Tag: protocol

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Why Radiologists Need To Protocol Cases

protocol

Like many institutions, we perform cardiac CTA studies at the behest of our emergency medicine, internal medicine, and cardiology colleagues. They say do the study, with or without a protocol, and the technologists jump without a reflexive thought. For example, one patient had a chest CT scan a few days earlier for shortness of breath. It turned out that the patient had enough calcium in their coronary arteries to make their vessels look like lead pipes. For those who know anything about cardiac imaging and CTAs, tons of calcium within the coronary arteries make it nearly impossible to interpret them for stenosis because of significant beam hardening artifact, limiting evaluation of the lumen.

Nevertheless, without batting an eyelash, the technologists completed the coronary CTA, which was uninterpretable for detecting coronary stenosis. It had a calcium score of over 4400! Now, if only someone had looked at the CT chest, we could have avoided the CTA chest at the cost of unnecessary contrast, additional radiation, and of course, the financial cost to the patient.

This case is a microcosm of what is happening to radiology. Scans come through fast and furious, making it difficult to vet the protocol and the priors on everyone. But, by letting cases get through the system without forethought and protocols, we expose our patients to subpar medicine. In light of these facts, here are some of the critical reasons why radiologists need to protocol cases.

Avoid Unnecessary Studies

How often do we get the wrong orders for the indication? Very frequently! Daily we get orders for CT scans that ask for contrast when none is needed and vice-versa. Of course, a patient with flank pain should not generally get contrast on the first scan if they are looking for stones. But, wrong orders for studies with contrast happen all the time, causing unnecessary exposure to radiation and contrast that is not needed. Protocoling can prevent most of that.!

A Protocol Can Make Sure Studies Are Done For The Right Reason

When technologists and nurses come up to me and ask if they are performing the correct study, the first question I always ask is, “why are we doing the study?” There is a reason for that. We get orders that are not necessarily for the indication that clinicians want. It could be a white blood cell scan for when a simple gallium scan is warranted. Nevertheless, we can correct most of these potential errors before they get to the table!

Protocols Can Add Information To The Case

Protocoling can add critical information to the case. It may help find a relevant prior like the cardiac CTA above. Or you might find a valid reason for a study that might not be evident initially. Perhaps, the doctor is looking for a fistula and needs rectal contrast. Sometimes, you can only figure that out by digging deeper. You know what they say… Garbage in. Garbage out!

Prevent Patient Discomfort

Many radiology studies are uncomfortable and difficult. A CT scan on a patient with severe back pain can be a nightmare. Imagine going through a CT scan in this situation when you could have avoided the test if the radiologist had protocoled it beforehand. Well, this issue happens all the time. We owe it to the patients to prevent additional harm!

Prevent Angry Clinicians

When we do not protocol cases before imaging, we do not get the answers that the doctors are looking for. This cycle leads to unhappy referrers that do not receive the intended study. And, we get these irate phone calls afterward. Do you want your clinician to send patients back to your department again? Well, if you consistently deliver the wrong studies for the patients, that will not happen!

A Protocol Can Decreases Costs

The costs to image patients are immense. And simply one incorrect study can cost the patient and the institution thousands of dollars. Protocoling is a tremendous backstop to ensure that health care costs are more reasonable. Sure, we may not have much time in our busy schedules. But, protocoling can certainly decrease costs to the system!

Protocol: An Easy Way To Prevent Bad Medicine

If your attending asks you to take a stack of patients and ensure the protocols are correct, it is not a waste of time. With all the benefits of eliminating waste and practicing good medicine, it is something that we should all do regularly. So, look at those orders before the hospital performs the studies. Protocoling can make a huge difference in patient care!

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Evaluating The Pancreas On A Triple-Phase CT Scan Is A Minefield

triple-phase

I don’t know about you. But, for me, my least favorite CT scan has been the triple-phase CT scan to evaluate pancreatic masses. And, by most accounts in my group, many of our radiologists feel the same. For this reason, I would like to call the evaluation of the pancreas on a triple-phase CT scan a minefield. Many pitfalls in making the findings and interpretations abound. And no one, including the physicians and patients, is ever satisfied. But I thought this might be a good time to go through some of the issues you might encounter!

Subtle Lesions On A Triple-Phase

Pancreatic lesions tend to be some of the most subtle ones to detect. They can be hypovascular or hypervascular, infiltrative or circumscribed, versus cystic or solid. Sometimes, we see them in only one phase out of many in a triple-phase protocol. Even worse, you may only catch one of these lesions on a coronal or sagittal plane, which is not well confirmed by any other. You can miss one of these lesions in about a billion ways.

Severe Consequences For Missing A Lesion

Patient Tragedies

The lesions that you miss in the pancreas can be killers, literally. Both complex cystic and solid lesions can rapidly grow and kill the patient. I’ve seen significant changes over a few months or even less. Even worse, you can make the case that the patient would have significantly fewer complications if you had caught it earlier. These complications can include more extensive surgery, more potent chemotherapy with its consequences, or broader radiation treatment plans for palliative care. And the list goes on and on.

Legal Tragedies

Also, with the potential patient tragedies for missing lesions comes the potential for malpractice lawsuits in the “retrospectoscope.” Judges and juries can easily mistake “not-so-subtle” pancreatic lesions for prospectively discovered subtle ones. Along with the possibility of doing significant harm to patients for missing findings, this discrepancy can cause high-cost malpractice lawsuits/claims. If you read enough of these studies, it is only a matter of time before you receive one!

Numerous Additional Findings

In addition to the problem of finding the primary lesion, many different additional findings can change a patient’s management dramatically. These findings can also be very subtle. I’ve seen numerous permutations and combinations of various venous and arterial thromboses that folks always miss. Then, there is a debate about whether a lesion surrounds a vessel and to what extent. This issue necessarily affects whether or not one gets surgery. And I can’t tell you how often that outcome can differ depending on who is reading the study. Of course, you also have subtle lymph nodes with the porta adjacent to the head of the pancreas and within the celiac axis. All these different additional findings that you have to think about can make your head spin. And the consequences of missing them are dire!

Angry Surgeons

Finally, you must contend with the people who ultimately ordered the study. These tend to be the busiest of surgeons. And for that reason, the word “ornery” almost does not do justice. These folks are often on the edge of burnout from overworking and complex patients. They have their requirements for the reader they want and how they want their studies. You will notice at your institution that they might call a study for this surgeon a Dr. “John Doe” protocol because every surgeon wants the triple-phase protocol done slightly differently.

The Triple-Phase Protocol For The Pancreas Is A Minefield!

As you can see, when you find one of these studies coming through your department, batten down the hatches and do not let your attention stray. Making the findings can be challenging, and there are potentially “oh” so many of them. Remember to look at all the images and phases. And make sure to relay all the information neatly and logically. The triple-phase protocol for the pancreas is not for the faint of heart. It’s a veritable minefield of potential misses and problems!