:
Yea. But not all STEMI a are tombstones and not all free air is massive.
Click to expand...

small loculated free air from self contained diverticulitis perforation can be very difficult to see. Many rads do not pay attention at the base of the diaphragm. Chest rad think they belong to abdomen and abdomen rad think they belong to chest....
 
Gotta respect the commitment on some level. They just keep on dropping rads knowledge bombs left and right in the thread, despite the multiple call outs.


TimesNewRoman said:
Dude. Why do you keep holding yourself out to be an expert on radiology as a Med student. Why are you talking about what can be difficult to pick up for those who don’t have radiology training when you don’t have radiology training. I don’t care if your Dad is an IR doc - your opinion on how a hospital contracts for PM radiology is of no consequence.
Click to expand...
 
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TimesNewRoman said:
Yea. But not all STEMI a are tombstones and not all free air is massive.
Click to expand...

ER docs should not miss STEMI. Period. It’s based on criteria.

I think what you mean is that there are some pts who have occlusive MI who don’t have STEMI, and those are harder to detect. Those patients are usually admitted and have delayed angiography and PCI to the patients detriment.

But ER docs should never miss STEMI.

And radiologists should not miss intraabdominal free air. If the radiologist isn’t sure, they can easily pick up the phone and call the doc who ordered the CT and talk to them about it. That is the equivalent of an ER docs talking to the cardiologist about subtle EKG findings. And you make a collective decision together.
 
Remember at the end of the day it’s the radiologists job to identify abnormal findings of the imaging study, and for the ordering doc to determine the significance of those findings. If it’s “there might be a few droplets of free air in the sigmoid colon in the setting of having acute sigmoid diverticulitis but it is hard to tell”, that is OK to say. I don’t fault rads on saying that. It can be hard to tell. It’s our job to risk stratify those patients and determine what to do with them, whether to call surgery, etc.
 
thegenius said:
ER docs should not miss STEMI. Period. It’s based on criteria.

I think what you mean is that there are some pts who have occlusive MI who don’t have STEMI, and those are harder to detect. Those patients are usually admitted and have delayed angiography and PCI to the patients detriment.

But ER docs should never miss STEMI.

And radiologists should not miss intraabdominal free air. If the radiologist isn’t sure, they can easily pick up the phone and call the doc who ordered the CT and talk to them about it. That is the equivalent of an ER docs talking to the cardiologist about subtle EKG findings. And you make a collective decision together.
Click to expand...

again “free air” comes with all shapes and varieties. If the reading rad don’t bother going through the abdomen/pelvis again with lung window toggled it’s entirely possible for them to miss very small loculated free air. Not to say it’s ok, but it can happen.
 
TooMuchResearch said:
I think even a good radiologist will miss the occasional free air if they have no idea what they're supposed to look for other than "rule out intra-abdominal pathology."
Click to expand...
Point well taken. I try to enter a helpful reason but sometimes I'm busy or lazy just like everyone else. I do think that my EMR/Ordering system buries by reasons. If I choose an item off the drop down it's easier for them to see but if I choose "Other" and enter an actual description in the free text box I don't think my rads see it unless they really look meaning click through some menus to see it.

It also seems like it's harder to get the techs to do stuff to point out things on plain films. We used to have radio opaque dot stickers we could put near abscesses or wounds to try to help. We used to tape paper clips with one leg pointing at what we were trying to look at. I've been told we just don't do that any more.
 
thegenius said:
ER docs should not miss STEMI. Period. It’s based on criteria.

I think what you mean is that there are some pts who have occlusive MI who don’t have STEMI, and those are harder to detect. Those patients are usually admitted and have delayed angiography and PCI to the patients detriment.

But ER docs should never miss STEMI.

And radiologists should not miss intraabdominal free air. If the radiologist isn’t sure, they can easily pick up the phone and call the doc who ordered the CT and talk to them about it. That is the equivalent of an ER docs talking to the cardiologist about subtle EKG findings. And you make a collective decision together.
Click to expand...

Should never and will never are different. I have not missed a STEMI but I know good docs who have, particularly inferior. When you get handed your 20th EKG in a shift where you’ve seen3 pph, I see how it can happen to a good doc.
 
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