A Matter of Protocol

July 4, 2014

Recommending protocols and then interpreting the exam’s study is a satisfying feeling for radiologists.

So there I was, chugging along on yet another busy telerad night, and opened what I thought was going to be yet another abdominopelvic CT for my interpretation. For a moment, I thought there had been a technical goof-up: there were no images in the case. I then realized that we were now “live” with a new, streamlined method of protocoling studies. This “case” was my prompt to enter, on the record as part of my workflow, recommendations for a study that had not yet been performed.[[{"type":"media","view_mode":"media_crop","fid":"25636","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4213108986150","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2374","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":"line-height: 1.538em; height: 182px; width: 150px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Previously, my experience with protocoling exams had pretty much ended with residency/fellowship. Post-training involvement with an imaging-study has typically begun with the actual imaging as a fait accompli. Here are the pictures, now dictate your report. Think the study was done the wrong way, or entirely the wrong modality was utilized for the provided clinical history? Too late now…dictate something to that effect in your report in case anybody cares.

This was especially the case in telerad, where one is remotely covering a bunch of different facilities, each with their own in-house rules as to how exams get done. Even if you might have had a chance to stop the ER from performing routine whole-body quadruple-phase CTs on pediatric trauma patients as an onsite member of staff, as a telerad you’ve got pretty much no weight to throw around.

Occasionally, when somebody onsite actually did think you might have some guidance to offer in advance of imaging a patient, they would reach out. You’d be phoned or instant-messaged, usually first via an intermediary, and asked if you would mind helping to protocol a study. Unless the study type was out of your comfort-zone or you were being an ornery not-team player, you would helpfully consent and then chat with the tech or clinician in the hospital regarding the issues at hand.

Unfortunately, this resulted in a bit more legwork and perceived hassle-factor for all involved than the onsite folks just cutting to the chase and doing the study without seeking an actual radiologist’s advice. Further, it was all verbal, and a protocoling rad typically wouldn’t even know whether his recommendations were heeded, since the actual imaging, once performed, would often wind up on someone else’s worklist. That rad might not agree with the protocol or even know who suggested it.

This, then, was a welcome change. The onsite folks could just submit their protocol request as they would any other radiology order, and it would get placed on a covering rad’s worklist with priority only superseded by super-emergent stuff like stroke or trauma studies. The rad could then dictate his protocol recommendations, digitally sign them (or pause to gather additional needed info from the site), and move on to other cases…and, when the protocoled exam actually got done, it would be treated the same as any “follow up” study, going to the same rad. Not only would he already have some familiarity with the case’s background…he’d have the satisfaction of seeing his recommendations followed.

And satisfying, it most definitely was. I’m looking forward to more of the same.