When program directors hear complaints about their residents, we find most do not stem from resident incompetence. Nor do the complaints relate to professionalism issues. Instead, a good majority arises from a lack of a timely response to reading cases. And these delayed reports result from a lack of appropriate triage. So, I think you know what we will talk about today. You guessed it! The topic is tadaaaa… how to triage your cases.
A Common Scenario
It’s 2 AM, and a bleary-eyed resident starts to pick off STAT CT scans from the worklist to catch up on his reading from the nighttime. A house physician rushes down from the floors to speak with the resident in a huff. She explains that she needs to discuss a case from a week ago that she must present for the tumor board the following day. The resident obliges. Thirty minutes pass, and the house physician leaves.
Next, a few minutes later, an ultrasound technologist stops by the reading room because she questions whether a renal cyst is simple or complex. Like a robot, the resident scans the patient in the ultrasound room to make the determination. Another 30 minutes go by.
While scanning the patient, the resident gets two beeps which he needs to call back. He gets to both those phone calls. One of the phone calls comes from a patient’s father, who asks a question about his son’s chest film from the previous day. The conversation drones on for 15 minutes, and the resident can barely get off the phone. But he does eventually. Right afterward, he quickly responds to the other phone call and promptly answers the nurse’s question on the other end.
The resident starts to reread the CT list, and a technologist interrupts his train of thought as he walks into the room. Solemnly, the technologist asks, “How much contrast should we give this patient with a slightly low GFR?”. Immediately, the resident attends to the technologist. However, the resident is unsure and looks through the literature to find the appropriate answer. After 10-15 minutes, he finds a piece of paper and says, “75 ccs of Visipaque.”
Finally, an angry emergency department attending calls to the radiology reading room, “Where the hell are the results from the nighttime CT scans? We have been waiting 4 hours. Sorry, but we are going to have to write this up as an incident in the morning!” Where did the time go by?
Ways To Triage In The Above Scenario
So, what could this poor weary resident have done differently to prevent himself from getting written up by the ER doc? Well, lots of things. For one, did he have to review the tumor board case with the house physician? No. Should he have spent 30 minutes determining whether the renal cyst was simple? Probably not. The resident could have delayed until the morning. Did the resident need to speak to the patient’s father for so long? I don’t think so.
To summarize some of the problems the resident experienced with triaging in the scenario above, I have divided some of the main concepts about radiology triage into the following paragraphs. Here are some general recommendations for triaging cases to avoid situations like this.
Keep Your Eye On The Prize
Remember… When you are on call, the first goal is not to kill anyone, and the second is not to injure anyone. By ignoring the STAT list and tending to other people’s “problems,” you are increasing your chances that something terrible will occur. Perhaps, the CT Abdomen/Pelvis for appendicitis with a positive study will get delayed. Or, you will miss that opportunity to catch that hemorrhagic stroke before it is too late. Delaying STAT reads can theoretically cause irreparable morbidity to your patients. Therefore… Keep your eye on the prize. Complete those studies that are urgent first!
Also, if the activity is not critical, you can delay it until the following morning. In the case of the ultrasound technologist questioning a cyst above, sure, it is an important question to answer. But not so much when you have a list of 5 or 10 STAT CT scans you need to look at. You always have the option of delaying such study until the AM.
It’s OK To Say No
At nighttime, you are going to get all sorts of requests. Some are important, and others are nonsense. Do not let your colleagues bully you into concentrating on peripheral activities that do not directly affect patient care. If you don’t have time to look at that tumor board case, simply say so. Sometimes saying no is just the right thing to do.
Attend To Your Study First, Then Your Colleagues
According to my previous blog, Should Radiologists Ignore The Phone?, residents pay a significant penalty when discontinuing their thoughts midstream. Error rates increase dramatically. More relevant to this post, however, the time to complete a study increases significantly, increasing your chance of causing an angry ER physician. Therefore, it is imperative that you briefly let your colleagues know that you need to complete the study first and will answer their questions as soon as you finish.
Triage And You
One of the most essential facets of the nighttime experience is learning to triage. Believe it or not, you will use these skills for the rest of your career regardless if you take call or not as an attending. What studies do you need to complete first? Who should you attend to? These are all triaging skills you need to learn to succeed. Using some basic triage concepts above, ensure your nights are shorter and safer!
Barry, you’ve outline triage for workplace distractions – a critical skill for the radiologist to focus on the worklist. Now … what of the STAT list? Who is the more urgent of the urgent? How does the radiologist take on case prioritization therein to ensure as you’ve noted they, “catch that hemorrhagic stroke.” Interested in your thoughts if you have a moment.
Hopefully, your hospital has systematically created a way to designate what constitutes a STAT CT scan. In truth, prior to picking up a case, there is no way for a radiologist to know who is “STAT”. So, you are relying upon the clinical acumen of your ED doctors and referring clinicians. Once the case reaches our image queue, the technologist labels the case STAT if it comes from the ED. If it arrives from the floors, the ordering physician will put a case order. either as STAT, priority, or routine depending upon the acuity. Similarly, outpatient cases are also labeled using that system.
We also have one more category called priority 1 for brain attack cases that are the most “time dependent”. These cases supersede the priority of all other cases. When I dictate cases, I tend to prioritize based upon this system in time order.
On a different note, since I am an attending and have to over-read the night resident cases and we also have nighthawk, I will go through the cases in slightly different order. I prioritize the nighttime ct abdomen and pelvis Stat studies without contrast because the nighthawks don’t read most non contrast cases and the residents have the highest miss rate with these cases. Then, I read the stat non-contrast brains and miscellaneous other non-contrast studies. I read the priority and routine non contrast cases in time order. And finally, I read the contrast enhanced studies last because the nighthawk has already looked at them.
One more thing. There is a separate school of thought that believes you should quickly scan all cases prior to reading anything just to weed out a scan with an emergency that needs immediate attention. I typically don’t subscribe to that philosophy because I believe you should try to read a scan correctly and slowly the first time so you don’t miss anything important. Rapid reads can sometimes make rapid bad calls!
Thank you for this! Most informative and helpful. Very much appreciated.