Dr. Pepe’s Diploma Casebook: Case 115 – SOLVED!

Dear Friends,

Today I am presenting radiographs of a 60-year-old man with a cough and moderate fever.

Diagnosis:

1. Viral pneumonia
2. Non-cardiac pulmonary edema
3. Pulmonary hemorrhage
4. None of the above

Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

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13
Nov 2017
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DISCUSSION 10 Comments

Slowly but surely, emergency radiology subspecialisation is being recognised, says Denmark’s first full-time emergency radiologist

This year, the main theme of the International Day of Radiology is emergency radiology. To get some insight into the field, we spoke to Dr. Csaba Traply, head of the emergency department radiology unit and chief emergency radiology consultant at the radiology department of Odense University Hospital in Odense, Denmark.

European Society of Radiology: Could you please describe the role of the radiologist in a typical emergency department in your country?
Csaba Traply: Our emergency department, which opened five years ago, is the first of its kind in Denmark. I was the first Danish radiologist to be employed as a full-time, emergency radiologist.
Together with my younger colleagues (who are in rotation in various radiology subsections, including our emergency section) we are part of a team in the emergency department. Our main focus is to give optimal, expedient examinations and diagnoses to incoming patients. Our goal is for patients to have a preliminary diagnosis within four hours of arriving at the emergency department, no matter what the time of day. In our case, patients usually receive a final diagnosis within this period, thanks to having a radiology unit physically located in the emergency department and available around the clock.
In other hospitals in Denmark, similar emergency departments have just been established. Unfortunately, not all of these will include an on-site radiology unit, and among those that do, not all will have an on-site radiologist.
Personally, I cannot imagine emergency radiology without the constant, physical presence of a radiologist, as the condition and required diagnostics for emergency patients can change rapidly. Therefore, I think that our presence and participation as part of the emergency team is essential.

Dr. Csaba Traply is head of the radiology unit in the emergency department and chief consultant in emergency radiology at the radiology department at Odense University Hospital in Odense, Denmark.

ESR: What does a typical day in the emergency department look like for a radiologist?
CT: In the early morning, only few new patients arrive. At around 10:00, the number of patients starts to increase, and the number of visitors peaks between 14:00–20:00. I think that this is a universal pattern in all emergency departments. Naturally, the workload follows this timeline.
Every morning begins by reporting examinations from the previous night, as well as visitation of the previous referrals and the beginning of new examinations. In the meantime, examinations of the newly arriving patients also commence.

ESR: Teamwork is crucial in an emergency department. How is this accomplished in your department and who is involved?
CT: As I already mentioned, in our emergency department, there is an on-site radiology unit with an on-site radiologist and technicians. We are an active part of the team, and in many cases, we are guiding clinicians to choose the appropriate examinations, and often our report influences patients’ treatment. This happens through direct communication and collaboration with the clinicians, often before our final report is released. So far, this works well and is a model in emergency medicine in Denmark. This is why I find it difficult to imagine that examinations take place in the emergency department, but the reporting takes place outside the emergency department.
If necessary, we cooperate and consult with the other subsections in our radiology department (e.g. neuroradiology, thoracic and abdominal radiology).

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Caceres’ Corner Case 170 (Update: Solution!)

 

Dear Friends,

Dr. Pepe had a cataract operation and cannot use the computer properly. He asked for my help and I collected two easy cases for this Monday. Hopefully, Dr Pepe will be back on Monday 13.

Case 1 is a routine control of a 68-year-old man operated for carcinoma of the oesophagus.

Case 2 is a routine control of a 52-year-old woman operated for carcinoma of the breast.

What do you see?

Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

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06
Nov 2017
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DISCUSSION 15 Comments

Croatian hospital study showed ultrasound requests doubled and CT requests tripled in 10-year period, says Rijeka-based specialist

This year, the main theme of the International Day of Radiology is emergency radiology. To get some insight into the field, we spoke to Prof. Damir Miletić, head of the radiology department at the Clinical Hospital Centre in Rijeka, Croatia.

European Society of Radiology: Could you please describe the role of the radiologist in a typical emergency department in your country?
Damir Miletić: Radiologists are involved with the majority of patients admitted to the emergency department because most adult patients require radiology services as part of their treatment. Sometimes we wonder if all these cases really are emergencies. However, during a busy shift, we don’t have time to check the indication, particularly for conventional radiography. We notice that proper clinical examinations are sometimes not only supplemented with, but often replaced with imaging and blood tests. That is magnified when the emergency department workload overwhelms the staff’s capacity. We encounter ‘defensive medicine’ in some clinical scenarios, but in emergency radiology, it is more evident than in other radiology specialties. Radiologists are imaging consultants for cross-sectional imaging indications like CT, MR or ultrasound in emergency settings because referring physicians are required to contact the radiologist to briefly explain their requests. Conventional radiography, however, does not usually require a radiologist’s approval.

Prof. Damir Miletić is an abdominal radiologist who is head of the radiology department at the Clinical Hospital Centre in Rijeka, Croatia; and chairman of radiology at the medical faculty at the University of Rijeka.

ESR: What does a typical day in the emergency department look like for a radiologist?
DM: A typical day for a radiologist in our country varies with the size of the hospital and its spectrum of specialty departments. In some hospitals, that means 20 patients per 12-hour shift. However in others, that number may increase up to 80 to 120 patients, including 10 to 15 CT scans and 5 to 10 ultrasound examinations. In hospitals with 24-hour shifts, that may be exhausting for radiologists and residents. In Croatian hospitals, interventional and paediatric radiologists have daily or weekly on-call duties. A pilot study in the Croatian university hospital revealed that ultrasound requests doubled and CT requests tripled within the 10-year follow-up, while the number of patients admitted to the emergency department is held constant. That study clearly shows a significant increase in cross-sectional diagnostics per emergency patient.

ESR: Teamwork is crucial in an emergency department. How is this accomplished in your department and who is involved?
DM: A typical radiology team in the emergency-radiology department includes a radiologist, a resident and a radiology technologist. During day shifts, they take care of emergency patients and synchronise emergency examinations with those of regularly scheduled patients. Frequently, experts in various radiology specialties are consulted and, when necessary, directly involved in problem-solving. They enrich quality of our radiological service, particularly when postoperative complications are suspected or in complex interdisciplinary cases. Overnight and weekend shifts are completely different because radiologists and residents are dealing with the whole spectrum of radiological emergencies. In paediatric emergencies, clinicians frequently follow their patients to radiology to attend the examination. This is also the case for adult patients who present with life-threatening emergencies and for patients who require a CT examination due to polytrauma.

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Additional residency training would be beneficial for Russian radiologists who share emergency radiology caseload, says Moscow-based specialist

This year, the main theme of the International Day of Radiology is emergency radiology. To get some insight into the field, we spoke to Moscow radiologist and radiology educator Dr. Elvira Akchurina, a senior radiologist in the Radiology Department of a Federal Center of Treatment and Rehabilitation in Moscow, Russia.

European Society of Radiology: Could you please describe the role of the radiologist in a typical emergency department in your country?
Elvira Akchurina: In our hospital, there is a radiologist on duty at night. The radiologist gets a request for an emergency study and gets acquainted with the case. In complicated cases, and if time permits, the radiologist speaks with the patient or emergency physician to understand the trauma and selects the best diagnostic approach. Radiologists control the examination and interpret its results. Then they discuss the radiologic findings with the emergency physician.

Dr. Elvira Akchurina, MD, PhD, works as a senior radiologist in the Radiology Department of a Federal Center of Treatment and Rehabilitation in Moscow, Russia.

ESR: What does a typical day in the emergency department look like for a radiologist?
EA: Usually it’s a busy day with lots of cases. During breaks radiologists interpret nonemergency cases.

ESR: Teamwork is crucial in an emergency department. How is this accomplished in your department and who is involved?
EA: Effective teamwork is the only way to get the correct diagnosis quickly. Timely diagnosis is crucial for finding the optimal treatment plan in emergency cases. In our department, we use a picture archiving and communication system (PACS), radiological information system (RIS) and hospital information system (HIS), and radiologists have access to patients’ charts. And, of course, the radiologist discusses the clinical history and key imaging findings with the referring physician.

ESR: How satisfied are you with the workflow and your role in your department? How do you think it could be improved?
EA: I like the organisation of workflow in my department and the friendly atmosphere between physicians and nurses. I think it would be better if emergency physicians would offer radiologists more clinical-history detail on patients and provide clearer indication for the examination.

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Teleradiology may diminish the use of ultrasound and reduce radiologists’ skill in its use says French expert

This year, the main theme of the International Day of Radiology is emergency radiology. To get some insight into the field, we spoke to Dr. Kathia Chaumoître, professor and head of the radiology department at North Hospital, Aix Marseille University, France.

European Society of Radiology: Could you please describe the role of the radiologist in a typical emergency department in your country?
Kathia Chaumoître: There are constant interactions between the emergency department and the imaging department. The radiologist is involved in every aspect of patient management: discussion about indication, choice of the best imaging technique, realisation or management of the examination, interpretation and transmittal of results.

Dr. Kathia Chaumoître is professor and head of the radiology department at North Hospital, Aix Marseille University, France.

ESR: What does a typical day in the emergency department look like for a radiologist?
KC: There is not always a dedicated team of radiologists for emergencies during the day. That depends on the size of the institution. Emergency imaging can be mixed with scheduled examinations, or it can be separated, with dedicated CT or MRI scanners. On nights and weekends there is a radiologist on site or on call for ultrasound, CT and MRI. There also are specific teams for interventional radiology, interventional neuroradiology and paediatric radiology, in the case of a teaching hospital.

ESR: Teamwork is crucial in an emergency department. How is this accomplished in your department and who is involved?
KC: In my department, all radiologists are involved in emergency work as part of their schedule. There is a dedicated CT unit for the emergency department (and two additional CT units for scheduled exams); two conventional x-rays rooms in the emergency department, one each for adults and children; and two ultrasound emergency rooms, one for adults and one for paediatric emergencies. Also, there are dedicated time slots for emergency MRIs.

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Caceres’ Corner Case 169 (Update: Solution!)


Dear Friends,

Today I am showing a PA radiograph of a 48-year-old smoker with a persistent cough. What do you see?
As in last week’s case, I will show additional images on Wednesday morning.

Check the images below, leave your thoughts in the comments section and come back on Friday for the answer.

Read more…

30
Oct 2017
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POSTED IN
DISCUSSION 25 Comments

Shortages of medical staff and equipment pose challenges in many emergency departments, says Romanian radiologist

This year, the main theme of the International Day of Radiology is emergency radiology. To get some insight into the field, we spoke to Dr. Radu Baz, an associate professor of radiology and head of the radiology department at Clinical County Hospital of Constanta, Romania.

European Society of Radiology: Could you please describe the role of the radiologist in a typical emergency department in your country?
Radu Baz: The radiologist is one of the most important members of emergency-service teams in Romania’s major hospitals. Radiologists here must examine and formulate rapid results for a large number of patients.
Because many emergency hospitals don’t have radiology imaging in emergency departments, radiologists dictate cases from the radiology department on emergency devices. In just one 24-hour period radiologists in our department dictated 220 x-rays, 70 ultrasounds and 45 CTs.

ESR: What does a typical day in the emergency department look like for a radiologist?
RB: Shifts start at 8:00, 14:00 and 20:00. During the morning and afternoon shifts there are three radiologists for conventional radiography, CT and MRI; ultrasound examinations often are conducted by the colleague responsible for conventional radiography. In most emergency hospitals, there are two radiologists on call: one who provides ultrasound and standard radiological assessments, and another for emergency CTs.

Dr. Radu Baz is an associate professor of radiology and head of the radiology department at Clinical County Hospital of Constanta, Romania.

Imaging (e.g. radiographic, CT and MRI) examinations are performed by radiology technicians or nurses, often under the direct supervision of physicians, who prioritise all cases. Physicians perform ultrasound examinations. Images are immediately transmitted to the hospital network for the use of clinicians and emergency physicians. Radiologists interpret images immediately from the x-ray console or from work stations in the reading room. Also, radiologists review complex cases in detail with clinician colleagues to assure proper case management.

ESR: Teamwork is crucial in an emergency department. How is this accomplished in your department and who is involved?
RB: Yes, indeed. Teamwork is essential in an emergency department. Direct and immediate collaboration with radiologists and their clinician colleagues helps us get through difficult cases. There often are situations when we call to ask advice from a radiologist colleague or ask to examine images while collecting clinical data. Also, there often are situations when we simply need to consult with a clinician on a case for a more in-depth approach.

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CT examinations up by more than 300% over 15 years, while number of emergency patients has increased only 10% says Swiss specialist

This year, the main theme of the International Day of Radiology is emergency radiology. To get some insight into the field, we spoke to Swiss radiologist Prof. Pierre-Alexandre Poletti, currently in charge of the emergency radiology unit and vice-chairman of the radiology service at the University Hospital of Geneva in Geneva, Switzerland.

European Society of Radiology: Could you please describe the role of the radiologist in a typical emergency department in your country?
Pierre-Alexandre Poletti: Emergency radiologists in Switzerland adhere to the most appropriate imaging protocols and algorithms for emergency patients to optimise and expedite the radiological management of emergency-department patients in term of quality of care and improvement of workflow.
Also, radiologists have to teach the fundamentals and the specifics of emergency radiology to the radiology residents in the emergency department. They must establish links and close collaborations between the emergency radiology team and the various subspecialties in radiology.

Prof. Pierre-Alexandre Poletti is currently in charge of the emergency radiology unit and vice-chairman of the radiology service at the University Hospital of Geneva in Geneva, Switzerland.

ESR: What does a typical day in the emergency department look like for a radiologist?
PAP: As part of their workflow, emergency radiologists work using various imaging modalities (mainly CT, ultrasound and conventional radiology) chosen to adapt to the specific clinical suspicions of the emergency physician. The senior radiologists supervise the examinations performed by the residents to discuss specific problems they may have. The radiologists participate in multidisciplinary events, such as case presentations, journal clubs, and morbidity and mortality meetings.

ESR: Teamwork is crucial in the emergency department. How is this accomplished in your department and who is involved?
PAP: Representatives of the radiological team have regular meetings with various emergency-team members to address the radiological and clinical-management concerns of emergency patients. Complex problems, such as the optimisation of imaging protocols and algorithms, are referred to small reflection groups, who will meet and return to their colleagues with a proposed solution.

ESR: How satisfied are you with the workflow and your role in your department? How do you think it could be improved?
PAP: Workflow is one of the main problems radiologists face in the emergency room, especially as it relates to CT imaging. Indeed, in our institution, like probably in many other hospitals, the number of CT examinations performed annually has increased by more than 300% (4,500 to 15,000) over a 15-years period, while emergency department admissions have increased only by about 10% during the same period. The satisfaction of emergency radiologists is linked directly to their ability to solve problems associated with this increased workload: long wait times for CT scans; psychological effects of heavy workloads on the radiological team; and disagreement with clinician colleagues regarding patient triage for the scanner. Read more…

Financial, structural and legal changes are necessary to improve radiology workflow, says Ukrainian radiologist

This year, the main theme of the International Day of Radiology is emergency radiology. To get some insight into the field, we spoke to Dr. Anton Nosov, MD, head of the radiology department at the Kyiv City Children’s Diagnostic Center in Kyiv, Ukraine

European Society of Radiology: Could you please describe the role of the radiologist in a typical emergency department in your country?
Anton Nosov: In our country, the role of a radiologist in the emergency department depends on situations outside of the hospital. Usually, radiologists are members of a multidisciplinary team, where they provide high quality, timely final readings for patients, which guarantees that decisions are made in consensus.
But everything changes in the case of extreme conditions, such as an unexpected military conflict (as we faced in eastern Ukraine) or other situations with enormous casualties (e.g. technogenic disasters or terrorist attacks). Such situations require rapid decision-making in conditions where there is a shortage of medical staff. In those cases, radiologists must draw quick conclusions directly from CTs or x-rays based on triage priority to ensure the survival of the most patients. This is a difficult job psychologically.

Anton Nosov, MD is a radiologist with a special clinical and research interest in emergency radiology.

ESR: What does a typical day in the emergency department look like for a radiologist?
AN: Of course, in the emergency department we face many cases every day, but the vast majority of them are trauma cases.
Trauma is a tremendous burden for hospitals and healthcare systems, affecting 135 million people worldwide annually. In Ukraine, the majority of these injuries are caused by motor-vehicle accidents, falls from heights and violent altercations.
The most pressing concern of any trauma team is stopping active haemorrhage, which is the most common cause of death in polytrauma patients.
Modern trauma management heavily relies on imaging, particularly CT scans. Most major centres now forego plain x-ray imaging in favour of diagnostic CT, which provides much higher sensitivity and can detect any active extravasation or bleeding. Our evidence suggests that well-timed use of CT increases the chance of survival in polytraumatised patients.

ESR: Teamwork is crucial in the emergency department. How is this accomplished in your department and who is involved?
AN: A multidisciplinary team is the only way to approach complex cases, such as polytrauma. We don’t have a fixed trauma team, but usually such a team consists of an anaesthesiologist, a radiologist, and a trauma surgeon or neurosurgeon. Trauma surgeons often serve as the case managers. The anaesthesiologist initiates ventilation of the patient; the radiologist interprets the imaging studies, and the trauma surgeon manages the case.

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