Radiology, Consults, Consult Corner

Consult Corner Radiology

How often do you call radiology for assistance? Learn how to present your case in the most efficient, professional manner — and how to avoid any pitfalls. Bradley Strout, MD, assistant professor of radiology at UT Southwestern Medical Center, offers insight into the specialty.

EM Resident: What is the most effective way to present a case to a radiologist over the phone?

The phone calls I receive from the ED are most often requests for advice on the best exam to order for a patient, requests for an over-read on an outside exam that the patient brought with him, requests for a delayed or missing read on an urgent exam performed today, or requests for clarification on an existing report. Please understand that frequently I am already dictating a case when I receive your phone call. If I am interrupted in the middle of a complicated exam, I may be trying to juggle listening to your request without derailing my train of thought on my current case. Simple requests for advice and quick radiograph reads are minimally disruptive. However, I may need to complete the dictation I have open before I can devote my total attention to a new CT, MRI, or ultrasound on a different patient. I might ask you to call back in 5 minutes, or I may ask for your phone number so that I may call you back when I have looked further into your request. A courteous, friendly, and professional phone-side manner will more quickly get you what you are seeking.

EM Resident: What basic workup would you like completed prior to being called?

When I receive a call, I want to know in one breath why you are calling. I need to make a decision either to stay with my current task and call you back, or mentally switch gears to help you and potentially lose track of what I was doing before you called. Please don't try to give me a patient's complete history and physical over the phone; it can cause information overload. A good example is the following: “My patient is having abdominal pain and I am worried he might have diverticulitis but cannot receive contrast due to elevated creatinine. Will a non-contrast CT be sufficient, or is there a better alternative you can suggest?”

If you call me to review a radiology exam, I appreciate it if you have already looked at the images or the report and are calling me for clarification.

If you need an over-read of an exam from another facility, I prefer that you have read the report from the outside exam and that you to explain why you need an over-read. When an exam is read a second time, the patient gets billed a second time; also, over-reads are just as time-consuming as an exam performed in-house. If, for example, a patient is being brought in with an outside diagnosis of acute appendicitis, explain why the report from the outside radiologist is deemed insufficient for your needs.

EM Resident: What do you consider to be urgent or emergent requests?

I generally consider it reasonable to request an emergent radiology exam if it will lead to a decision to admit or discharge the patient today, such as if the suspected diagnosis would lead to surgery today, or if the results of the exam will otherwise impact the patient's care received today. I do not like to see CT or MRI exams ordered “STAT” out of the ED to evaluate for interval change of a known indolent, slowly progressive disease such as spread of cancer. Neoplasia would be best followed with scheduled outpatient exams, or with a “routine” rather than “STAT” urgency as an inpatient.

EM Resident: What are some common radiology exams that an EM resident should feel comfortable reading?

I expect all physicians to be able to interpret a basic radiograph. Non-radiologists should be able to tell if an ED patient has large pneumonia, moderate to large pneumothorax, probable bowel obstruction, or displaced bone fracture. A physician should be able to place a catheter, tube, or drain into a patient and then be able to look at a subsequent radiograph to tell if the catheter is correctly positioned. Most catheters/lines are radiopaque and easily seen on a radiograph from across the room. If the radiograph is difficult to interpret or the suspected diagnosis is subtle, please call me and I will happily discuss the image with you — but make sure you at least tried and looked at it first.

EM Resident: Top 3 Ž pet peeves?

  1. It is not appropriate to shotgun-order multiple exams from different modalities for the same indication. For example, all too often I encounter requests for CT of the abdomen and pelvis at the same time as a request for an abdominal ultrasound — both for the indication of abdominal pain. If the diagnosis is made on the first exam, the hospital loses money and/or wastes resources with further imaging.
  2. I think that non-radiologists sometimes forget that radiology is a type of consult service. At night when I am the only radiologist on duty, I am in charge of the department, and I am legally responsible for the exams performed. It is my duty to decide if a radiology request is reasonable and safe for the patient. Unfortunately, I don't always have all the necessary information about the patient's illness when a computerized request comes to my attention. If we have a conflict of opinion, I invite you to call me so that we can have a discussion regarding the necessity of the requested exam.
  3. All too often I am asked to give a quick, over-the-phone impression of a radiograph. No problem! For me, a radiograph is a very quick interpretation; almost the moment it comes up on the computer monitor, I have a pattern-recognition first impression. This is not the case with multi-image exams like CT, MRI, and sometimes ultrasound. These exams encompass a thorough search of all organs, a time-intensive evaluation where I may not arrive at a complete impression until I have reached the end of a dictation. If you wish to ask me a pointed question such as “Does he have a ruptured appendix?,” I will interrupt the exam I am currently dictating and gladly look at your case to answer your question. But, if you call me up and ask me to read a CT or give an impression on a CT I have not yet seen, I will likely tell you I will read that exam next, after I have concluded the one already in progress.

EM Resident: Other pearls of wisdom for emergency medicine residents?

    1. Get to know your radiologists in person. Establish a friendship or at least a professional relationship. If you and your radiologists see each other as real people, you will develop a measure of trust and respect for each other, which will translate into better patient care.
    2. Please tell me the indication for the exam, not what you think might be the diagnosis. For example, a good indication for a CTA Chest is chest pain or shortness of breath. Don't give me an indication of “Rule out PE.” I am already going to evaluate for PE; that is one of the most important things we look for when we read a CTA Chest. The billing department needs a solid indication order to submit a bill to the insurance provider.
    3. Chest radiographs are often terrible. We have had them for well over 100 years, but that doesn't make them good. I have seen radiographs that looked clear, but CT exams performed later the same day showed a lemon-sized tumor of the posterior lung base, or a moderate-sized pleural effusion, or a multifocal pneumonia. Chest radiographs are quick, cheap, and low radiation. They are a reasonable starting point when working up a patient, but they may have poor sensitivity compared to CT or MRI.