Radiology malpractice: The danger of interpreting a CT or MRI without talking to anyone about the patient
When a doctor orders a scan and does not talk to the radiologist, important information can be left out
I am working on a medical malpractice case now where one of the defendants is a neuroradiologist whom we believe misread a head CT scan. As a result, a patient was misdiagnosed and discharged home only to have a stroke a few hours later.
As a Houston, Texas medical malpractice attorney, in this case, as in all medical negligence cases, I retained relevant medical experts to review the records and provide opinions. I recently presented our neuroradiologist for deposition and was treated to a few hours of testimony on how brain or head scans should be handled in order to preserve patient safety.
In my case, the patient was complaining of the “worst headache of his life.” I put that phrase in quotation marks because those are classic buzzwords that something serious is wrong. It could be a dissected cerebral artery—as it ended up being in this case—or could be a cerebral aneurysm.
I think pretty much any doctor who treats such patients would agree that the initial radiology order should be a head CT scan without contrast. In this case, the neuroradiologist interpreted the scan as showing no acute changes. She also included in the radiology report the identification of an area of the brain that was suspicious for chronic changes and a comment that she did not know what caused the chronic changes.
You might be wondering about the difference between acute and chronic changes. Both terms refer to timing. While various medical specialties have differing time periods in mind when using these terms, generally speaking, an acute finding is hours, days, or weeks, and a chronic finding is longer than that.
In my client’s case, a cascade of errors followed the neuroradiologist’s botched reading of the head CT scan.
The neuroradiologist did not call the emergency physician to find out more information about what brought the patient to the hospital. If she had done so, she would have learned that this was the man’s third day in a row for an emergency room visit complaining of an unrelenting headache and that two days earlier a head CT scan from another facility had been interpreted as completely normal.
The emergency physician who reviewed the radiology report did not call the neuroradiologist to ask about the suspicious chronic changes. When I deposed the ER doctor, he said he was not sure how the chronic changes were related to the patient’s persistent headache, or even if the headache was chronic.
After the CT scan, the ER doctor ordered a consult with a neurologist. The neurologist also looked at the CT report and images. The neurologist chose not to call the neuroradiologist. As the clinical doctors involved in this patient’s care, the neurologist cleared him for discharged and the ER physician sent the patient home.
Our neuroradiology expert testified that if there had been any conversation with the neuroradiologist, it would have led to an order for advanced imaging, like an MRI, MR angiogram, or CT angiogram, which would have provided more detailed information that would have allowed proper diagnosis and treatment.
This whole set of facts got me thinking about how the practice of radiologists has changed over the past 10 years.
For many hospitals throughout the State of Texas and nationwide, most neuroradiologists and radiologists of their medical staffs interpret scans remotely from their homes and offices. While the quality of images is no different than if they were sitting next to the scanner the hospital, it does create an artificial communication barrier between the off-site radiologists and the doctors in the hospital. It used to be that the doctor ordering a scan could walk down the hall and talk it over with the radiologist. No more.
Even the manner in which scan images are presented to radiologists for interpretation has changed. Radiologist have computer systems at their homes or offices that they use to review scans from hospitals. New images pop up on the system like an email on your computer, except they are prioritized by urgency. Stat images, which typically include anything ordered from the emergency room, are to be interpreted as soon as possible. Routine images do not have the same urgency.
When the radiologist clicks on a new image for review, he or she is typically only provided with a few short words to explain why the scan was ordered. The words might say nausea, headache, or stroke. Most electronic medical record systems do not give the opportunity for much of a narrative explanation, even though it would be helpful in guiding the radiologist in what to look for.
In addition, it is typically the hospital computer, rather than a physician, who decides which radiologist interprets a follow-up scan. In other words, the original radiologist who interpreted the scan as inconclusive might not get a follow-up scan that was ordered to provide more detail.
I read about a case where this practice turned into a big problem.
An adult woman with a family history of cerebral aneurysms went to the hospital because of a sudden severe headache. In MR angiogram (MRA) showed a focal dilatation of a cerebral artery, which was suspicious for a cerebral aneurysm. The ER doctor ordered a CT angiogram (CTA) to clarify what was going on in the area.
The hospital computer system assigned the CTA to a different radiologist who was unaware that the study was for further clarification of a suspected cerebral artery aneurysm. Even though the first study, an MRA, was available with a few clicks of his mouse, the neuroradiologist did not review it and interpreted the CTA as normal. The patient was discharged for the hospital without further treatment. Two years later, the aneurysm ruptured, leaving the patient with a major disability from a stroke.
What you can do
In modern medicine, with electronic medical records and off-site radiologist, it seems like quite often the right hand does not know what the left hand is doing.
I believe it is a good idea to ask for a copy of the radiology report and imaging CD any time you have a CT or MRI. If you need follow-up testing, be sure to bring these materials with you and give them to your doctor for review and comparison. If you notice that a radiology report does not reference a comparison to prior testing, bring that up with your doctor.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. In 2017, H Texas magazine named him one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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Published in the July/August 2018 edition of "The Houston Lawyer" magazine