Forgot To Look At The Priors? Disasters Can Happen!
There are a few tenets in radiology that are unbreakable. One of these doctrines is to always look for priors. So, what are some real stories about what can happen to you if you forget them? To bring home this point, I will give you four examples of what can happen if you leave out the prior exam. The results speak for themselves. And these are just the tip of the iceberg!
The Phlebolith That Just Gets In The Way
New radiologists, especially, will often have a disease called happy eye syndrome. They make a diagnosis and forget about everything else. One of these critical steps they forget is remembering to look at priors. And, one such resident happened to do just that. One night, a resident saw a calcification probably in line with the ureter. And the urinary tract collecting system was slightly prominent. And, she called it an obstructing 6 mm stone.
The next day, the overnight attending looked at the case and saw the same calcification at the same location four years ago on a previous with and without contrast CT scan. And, it was not even associated with the ureter!
So, what happened to the patient? The surgeon sent the patient for surgery. But fortunately for the patient, they never got to operating suite. A well-placed phone call from the morning attending prevented an unnecessary operation. But, that was surely a close one!
The Overnight V/Q Scan- Not Just A Harmless Test!
Very commonly, the resident at nighttime use the V/Q scan as a means to sharpen their skills. But, it is not necessarily a safe test if not used the right way. One night, a resident called multiple mismatches at both lungs with a negative chest x-ray as a study highly suspicious for pulmonary embolus. And, correctly so, of course, if they didn’t have the priors!
So, the overnight physician started the patient on a course of coumadin. Guess what? The next day before the attending came into the hospital; this patient developed a change in mental status. And, the CT scan showed a focal hemorrhage. Now, whether the cause of the bleed was this coumadin dosage is debatable. But, once again, it demonstrates the power of the prior!
The Angry Oncologist (And Patient)
Typically, oncologists order studies to decide whether or not their patients should get a change in chemotherapy. In one such case, one attending read a lung cancer oncology chest, abdomen, and pelvis. There were lesions in the bone, liver, and lung. He reported the results, never bothering to check the script and the request for comparison to priors.
It turns out this patient was on an experimental protocol that demanded precise timepoint interpretations compared to the previous study. Due to the lack of description of change on the CT scan compared to the priors, the oncologist could not determine what to do next. Since the new results did not come back until after the deadlines, the study removed the patient from the treatment protocol! Bye-bye successful therapy!
The Thyroid Nodule From Hell
Thyroid nodules seem to be a common indication for a thyroid ultrasound. And, many of us consider ultrasound to be a relatively benign informative examination. But, so not so much for this next unfortunate bloke.
One radiologist interpreted an ultrasound thyroid examination as a suspicious 1.5 cm nodule at the right lower pole of the thyroid. And, he decided to recommend a biopsy. Of course, in small letters at the bottom of the technologist’s report, the technologist said the patient has two different MR numbers, and please compare these to the priors. Unfortunately, the radiologist missed this statement.
So, the endocrinologist sent the patient for a biopsy. Also, unbeknownst to the interventional radiologist, the patient never knew that the patient had priors. Well, what happened? Of course, the radiologist completed the biopsy, and the patient developed a large hematoma in the neck with associated complications. And, only afterward, the referring physician realized that the patient did have another study. Guess what, the nodule was stable all along and didn’t need a biopsy. The patient was stuck with a needless nasty hematoma!
Priors: Don’t Forget Them!
I think you get the point. But as painful as it may be to hear the same recommendation again, it is worth repeating over and over, don’t forget the priors. These are just a few of the potential disasters that lie in wait for you if you break this tenet of radiology. And, it’s a great way to disrupt the chain of excellent patient care!