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ACAD-AE-MED  June 2003

ACAD-AE-MED June 2003

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Subject:

Re: Are we Clinicians?

From:

Doc Holiday <[log in to unmask]>

Reply-To:

Accident and Emergency Academic List <[log in to unmask]>

Date:

Thu, 26 Jun 2003 01:08:18 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (136 lines)

I have been in some serious doodoos before for writing about this subject in
the press. I had exceeded the limits of good tastes in making comments
implying that "it takes a clinician to identify another" to explain why
radiologists ask these stupid questions.

I have grown up (a tiny bit). I no longer even get angry when this happens.
When they lose contact with patients, many radiogists lose contact with the
whole world of medicine as a whole. Some of them last saw daylight (outside
the viewing room) when A&E did not yet exist as a specialty... Did someone
say "dinosaur"? So, Simon, it is not YOU who is out of touch with reality...

I have seen these situations diffused in many ways (although never through
an "incident form"). One of the best solutions recently thrust into our
hands are the government targets:
1. Radiologist demands "clinician" see patient before CT.
2. ED doc says "thanks. I'll get back to you."
3. ED doc calls up one of those recently materialised manager-types whose
life seems nowadays to revolve around the 3h59m target. Tells him/her that
patient could be discharged if CT normal or prepped for respective admission
if not. Patient will be "on the clock" waiting for a "clinician".
4. Management-type makes radiologist understand... (yes, they DO have their
uses)

Phil, last time I was asked whether medics have agreed to do a LP if CT is
normal, I explained to the radiologist that the medical SHO on duty had just
recently been my SHO and that he would love to practise this skill, which I
taught him, but he needed my to OK it first, since this was MY patient and I
would not OK it without a CT. It is also easy to just say "hold on" and pass
the phone to one of the A&E SHOs who can then say he IS the medic on call...
They really appreciate the laugh when you do that. Once, I got a medical
student to say it...

A really good one is when a radiologist comments about what a waste of time
it is to CT a person with neurological deficit who is XX years old (same for
DNAR orders or any other procedure for which ageism is proposed as a
gate-keeper). My favourite reply is something along the lines of "sorry, I
haven't checked this for a while. What IS the age limit nowadays?"

But once I was witness to the funniest "clinician" request episode.
1. SHO and consultant involved in case of young-ish man with severe
headache. Teaching session ends with all satisfied that CT indication is a
no-brainer in this case.
2. Consultant calls radiology registrar but identifies self as "Dr. X in
A&E" (I don't think radiologist realises this is a consultant).
3. Consultant looks up from phone in disbelief and says, "she wants me to
approve this with a clinician..."
4. I jokingly point out the medic in call writing notes next to me.
5. Consultant, loud enough for radiologist to hear over phone, calls over
the medic to "tell her he wants a CT"
6. Medic comes to the phone and says, literally, "please do a CT". I'm not
kidding - that's what he said.
7. Medic listens some and then hands phone back to consultant. "I know he
has not seen the patient. Neither have you. That's why I (emphasis here)
made the decision to have a CT done." The tone of voice now is not angry,
but is the one which, if you have any insight, tells you to curl up in a
ball and humbly submit... No such luck. Conversation continues. Consultant
at some stage DOES mention he is a consultant - it makes no difference -
radiologist wants medic to look at patient and request CT.
8. Still polite and good-natured, although obviously disappointed,
consultant gives up. Calls radiology consultant on call. Problem sorted.
Radiology consultant contacts radiographer and she does the scan (it's NAD
and so is the LP later). Consultant is present in CT while scan is done,
reads own CT then radiographer calls radiologist to come down and report it
anyway.

----------------------------------------------------------------

From: Dr P Munro <[log in to unmask]>

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 and for non-trauma we will scan
(www.sign.ac.uk)
and for non-trauma we will scan:
coma ?cause
clinical SAH with altered LOC, focal signs or persistant vomiting.
Using these we have aa audited pick up rate of about 30% for trauma and 20%
for non-trauma abnormal scans.
The last time I was faced with an SAH problem like the one described I
pointed out to the radiologists:
"I am genuinely worried this person has a subarachnoid haemorrhage - if they
dont, then we don't need to worry much, if they do they have a 25% chance of
being dead in the next 24 hrs and I would transfer them to our neurosurgery
unit tonight if the diagnosis confirmed"

Other points - a negative scan is not some kind of defeat, it is a win-win
situation - we do not have to take any other immediate action and the
patient doesn't have a life-threatening condition. Hoorah! Also a negative
scan in someone GCS3 with fixed pupils mandates continuing intensive care
until other diagnoses are excluded (TCA OD is the most common one).

Before anyone says I have not forgotten about LP in suspected SAH with a
normal scan. This is also a common ploy to dissuade us from scanning
someone.
Radiologist "Is this patient going to have an LP if the scan is normal"
Me "yes - WHAT'S YOUR POINT?"

In short- yes, you are a clinician and they are not. Offer to swap.

Phil Munro
A&E Glasgow

----- Original Message -----
From: <[log in to unmask]>

>I've just had the most staggering conversation with a radiologist.  I was
requesting an urgent CT scan on a young patient with acute onset of
headache, left sided hemiplegia and a history of previous SAH secondary to
an AVM.  The radiologist smiled and said:
 >
 > "Has this lady been seen by a clinician yet?"
 >
 > When I suggested that I was the clinician dealing with this patient (and
to imply I was not a clinician was somewhat insulting) he refused to accept
my standing and insisted that she be seen by "a clinician".
 >
 > It would appear that five years of general training, five years of
specialist training, three postgraduate exams and a consultant job in
waiting is not enough to be classed as a clinician.
 >
 > Besides this general insult was the opinion that a CT for a ?sub
arachnoid
was urgent and not an emergency as it would make no difference to the
immediate outcome.  Now within reason I can just about understand this.  I
don't request CT scans at 5am for 95 year olds with acute hemiplegias but at
16.35 for a lady in her 30s?
 >
 > Am I completely out of touch with reality?
 >
 > Dr Simon McCormick
 > SpR Emergency Medicine (on of the last clinical specialties left)

_________________________________________________________________
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