Tag: cases

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The Last Case Bolus Phenomenon!

bolus phenomenon

Ever notice that the end of a shift tends to have a bolus of cases? Just as you are allowed to leave the building, you find yourself with multiple studies that you need to read emergently. Usually, they are more complicated, and you don’t leave your station near when you are “supposed to be” finished. Well, this bolus phenomenon is not by any means random. Based on logic and my experiences, there is much more to this phenomenon. So, let’s go through some of the causes why you suddenly experience more cases that can often be the most difficult ones right at the end of your shift. You may be surprised at the reasons!

Transitions Are Not Smooth

Down in the emergency department, just like in radiology, no one wants to leave over work for the next ER attending shift. So, they will often order a bolus of cases so that the next physician does not have to write for them. This process causes a sudden cluster of studies in the radiology department. And, at this point, toward the end of your shift, you also feel the heat.

The ER Doctor Likes Your Work

Here is some good news/bad news for you. Guess what. Sure it’s great that the ER physician downstairs likes your dictations and diagnostic acumen. You have made a friend for life! However, that same phenomenon can lead to a bit of pain; right before your shift ends, they will try to get in as many patients as possible so that the physician downstairs will get all your dictations before the subsequent radiologist arrives. Sometimes, it does not pay to be the best!

ER Shifts End The Same Time As The Radiologist

Unfortunately, we like to begin and end shifts at typical times. Ten o’clock can be a standard time for physicians to leave. So, as the radiologist, you are not alone at that time. Therefore, you will receive the bolus of cases that need a disposition at the same time that you will leave. In this case, you can resolve this issue by changing the timing of shift changes so that they don’t coincide.

Transport Logjam

Ever take a gander outside the reading room, only to see ten patients in beds in line in the waiting area, waiting for their study. A lack of transporters can often cause this logjam. And, the same lineup often happens in reverse when they need to leave. These logistical issues often occur when your hospital does not pay enough to get these transporters to do their jobs. A hospital is only as good as its weakest link!

Pressure For Disposition, a Definite Cause For The Bolus Phenomenon

Finally, some emergency medicine physicians can become fickle. These emergency medicine physicians delay and protract until they finally decide what to do. And they must make this final decision before the end of their shift. To do so, they will probably need that definitive imaging study to confirm or refute their suspicions. So, these examinations culminate their thought processes right before they leave. You are there reading CT scans for them to reap the benefits!

The Last Case Bolus Phenomenon Is Not Random!

It feels painful to experience a large cluster of cases at the very end of your day, right before the end of your evening. However, contrary to what you might think, it is not a random process. Poor transitions, ER physician fans, problematic timing, transporters, and pressure for disposition, are all factors that often cause this bolus phenomenon. Some of these factors you can change and others not so much. It’s one of those hazards we experience when a shift is about to end. It’s just part of the job!

 

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How To Present A Great Case Conference

case conference

During residency, you must choose a case to present to your colleagues or faculty in a formal setting. Many of you will be flying by the seat of your pants without instruction on how to do so. So, how do you select which case from the past week, month, or year? What features make up an excellent case for discussion at a case conference? And what exactly should you discuss during the presentation? These questions and more I will answer as we discuss how to present a great case conference.

Which Case Should I Choose?

On any given day, you will encounter multiple cases that have the potential to become excellent cases for a conference. Some studies may have confounded you or your faculty. Other times, your attending may love a case for some reason. Then, your attending may want a classic case of a particular disease entity. In these situations, how do you pick among all the possibilities?

Typically, I look for cases on a particular theme I want to address. Even better, the study may have addressed several points that created interesting discussions or controversies. Then, I check to see if the case runs through multiple imaging modalities. What do I mean by that? The best cases show a particular diagnosis in many different ways. For instance, say you are interested in showing lung cancers at this specific time. So, a perfect case would be a lung nodule on plain film that the hilum may partially hide. Then in the same study, you have a CT scan showing the mass abutting the hilum with subtle adenopathy within the mediastinum. And perhaps you also have a PET-CT scan demonstrating additional hypermetabolic nodes present on the scan and a hidden osseous hypermetabolic lesion in a vertebral body. Cases that show a finding or related findings in multiple modalities reinforce the subject matter well.

How To Prepare For The Discussion

So, you’ve found this extraordinary case. First, make sure that you can describe the findings appropriately. If you have less experience, you may want to run it by a faculty member or senior resident to confirm that you are conveying the description correctly.

Next, like any good physician, you should read on the topics extensively. In the case I described above, you need to read about lung cancer diagnosis, staging, and treatment basics. Additionally, you should learn how the radiological diagnosis affects the management of the patient. For instance, how does the presence of hypermetabolic nodes and a vertebral body lesion affect the outcome of the patient? Ultimately, you want the listeners to perceive you as the expert on this topic for the presentation.

Moreover, you want to be able to answer almost any question thrown at you. In other words, go to town! By reviewing the topic extensively, in essence, you are not only going to improve the discussion and your ability to answer questions, but also you are studying for the boards at the same time.

What Should You Discuss At The Case Conference?

The lung nodule example above lends itself well to discussing the findings on each of the modalities, the differential diagnosis, the final diagnoses, and the pathophysiology behind the final diagnoses. Furthermore, the topic will lead to basic management principles like how vertebral lesions change treatment.

I would first review the findings similar to the standard logical approach of taking cases. And then, I would discuss the differential diagnosis and the management in that order, just as if you were taking a case during a faculty presentation. If you want to make the case conference a bit more spicy and controversial, you can discuss whether the case met the ACR appropriateness criteria for the symptoms given. Usually, you will get multiple opinions from different attendings if the ordering physician approaches the workup correctly. It would help if you strived to guide the discussion to ensure it follows an appropriate path. With a case like this, the debate can ensue for a while!

Case Conference As A Tool For Learning

You primarily need to remember the end goal whenever you create a conference. In a typical case conference setting, the presenter should want the audience to learn a few essential points by the end of the discussion. Too much information will overload the learner. Likewise, too little information may not reinforce the concepts. So, try to strike a balance after discussing the specific case.

In the end, you should view case conferences as a tool for learning, not as a burden. They are opportunities to learn a topic in great detail and the art of presenting. Moreover, each presentation you perform builds upon the knowledge that you have. I still remember the case conferences I created when I was a resident. Just like I did, if you prepared appropriately, you will use the strategies and information you learned from your case conferences when you become a faculty member yourself many years from now!

 

 

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The Precall Quiz: Mechanics of The Test And Preventing Failure

It’s getting to be that time of the year. Spring… Ahhh… Birds chirping, snow melting, and oh yeah… of course… first year resident preparation for the first night of call. Often times this process begins with a bang called the Precall Quiz.  Although it is not a specifically required measure for being able to start call, it is a way that many residencies assess the functioning of the soon-to-be second year in a “real-world” situation. Sometimes the residency program sets up the precall quiz. Other times, the residents create it. Regardless of who prepares the exam, the first year resident needs to prepare the same. Since the contents of the examination are generally limited to call cases, he/she should be able to expect what is going to be present on the quiz and be able to pass it without question. In today’s post, I am first going to go over the mechanics of a proper recall quiz, whether prepared by the chief resident or program director. And then most importantly, we will talk about how a resident should prepare to pass the test and make sure to feel “comfortable” taking his/her call for the first time. Here we go!

For The Residency Program: What Is A Fair Precall Quiz?

A precall quiz should consist of both the material/contents needed for the first night of call as well as be similar to the way that cases are taken on a night call. What does that mean? Emphasized cases should be situations that could “kill or severely injure patients” or are very common. In addition, it should also contain a few normal variants. These components will most simulate a real night on call.

Furthermore, the style of the examination should be given in the same way that call is taken. In other words, it should probably be administered on a PACS workstation in the way that cases are usually evaluated. Some residencies may still use the PowerPoint format. But, I think there is a danger to giving an exam with cases in this style. Giving individual pictures in a PowerPoint presentation format only assesses knowledge base and not the ability to find lesions on imaging modalities. Both of these qualities need to be evaluated prior tuo beginning call. Or else, a resident that passes this sort of examination is not truly assessed on all the fundamental knowledge bases needed to assess call competency. In fact, these residencies may be setting up certain residents for failure without the appropriate learned “finding strategies” when night call begins.

For The Examinee: How To Pass A Precall Quiz?

Studying should theoretically begin when the resident starts residency. However, many times residents will often cram knowledge into a short period of time prior to an exam. Either way, the examinee should really concentrate on ER case studies prior to taking the test. These should be the killer diseases such as aortic ruptures, pnemothoracies, neurological bleeds and infarcts, and so on. Also, you should be looking at lots of cases that are very common with some morbidity such as appendicitis, diverticulitis, cholecystitis, and more. I would recommend the Emergency Radiology Case Review Series as one resource that would be very help for taking the taking quiz. But, of course, it just a starting point. Make sure to look at hundreds of versions of the common disease entities so that there are no surprises on your first call night. It can be as simple as Googling appendicitis and looking at all the ways that this disease entity presents. But, it is just as important to attend your rotations real time so you have the experience of knowing how to use the PACS system to scroll and find these disease entities in a “real word” setting.

How To Feel “Comfortable” On That Dreaded First Night of Call

OK. I lied a bit at the beginning of this post. The truth is that no trainee radiology resident ever truly feels comfortable on their first night of call, unless you were born with the genius gene or you are missing the emotion of fear! So, do not expect to feel entirely in your element. That being said, if you know cold the entities that will kill or severely injure patients, have studied appropriate cased base material, and attend your daily rotations it is very unlikely that you injure anyone. The knowledge that you passed your precall quiz and know the basics should put you in good staid. Remember that most radiologists before you have been through the same situation as you and most have made it through the first night of call unscathed. And if you listen to me,  just like them, you will make it through the process too!