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STUDY APPROVALS:
- Obtain all the pertinent info for CT, US or other imaging requests.
- Tell the requesting clinician that you will run it by the Resident.
If there are any problems or questions, you will call them back.
Do not keep the requester on hold while you go present it to the
resident.
- If a pertinent detail is pending (eg creatinine or urine HCG),
ask the requester to call back with the information when it is
available and inform them the study will not be performed without
that information.
- Present the case to the resident.
If they approve it, make sure they protocol the study in IDX.
- Inpt ultrasounds need to be scheduled by the ED secretary or
the US tech before they can be protocolled.
- Also, check with the US tech at the beginning of the shift to
see if he/she wants to be called for each approved US or if he/she
wants to just go by IDX.
Ultrasound Approvals:
- All ultrasound approvals (inpatient and ED) are approved and
protocoled by the ED radiology resident.
- If you or any clinician need to speak to the ultrasound tech
or fellow (fellow is in house usually until 8 pm), call 8-9402
(option 3).
- Routine carotid ultrasounds are not done after hours or on weekends.
Only limited carotid ultrasounds in the setting of trauma to look
for dissection are performed.
- General arterial surveys (native vessels) of the extremities
with ultrasound are not performed. If a patient has an arterial
graft, it can be evaluated for patency, etc.
If inpatient ultrasound is requested:
- Ask why the study is urgent. Only urgent inpt studies are done
after hours.
- If the patient is not an ICU patient, confirm that the patient
can travel (i.e., come down to Radiology for the study). In general
floor patients do not need portable exams (“the patient
doesn’t want to come down” is not an appropriate reason).
After hours/on weekends, there is limiting staffing for ultrasound
techs – portable exams are very time consuming and prevent
the tech from taking care of ED cases.
- Any issues, discuss it with the resident.
If transvaginal ultrasound is requested:
- What is the urine HCG?
- If she is pregnant and less than 10 wks, please remind the requester
to send off a serum HCG. The study will not be delayed while waiting
for the results, but we need to have it cooking so we can accurately
read the study.
- Is the woman bleeding?
- If a younger patient (particularly adolescents), has she ever
been sexually active (can’t do TVUS on young women (or children)
who have never had intercourse without their (or their parent’s)
explicit consent). In general, we don’t do TVUS on kids.
CT Scan Approvals:
- If contrast is required, ask for CREATININE
(from that day)
- Urine HCG for women less than 50 years old
(don’t just ask “is she pregnant?”)
- ALLERGIES (If positive, ask what the reaction
is)
- Patient MUST usually have a peripheral IV.
Central lines do not work for some studies. In general, for general
survey studies with IV contrast (CT abdomen/pelvis, CT of neck,
etc), a central line can be used. Any type of CT angiography (PE
protocol, CTA of the neck, dissection protocol) must have 20G
peripheral line or larger – NO central lines. External jugular
(EJs) line cannot be used in any case.
- Pulmonary CTA (PE Protocol) in pregnant patients requires special
documentation of informed consent.
CT approval exceptions:
- CT Brain without contrast does not require
approval.
- CT C-spine without contrast does not require
approval for patients age 55 and older.
- Inpatient Neuro: Approval and read requests
for CT of head, neck or spine on inpatients are
typically referred to neuroradiology.
MRI of head, neck, or spine approvals:
- All requests handled by the Neuroradiology fellow on call. The
same rule applies for CT head, neck or spine cases on all inpatients.
See later section on Neurorad
Fellow.
Body or Musculoskeletal (MSK) MRI approvals:
- There are very few emergencies requiring body or MSK MRI after
hours, so get the brief details of the case, particularly why
it is urgent.
- Get a pager # from the requesting clinician so you can call
them back – since it may take a little while to work it
out.
- Discuss it w/ the ER resident. If they feel it is appropriate,
they will help you figure out who needs to be contacted.
Nuclear Medicine:
- The pager number for the Fellow is on www.amion.com
(log-in: yu rad)
Interventional Radiology:
- All requests are handled by the IR fellow on call. See later
section on IR Fellow and specific
instructions regarding urgent procedures.
READING STUDIES:
For all read requests, first check on Synapse to see if:
1. The study has actually been done/loaded (portable films always
have a slight delay), and
2. The study has been dictated already.
- If the study has not been done and it is a CT or US, make sure
it has been approved/protocolled (check IDX).
- Questions about when an xray will be done can be referred to
the ED radiology secretary (8-2355)
- If the study has been dictated, read them the impression or
refer them to Synapse for the report.
- For unread ED cases, check with the appropriate resident (plain
film vs CT/US) about it.
- For unread inpatient cases, see Neuroradiology
and Teleradiology sections.
- For VA cases, see VA section.
- For Yale Health Plan, check
with the appropriate resident (plain film vs CT/US) about it.
Regarding Inpatient Neuro Studies (and ED petrous bone or
Neuro CTA studies):
- When an inpatient neuro study has been performed AND requires
an urgent/emergent reading, the Neurorad
fellow (and ultimately the associated neurorad attending)
is responsible for interpretation.
- The Neurorad fellows
traditionally go home, after they have completed their readout
and associated emergent case-work on weekend days. This time is
variable. It does not change the ultimate responsibility, however.
- Just as a reminder, the Neurorad
fellow is also responsible for ALL (including ED cases) Petrous
Bone and CTA (Circle of Willis Studies).
Regarding "Wet" Reads:
- Residents should NOT be giving wet-readings,
except under extraordinary circumstances. The attending is physically
in the room to avoid this.
- The medical student should NOT be communicating
results on trauma cases.
- If incidents occur where an "incorrect" wet read is communicated
by a resident or med student, please notify Dr.
Howie Forman ASAP.
RADIOLOGY RELATED QUESTIONS:
Calls frequently pertain to how someone can reach a particular service:
Interventional Radiology:
- The IR Fellow pager is 370-0915 (It is the
only pager number that never changes)
- When queried about V/I services, through the ED, we appropriately
refer clinically urgent cases to the V/I beeper. However, there
are rare cases where the clinicians may need faster or additional
contact info. In such cases, the backup number (as listed on www.amion.com)
is 785-7026. While this number requires an extra
step (reaching an answering service and then a return call from
the attending), it is the most direct way to reach the attending
on call. Please use your judgment in calling this number, but
do not hesitate to do so, when such an emergency arises.
Neuroradiology Fellow:
- On normal weekdays, there is a Fellow in house until 11pm. They
handle all inpatient requests for approving or reading neuroradiology
exams, e.g., head CTs, brain MRIs, etc (phone numbers 8-3173 and
8-6215).
- On weekends, the Fellow is in house both Saturday and Sunday,
but the hours vary. They are usually here at least between 9am
and 2pm.
- Outside of the above times, inpatient neuro CTs are generally
read by the ED team. Specialized CTs (eg CTAs) may be referred
to the Neuro Fellow on call. During Teleradiology hours when the
Neuro fellow is not in house, inpt head CTs can be referred to
the Teleradiologist.
- Outside of the above times, all neuro MRI issues should be referred
to the Neuro Fellow on call. You can figure that out on amion
or from the neuro call schedule usually hanging on the bulletin
board. If you can’t find it, ask the resident.
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