Reading CTs: essential skill?

[Janders]

I think we're pretty much on the same page, but are you saying that you critically look at a CT that you order and make decisions based on your read alone? Bc if you do, then yea you should learn how to read imaging (this may be true if you're in a rural area). If you always wait for the final read before discharging or calling up to admit though, then I still feel like the hours your put in studying are better used on other things since your management is independent of your read. Right? I would put most people in that category.
...
What I'm trying to say is that your management doesn't change based on how well you can interpret images (POC ultrasound excluded), so why spend all that time trying when you could get better at something else? I don't re-interpret pathology slides from my biopsies or go talk to ER patients to check your h/p's. I just trust that my colleagues are better at it than me and think that my time is better spent getting smarter at what I do instead of what my colleagues do. And I don't buy the 2 examples you gave because of above and I think they're only loosely related to what we're talking about.

As one of the earlier members of this thread, who strongly encourages ED physicians to be at least semi-competent at the emergency interpretation of basically all imaging they order...

I ABSOLUTELY make decisions including medications, transfusions, emergent consultation, and transfer based entirely and solely on MY read of CT imaging (and X-ray, and bedside U/S) prior to getting a final read. Now this doesn't mean I am equal to a real radiologist at reading torso CT! ESPECIALLY if you are getting into specifics like differentiating types of hepatic masses, etc. But that is not what I care about. I care about-- Holy **** there is a huge RP bleed! Yep thats a Type A dissection alright. Oh yeah, big SBO with a transition point, look how big that stomach is. Hey, thats a classic appy. Oh look at those rib fractures and pneumohemothorax. Wow a SDH with 1cm of shift, give-or-take. Ah, classic diverticulitis. Oh ****, its diverticulitis but there is a lot of free air.

I work in a small-medium ED in a smaller hospital near a bunch of meccas, and with virtual radiology I typically wait 1hr for reads but I've had common periods of 2-3hr waits. For many specialties, I am calling and arranging stat-transfer for true emergencies, and waiting 1-2hr to do this is just crap medicine, pure and simple. I may not personally ex-lap someone from my read of perforated diverticulitis with air all over the belly, but I absolutely get broad abx and my surgeon inbound based on my read...

Basically, the more emergent, time-sensitive, and obvious the pathology, the more frequently I act on my reads.

Chest pain with severe hypotension, repeated syncope, and tube-oh-truth shows saddle PE with an RV twice the size of the LV... I mean I can immediately act on that or wait 90min to get a phone call and get to listen to that relaxing hold music for a couple minutes

Even in the absence of immediate life-threatening pathology, I get the ball rolling with my consultants if there is clearly something that requires them (appy, SBO, acute chole, etc).

Then, separately from this expedience advantage, there are the added benefits of:
(1) Two sets of eyes, less misses [I can make a list of missed emergent conditions that would boggle your mind]
(2) I've touched the patient, I've talked to the patient, I've seen the labs, I have certain advantages, less misses
(3) CT is freaking cool, and I like looking at it... just not for 8hr straight.

Of course I read all X-rays for 12hr a day everyday, so those always are acted on prior to a final real...

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[BoardingDoc]

I think we're pretty much on the same page, but are you saying that you critically look at a CT that you order and make decisions based on your read alone? Bc if you do, then yea you should learn how to read imaging (this may be true if you're in a rural area). If you always wait for the final read before discharging or calling up to admit though, then I still feel like the hours your put in studying are better used on other things since your management is independent of your read. Right? I would put most people in that category.

POC ultrasound is different than what I do and not a great analogy. FAST exams are def not my thing either. For example, if the patient's labs are fine and their history and exam is not concerning and you don't see anything grossly wrong on your POC ultrasound, then that's a good thing and 99% chance they wouldn't benefit from a formal ultrasound. I don't think you should stop doing those. That stuff helps improve efficiency and triage. I'm saying that I think if you see something in the GB that's not normal, you don't just treat. You order a formal US. Right?

In small town Alabama, you're probably going to reduce and cast. In NYC, you may call ortho resident to come reduce and cast. In between sized ER dept, you may just reduce and splint. But either way they follow up with ortho who either re-reduces if you've done a crappy job, casts if you've done a good job and it's non-operative, or even re-casts if there's been a big time interval and the swelling has gone down so they can get a better cast than when the patient saw you, or book the patient for surgery. In a couple of those scenarios, you doing a good reduction and splint helps. So I think you should continue to reduce and splint.

What I'm trying to say is that your management doesn't change based on how well you can interpret images (POC ultrasound excluded), so why spend all that time trying when you could get better at something else? I don't re-interpret pathology slides from my biopsies or go talk to ER patients to check your h/p's. I just trust that my colleagues are better at it than me and think that my time is better spent getting smarter at what I do instead of what my colleagues do. And I don't buy the 2 examples you gave because of above and I think they're only loosely related to what we're talking about.

I don't think any of us are reading our own CTs and DCing the patient if we think they're negative. That said, if someone has a PE on the CT which is readily apparent and my nighthawk reading service is taking forever... yes, I'll start heparin and admit and just tell the hospitalist to followup on the complete read when it's available.

If I see a small area of free air on an Abd CT, I'm going to call surgery right away instead of waiting on a read. Blood on a noncon head? I don't need to wait for a formal read to start mgmt. Etc etc etc. All of that said, I feel like everything I mentioned is something that we all learned how to do during an EM residency (hopefully).

Edit: typos.

 

[Groove]

That's a good book.

I'd like to caution you about looking at it yourself, then reading the report. What I see as a radiologist is not what I put in the report. And if you come back and talk to me, I may come down harder on or against some things that I just can't put in writing. I blow off a lot of things, downplay some, don't mention others and word play quite a bit depending on what I think should be done for the patient. For example, "disc material is abutting the exiting nerve root" or "disc material is impinging on the left S1 nerve root. Correlate with a left S1 radiculopathy". Using hyperbolic words like "obliterating" the perineural fat instead of using the word "encroaching". Words like "almost certainly benign" or "cancer until proven otherwise". And of course, I miss things too. Miss stuff every day. Every radiologist does. So just because it's not in the report, doesn't mean what you're seeing isn't real.

Thanks for your contribution to the thread. It's always helpful having the perspective of other specialties in here. That being said, I think you probably have a very poor understanding of our specialty and that's perfectly fine. I agree completely with Jander's response and would encourage you to read it. The short answer is that we absolutely do make immediate management decisions based on our own interpretation of imaging studies. Read his examples. I can't count how many PE's I've started heparin on before the radiologist has given me a call or how many neurosurgeon's I've called for an SDH, ICH or SAH prior to radiology's call back. It's also standard of care in our specialty to possess a fundamental proficiency in interpreting XR and CT. Now, there's absolutely no reason to feel defensive of your turf as we will never be as proficient as you are in diagnostic radiology. Nor do we as emergency physicians need to choose between being "below average" in radiological interpretation and "above average" in emergency medicine. Believe it or not, it's actually very easy to be an expert in emergency medicine and pretty good (for a non-radiologist) at interpreting x-rays, CT's and ultrasounds. That being said, I rely heavily on the diagnostic interpretation of my radiologists. We couldn't function without you guys and aren't looking to obtain the level of mastery that you guys possess. I'm very cognizant and sensitive to the radiologists' inability to correlate a study with something as tangible and concrete as a basic history and physical exam which is why I am liberal in the comments under "reasoning for exam" so that they can take that into context.

Another reason to possess these skills, which you've already touched on, has to do with the reality of non academic/community practice which is that I don't have quality reads 24/7. My radiologists don't want to dictate full reports after 9pm, so they read from their home computer over their home internet connection and type 1 or 2 lines in a preliminary "wet read" report. Sometimes the report has nothing more than a few letters or "NAF". Prelim reads are between the hours of 9pm and 7am at which point they have an in house radiologist over read the night reads and provide full dictated "final" reports. We can't get a nighthawk service because the radiology group would have to pay for it and they are already contracted to provide all radiology services for our two hospitals. We've been fighting for full 24/7 reads for a few years now and slowly been making progress but as you can see, having a radiologist in house 24/7 is wishful thinking in many community hospitals (even busy ones like ours).

 

[deleted109597]

I would like to point out that I don't work in a hospital where ortho comes down and casts patients. I would bet 95% of us are the same. Hell, I've never worked anywhere that ortho came down and casted.

 

[BoardingDoc]

I would like to point out that I don't work in a hospital where ortho comes down and casts patients. I would bet 95% of us are the same. Hell, I've never worked anywhere that ortho came down and casted.

They didn't even do that at the tertiary care center where I trained. The only place I've ever seen it happen is in a large pediatric hospital in their ED.

 

[RadsGuy]

Well I knew it'd be controversial when I sent it. Not why I sent it btw.

Again, I think we're still mostly on the same page but pretty much everyone who responded misread my comments.

1. I said multiple times that you should look at your own images and if you look at my comment on #47 of this thread you'll see that I'm in agreement with your comments about the value of you looking at your own imaging:
"I think the real advantage of you knowing how to look at scans is that sometimes when the rads get behind, it helps when you look at the studies and let us know that something is really wrong (massive bleed) and needs to read sooner rather than later. I have personally, unfortunately, sat on perforations and bleeds for over an hour because the volume is too much to keep up so it helps to have you looking as things come off. The CT and MRI techs help us out too with this because they can see the images as they come off and they usually call and say, "hey the images are only have done but you may want to take a look at this, it looks messed up".

2. I said "ortho resident", not ortho attending. Ortho attendings don't come down to cast, but the ortho interns at many hospitals certainly do.

So, again, I agree that you should look at your own images bc if there is an OMG finding, then it's good to either call radiology, start treatment, or both. That's good medicine. Turn around times exist I admitted that I've sat on major findings for over an hour bc it's busy. And I also readily admitted that I miss things every day. ER docs have picked up things that I've missed no doubt.

What I take issue with is the approach. Get good enough to see the obvious things that roll through the ER (appy, dissection, SBO, PE, etc.), but beyond that, I don't think it's worth your time to get into the weeds with radiology. NO ONE gave that advice. Everyone said you should learn how to read imaging, but nobody commented on the stopping point where it's probably not to your benefit. Nobody cautioned against the false sense of security that some docs get by looking at their own imaging and discharging the patient or calling the wrong admitting team (yes this happens, you must admit that). Just 2 weeks ago, and ER doc gave thrombolytics to a patient she thought had a massive PE and called in IR for emergent catheter directed thrombolysis. Guess what, normal Chest CT with respiratory motion artifact. I'm not making this up. There's no hurt ego. There's no turf war. I want you to look at your own imaging. I just think you should slow down a bit because it can lead you down some terrible paths. Even in this thread someone talked about right heart strain on a CT. 99.9% ER CTs are not cardiac-gated and all the papers about right heart strain are on cardiac-gated CTs. So don't make that call on CT because it could just be normal cardiac cycle. Get an Echo if you think there's right heart strain. Right heart strain on CT is mostly academic, but not practical.

Janders did admit that you look at imaging because it's cool. I think that's a big reason why people do it, not because they think they're going to see anything different or better, but because it's cool. And I'm ok with that as long as we're being honest about why we do it.

 

[Groove]

Oh c'mon man...we've all got examples like that. If I had $20 for each of the times I've called rads back to add an addendum for something they've missed, I could pay for my next ski trip. Everyone makes mistakes. All specialties. Ours is no exception. That's no reason not to try to read your own CT. I fail to see the cautionary logic for not putting in time to gain additional mastery of CT. We're emergency physicians so it's obviously beyond useful for us to be able to spot things as early as possible. Plus, learning and expanding ones knowledge base is the beauty of medicine. There's always something that we can become better at... For many of us, it's that challenge that keeps things interesting. Yes, many times if I spot something I'm calling up rads immediately to verify. That's the usual process for us though there's always some exceptions.

You do realize that neurology and neurosurgery read their own CTs right? The same goes for general surgery. Why is it so alarming that we do the same in the ED?

P.S. I can't remember the last time I saw an acute fracture casted in the ED. Do you mean splint?

 

[meister]

Thread’s not very controversial. EM residents should absolutely get comfortable recognizing emergent CT pathology, the more emergent the more you should be familiar with it. Particularly since some of you apparently aren’t lucky enough to have my group reading for you with 24/7 final reads with 30 minute TATs. Radiologists should take note that the longer your reads take, the less reliant on them people get.

 

[turkeyjerky]

What I take issue with is the approach. Get good enough to see the obvious things that roll through the ER (appy, dissection, SBO, PE, etc.), but beyond that, I don't think it's worth your time to get into the weeds with radiology. NO ONE gave that advice. Everyone said you should learn how to read imaging, but nobody commented on the stopping point where it's probably not to your benefit. Nobody cautioned against the false sense of security that some docs get by looking at their own imaging and discharging the patient or calling the wrong admitting team (yes this happens, you must admit that). Just 2 weeks ago, and ER doc gave thrombolytics to a patient she thought had a massive PE and called in IR for emergent catheter directed thrombolysis. Guess what, normal Chest CT with respiratory motion artifact. I'm not making this up.

Man, I consider myself a little (over)confident sometimes, but that's crazy. Ive transferred plenty of head bleeds based on my own read, but always call our rads before initiating treatment on something harder to read like a CTA. Also, why would they both give TPA and call IR, isn't it usually one or the other.

Jesus Christ, that must have been some artifact. I have to imagine she got canned for that one. The look on her face must have been hilarious

 

[deleted109597]

Everyone said you should learn how to read imaging, but nobody commented on the stopping point where it's probably not to your benefit. Nobody cautioned against the false sense of security that some docs get by looking at their own imaging and discharging the patient or calling the wrong admitting team (yes this happens, you must admit that).

I frequently do. Sometimes the teleradiologist takes an hour to read it. If I see free air, or ICH, or any number of things I can identify, I can have them going away within 20 minutes.
I'm not taking about exact measurements of kidney stones, and I don't discharge anybody that I'm reading their CT as negative, only positive findings.

Guess we will have to agree to disagree.

 

[RadsGuy]

Man, I consider myself a little (over)confident sometimes, but that's crazy. Ive transferred plenty of head bleeds based on my own read, but always call our rads before initiating treatment on something harder to read like a CTA. Also, why would they both give TPA and call IR, isn't it usually one or the other.

Jesus Christ, that must have been some artifact. I have to imagine she got canned for that one. The look on her face must have been hilarious

She called IR to come in before even ordering the CT because the patient was hypotensive. IR said they're coming in because the doc was so worried on the phone and painted a pretty dire picture. She then got the CT and of course the patient was 300lbs so the CT was terrible and there was respiratory motion. I think she thought that the patient was gonna die anyways, so why not blast the tPA?

We all miss things. There are good misses and bad misses though. And I've had my fair share of bad misses so not trying to talk down to anyone.

 

[RadsGuy]

Oh c'mon man...we've all got examples like that. If I had $20 for each of the times I've called rads back to add an addendum for something they've missed, I could pay for my next ski trip. Everyone makes mistakes. All specialties. Ours is no exception. That's no reason not to try to read your own CT. I fail to see the cautionary logic for not putting in time to gain additional mastery of CT. We're emergency physicians so it's obviously beyond useful for us to be able to spot things as early as possible. Plus, learning and expanding ones knowledge base is the beauty of medicine. There's always something that we can become better at... For many of us, it's that challenge that keeps things interesting. Yes, many times if I spot something I'm calling up rads immediately to verify. That's the usual process for us though there's always some exceptions.

You do realize that neurology and neurosurgery read their own CTs right? The same goes for general surgery. Why is it so alarming that we do the same in the ED?

P.S. I can't remember the last time I saw an acute fracture casted in the ED. Do you mean splint?

Casted by FP docs who work in small town ERs in middle of nowhere Iowa.

 

[RadsGuy]

Guess we will have to agree to disagree.

I think you get my point though

 

[deleted109597]

Casted by FP docs who work in small town ERs in middle of nowhere Iowa.

Still doesn't happen. We don't cast people with early fractures. We splint them.
Also, not every hospital has ortho residents or interns. I've worked in exactly 1 hospital that has them actually.

This has been a reasonable discussion, but it's starting to get into a fair amount of he said/she said. It's irrelevant.

For the record, CT interpretation is required on your oral boards, and there are plenty of questions on the written boards pertaining to them as well. It's part of our job. Learn it.

 

[deleted859535]

For the record, CT interpretation is required on your oral boards, and there are plenty of questions on the written boards pertaining to them as well. It's part of our job. Learn it.

A good point. For the folks who haven't taken the boards yet: core EM bread and butter radiologic diagnoses are fair game. This shouldn't be a big deal by the time you are taking boards.

 

[Groove]

Casted by FP docs who work in small town ERs in middle of nowhere Iowa.

Sloppy and weak. I'm also still doubtful. Most FPs have no idea how to put on a cast. Hell, most FM residents that I've taught how to splint struggle big time because they have little to no formal training for orthopedic injuries. If these guys are indeed placing casts over acute fractures then they either must love compartment syndromes or ridiculously loose fitting and worthless casts. That also tells me they aren't consulting ortho for any of their fractures which is also unusual. There's no way an orthopod is telling them to cast an acute fracture.

 

[VA Hopeful Dr]

Sloppy and weak. I'm also still doubtful. Most FPs have no idea how to put on a cast. Hell, most FM residents that I've taught how to splint struggle big time because they have little to no formal training for orthopedic injuries. If these guys are indeed placing casts over acute fractures then they either must love compartment syndromes or ridiculously loose fitting and worthless casts. That also tells me they aren't consulting ortho for any of their fractures which is also unusual. There's no way an orthopod is telling them to cast an acute fracture.

The more rural FM programs will do their own casting, but that's in the office 1-2 days after injury.

 

[RadsGuy]

The more rural FM programs will do their own casting, but that's in the office 1-2 days after injury.

You're right. That's what I meant. I didn't get the reference in the first few comments and had to re-read my original post.