Emergency Imaging. Alexander B. Baxter
start coverage in the emergency depart-ments (ED) of their institutions. It is ex-tremely common for the resident on this service to be busy giving initial readings, handling clinical and technical questions, filling out study protocols, and discussing and negotiating with other services over work-up decisions. For these novice radi-ologists beginning their emergency imag-ing training, it is a rather sudden jump into very cold water at the deep end of the pool, with a shark or two perhaps ramping up the anxiety.
ED imaging is a very demanding under-taking. A huge amount of information must be rapidly acquired before a resident can safely be released into this environment. Yes, there may be an attending radiolo-gist to consult, but most likely he or she is also in “survival mode” and may have little time to answer questions and perhaps only rare opportunities to provide formal teach-ing. The pace of work in the emergency department is uncontrollable, and there are time limits for many types of studies to be reported and finalized. Surrender is not an option; the resident-in-training has an awesome task to perform to stay afloat.
Thirty-three years ago, when I was a junior resident, coping with ED radiology was quite a bit less challenging. Chest and bone radiographs were by far the most fre-quent studies. CT was still uncommon; it was time consuming and used mainly for assessing the brain. Occasionally, a barium GI study, sonogram (B-mode), or nuclear-medicine scan would turn up for review. The interpretations were not checked un-til early the next morning, so I had a few
hours to verify my opinions, although with far fewer resources to consult than are available now. I even got three or four hours of sleep most nights. I thought I was working extremely hard, but today’s radi-ology residents work under greater time pressure, handle far more studies, have more and varied responsibilities, and need to know more.
The advent of fast and readily avail-able CT, and the general recognition that patients should receive equivalent medi-cal care anytime they arrive in the ED, prompted the introduction of in-house at-tending and resident-level coverage 24/7 to quickly provide imaging reports. CT, in particular, provided accurate diagnostic in-formation covering a far wider spectrum of diseases than was available before the ex-tensive deployment of CT. Comprehension of more detailed CT anatomy and recogni-tion of a greater variety of emergency pa-thology throughout the body was required. CT protocols had to be planned with great-er precision to acquire specific information targeted to particular diagnoses. CT devel-oped into the backbone of diagnosis in the ED, and its use has steadily increased given its wide range of applications, greater ac-curacy for diagnosis, and ready availability.
In recent years, MRI has also been used more frequently to answer diagnostic ques-tions where CT either has little or no role or to clarify and expand upon the informa-tion provided by CT. Knowledge of MRI ap-plications, protocols (sequences) required, and the appearance of various pathologies is increasingly necessary as MRI units are placed closer to or within the ED. Of course, radiographs remain the most frequently performed emergency imaging study. So-
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nograms and nuclear-medicine studies are still commonly evaluated by the on-call resident. Using sonography’s various modes can be particularly time consuming to perform and challenging to interpret.
Quite clearly, the relatively young sub-specialty of emergency radiology requires diagnostic competence across many mo-dalities and covers a broad range of trau-matic and nontraumatic pathology. In addition, there are steadily increasing requirements for prompt interpretation of imaging studies to address rapidly pro-gressive and immediately life-threatening illnesses. Greater demands to perform fast and accurate triage, decrease expenses and waiting times, and maintain open beds in the ED require ever-faster study interpre-tation. There is not much time for reflect-ing upon one’s report.
In writing Emergency Imaging: A Practi-cal Guide, Dr. Alexander Baxter, assistant professor of radiology at New York Univer-sity, had the radiology resident, preparing to cover the ED, in mind. The book he has written encompasses a wide variety of pa-thologies that are likely to be seen in the ED, emphasizing fundamental approaches to interpretation and providing well-estab-lished, useful information about a particu-lar condition. Dr. Baxter has a true passion for teaching and is exceptionally good at it. His knowledge of emergency radiol-ogy is extensive, given his long clinical and academic experience at a busy emergency-trauma center. He is a master at both how to teach eectively and what to teach to give the medical student, radiology resi-dent, and more seasoned radiologist what they need to build or reinforce their basic understanding of the subject and to create a foundation for more advanced learning.
The book attains this goal with a smooth-flowing, consistent literary style. Each chapter starts with a general review of pertinent anatomy, a checklist of struc-
tures to focus on in an initial survey, study indications, protocols (mainly CT), special details of anatomy, clinical presentations, imaging correlation, and—for some enti-ties—basic treatment. The book succinctly covers considerable ground, describes the important items one must recognize in or-der to construct a reasonable dierential diagnosis, and provides excellent images that clearly illustrate the diagnosis under consideration.
Emergency Imaging: A Practical Guide fills a vital niche in preparing trainees for their entry into the demanding environ-ment of emergency imaging and provides a solid foundation for acquiring more de-tailed knowledge and a deeper understand-ing of the subject. This book also serves as a refresher course for more experienced radiologists to renew their acquaintance with less commonly encountered emer-gency conditions and to pick up current in-formation pertinent to the field. This book would also be very useful to emergency medicine residents and intrepid medical students. The authorship of Emergency Im-aging: A Practical Guideis a one-man show and so required tremendous time and fo-cus. Dr. Baxter is to be congratulated for recognizing the need for this book and for his dedication to teaching. His book is the ideal starting point for learning emergency radiology. It will help residents swim con-fidently before jumping into the deep—possibly shark-infested—waters of the ER reading room.
Stuart E. Mirvis, MD, FACR
Professor of Radiology Department of Radiology and
Nuclear Medicine University of Maryland
School of Medicine Past President of the American Society of Emergency Radiology
Baltimore, Maryland
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Like the oral board examination in Louis-ville, independent overnight call in radiol-ogy residency is a rite of passage that may soon be history. Twenty-four-hour-a-day attending coverage is now the standard at many medical centers, so the beginning resident is less likely to experience the ter-ror of interpreting an unfamiliar or com-plicated study on his or her own, possibly with a fearsome surgeon breathing down his or her neck. But even with an in-house attending to lean on, the complexity and variety of emergency imaging studies, as well as the pace of work, can still be daunt-ing for the trainee.
Intended as an introduction, a referencetool, and a starting point for further inquiryand study, Emergency Imaging provides an
overview of the most common conditionsencountered in trauma and emergencypractice, as well as an approach to imag-ing study selection and interpretation. It isdesigned to prepare radiology residents foron-call coverage, build confidence in their interpretation skills, and provide ready ac-cess to the practical information they shouldhave on hand in the emergency radiologyreading room. This book should also be ofvalue to clinicians who wish to improvetheir understanding of acute radiology.
I hope that Emergency Imagingwill con-tribute to the eorts of residents and more seasoned physicians in their pursuit of first-rate patient care through thoughtful study selection, interpretation, and radio-logic consultation.
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