One advantage of being in a smaller hospital is that you get to know pretty
much everyone. Once you establish your credentials with the radiologists
they accept requests from you, just takes a few years- if they've been used
to A and E consultants being managers who run the odd soft tissue clinic,
keep the waits down in minors, but can't be relied on to do a neuro exam or
read an ECG it takes some time to change their philosophy. But its been a
while now since I've had a radiologist turn down a request for any
investigation (some genuine discussion as to which investigation would be
best, but no refusal or insistence on someone else seeing the patient- a big
change from a few years back when they wouldn't scan without a request from
the inpatient team).
If you have a disagreement at night you're never going to change anyone's
mind while they're still drowsy- better to have a chat with them the next
working day to sort it out for future reference.
Sad to hear that radiology registrars are still trying to block requests for
investigations from A and E- I'd have thought that registrars would have
cottoned onto us being emergency physicians.
>
> This is very depressing bur all too familiar. What we have
> managed to agree
> with our radiologists is that we use the SIGN head injury criteria for
> trauma scans
BTW, the nice guidance is now out
(http://www.nice.org.uk/pdf/cg4nicealgorithm3.pdf) and is a bit more
liberal- for instance scan for over one vomiting episode, any fit, any lack
of full orientation 2 hours post injury, any loss of consciousness or
amnesia in patients over 65, dangerous mechanism or coagulopathy.
> Consultant is present in CT while
> scan is done,
> reads own CT then radiographer calls radiologist to come down
> and report it
> anyway
No objection to this. I can report a CT to the extent of whether or not
anything needs doing that night, but I still like a radiologist to look for
the clever stuff.
> I have seen these situations diffused in many ways (although
> never through
> an "incident form")
Final line of approach, that. If you regularly disagree with a radiologist
and neither of you can be persuaded, then at least this makes management
aware of the fact that there are seriously conflicting views held by two
senior clinicians (particularly in a case like this where it sounds like one
department has a policy that overrules sound clinical judgement- never a
good idea), and maybe you can get a referee in. Never come to this yet for
me fortunately, but you might have to do it. Gets down to a risk management
issue and if it comes to the crunch it might not be nice explaining to a
coroner that you'd been unhappy with this policy for years but never done
anything about it.
Matt Dunn
Warwick
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