Imaging Iatrogenics

May 31, 2013

I'll likely never name a medical condition for the textbooks, so my best chance at contributing to radiological history would be with a colloquialism. Here are a few.

It didn't take much of med school for me to start disliking the practice of naming diseases after people. When you're memorizing a million and one factoids for your next exam, proper names are generally less helpful than those more descriptive.

 Just think of how much harder it would be for you to commit suppurative appendicitis, ureteropelvic-junction obstruction, and pulmonary embolism to memory if they were called things like Oscar's Disease, Sheldon Configuration, and Barnabus Syndrome. Especially if Dr. Barnabus went on to discover and put his name on another half-dozen medical phenomena in unrelated areas of medicine.

As I do zero academic research and am therefore highly unlikely to ever name a medical condition for the textbooks, I figure my next best chance at contributing to radiological history would be to come up with a colloquialism. Invent enough of these, and one might just catch on.

Throughput phenomenon. More frequently encountered in busy ERs, you know you're dealing with throughput when no patient ever gets a CT with PO contrast, and even IV is a vanishing rarity. You can confirm this by bringing it up as an interdepartmental issue. It'll take some time; first you'll have to wade through a bunch of verbiage from the ER staff implying that you, the radiologist, have no idea what you're talking about when you express a preference for contrast in certain clinical scenarios - if you're competent at all, you're supposed to be able to diagnose pulmonary emboli with 99.6 percent accuracy on a noncon study, because the Malawi Journal of Emergency Medicine said so.

But eventually, the truth will come out: The ER is super busy, they will opine with the tone of combat veterans, and they need to increase throughput and patient flow. Niceties like an i-STAT creatinine check before IV contrast might turn a 10-minute ER visit into a 23-hour ordeal, don't you know.

Cool Hand Luke artifact. "What we've got here is failure to communicate." Specifically, between the technologist and the patient. One way or another, the patient has not gotten the message that she needs to hold still, breathe (and refrain there from) at opportune intervals, and drink contrast in proper dosage at a certain pace. Whether the patient is intoxicated/demented/belligerent and didn't get the memo, the technologist didn't clearly convey instructions, or the hospital didn't have a Xhosa translator on-call to facilitate interactions, the end result is the same: A big motion blur where there might otherwise have been a diagnostic image, possibly with the entire load of oral contrast freshly dumped into the stomach 30 seconds before scanning began.

Henry Ford syndrome. When a referring clinician lives by the philosophy that "History is bunk," and decides that a clinical indication of R/O PATH is better than "four days status post lysis of adhesions, patient with history of ovarian cancer now having left midabdominal colicky pain and increasing white count with fever," you have a case of Henry Ford syndrome on your hands.

Although the ensuing "could be this, could be that" report you are then forced to generate when the clinician is unavailable for comment might seem to indicate the patient is the one with the syndrome, it's really the referrer-just looking at a bundle of other studies he's ordered with the same carelessness will demonstrate this.

HAL 9000 syndrome. Unlike Henry Ford syndrome, the terse and unhelpful clinical histories in this instance are not the fault of the ordering clinician, but rather the super expensive computerized order entry system the hospital got last year without the input of a single practicing physician. The referrer really did want to convey a valuable history, but the computer provided him with absolutely no way to do this. He was instead forced to select from a short list of approved indications for the study he wanted, and the list item he selected is the only history you will be seeing. You may develop a suspicion that you are dealing with HAL-9000 when 95 percent of the chest X-rays you receive are for "Chest pain - left."

Triggerpull procedure. Refers to any imaging study by which a competent, confident radiologist looks at a patient's tangle of hedged reports from previous exams (whether they were appropriate studies or not), reviews the current images, mentally summates all of the available data, and arrives at a conclusive diagnosis, "pulling the trigger" without a bit of verbal hesitation or qualifiers in the report. Next case!