Trust Me, I’m a Radiologist

May 30, 2014
Laurence Spitzer, MD

Radiologists tend to get a bad rap, but when it comes to imaging studies, we know best.

I have to admit it. Sometimes it blows my mind that some of my colleagues in other fields of medicine still believe that radiologists are not “real” doctors. I truly believe that the prehistoric vision of the radiologist sitting in a dark room reading a few chest X-rays, a couple CTs and a smattering of ultrasounds, and out the door and home by 3:30 pm, still stands.

In our world, we all know that this is the farthest thing from the truth. The majority of us would agree that we are working harder now, reading more cases and being asked to do more with less, than in previous years. Even though we hear that volumes are down, it doesn’t seem that way to me. Our colleagues in the ED, the intensivists in the ICU, the hospitalists on the floors and the primary care docs and specialists in the outpatient world seem to be ordering more and more studies.

That brings me to the point of my story.

Why don’t people trust us?

Let me preface the following story by saying that this account actually happened, and that there has been no embellishment for the sake of entertainment or to provide humor. I kid you not.

The other day at work, while assigned to the CT rotation, one of the CT techs called to tell me that one of our referring surgeons had sent in a patient of his for a CT of the abdomen and pelvis, with IV contrast. The patient had a complicated history of multiple prior surgeries for bowel obstructions, and reportedly had prior CTs done at outside institutions for such.

The doctor’s request stated, “abdominal pain; evaluate for bowel obstruction.” As per protocol, when the technologist queried the patient as part of our department’s routine screening, the patient told the technologist that after a previous CT scan with contrast, she developed hives, chest pain and tongue swelling that required her to be admitted to the hospital.

When the technologist relayed this story to me, it was a no-brainer. Any patient having a previous reaction to IV contrast predisposes that patient to another reaction. We would do the study without contrast, as having IV contrast is not essential to diagnose a bowel obstruction, and certainly, the risks of a serious contrast reaction carries more weight than anything we would not be able to diagnose on the study.

I instructed the technologist to notify the patient and the surgeon of this, and assumed that the issue had been put to rest. Much to my surprise a few minutes later, the technologist called me back to tell me that the surgeon wished to speak to me. Huh? Mind you, I know this doctor fairly well, and he has a decent reputation. I do not have nor have had any conflict with him in the past. He proceeded to tell me that despite the patient’s history of having a legitimate contrast reaction in the past, he wanted the study to be done with contrast, and when I asked him why, his response was, “there is a better chance of seeing a bowel obstruction with contrast.” Hmmm. Had to think about that one for a minute.

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After about three seconds of thought, I asked him, “Just out of curiosity, where did you come up with that idea?” To which he replied, “It’s a known fact, and it’s what I was taught in my surgical training. I will assume the risk and I discussed this risk in detail with my patient.” Wow. Must have been some surgical residency program. Not going to argue with that logic. Then to cover my behind, I figured I needed to talk to the patient and inform her that despite what her surgeon has told her, it goes against what I am telling her to do as a radiologist, and it also goes against what my training has taught me. I told the patient in clear language that what she was about to do was against my advice, and that I would not assume any responsibility for her actions. She understood all of this, and I made sure to document such (in 10 ft letters!) all over her chart. I relinquished control, and was resigned to do the study, as ordered. Planning ahead, I alerted our dept. nurse of the impending CT and its potential consequences.

No sooner than about three minutes after the scan was performed, I was called into the scanner because the patient developed hives all over her neck and torso, and told me that her tongue was feeling puffy. Her face was flushed, and she became tachycardic. Gee, you think it’s a contrast reaction? While these symptoms were running their course and I was resuscitating her with IV fluids, supplemental O2, IV Benadryl and soothing words of comfort, etc. She had the audacity to ask me, “Why was this happening to me?” Hmmm let me think about that for a minute.

Luckily, the patient’s symptoms subsided after about one hour, and she was back to her baseline. When she was feeling better, I again attempted to advise her that what she had just experienced was clearly a reaction to IV contrast and that she should be aware of this for the future if she is to require subsequent CT exams. The consequences could easily have been worse and even result in death.

What was her response? “Thank you for your help. I should have trusted you, but now all of this has made me late for my next doctor appointment.”

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