Hot Potato, Hot Potato

July 8, 2016

Are radiologists the only ones in a rush when it comes to critical findings?

Many years back, I determined that there was a corollary to Murphy’s Law, and called it Murphy’s Power. I figured that not only could I count on things going wrong, I might be able to leverage the mysterious motivating force that makes plans go askew to work in my favor.

Waiting interminably for an expected phone call, for instance, I would intentionally busy myself with something else, such that the phone would ring the moment I could not get it…but at least then I could phone back shortly after and hopefully catch my quarry.

Whether or not I’m making intentional use of it, Murphy’s Law and Power present themselves on a regular basis. Frequently, the occurrence of “critical” cases right at the end of my scheduled working hours.

It would make for a pretty telling graph-X-axis being the time of my typical 10-hour workday, and Y being the number of cases requiring me to get on the phone with the referring clinician, or someone else taking care of the patient. I’m not saying I never get such cases earlier in the day, but their frequency climbs impressively as I approach quitting time.

What makes this problematic is not simply that I get stuck waiting to speak with one or more clinicians for a few minutes after my shift is over; heck, I work a bit past the hour more often than not to finish up cases or simply because I get paid per study and there’s always more work available.

No, Murphy’s real zinger for me is that these inevitably wind up being the instances where no responsible clinician can be reached. He’s not answering his pages, or the guy who ordered the study is no longer on the case as a result of shift change, transfer of the patient, or other circumstance such that nobody even knows who’s the right person to contact.

It’s bad enough when the “critical” call is simply for facility protocol (all head CTs for stroke get phoned in, no matter how normal), but even worse when there’s something genuinely abnormal that needs attention. One starts to wonder whether the “responsible” clinician is wary of being notified that there is a “hot potato” situation, and is trying his darnedest not to have to take ownership of it.

These cases have taken me, I do not exaggerate, more than an extra hour to resolve on occasion. Especially at such times, I wonder: Are we radiologists the only ones beating ourselves up to get timely critical calls accomplished and documented in the patient record?[[{"type":"media","view_mode":"media_crop","fid":"50089","attributes":{"alt":"Hot potato","class":"media-image media-image-right","id":"media_crop_9900681868695","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6096","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 159px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Johnny Sajem/Shutterstock.com","typeof":"foaf:Image"}}]]

We have mandated CME on the subject. Critical calls get covered in orientation for every health care facility I’ve encountered. It’s more than fair game for QA (that is, if you read a case 100% correctly but fail to call in significant findings, it’s at least as bad as a “miss”). I’ve heard rads exhorted to phone in findings even before they formally dictate and sign off reports, lest those precious seconds matter.

I don’t think I’ve ever heard a word on the subject from the clinical end, beyond the common sense that even med students need no instruction to know: Answer your pager, cell phone, whatever when it goes off. And if you’re not on duty, your coverage has to be known to whatever operator (or software) is handling pages.

It’s not rocket science, but somehow this simple system seems to break down routinely. When it does, near as I can tell, those left holding the bag are the rads, the operators and nurses whose time gets wasted trying to help us find a relevant clinician, and, lest it need saying, the patients (hopefully rarely), as a result of delay in treatment. The clinicians and the hospitals employing them don’t seem to hear much about it as long as the incident has not resulted in lawyers getting involved.

Were I a mucketymuck in such a facility, I would very much want to hear from the rads whenever they experienced difficulty completing a “critical” call. I might, for instance, put a limit on how much time should reasonably elapse between the moment a radiologist starts trying to reach someone, and the time the important information is communicated. Any time that limit got exceeded, it would rise to the level of a dreaded “never event,” and be investigated accordingly.