Radiology Call- A Rite of Passage
Every year around the beginning of July, I see some of the most haunted radiology resident faces, right around 10:00 pm, just after the attending evening shift ends, and the resident night shift begins. It is almost always a second-year radiology resident who happens to be beginning his/her first night of call. What if I miss something important? What if I say something stupid? Will I be able to handle the intensity? Will I fall asleep? And most importantly, will I kill someone?
The answers to these burning questions are only unlocked after the resident takes the first night of call. It is only after this event that the resident and the program director know whether or not he/she can handle the burdens of a radiologist. Everything in the first year leads up to this point: the precall quiz, the intense reading, the conferences, and the studying. It’s crunch time.
Just before the first night of dreaded call, my famous last words are: you begin the night as a boy/girl and you will end the night as a man/woman. Why do I say that? Because I think there is truth in that statement. Until you have the responsibility of independently making decisions for patients, you can never be a full-fledged radiologist. It’s like all those ancient traditions in all religions/cultures like hunting that first wild boar, the confirmation, the bar mitzvah, etc. You are now allowed to function as an independent freethinking human being who can make decisions on your own. Until that point, you are merely an observer, not an active participant.
Since call is such an intense and important experience, there are multiple things you must do to make it valuable and safe. I am going to enumerate 8 simple golden rules of night call I wish I knew prior to beginning those fated first nights to come. I urge that all are followed in order to enrich your education in a safe manner. Do not stir the wrath of your fellow staff members and program directors in the morning by breaching these rules!
- Look at every film with these primary thoughts- what will kill the patient and what is common?
I can guarantee you that if you look at every film with these thoughts at the forefront of your brain and you have done the prerequisite work to get to call, you will not severely harm any of your patients. When you look at a chest film, always think pneumothorax. When you look at a female pelvic ultrasound, always think ruptured ectopic. When you look at a CT scan in a patient with right lower quadrant pain, always think acute appendicitis. And, so on, and so forth… Thinking about badness will prevent undiscovered horribleness in the morning.
Likewise, when you look at films always think about the most common diagnoses first and you will be right much more often than wrong. For instance: Opacity on a chest film- pneumonia, not Hampton’s hump. Restricted diffusion on a brain MRI- infarct, not ependymoma. Abnormality on a GI bleeding scan, think primary GI bleed, not Meckel’s diverticulum with bleeding gastric remnant. I can guarantee your attending will be looking at you funny if you come up with too many zebras!
- Always, always, always maintain your search pattern in every study.
In the radiology world, one of the main ways to miss something is not to look for it. There are going to be times in the middle of the night when the pressure may seem insurmountable and you need to deliver an answer at that second. A team of 4 angry surgeons comes down and asks, “What is going on with the film?” and needs to know now! An inpatient resident shoves a chest film in front of your face and says, “What’s going on here?” The emergency medicine doctor is calling incessantly to get a read on that CT chest for dissection. In each of these cases, I don’t care how emergent and immediate they need the answer, always step back and go through your search pattern. This is a cardinal mistake that everyone makes at one time or another. Avoid it! Step back and say give me a moment. Go through each organ or region in a rigorous manner. You will look a hell of a lot less stupid than blurting a diagnosis/finding out only later to realize it was wrong because you haven’t thoroughly analyzed the study. One of the worst feelings is having to find the doctor that just left your department with the wrong answer who is getting ready to begin surgery that is not needed or is going to discharge a patient that needs to stay in the hospital!!
- If there is no harm to the patient, it is easier to do the study than to fight it.
This is one piece of sage advice that most residents take a while to learn. At nighttime, you will have limited time for everything. You are going to be pulled in fourteen different directions at once. You are going to be getting calls from the emergency department, the floors, the surgeons, etc. And often times, these events tend to happen all at once. So, I urge you that if there is a study that is reasonable, just do the study. You will spend more time and energy on preventing a study from getting done than just completing it. Of course, if the study is going to do significant harm to a patient, then obviously avoid it. But, that is the exception rather than the rule. That fluoroscopy study to rule out foreign body that you try to block after the resident ordered it: I can guarantee it will come back hours later when you are either exhausted or have lots of things going on at once. So, just do the study!!!
- Don’t let your temper get the best of you, you will hear about it in the morning!
There are going to be times for every resident when you encounter a curt gynecologist, a rude surgeon, a loud demanding resident, and so on. You yourself are likely going to be grouchy and tired as well. It may seem like a good idea to talk back to that person in a similarly rude and unprofessional manner. Or, you may want to take a swing at one of these annoying chaps. But, don’t do it. One of the most common complaints we get at nighttime is a letter written by an attending or resident saying this radiology resident was unprofessional and handled the situation poorly under pressure. This will come regardless of whether the radiology resident is right or wrong. And often, it will stay in the resident’s file/record. Don’t let that be you!!!
- Resident matters are best handled by residents. Attending matters are best handled by attendings.
At nighttime, there are going to be times when an attending radiologist is needed. Make sure you don’t go in over your head. Call your attending when necessary. The worst thing that you can do in the morning is to perform a procedure that your attending should have done or make a phone call that really should have been handled by your attending, only to find out that the wrong thing happened. It will become the talk of the town among the department, and not in a good way… A brain scan always needs to be read by an attending because of litigation issues. An intussusception reduction should always be in the presence of a radiologist. And, so on and so forth… Don’t go over your head!
Likewise, if there is a resident issue at nighttime, try to handle it yourself. If they are asking you whether to give the contrast or not, make that decision. If a resident comes down to ask a question, answer it. You will only learn how to make the smaller decisions by playing the role of a radiology resident.
- Ask for help if you can’t handle something at nighttime.
There are going to be times when the job may be too much to bear for one person. (A disaster happened with every patient getting a full body CT scan) There are going to be questions that can only be answered by an expert. (A subtle abnormality on an emergent Neuro CTA) And, there are going to be administrative issues that can only be handled by your chairman or program director. (The MRI broke – should we recommend sending patients to another hospital?) If there are issues such as these that come up at nighttime, make sure to call the appropriate channels going from lowest to highest in command. If it is a patient question that you are not sure about, ask your chief resident. If he/she can’t answer the question, you may want to ask the assigned attending on call. And, up the chain, it goes.
If you decide to handle everything yourself and it is inappropriate for your level, you can almost be certain that there will be repercussions in the morning. So please, ask for help when it is needed and appropriate!!
- Always answer your beeper/phone/pager.
On occasion, we hear about a resident who was caught sleeping or not answering their pager at nighttime. Unfortunately, those residents will often get written up in the morning for lack of timely dictation, etc. So, simply jack up the sound on your beeper/phone/pager. And, take all calls!!!
- Look at the films. Don’t rely on the ER or Nighthawk reads.
Being on call is the time to remove the umbilical cord and develop independence from your mentors/attendings. So, make sure not to repeat a dictation or reading that is already present. You should do everything de novo/from scratch although you should look at their reads afterward. It also looks really silly when the resident dictation matches the nighthawk dictation verbatim and hints that the resident may not have looked at the films. When I am on in the morning, I appreciate the extra set of eyes that a resident used to check the cases even though others have looked at the study. And, it is not infrequent that our residents catch important findings that the nighthawk didn’t notice. So please, do your own independent reads/dictations!!!
Call is a difficult but integral part of raising a radiology resident right. It is a time of trials and tribulations. You too can and will make it through this harrowing trial as you long as you follow the golden rules. Good luck!
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