The Radiologist Examined a Patient!

Those of us in the medical field know the radiologists – the doctors who read xrays, CT’s, etc. – usually sit in their dark room all day and read films, often times with CYA statements at the end of their official report that say something like, “_____ cannot be excluded, and so a [another imaging study inserted here] would be recommended …”.  The type of person who typically goes into radiology is a person who doesn’t much like dealing with other people, and so they only “see” patients when, and if, they have to do a procedure, or if they pass them in the hall. It is rare that I even have the chance to discuss my clinical exam with a radiologist since they don’t usually seem to care about our seemingly worthless thoughts.

But in my hospital, I have the great honor (doesn’t always feel that way) of working with some of the smartest doctors in the world when they moonlight here away from their Ivory Tower. Their hospital is internationally recognized as one of the best medical centers in the world. Among this distinguished group are the radiologists that will moonlight here on weekends. I have to say that some of them have their nose so stuck up in the sky that we only look like ants to them, and that is how they speak to us. But something cool about medicine is that experience almost always trumps medical training. There are many nurses I would rather have treat me that some of doctors I have had the horror to meet.

So, last week I came into work and my first patient was a poor old woman who was run over accidentally by her husband with a farm tractor. I called to request a CT of the chest, concerned about flail chest and significant thoracic injury. The Ivory Tower radiologist balked at my request and stated with great annoyance (how dare I interrupt his computer game) that he would read it, but that he thought it was totally unnecessary. He felt a simple x-ray should provide adequate information. I responded by saying innocently that I was unaware that x-rays would show vessel damage since after all there are some big pipes running through the chest (aorta, IVC, subclavians and oh, that darned thing that keeps beating).

He made getting the CT a chore as well (some sort of punishment I suppose) by having the techs refuse to do it until I checked her kidney function. It was a trauma! Why should I wait for kidney function? But they insisted.

He humbly called me back an hour into this poor woman’s ER course to tell me, “Man, this lady’s really messed up!” I asked if that was his medical diagnosis.  The “official” report was that she had broken 10 ribs on one side, had a collapsed right lung, and bilateral lung bruising. Nah, we didn’t need that CT now did we? I resisted the urge to rub it in and focused on taking care of the patient instead.

But every now and again, we do get an exceptional resident from the Ivory Tower. This weekend, I have the true honor to work with one such radiologist. Professional and personable, so much so that I am almost convinced that he is not a radiologist by training. Maybe he’s like that guy from Catch Me If You Can? He doesn’t call us to give us reports, but comes in to see us in person on almost every case in order to discuss the case and provide his report. This not only makes him courteous, but way smarter than the other radiologists because getting the clinical backdrop is a very good way to not miss something important. When you understand in detail why the test was ordered , it helps you zoom in on the area of concern with a different perspective.

But then he did the unthinkable. Our stellar resident actually went and examined the patient! I don’t think that in all my years of medicine I have ever witnessed such an event. I thought radiologists had lost the art of examining patients by the time they finished their internship, but this guy proved us wrong. Kudos to you my friend and maybe you will be an inspiration for the others in your field to come back down to earth.

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8 Responses to The Radiologist Examined a Patient!

  1. c says:

    “I responded by saying innocently that I was unaware that x-rays would show vessel damage since after all there are some big pipes running through the chest (aorta, IVC, subclavians and oh, that darned thing that keeps beating).”

    “The “official” report was that she had broken 10 ribs on one side, had a collapsed right lung, and bilateral lung bruising. Nah, we didn’t need that CT now did we? I resisted the urge to rub it in and focused on taking care of the patient instead.”

    Rub it in? Did she have vessel damage?

    • ER Doc says:

      The patient did have pulmonary contusion (which is small vessel damage) and hemothorax. X-ray misses pulmonary contusion early on as it often takes anywhere from 6-24 hours to become apparent and this was an injury that was less than one hour old. The point that was being made is that when you have that degree of trauma you don’t question getting a CT as this is standard care in any trauma center. This was something that even this rad agreed with after the fact. My disappointment was his immediate disregard for my clinical acumen followed later by his humility for having minimized the event.

      • c says:

        “The point that was being made is that when you have that degree of trauma you don’t question getting a CT as this is standard care in any trauma center. ”

        I completely agree. And in this situation she should have gotten her CT immediately, as she would have in the fancy-pants trauma center no question.

        I enjoy your blog and I regretted posting that, but I’m a CT tech overly sensitive about ER docs in my hospital yelling “this is a trauma patient, we’re not waiting for labs!” when the patient is stable enough to (not be monitored, walk to the bathroom, sleep through the CT, ect, ect…) wait to evaluate kidney function before we inject them.

        Added to that is the love I have for my awesome IR rads who deal with patients daily, I think I was overly defensive.

      • ER Doc says:

        Thanks for your comment C and for your statements. I can understand when some doctors can be unreasonable towards techs and in all honesty, the biggest point I was trying to make was that we are all on the same team and no one should act above the other. Kidney function tests in stable patients are there for a good reason and should be respected, and any doc who disregards them is an idiot because it will be his neck on the chopping block if the patient has kidney damage from dye. So, I agree with you. And yeah, IR is awesome – I was very tempted to go down that route as I think some day it will displace a lot of what is now surgerical intervention.

  2. Tunde says:

    Just when you think your colleagues are all the same, and stuck up you get a sign, and realize not to generilize. Hm, I think we all came accross with people who has GOD complex, and we learn to shake it off. Eventually everyone will descend to EARTH sooner or later…yes sometimes later, but what counts is the endresult.
    In healthcare we should focus on the patient care as a team, and not to make anyone feel that they are below us. We are human, doctors, nurses and the support staff are all important, achiving what we have sworn to do… helping people and saving lives.

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  4. Med reg from Perth says:

    I’ve met a few who i’m sure take delight in refusing as many requests as possible. There’s this one particular registrar who took one look at my request and said “no” without looking up nor qualifying his refusal. I didn’t make a fuss but is struck me as highly unprofessional. If I haven’t requested the correct test, explain why and suggest an alternative, don’t be a jerk.

  5. Thanks for sharing the blog. Yes, sometimes radiologist can examine patient out of their work. They are extra ordinary.

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