Podcast #125 - Check All Images
The department is busy and you want to keep the flow running smoothly. It is easy to cut corners when it comes to imaging. After all, a radiologist will be reviewing those images. If you are lucky, those images will be read within minutes of them being taken. Why then, should you review those images that you ordered?
It is rather straightforward in a sense. If you ordered the images, you are responsible for that test just like any other test you order. However, we have the benefit of another individual that can potentially review our test in real time. Like any other human though, they are at risk to make errors.
Redundancy in medicine can be beneficial with certain high risk processes. This can be seen in varying forms such as checklists including handoffs. In this case, the redundancy is a second set of eyes. In many cases, we have the benefit of knowing the clinical picture whereas the radiologist may have some information but rarely enough to correlate the images taken with what is present on assessment.
The ordering clinician can review the images obtained for a couple of reasons. One is to rapidly identify pathology and use information from the imaging to correlate with the rest of the assessment. This can be extended to also look to see if anything was missed by the radiologist. Another reason is to also better understand in the future what was found to better interpret images in the future.
You may be curious about reviewing what the radiologist has already read to see if anything was missed, but human error is prevalent with radiology just like any other medical specialty. This can be worse when studies are sent out to overnight reading services. Another problem is when we order images that focus on a large area although our primary concern is focused to one or a few places. Although many of the missed findings in the setting of whole body CT after polytrauma are not significant, over 85% of them were missed on the initial imaging. Another example from the pediatric orthopedic setting found that both the orthopedic surgeon and the radiologist could miss important findings on imaging with 1.0% and 1.7%, respectively. Radiologists have attempted to come up with strategies to reduce errors, but none are universally accepted. There is a very recent article that specifically discusses this with residents reviewing CTs of the abdomen and pelvis.
What do you do when you start reviewing your imaging and you think you do find an error? This is a great time to reach out directly and ask them to review the images with you. You may very well find that there is specific reasoning for why they read the imaging a particular way or that they did not focus on that part of the imaging study. This should be an open and cordial discussion.
If you are entirely new to reading imaging, there are plenty of courses you can take including at conferences. However, another option is to reach out to your local radiologists and see if you can spend time with them. Another option is working with specialists who read their own images and get their specific feedback. Finally, you can work with your colleagues if they are experienced with imaging. Although it is a separate topic, point of care imaging like bedside ultrasound can significantly improve diagnostic abilities especially in learning ultrasound.
No matter the approach, they key is to learn and start reviewing all the images you order. In emergency medicine, this should be common practice. Even when shifts are busy, we can find things on imaging that the radiologist could easily miss. This is even more problematic with findings that are relatively straightforward but have significant consequences such as an intracranial hemorrhage. As we move into the new year, consider adding this as a resolution.
Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook. Remember to look us up on Libsyn and on iTunes. If you have any questions you can also comment below, email at email@example.com, or send a message from the page. We hope to talk to everyone again soon. Until then, continue to provide total care everywhere.
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