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. Rather, a good majority arises from 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 are going to 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 in order to catch up on his reading from the nighttime. A house physician rushes down from the floors to speak to with the resident in a huff. She explains that she needs to discuss a case from a week ago that she must present for 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 goes by.
While scanning the patient, the resident gets 2 beeps that he needs 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 read the CT list again 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 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 go over the tumor board case with the house physician? No. Should he have spent 30 minutes determining whether the renal cyst was simple? Probably not. It could have been 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 that the resident experienced with triaging in the scenario above, I have divided some of the main concepts about radiology triage in the next few 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 goal is not to injure anyone. By ignoring the STAT list and tending to other people’s “problems” in essence you are increasing your chances that something bad is going to occur. Perhaps, the CT Abdomen/Pelvis for appendicitis with a positive study will be delayed. Or, you will miss that opportunity to catch that hemorrhagic stroke before something could be done. Delaying STAT reads can theoretically cause irreparable morbidity to your patients. Therefore… Keep your eye on the prize. Complete those studies that need to be read first!
Also, if the activity is not urgent, you can always 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 scan that 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 upon peripheral activities that do not directly affect patient care. If you don’t have time to look at that tumor board case, just 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 they discontinue their thoughts midstream. Error rates increase dramatically. More relevant to this post, however, the time to complete a study also increases significantly, increasing your chance of 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 important 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 should be done first? Who should you attend to? These are all triaging skills you need to learn to succeed. Using some of the basic concepts of triage above, ensure that your nights are shorter and safer!