Unidentified Foreign Objects

September 29, 2017

Foreign objects and incomplete history in radiology.

As a teleradiologist covering predominantly urgent and emergent-care facilities, I probably see more imaging than most rads for the purpose of detecting and localizing items that people shouldn’t have inside themselves.

When positive, a lot of these cases are far from subtle, and some are downright entertaining. I don’t think I’ve yet encountered a rad who doesn’t have at least a couple of good stories with upshots of “How did [object X] get there??!?”

A lot of the cases I get are negative, or seemingly so. But with the lousy information commonly provided by the referring clinicians, there’s a lot of uncertainty. And, by “lousy,” I mean absence of.

“R/O foreign body” is not an appropriate clinical history, folks. I’m on the fence as to whether “Foreign body” is even worse, since all too often they just didn’t bother writing the “R/O,” but the remaining two words imply that a foreign body is known to be present. Thus, any rad failing to see one is missing something.

I’ve been on the verge of creating a dictation macro for these cases a few times. One of these days, I’ll get fed up enough to actually do it. Something like “No radiodense foreign body detected. Advise careful correlation regarding expected size, configuration, material, and location of same.”[[{"type":"media","view_mode":"media_crop","fid":"63607","attributes":{"alt":"Foreign object on X-ray","class":"media-image media-image-right","id":"media_crop_8901563626779","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"8125","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: 132px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Ken Cook/Shutterstock.com","typeof":"foaf:Image"}}]]

Unknown to me, for instance, is whether a given clinician knows that, no, not every foreign body is going to be visible by X-ray. Heck, even I don’t know whether every hypothetical small item is going to be visible. If at all possible, I’d like FB X-ray studies to include a separate image of a piece of the FB in question, so I know what I’m looking for. Maybe an image of the piece placed on the palm of the patient’s hand, to demonstrate how visible it should be when superimposed by soft tissue, bone, etc.

That would also be useful when I get “instrument count” films from the OR, especially years back when I hadn’t seen too many such studies yet, and wasn’t 100% sure what I was looking for. If you can’t be bothered to jot down what you’re missing (surgical sponge, needle, etc.), just have the XR tech snap a pic of one of those items and include it in the study.

I also don’t think it’s unreasonable for us to expect a bit of info as to where the foreign body is expected to be, or how it got there. Showing me pics of a chest or abdomen and telling me “R/O FB,” I have no idea whether you know (or think) that the patient swallowed or inhaled the thing. Or if you’re looking for a broken fragment of a vascular catheter. Is that pixel of density at the edge of the image a tiny bit of shrapnel, or just an artifact? Give me zero relevant information, and I kind of have to mention it in my report.

Yes, we could pick up the phone and call to get more information about the case, or (as some uncaring referrers snarkily suggest), go over to review the patients’ charts ourselves…that is, when we’re not telerads reading from the other side of the country. Regardless, when every case you and your fellow clinicians send to us has the same lack of information, we no longer have the time for such sleuthing-and really, does it make any kind of logistical sense for us to put in that sort of legwork when it would have taken you (or your ancillary staff) an extra 5 seconds to provide just a bit more of a proper “reason for exam?”

I’d be more understanding if this were a carnival game. Like trying to fool the guy who’s supposed to be guessing your weight. But it’s not-we’re all supposed to be on the same side, doing what’s best for the patients.