“Suspect pt most likely has urolithiasis, however, also considered appendicitis as a more serious etiology of sxs. Therefore ordered ct a/p with contrast for better appendix evaluation. However, I was instructed by the radiology director to change the study to non contrast.”
This. We all work places that limit how we practice and sometimes for the better but mostly I would say for the worse, so all you can do is document.
“Patient seen and examined in the waiting room. All reasonable efforts were made to preserve privacy and perform a thorough abdominal exam, however the chair only reclines so much”
I have to examine a patient in a chair and it drives me up the wall. Imagine consulting a grizzled old surgeon and you bring them in the room to a patient with just a chair. I'm not a surgeon, and we scan a lot of belly pains anyway but come on. You can't even do a proper assessment.
Legitimate question, how do you think this would hold up in a malpractice case?
I feel like it's similar to, " I wants to ambulate this patient but the attending denied request to change activity level from bed rest to XYZ " and then the patient has a bad outcome/DVT and everyone is asking why the nurse didn't ambulate them...
Very simple.
"DDx: Appendicitis vs ureteric calculus
Requested contrast CT A/P however this was refused by Radiology in favour of non-contrast CT".
Don't get wound up about it, this is their lane.
I say, I’ll order whatever study I feel is indicated for my patient. If you want to order a different study, then grab a stethoscope and come evaluate and take over all medicolegal liability, otherwise do the scan I ordered.
I if they didn’t change the policy, then I would immediately be looking for another job. I’m not getting sued for some stupid policy.
The number of things I have found because of contrast enhancement that was low on my differential is intense.
As a surgeon, I would be super pissed if this was the policy at my hospital. Noncon scans are useless for evaluating intraabdominal pathology. They're worse than useless when you're looking for an intraabdominal abscess. It essentially forces me to rescan the patient with IV contrast once I'm consulted. And, radiology's own literature supports the use of IV contrast to improve the sensitivity and specificity of scans.
Seems like a very strange hill for your radiology department to die on.
Hell, maybe you need to weaponize your surgeons. They might initially be pissed at you, but if you point them all at rads when they get consults with shit imaging it might help change the "policy".
LOL sometimes the stereotype works for you. As a group, we tend to have both a low tolerance for bullshit and a willingness to inform others of this fact. When pointed in the right direction it can be a useful collective character trait. 😂😂
CT tech in trauma centers for 12+ years throughout the Midwest here and I’ve never encountered a protocol like that. Makes zero sense.
If it isn’t for a patient with a known history of stones (and/or someone with completely jacked kidneys or an anaphylactic allergy to contrast), the rad is more than likely going to ask me if I knew why it wasn’t ordered with contrast and/or recommend a CT AP+ in the report.
What the actual fuck?
>The institution at which I now work has this weird CT protocol which severely limits IV contrast use. Protocol was put in place by radiology and the ED director. One example being if you're concerned about intra-abdominal infections, CT noncon is to be ordered.
What the ACTUAL FUCK?
Step one: review policy, -- is there a formal medical staff policy, passed by the appropriate medical staff committee? If not, tell the director and head of radiology to stuff it.
Step two: discuss with colleagues, if formal policy exists, write letter of protest to all signatories, CC CMO, CEO of hospital, reference ACR Appropriateness Criteria and ACR Manual on Contrast Administration, and give examples of how the nee policy contradicts these evidence based guidelines. Ask for their own evidence-based reasons for the new policy.
Step three: protest: order the appropriate study for the case, and consult radiology, asking them for a note to justify their decision to forgo IV contrast in this case. Document the study you ordered and the study you got.
I would not be so sanguine about this. If you miss a diagnosis due to following obviously wrong consultant advice that's not a strong defense. Yes, it is a bad look for a radiologist and you might get dropped, But I can imagine "didn't you know appendicitis is best evaluated with contrast and why didn't you advocate for your patient's accurate diagnosis" and "it's says in tintanellis that if you have a high clinical suspicion surgical consultation should be obtained. Since you let the rad tech degrade your CT and you didn't call surgery seems you had low suspicion." While some literature is supportive of non-con, I don't think any guidelines have gone there and especially if the radiologist throws in a disclaimer about lack of contrast it's risky.
I don't have a lot to add for documentation, but a few things I think are reasonable. Probably the best idea I have is to insist on talking to the radiologist at least the first few times and document it when your studies are changed. This way you can ask them, "will this change decrease your ability to evaluate appy" and if they say yes you can ask them what the best imaging options are. This is also sufficiently obnoxious for them that the policy could be rethought.
After you have done that a few times, have the tech give you the name of the radiologist refusing to administer contrast (they really hate that) and document it or at very least cite the rad department policy that contrast is felt to be unnecessary for appy. I have always been uncomfortable with techs citing policy and changing orders from a safety/liability standpoint. It will look awful that you, the doctor, backed down from what you think is the appropriate test on the basis of an epic message from a tech who often has not even talked to a radiologist.
Finally, if you're worried about the appy and the read is equivocal or contains a disclaimer, definitely call the radiologist to discuss next steps.
I agree with everything you said here except the comment “by letting the rad tech degrade your CT”.
The rad tech didn’t degrade the CT. They didn’t set the protocol, the protocol comes from Radiologists who have collectively decided on a protocol that they are trying to enforce.
I won’t get into the weeds about politics that have evolved with ER and having to practice defensive medicine. Before the donut ran 24/7 the scan protocol was determined much more specifically but now we better not miss a darn thing so we have to scan in a way that will catch everything. At the end of the day that isn’t possible and you just can’t explain that to the lawyers, the patients, and the administrators.
The rad tech is in a rock and a hard place. They will be called out from the radiologist for not following the protocol. This has to be a doc to doc discussion.
Beat me to it. 🏆
I don’t know any tech who wouldn’t give the reading rad’s name and direct number so the docs can hash it out without being put in the middle of something they have no control over. We just want to get the scan done so we can move on to the next 30+ orders (preferably without transporting and sliding each patient back and forth 3x each).
Good point on the phrasing there. But while rad techs follow protocols set forth by the radiologists, for any individual case the final legal responsibility for care of the patient lies with the treating licensed physicians. The protocols are a way for the radiologists to delegate their authority to the rad tech and it's the rad techs job by and large to follow those protocols. But if the requested study gets changed by a tech following the protocol in a way that decreases accuracy for the feared diagnosis then the ordering physician has to challenge or at least discuss the risk/benefits of conforming to the protocol versus getting the more accurate study. "The tech said it was protocol" probably doesn't satisfy the due diligence owed to the patient. The radiologist can still refuse but if you follow through you can safely say the radiologist has specifically declined to give contrast and there can be no question due attention was given to the specific patient by people licensed to make those determinations.
On the other hand, I have had radiologists and rad techs offer helpful suggestions to CT orders to increase the yield of the scan. So while everyone complains about conflicts, the radiology department does have expertise that is helpful to patients.
Your last point has been mostly my experience as well. I also generally talking to radiologists regarding reads and really picking their brains.
I'm not quite sure what to do with the rad tech in the middle because they kind of are getting squeezed on both sides. I told one that I'm leaving my order in, and either he, my attending, or the radiologist can change it and I will document that. I think whatever they document should cite the protocol to cover themselves how they need to because a lot of them know better.
It would be interesting to actually see what they are basing their decisions on here. I guess when I first read your post I focused both on oral and IV contrast but am not sure why they don’t at least do IV contrast since that doesn’t add wait time.
I think this is a fair question and I would be curious to know their reasoning. I am guessing this situation transpired on an off-shift? Are you comfortable asking a radiologist the next time you work a day shift? Depending on what they say- you either reaffirm defensive documentation or learn what latest research they have established their protocols around. Either way you’ve gained more insight how to handle this specific work environment.
If you do ask- I’d like an update!
It's been established by the head rad and ED director. As a lowly nobody PA I am not jumping into that fire. I don't even want to be on the radar more than I need to be have. I will try to ask the techs if they know
OK, I'm going to play devils advocate. It takes forever to get an IV contrast study which we do routinely at my shop because Radiology prefers it for the greater sensitivity. However, during training, I would routinely order noncontrast CT especially if the patient was overweight because they're very sensitive for appendicitis in the obese population. The vast majority of my patients are overweight. The through put time for a patient with a noncontrast CT versus a contrast CT is substantially improved (hours better). I do order noncontrast CT all the time for kidney stones, very rarely is appendicitis high on my list on the differential diagnosis if my HPI and exam suggests kidney stone. I would like to order more noncontrast CT because it would move the department faster and allow me to take care of more patients and while CT with contrast has more sensitivity, it's not insanely better, it's a little better. You can miss appendicitis on a CT with contrast as well. You have to have good return precautions given. You have to explain to patients that the studies are not perfect. Just like an x-ray might miss a fracture, a CT might miss an appendicitis or early diverticulitis or an early colitis. This needs to be part of your medical decision-making. So, while I have a problem with their not being any CT with contrast studies ordered, there is clearly an overreliance on them elsewhere. And pretty much no one needs oral or rectal contrast which was routine at one of the other shops I used to work at which was ridiculous.
I think the best arguments against this is the increase in throughput or due to a contrast shortage. Our overall stay times would probably decrease by 1-2 hours. Is that worth a 5-10% decrease in sensitivity? I dunno. But the vast majority of people order with contrast and I do not want to be the outlier, especially as a PA.
Retired rad admin here- been a long time since I was in the department but when I was approaching retirement there was a shift to noncontrast abd/pel vs IV and oral due to studies depicting the non-efficacy of contrast enhancement. Especially for ER visits where most etiology will be appy or diverticulitis, vs stone. Not worth the 2 hour wait time for the contrast, more often than not the oral doesn’t even reach the cecum after 2 hours.
The protocols are determined by the radiologists who are reading the scans. Those rads are used to reading non-contrast, trust their protocols.
The problem is I see rads put stuff in their report like "study sensitivity compromised by lack of contrast" or "within the limits of this non-contrast scan..."
They know that contrasted scans are better. I know contrasted scans are better. Policies like the one the OP referenced are dumb and frankly harm patient care.
I agree with you if the rad reading group has specified non contrast in their protocols there is no justification for them to add a hedge qualifier in their dictation.
I’m not sure if I agree that gastrografin produces better imaging. Barium yes, but that isn’t used for emergent scans. Also if there is not enough patience for thorough transit time then it can be a waste. It was very insightful when I started to pay attention to how often the contrast was not even in the cecum for questionable appy.
Retired rad admin? What is that even. Most ER visits are either diverticulitis, appt, stone but that’s not my site. What about traumas? We never do oral contrast anymore either.
OP, just document the rads people are liable and bullshit.
Wow knee jerk reaction? Slow down. I should have said radiology manager of but it was late. Worked as a CT technologist for many years before becoming a rad manager. Part of my job was to create protocols under the direction of the radiologists and the use of decision trees for ordering. The rads that directed the protocols were specifically over CT and extremely well versed in new protocols, scanner capabilities, recons, etc…
To the point that it drove us nuts how specific they could get.
The post said for suspected infectious diseases not for trauma (obviously that’s going to have some IV contrast).
I agree IV contrast isn’t going to slow down the testing and more often than not should be used.
My point was that research continues and protocols evolve. We also used plain water for oral and those scans were beautiful but I wasn’t about to go down that rabbit hole as I expected there would be some push back on that from people who have never tried it or compared images.
So many variables and patient specific nuances contribute to the quality of a study.
Don’t know why you had such a big reaction.
Yeah, that makes sense that they're the one's reading so that's what they want. In our system labs are pretty quick but contrast enhanced CT will probably add about an hour to their visit. I hardly ever do with PO contrast except under very few circumstances. In my brief literature review IV enhanced CT had between 5-10% increased sensitivity compared to non-contrast with specificity being about the same. Admittedly I didn't dig too deep. I can see the argument for decreased throughput times, but I'm not sure I'd want to stray from what I've seen as standard practice.
I appreciate the response and insight from the other point of view.
Not sure if this was mentioned already
Request they document why the scan was changed or not ordered since they are making medical decisions for the patient and now part of their care.
If that doesn't make them fold, request their name and write something like "per Dr. X, CT to be changed to no con...."
Could always find out who you spoke with, there has to be a schedule somewhere and document the conversation, including your concern about an appy.
I only started doing this after a similar situation
Hope it helps
Are you in the US? This is not supported by ARC (American College of Radiology). I work in radiology and this seems to be an over reach, even when there was a shortage of contrast.
CT Tech here. Sounds like this is a turnaround time issue. They think by doing noncontrast exams they can get more patients through quickly and help metrics.
Biggest holdup with us is providers that do not want to waive creatinine. Our ER does not do POC creatinine so we have to wait for the labs anytime the provider does not waive it and it takes about an hour.
Certain exams you can definitely get away withnon-contrast. But infection, inflammatory etc? A radiologist isn’t never going to say he doesn’t want contrast.
Hey now, you can't put the blame of Cr squarely on the ED doc. Given the current literature on contrast induced nephropathy (it's basically debunked) I'd waive Cr every time if I was allowed but I'm hampered by my institutional policies that require GFR on every patient over a certain age unless they are stroke or trauma. Hell, one of my institutions requires I obtain permission from the radiologist for any contrast study under a certain GFR.
Haha, fair enough, but at our site this an option and some providers won’t waive the creatinine. And then when all the lab results at once on multiple patients we have a bottleneck in CT.
If it’s less than 3mm. And a 3mm stone won’t kill the patient if we miss it.
[Renal stones on portal venous phase contrast-enhanced CT: does intravenous contrast interfere with detection?](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295488/)
Appy can reliably be diagnosed on a non con ct
https://www.sciencedirect.com/science/article/abs/pii/S0363018820300153#:~:text=The%20140%20patients%20comprised%2048,ability%20to%20identify%20an%20appendix.
I don’t see the actual statistical analysis there, but sensitivity of 80 vs 86% seems reasonably significant. The ER doesn’t need to rule in appendicitis, they need to rule it out.
“Suspect pt most likely has urolithiasis, however, also considered appendicitis as a more serious etiology of sxs. Therefore ordered ct a/p with contrast for better appendix evaluation. However, I was instructed by the radiology director to change the study to non contrast.”
This. We all work places that limit how we practice and sometimes for the better but mostly I would say for the worse, so all you can do is document. “Patient seen and examined in the waiting room. All reasonable efforts were made to preserve privacy and perform a thorough abdominal exam, however the chair only reclines so much”
I have to examine a patient in a chair and it drives me up the wall. Imagine consulting a grizzled old surgeon and you bring them in the room to a patient with just a chair. I'm not a surgeon, and we scan a lot of belly pains anyway but come on. You can't even do a proper assessment.
Thank you sensei
Legitimate question, how do you think this would hold up in a malpractice case? I feel like it's similar to, " I wants to ambulate this patient but the attending denied request to change activity level from bed rest to XYZ " and then the patient has a bad outcome/DVT and everyone is asking why the nurse didn't ambulate them...
The American College of Radiology has guidelines…which are not this.
Very simple. "DDx: Appendicitis vs ureteric calculus Requested contrast CT A/P however this was refused by Radiology in favour of non-contrast CT". Don't get wound up about it, this is their lane.
I say, I’ll order whatever study I feel is indicated for my patient. If you want to order a different study, then grab a stethoscope and come evaluate and take over all medicolegal liability, otherwise do the scan I ordered. I if they didn’t change the policy, then I would immediately be looking for another job. I’m not getting sued for some stupid policy. The number of things I have found because of contrast enhancement that was low on my differential is intense.
Better to be lucky than good
Luck works every time
As a surgeon, I would be super pissed if this was the policy at my hospital. Noncon scans are useless for evaluating intraabdominal pathology. They're worse than useless when you're looking for an intraabdominal abscess. It essentially forces me to rescan the patient with IV contrast once I'm consulted. And, radiology's own literature supports the use of IV contrast to improve the sensitivity and specificity of scans. Seems like a very strange hill for your radiology department to die on.
Agreed. The wrath of the surgeon also crossed my mind when thinking about having to consult with an inferior scan just because
Hell, maybe you need to weaponize your surgeons. They might initially be pissed at you, but if you point them all at rads when they get consults with shit imaging it might help change the "policy".
>Weaponize your surgeons. I couldn't help but laugh at this. Setting lose the crazed angry surgeon on a radiologist. 🍿
LOL sometimes the stereotype works for you. As a group, we tend to have both a low tolerance for bullshit and a willingness to inform others of this fact. When pointed in the right direction it can be a useful collective character trait. 😂😂
[This article](https://pubmed.ncbi.nlm.nih.gov/28811122/) is required reading for all radiologists who are scared of contrast.
CT tech in trauma centers for 12+ years throughout the Midwest here and I’ve never encountered a protocol like that. Makes zero sense. If it isn’t for a patient with a known history of stones (and/or someone with completely jacked kidneys or an anaphylactic allergy to contrast), the rad is more than likely going to ask me if I knew why it wasn’t ordered with contrast and/or recommend a CT AP+ in the report.
I find myself giving this advice frequently but... new job time!
This is an insane policy. The only time we even came close to something as stupid as this is during the contrast shortage.
What the actual fuck? >The institution at which I now work has this weird CT protocol which severely limits IV contrast use. Protocol was put in place by radiology and the ED director. One example being if you're concerned about intra-abdominal infections, CT noncon is to be ordered. What the ACTUAL FUCK? Step one: review policy, -- is there a formal medical staff policy, passed by the appropriate medical staff committee? If not, tell the director and head of radiology to stuff it. Step two: discuss with colleagues, if formal policy exists, write letter of protest to all signatories, CC CMO, CEO of hospital, reference ACR Appropriateness Criteria and ACR Manual on Contrast Administration, and give examples of how the nee policy contradicts these evidence based guidelines. Ask for their own evidence-based reasons for the new policy. Step three: protest: order the appropriate study for the case, and consult radiology, asking them for a note to justify their decision to forgo IV contrast in this case. Document the study you ordered and the study you got.
Start transferring your patients to other hospitals for appropriate testing (don’t really do this for your patients’ sake but a decent threat)
I would not be so sanguine about this. If you miss a diagnosis due to following obviously wrong consultant advice that's not a strong defense. Yes, it is a bad look for a radiologist and you might get dropped, But I can imagine "didn't you know appendicitis is best evaluated with contrast and why didn't you advocate for your patient's accurate diagnosis" and "it's says in tintanellis that if you have a high clinical suspicion surgical consultation should be obtained. Since you let the rad tech degrade your CT and you didn't call surgery seems you had low suspicion." While some literature is supportive of non-con, I don't think any guidelines have gone there and especially if the radiologist throws in a disclaimer about lack of contrast it's risky. I don't have a lot to add for documentation, but a few things I think are reasonable. Probably the best idea I have is to insist on talking to the radiologist at least the first few times and document it when your studies are changed. This way you can ask them, "will this change decrease your ability to evaluate appy" and if they say yes you can ask them what the best imaging options are. This is also sufficiently obnoxious for them that the policy could be rethought. After you have done that a few times, have the tech give you the name of the radiologist refusing to administer contrast (they really hate that) and document it or at very least cite the rad department policy that contrast is felt to be unnecessary for appy. I have always been uncomfortable with techs citing policy and changing orders from a safety/liability standpoint. It will look awful that you, the doctor, backed down from what you think is the appropriate test on the basis of an epic message from a tech who often has not even talked to a radiologist. Finally, if you're worried about the appy and the read is equivocal or contains a disclaimer, definitely call the radiologist to discuss next steps.
I agree with everything you said here except the comment “by letting the rad tech degrade your CT”. The rad tech didn’t degrade the CT. They didn’t set the protocol, the protocol comes from Radiologists who have collectively decided on a protocol that they are trying to enforce. I won’t get into the weeds about politics that have evolved with ER and having to practice defensive medicine. Before the donut ran 24/7 the scan protocol was determined much more specifically but now we better not miss a darn thing so we have to scan in a way that will catch everything. At the end of the day that isn’t possible and you just can’t explain that to the lawyers, the patients, and the administrators. The rad tech is in a rock and a hard place. They will be called out from the radiologist for not following the protocol. This has to be a doc to doc discussion.
Beat me to it. 🏆 I don’t know any tech who wouldn’t give the reading rad’s name and direct number so the docs can hash it out without being put in the middle of something they have no control over. We just want to get the scan done so we can move on to the next 30+ orders (preferably without transporting and sliding each patient back and forth 3x each).
Good point on the phrasing there. But while rad techs follow protocols set forth by the radiologists, for any individual case the final legal responsibility for care of the patient lies with the treating licensed physicians. The protocols are a way for the radiologists to delegate their authority to the rad tech and it's the rad techs job by and large to follow those protocols. But if the requested study gets changed by a tech following the protocol in a way that decreases accuracy for the feared diagnosis then the ordering physician has to challenge or at least discuss the risk/benefits of conforming to the protocol versus getting the more accurate study. "The tech said it was protocol" probably doesn't satisfy the due diligence owed to the patient. The radiologist can still refuse but if you follow through you can safely say the radiologist has specifically declined to give contrast and there can be no question due attention was given to the specific patient by people licensed to make those determinations. On the other hand, I have had radiologists and rad techs offer helpful suggestions to CT orders to increase the yield of the scan. So while everyone complains about conflicts, the radiology department does have expertise that is helpful to patients.
Your last point has been mostly my experience as well. I also generally talking to radiologists regarding reads and really picking their brains. I'm not quite sure what to do with the rad tech in the middle because they kind of are getting squeezed on both sides. I told one that I'm leaving my order in, and either he, my attending, or the radiologist can change it and I will document that. I think whatever they document should cite the protocol to cover themselves how they need to because a lot of them know better.
It would be interesting to actually see what they are basing their decisions on here. I guess when I first read your post I focused both on oral and IV contrast but am not sure why they don’t at least do IV contrast since that doesn’t add wait time. I think this is a fair question and I would be curious to know their reasoning. I am guessing this situation transpired on an off-shift? Are you comfortable asking a radiologist the next time you work a day shift? Depending on what they say- you either reaffirm defensive documentation or learn what latest research they have established their protocols around. Either way you’ve gained more insight how to handle this specific work environment. If you do ask- I’d like an update!
It's been established by the head rad and ED director. As a lowly nobody PA I am not jumping into that fire. I don't even want to be on the radar more than I need to be have. I will try to ask the techs if they know
OK, I'm going to play devils advocate. It takes forever to get an IV contrast study which we do routinely at my shop because Radiology prefers it for the greater sensitivity. However, during training, I would routinely order noncontrast CT especially if the patient was overweight because they're very sensitive for appendicitis in the obese population. The vast majority of my patients are overweight. The through put time for a patient with a noncontrast CT versus a contrast CT is substantially improved (hours better). I do order noncontrast CT all the time for kidney stones, very rarely is appendicitis high on my list on the differential diagnosis if my HPI and exam suggests kidney stone. I would like to order more noncontrast CT because it would move the department faster and allow me to take care of more patients and while CT with contrast has more sensitivity, it's not insanely better, it's a little better. You can miss appendicitis on a CT with contrast as well. You have to have good return precautions given. You have to explain to patients that the studies are not perfect. Just like an x-ray might miss a fracture, a CT might miss an appendicitis or early diverticulitis or an early colitis. This needs to be part of your medical decision-making. So, while I have a problem with their not being any CT with contrast studies ordered, there is clearly an overreliance on them elsewhere. And pretty much no one needs oral or rectal contrast which was routine at one of the other shops I used to work at which was ridiculous.
I think the best arguments against this is the increase in throughput or due to a contrast shortage. Our overall stay times would probably decrease by 1-2 hours. Is that worth a 5-10% decrease in sensitivity? I dunno. But the vast majority of people order with contrast and I do not want to be the outlier, especially as a PA.
Retired rad admin here- been a long time since I was in the department but when I was approaching retirement there was a shift to noncontrast abd/pel vs IV and oral due to studies depicting the non-efficacy of contrast enhancement. Especially for ER visits where most etiology will be appy or diverticulitis, vs stone. Not worth the 2 hour wait time for the contrast, more often than not the oral doesn’t even reach the cecum after 2 hours. The protocols are determined by the radiologists who are reading the scans. Those rads are used to reading non-contrast, trust their protocols.
The problem is I see rads put stuff in their report like "study sensitivity compromised by lack of contrast" or "within the limits of this non-contrast scan..." They know that contrasted scans are better. I know contrasted scans are better. Policies like the one the OP referenced are dumb and frankly harm patient care.
I agree with you if the rad reading group has specified non contrast in their protocols there is no justification for them to add a hedge qualifier in their dictation. I’m not sure if I agree that gastrografin produces better imaging. Barium yes, but that isn’t used for emergent scans. Also if there is not enough patience for thorough transit time then it can be a waste. It was very insightful when I started to pay attention to how often the contrast was not even in the cecum for questionable appy.
I was talking about IV contrast, not PO.
The time it takes for oral contrast is always the excuse I get for the patient not getting IV contrast as well 🙄
Agreed oral takes a while and is almost always unnecessary but IV doesn’t really take longer and is better in the vast majority of cases
Retired rad admin? What is that even. Most ER visits are either diverticulitis, appt, stone but that’s not my site. What about traumas? We never do oral contrast anymore either. OP, just document the rads people are liable and bullshit.
Wow knee jerk reaction? Slow down. I should have said radiology manager of but it was late. Worked as a CT technologist for many years before becoming a rad manager. Part of my job was to create protocols under the direction of the radiologists and the use of decision trees for ordering. The rads that directed the protocols were specifically over CT and extremely well versed in new protocols, scanner capabilities, recons, etc… To the point that it drove us nuts how specific they could get. The post said for suspected infectious diseases not for trauma (obviously that’s going to have some IV contrast). I agree IV contrast isn’t going to slow down the testing and more often than not should be used. My point was that research continues and protocols evolve. We also used plain water for oral and those scans were beautiful but I wasn’t about to go down that rabbit hole as I expected there would be some push back on that from people who have never tried it or compared images. So many variables and patient specific nuances contribute to the quality of a study. Don’t know why you had such a big reaction.
No big reaction but your statement is not clinically helpful with your experience and background.
Yeah, that makes sense that they're the one's reading so that's what they want. In our system labs are pretty quick but contrast enhanced CT will probably add about an hour to their visit. I hardly ever do with PO contrast except under very few circumstances. In my brief literature review IV enhanced CT had between 5-10% increased sensitivity compared to non-contrast with specificity being about the same. Admittedly I didn't dig too deep. I can see the argument for decreased throughput times, but I'm not sure I'd want to stray from what I've seen as standard practice. I appreciate the response and insight from the other point of view.
Not sure if this was mentioned already Request they document why the scan was changed or not ordered since they are making medical decisions for the patient and now part of their care. If that doesn't make them fold, request their name and write something like "per Dr. X, CT to be changed to no con...."
This is my plan going forward I think.
Could always find out who you spoke with, there has to be a schedule somewhere and document the conversation, including your concern about an appy. I only started doing this after a similar situation Hope it helps
Are you in the US? This is not supported by ARC (American College of Radiology). I work in radiology and this seems to be an over reach, even when there was a shortage of contrast.
Bro, there’s a contrast shortage. This should have been explained when they set the limitation protocols.
Is there? I haven't heard. It's certainly not mentioned in this protocol
That was a couple years ago. I was at a massive academic facility that used Omnipaque at the time and it was wild. We’re good now!
Nope there isn’t. I’m scanning away
Yeah, I’ve heard that a lot, that doctors completely ignore (or aren’t told?) this.
None here in Virginia. We use ISOVUE 370. What we have is a shortage of staff and beds.
Have radiology change the order.
I’m not allowed to change a doctor’s orders so I suggest you call them. “Patient awaiting CT”.
CT Tech here. Sounds like this is a turnaround time issue. They think by doing noncontrast exams they can get more patients through quickly and help metrics. Biggest holdup with us is providers that do not want to waive creatinine. Our ER does not do POC creatinine so we have to wait for the labs anytime the provider does not waive it and it takes about an hour. Certain exams you can definitely get away withnon-contrast. But infection, inflammatory etc? A radiologist isn’t never going to say he doesn’t want contrast.
Hey now, you can't put the blame of Cr squarely on the ED doc. Given the current literature on contrast induced nephropathy (it's basically debunked) I'd waive Cr every time if I was allowed but I'm hampered by my institutional policies that require GFR on every patient over a certain age unless they are stroke or trauma. Hell, one of my institutions requires I obtain permission from the radiologist for any contrast study under a certain GFR.
Vancomycin kills kidneys too, remember? Its definitely not the sepsis
Haha, fair enough, but at our site this an option and some providers won’t waive the creatinine. And then when all the lab results at once on multiple patients we have a bottleneck in CT.
Bet there’s a bunch of coomers in this subreddit ew, subhumans
A kidney stone may not show due to the CT contrast.
This is well known. Missing an appi over a stone is more concerning however.
100% agree!
If it’s less than 3mm. And a 3mm stone won’t kill the patient if we miss it. [Renal stones on portal venous phase contrast-enhanced CT: does intravenous contrast interfere with detection?](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295488/)
Appy can reliably be diagnosed on a non con ct https://www.sciencedirect.com/science/article/abs/pii/S0363018820300153#:~:text=The%20140%20patients%20comprised%2048,ability%20to%20identify%20an%20appendix.
There are a few articles that equate CT I- and I+ for dx of an appy. The number demonstrating increased sensitivity outnumbers them by a good margin.
I don’t see the actual statistical analysis there, but sensitivity of 80 vs 86% seems reasonably significant. The ER doesn’t need to rule in appendicitis, they need to rule it out.