Reading Chest X-rays

[Quixotic]

Well, I am just starting internship and found out that there is no overnight radiology coverage for plain films. That means we have to read our own chest x-rays and abdominal films. I didn't take a radiology elective during medical school. I am not worried about missing a large pneumothorax or pneumonia, but I don't want to miss more subtle things. I have seen too many residents think they should put in a chest tubes when their apparent pleural line turns out to be a skin fold.

Does anyone have any good suggestions for quick reads and good resources?

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[DrBowtie]

Felson's

 

[Gastrapathy]

Just CT everyone. R/O PE and appy.

 

[deciding]

I used Felson in my radiology rotation as well and it taught me the basics of Chest X-rays. If you are after something that is more portable and has higher fidelity images then try an iBook. One of my friends says his program director is trying radiology iBooks as part of their curriculum this year. Here is a link to the Chest book they are trying. Looks cool, but I haven't used it. I think you can download a chapter for free. Super cheap.


https://itunes.apple.com/us/book/fundamental-chest-radiology/id664902858?ls=1

 

[Arcan57]

Just CT everyone. R/O PE and appy.

If I want to know what the lungs sound like I'll get a chest x-ray. If I want to know what the CXR shows, I'll get a CT...

 

[wickedskillz]

If I want to know what the lungs sound like I'll get a chest x-ray. If I want to know what the CXR shows, I'll get a CT...

Haha

 

[Quixotic]

Thanks for the input. I went ahead and bought the Fundamental Chest Radiology iBook. There was a free chapter I was able to download. The content seemed high yield and it was less than $15 so whatever. The rest of the book was even better. There is an anatomy section that details the lobes of the lungs, vasculature, etc. Makes it seem like reading chest x-rays should be easier. We will see how it goes when I actually have to do it on call.

 

[Bostonredsox]

Well, I am just starting internship and found out that there is no overnight radiology coverage for plain films. That means we have to read our own chest x-rays and abdominal films. I didn't take a radiology elective during medical school. I am not worried about missing a large pneumothorax or pneumonia, but I don't want to miss more subtle things. I have seen too many residents think they should put in a chest tubes when their apparent pleural line turns out to be a skin fold.

Does anyone have any good suggestions for quick reads and good resources?

Learn what the slide sign is. Then stick an US probe on their chest. You'll find your pneumos in real time.

 

[agranulocytosis]

Well, I am just starting internship and found out that there is no overnight radiology coverage for plain films. That means we have to read our own chest x-rays and abdominal films. I didn't take a radiology elective during medical school. I am not worried about missing a large pneumothorax or pneumonia, but I don't want to miss more subtle things. I have seen too many residents think they should put in a chest tubes when their apparent pleural line turns out to be a skin fold.

Does anyone have any good suggestions for quick reads and good resources?

I find this strange. In general, there's always an attending available, even they're not in-house. It's typically a service called NightHawk (read: outsourced) or something like that. All the programs I've been to have had some sort of in-house coverage, but there should be someone available over the phone to review chest films overnight.

Ask your seniors, but my algorithm would be to order the film, look at the study, call the operator and ask for the radiologist on call, then review the film with him/her.

 

[colbgw02]

I find this strange. In general, there's always an attending available, even they're not in-house. It's typically a service called NightHawk (read: outsourced) or something like that. All the programs I've been to have had some sort of in-house coverage, but there should be someone available over the phone to review chest films overnight.

Ask your seniors, but my algorithm would be to order the film, look at the study, call the operator and ask for the radiologist on call, then review the film with him/her.

I've worked under a number of different after-hours models, including one where the overnight radiologist doesn't routinely read radiographs. I have some problems with this, but I digress...

If the workflow is set up this way, it's for a reason. Either the overnight guy's cross-sectional workload keeps him too busy to worry about plain films, or the hospital is trying to keep the razor-thin radiograph profit margins from going to the teleradiologist.

Regardless, given your situation, I would advise against routinely reviewing radiographs with the on-call radiologist. No one ought to mind the occasional curbside about an interesting or difficult case, but if you do it routinely or too often then you'll piss off the radiologist, your hospital's accounting office, or both.

 

[dpmd]

If the workflow is set up this way, it's for a reason. Either the overnight guy's cross-sectional workload keeps him too busy to worry about plain films, or the hospital is trying to keep the razor-thin radiograph profit margins from going to the teleradiologist.

This is our institution. For years we had zero reads at night unless we called in with a good enough reason to drag the guy in from home (they didn't have PACS access at home because they didn't want us to be more willing to call them I think, although problems with resolution and such may have also contributed). Now we have this nighttime radiology thing they are trying and the budget they had decided on for it (I think they meant for it to last the year) was blown in the first few months just from trauma ct's and no plain films or other imaging (except maybe ct angio for pe) being read. We are now back to only getting a read if we really think we need it, but now the person isn't one of the 5 rads guys covering the entire hospital (meaning they are keeping resident style hours if they get called in for anything-hard to imagine why we have a high turnover). Honestly, I would say that by the end of intern year I was pretty comfortable figuring out the important findings for plain films and CTs just because so much was riding on it and because my senior helped me learn. No way I am finding that small lung nodule or some other subtle crap, but pneumo versus not or badness on and abd/pelvis CT I felt good enough to make big decisions like admit or d/c with.

 

[dpmd]

I guess our daytime stuff also was a good learning opportunity because unless you went directly to a rads about it your read often times wasn't done for a couple of days (longer for the CXR's for some reason). The situation is different now with the ED reads getting done same day up to a certain time and the other stuff sometimes being done quickly also. Not sure if they hired more rads (there are new people but not sure if the overall number has increased) or made them work longer or somehow harder (maybe tied pay to production?, or just the new people are faster). The downside to that is now the residents are tending to rely on the reads too much and not looking at their imaging.

 

[nlax30]

We're a community shop and have in house rads coverage usually until about 11 or so. If not in-house until then at a sister hospital across town that shares reading responsibility. After 11pm or midnight there's overnight reads with a teleradiology firm for CT's but not plain films.

I'm sure I could send a plain film to be read but in the past couple years I haven't had to yet. Anything critical enough on a plain film to affect my immediate management overnight on the floor I'm comfortable enough picking up myself.

 

[Bostonredsox]

We're a community shop and have in house rads coverage usually until about 11 or so. If not in-house until then at a sister hospital across town that shares reading responsibility. After 11pm or midnight there's overnight reads with a teleradiology firm for CT's but not plain films.

I'm sure I could send a plain film to be read but in the past couple years I haven't had to yet. Anything critical enough on a plain film to affect my immediate management overnight on the floor I'm comfortable enough picking up myself.

Same here. Overnight they just read CTs. I look at plain films myself. The only times I have had uncertainty about a PTX, I stuck an US probe on them. I suppose I could have sent the chest film out to be overhead by the tele guys on the middle of the night. It if US didn't give me the answer, I probably would just non-con CT them. Can't think of much else I would need overread for emergently on a chest film.

 

[deciding]

I agree, there are only a few things that require immediate intervention for a patient based on radiographic findings. We had two instances. However, it is important for every clinician to be able to read plain radiographs since they don't know where they will end up relative to radiology coverage.

The first case was an arterial placement of a CVC. I know you are saying this should be obvious with pulsatile blood. Well, this patient was septic and hypotensive so it wasn't obvious. Luckily the pt only received fluids until the morning instead of antibiotics directly into the heart. It was the radiologist that suggest the arterial placement. Sure enough blood gases confirmed his suspicion.

The second case was a pericardial effusion with tamponade. The overnight resident thought it was standard cardiomegaly. They didn't review the previous imaging and it turned out to be a pericardial effusion with tamponade. As the pt crumped they called the radiologist and they told them to do an ECHO. Immediately after the ECHO they placed a pericardial drain and saved the patients life.

It doesn't matter what resource you use, just learn the basics of radiographs for the patient benefit.


https://itunes.apple.com/book/funda...y/id664902858?l=ja&mt=11&v0=9988&ign-mpt=uo=1

http://www.amazon.com/Felsons-Principles-Roentgenology-CD-ROM-Goodman/dp/1416029230

 

[Herpeto]

https://itunes.apple.com/book/funda...y/id664902858?l=ja&mt=11&v0=9988&ign-mpt=uo=1

http://www.amazon.com/Felsons-Principles-Roentgenology-CD-ROM-Goodman/dp/1416029230

I second that. Every clinician should be able to look at a chest xray and make the big findings. The janitor can see a lobar pneumonia. But seeing enough images to become comfortable with a pneumothorax and pneumomediastinum only comes with repetition. Have a readily available resource.

The subtle findings are why radiologists train 5 years. Similarly, every radiologist should be able to tell when a patient is doing poorly on their scanner or in the radiology department and know how to deal with it emergently until more experienced help arrives.

 

[Impromptu]

The carina is an important landmark to identify. From there you can pretty accurately assess ETT and central line placement, which are the 2 biggest reasons I got chest x-rays.