Emergency Imaging. Alexander B. Baxter
For encouraging me to begin this projectand helping me see it to completion, I grate-fully acknowledge the support of MichaelSelzer, Timothy Hiscock, William Lamsback,J. Owen Zurhellen IV, Kenneth Chumbley,Haskel Fleishaker, Mark Bernstein, ChristaMuscato, Carolyn Boltin, Melvyn Feliciano,John McMenamy, Aspan Ohson, Ariel Fried-man, and Mariya Kobe.
I oer my sincere appreciation to Trudi Cloyd for her heroic assistance with re-search and writing during her final year of medical school. And I thank the medical students who generously sacrificed por-tions of their summer vacations to help with research: Zachary Adler, Fernando Cuadrado, Brianna E. Damadian, Lauren
Foster, Rachel Kaplan, Antonio Pires, Yoon Kyoung Choi, and Prabhjot Singh.
In addition, this book benefited from the expert editorial skills of Abby Bus-sel, the artistic abilities of Monte Antrim,and the technical assistance of MarthaBurzynski.
I would also like to acknowledge the physicians who have profoundly influ-enced my development as a radiologist: Alexander R. Margulis, Steven Ross, Hideyo Minagi, and William D. Robertson.
Finally, this work would not have been possible without the inspiration, influence, and example of my teachers in other disci-plines: John Teramoto, Tsutomu Ohshima, Tony Geballe, and Robert Fripp.
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◆Observing and Interpreting
Some examinations, such as a radiograph of a simple fracture in a long bone, can be appreciated immediately and accurately. Others, especially those involving com-plex anatomic structures such as the hand, wrist, or foot and most cross-sectional ex-aminations, require a structured approach to ensure that all elements of the study have been reviewed. In reality, most radiologists and other observers use a combination of immediate recognition, or “gestalt,” and a mental checklist, and the mix changes with experience. It is much easier to recognize an important finding if one has seen it be-fore, preferably many times before.
Appreciating the significance of an im-aging finding is as important as its recog-nition, and “normality” on a radiograph is a function of many factors, including age, body habitus and composition, radiograph or computed tomography (CT) image qual-ity, and position. Experience and practice leads to both sensitivity in detecting subtle abnormalities and an understanding of whether a finding is truly pathologic.
◆Reporting
The imaging report is the radiologist’s work product. It consists of two major elements: a written description of all observations that support the diagnostic impression and a summary that contains one or several diagnoses and any necessary discussion or recommendations. The format of the report may vary depending on the type of study and the preferences of the radiologist
or their institution, but it should always in-clude the following:
• Body part imaged
• Technique
• Indication and relevant history
• Comparison studies (if any)
• Findings
• Impression
It is important to present one’s findings and conclusions in a clear, organized, and succinct manner. Unfortunately, many re-ports are hobbled by wordiness, jargon, and redundancy.
Reports should be complete, but the ra-tio of “signal to noise” should be as high as possible, especially in the emergency setting. No one has time to wade through excessive, meandering, or unnecessary de-scription of findings not pertinent to the primary goals of the treating emergency physician: acute management, patient disposition, or safe discharge from the emergency department. Although every radiologist will develop a personal style, usually by emulating teachers and col-leagues, application of some basic princi-ples will result in reports distinguished by clarity, brevity, and meaning.
Describe findings anatomically, espe-cially when reporting studies of anatomi-cally complex regions, such as the neck and abdomen. Within this context, try to address the findings relevant to the clinical question early in the report, and note inci-dental findings later.
If many findings—such as multiple fa-cial fractures, intracranial metastases, or enlarged lymph nodes—need to be ac-
2Emergency Imaging
ments and grading assignments necessary for surgical planning are usually best left to the treating physician, who usually has direct access to images and considerably more detailed clinical information than the radiologist does.
◆Incidental Findings
“Incidentalomas”—cysts, nodules, osseous lesions, and visceral or other soft tissue masses—are frequently detected on im-aging studies. Most are obviously benign, such as simple renal cysts or small ovar-ian cysts in reproductive-age women, and need not even be described. The radiolo-gist should report any unexpected finding that could potentially endanger the patient in the future or that needs further imag-ing evaluation.At minimum, any patient with such a finding should be directed to appropriate primary or specialist physician referral. The radiologist should document that this has been communicated to the emergency physician in the report. Com-mon incidental findings will be addressed by anatomic region in each section of this book. The most commonly encountered in-cidental findings include lung nodules and abdominal visceral cysts or masses.
◆Learning Radiology
Diagnostic radiology is a broad discipline, and the scope of essential knowledge can be daunting to the student or resident. It is helpful to define learning goals at dier-ent stages of training and to remember that learning radiology, like learning anything, is a cyclical process of returning to the be-ginning again and again. Because one aim of this book is to support the novice radiolo-gist and the learning that takes place in the first year of residency, the following sug-gestions are presented for consideration.
As a first-year resident, one’s focus should be on learning the relevant anatomy for each rotation, learning to communicate results clearly both in reports and verbally, and acquainting oneself with the several hundred conditions likely to be encoun-tered in the emergency setting. These also
counted for on a single report, list each one on a separate line rather than in a densely packed paragraph. Summarize the pattern or condition in the report’s impression.
Avoid using “there is” before each find-ing. “No pneumothorax,” for example, de-livers the same information as “There is no pneumothorax.”
Avoid “is seen,” “is noted,” “is demon-strated,” and the like. These are the equiva-lent of putting “there is” in front of each finding. Simply state the finding.
Avoid “of the.” It is usually possible (and preferred) to put an adjective in front of the noun it modifies. “The neck of the femur” is better described as “the femoral neck.”
Avoid abbreviations and jargon. You do not know who will be reading your report. MR can mean mitral regurgitation to one physician and mental retardation to anoth-er. It is best to spell out most words and use conventional anatomic terminology: “The first carpometacarpal joint,” for example, is understood by anyone who knows basic anatomy. Its synonym, “the basal joint,” is known to hand surgeons but not necessar-ily to psychiatrists or internists, who may be caring for the patient.
While eponyms make for useful short-hand, they should be used in addition to, rather than in place of, a clear anatomic description: “A transverse,