The Dog Ate My Contrast

Sometime between midnight and dawn within the past few days, I encountered one too many abdominopelvic CTs with zero contrast on board. The mush of gray pixels on my screen, nicely homogenized by the patient’s lack of fat and considerable motion artifact (does anybody tell these folks to hold still, anymore?) could have contained just about anything - a hot appendix, a droplet of free air, the monster from “Alien”…

And then I saw it. This was one of those uncommon instances where the technologist had actually included a note as to why no contrast was utilized. Reason: “Patient is young.” Hey, at least it was more informative than “MD ordered without contrast.”

Reading studies from more hospitals at once than I have ever done before, I have had my eyes opened to a number of new lame excuses for not giving enteric or intravenous contrast. You can’t blame the clinicians too much - after all, it must get boring using the legit ones over and over (lousy renal function, allergy, etc.). And they can’t realistically commit to writing their other rationales for unenhanced scanning:

This is the ER. We need throughput, and giving contrast takes time. Do you know how long it takes to put in an IV nowadays?

We’re running low on contrast, and the next delivery truck isn’t due for days. We’re saving the stuff for real emergencies like the Zombie Apocalypse.

Aspiration risk. (Actually, the patient is doing just fine, but you know how icky that stuff tastes, so better safe than sorry.)

The radiologist looks way too smug after the last CT, but he probably only made that amazing diagnostic pickup because it was so easy to read with the contrast enhancement we permitted. Better take him down a few pegs.

This facility uses GE Healthcare brand contrast, and I just shorted GE in my 401(k). Using their products runs counter to my financial plan.

I read somewhere that contrast is not statistically necessary to make the clinically-suspected diagnosis. If I remember the source, I’ll send you the article.

Contrast is a Communist plot to pollute our precious bodily fluids, and I won’t be a part of your nefarious scheme, “Comrade.”

Patient doesn’t really need the scan anyway; we’re ordering it as part of our defensive medicine CYA plan. Contrast would just be one more wasted resource.

Patient’s dog sitter’s stepbrother’s former piano instructor once sneezed at a fish market. Could be an iodine allergy. We don’t have the time to premedicate.

Facility embarked on a “Was this contrast really necessary?” campaign a few weeks ago, and the administrator running the program is concerned that stats are trending in a way that he won’t get his incentive bonus this year, so he’s cracking heads.

Another radiologist - I didn’t catch his name - told me the study would be better without contrast. Why isn’t he reading it?