Patients are endangered when clinical and ER doctors do not communicate with radiologists

 

Many doctors order x-ray, CT, or MRI scans without providing much patient information to radiologists and then do not review the images themselves

 
April 20, 2018

I recently read the results of an online survey conducted by a physician group that looks at ways to prevent medical malpractice. As a former hospital administrator, I love to see healthcare providers taking a proactive approach, like this, that can improve patient safety.

The survey dealt with whether emergency room (ER) physicians review diagnostic imaging studies, like x-rays, CT scans, and MRIs.

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While this rather informal survey was not intended to be scientifically or statistically valid, the results  were interesting to me, based on my experience in handling many cases involving radiologists and other physicians missing significant findings on radiology studies.

The survey found that ER physicians ordering a plain film x-ray viewed the images themselves:  30% always, 40% generally, 29% sometimes, and 1% never. The ER doctors said that, for this type of imaging, 9% depend entirely on the radiologist’s report, 12% look at the images for their own edification, 41% assessed the images based on their own knowledge of the clinical context, and 38% assess the images and discuss any concerns with the radiologist.

Regarding advanced imaging, like a CT or MRI scan, 14% of ER physician said they always viewed the images themselves, 29% generally did so, 47% sometimes did so, and 10% never looked at them themselves. For advanced images, 35% of emergency physicians depend entirely on the radiologist interpretation, 31% look at the images but only for their own edification, 16% assess the images based on their knowledge of their clinical context, and 18% assess the images and discuss any concerns with the radiologist.

These results are both enlightening and a little frightening to me. In the preceding two paragraphs, I italicized what I find to be the most significant data. For plain film x-rays, 79% of ER doctors look at the images and apply their knowledge of the patient’s clinical context—meaning what they can see and assess by seeing the patient in person. For advanced imaging, like CT and MRI scans, though, only 34% do so.

This leads to the question of how reliable can a radiologist’s interpretation of a diagnostic study be with limited or absent clinical information.

Clinical doctors and radiologists

ER and other physicians seeing patients order diagnostic radiology studies based on clinical findings or indications. In other words, the doctors ordering the studies are looking at and assessing the patient in person.

On the other hand, radiologists and neuroradiologists (radiologists with additional training to read brain scans), never see the patients whose diagnostic imaging they are interpreting. In fact, at many hospitals, the radiologists are not even located on site, but rather are reviewing images on a computer screen in a dark room at their homes or offices across town or even in another part of the state.

I have deposed a lot of radiologists and neuroradiologists. In every recent case, they explain how they have computer systems equipped with special software to view diagnostic images. When images need to be interpreted, notices pop up on the computer screen and the images are queued. If a doctor has ordered a “stat” MRI, CT scan, angiogram, or other study, it goes to the top of the list. Some systems are set up to put all ER orders at the top of the list as well.

Importantly, though, when the images show up on the radiologist’s computer for interpretation, only a few words are provided as to why the study was ordered in the first place. Even those words are sometimes rather random.

For example, I am currently handling a lawsuit involving care that was provided at Memorial Hermann Northeast Hospital, in Humble, Texas. A major issue in the case is the neuroradiologist’s interpretation of the brain CT scan without contrast, which was ordered by the emergency room provider. The Dallas-based medical expert who we retained reviewed the case said that the neuroradiologist who interpreted this CT scan for the hospital at an off-site location did not read the scan properly.

The radiology report for the scan begins with a section that says, “Signs and Symptoms: Headache with Dizziness and Giddiness.” In other words, this should be the reason that the ER physician apparently ordered the CT scan.

When I deposed the ER physician who ordered the CT scan, though, he did not agree that the patient had a headache with dizziness and giddiness when he ordered the CT. He explained that, “At the time the system . . . for ordering or putting in orders for a CT of the brain, there was a drop-down list of indications.” He selected the drop-down option for what he felt was closest, but conceded that the information provided to the neuroradiologist was, in his words, “Not entirely accurate.”

The Memorial Hermann electronic ordering system apparently did not allow the ER doctor to put in more information as the indication for the order. I believe that that information would have been helpful to the neuroradiologist, helping to guide what to look for on the scan. After all, this patient had returned to an emergency room for three days in a row with the worst headache of his life, associated with nausea, vomiting, and vision problems.

The neuroradiologist interpreted the scan as showing “No CT evidence of acute intracranial process.” Our neuroradiology expert, though, reviewed and interpreted the same imaging as showing an “acute and emergent” condition, “complete effacement of the sulci (CSF spaces) along the high right convexity; this is completely abnormal for a 38-year-old male.”

The ER physician discharged the patient later that day. Within a few hours, the patient had a massive stroke. While our medical experts have identified several mistakes in the care of this patient, I believe that better communication between the emergency room doctor and neuroradiologist may have avoided this tragic outcome.

Think back to the ER physician survey discussed above and how only 34% of those surveyed review MRI and CT scans themselves. I think that my client's story reveals the danger to patients that exists when the physician team does not match clinical information to radiology findings.

We are here to help

If you or a loved one has been seriously injured because of a misinterpreted diagnostic radiology scan, like an x-ray, MRI, CT, or angiogram, call the experienced medical negligence attorneys at Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.

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Robert Painter is a medical malpractice and wrongful death lawyer at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who files medical negligence lawsuits against hospitals, doctors, pharmacies, surgeons, anesthesiologists, and other healthcare providers. In 2017, H Texas magazine recognized him as one of Houston’s top lawyers. Also, in 2017, the Better Business Bureau honored Painter Law Firm PLLC with its Award of Distinction.

Robert Painter

Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.

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