Medical School 2020, Year 4, Week 30 (Radiology, week 2)

I ask to focus on abdominal CT during this final week of radiology, which turns me into an expert on finding steatosis (fatty liver, caused by alcohol, viral hepatitis, or obesity). It’s easy to identify because it’s on every abdominal and pelvic CT! Prasanna’s partner explains how to differentiate steatosis from fibrosis/cirrhosis by the liver morphology. CT can differentiate interfaces between air (-1000 Holmzfeld units), fat (-100), water (0), soft tissue (30), and bone (1000). The liver and spleen should be similar densities. As fat infiltrates the hepatocytes, however, the liver density begins to drop below 60. NASH (non-alcoholic steatohepatitis) is expected to surpass alcohol-associated liver failure to become the number one cause of liver transplantation. The radiologist explains, “The liver edge should be smooth. Once fibrosis occurs, it becomes nodular. Cirrhosis is also associated with enlargement of the caudate and left lobe. You can do a ratio, but just eye-ball it.”

The abdominal work list is exploding. The attending yells, “Six scans come off one scanner in one hour. Six abdominal scans. Why couldn’t they have interweaved some lumbar and head CT? Come on! I can do maybe 5 CTs per hour. Six from one scanner, and this seat covers five other scanners. We are just getting slammed.” As soon as he is done venting and has refocused on another case, his phone rings. “Come on!”

We overhear Prasanna yell, “God Dammit.” We walk over to investigate. Prasanna waves me in. “This is the MRI from the hip arthrogram we did earlier today. What do you see?” Based on irregular T2 signals with T1 replacement (bone marrow destruction) and articular cartilage flattening, I answer, “O-N.” Osteonecrosis is bone death, typically due to reduced blood flow. He tries to pull up the X-ray. “They didn’t get a f***ing X-ray. This is why you always get an X-ray first. This could have been diagnosed weeks ago instead of waiting for an MRI. He’s going to lose both hips.” I ask what caused this? “O-N can be caused by lots of things. Osteomyelitis (or infection of the bone) is one, but I don’t think both his joints are infected. It could be from long-term steroid use, inflammatory conditions, congenital abnormalities, and trauma. There’s a whole differential. Sometimes it’s just idiopathic [unknown cause].”

We do a leg bone length study on a 13-year-old. Children who suffer a broken leg can end up with one leg growing dramatically longer than the other. We measured from the top of the femoral head to the top of the talus. “The truth is orthopedists do their own measurements, so I don’t get too technical. Each has his or her own favorite method. Some old school private practice orthopaedists keep their radiographs in-house. I do all this for our health system billing and CYA. They need our help for MRIs and CTs.” Prasanna asks, “What do you think the most common lawsuit is for orthopaedists that keep radiographs in house? … Missing lung cancer on a shoulder X-ray.”

On Friday, I work with a guy who finished radiology training only three years ago. “This seat [MSK] is so boring that it erodes my soul.” He drones “Normal” into PowerScribe after every X-ray, which allows ample time to discuss the coronavirus: “I don’t think people realize what is coming. The virus is reported to have almost a 20 percent infection rate. On the cruise ship, one asymptomatic person infected 600 people. Our health system covers about 1 million people. We have 54 ICU beds. The numbers just don’t work.”

[Editor: This is late February 2020, about two months after the media began intensive coverage of COVID-19. As it happens, the hospital never did run out of ICU beds. The hospital filled up completely in January 2021, but mostly because patients couldn’t be discharged to their nursing homes so long as they tested positive for COVID-19. See “Our hero’s hospital is full (but not with patients who should be there)” in which I noted “Essentially, the hospital is packed because, even with nearly a year to prepare, state and local health departments that regulate hospitals and track hospital capacity couldn’t get organized to turn empty hotels into Covid-19 halfway houses.”]

The junior radiologist continues: “On top of this will be a supply crisis. Our health system reverts back to the medieval age when we don’t have common medications. Penicillin is not made in the US anymore. There is going to be a huge shortage of needles. China supplies everything, and they are shut down.” Is he stockpiling? “Oh yeah.” He grabs another coffee, his fifth today. “Let me get caught up.” He speeds through 10 radiographs in a few minutes, dictating with prefilled phrases. He turns to me. “The three fastest radiologists I have ever seen are all here. The fastest offered to do 1.5 lists and get paid at 1.5 FTE. I can see his point because he could handle it, but it would set a dangerous precedent if all you care about is speed. His offer was rejected, so he started the medical student clerkship. We’re not all as fast as him, so we fall behind when students are here.”

We review a pelvic CT. He laments, “Look at this! Hip pain. It doesn’t specify if the pain is in the hip joint, greater trochanter, or SI joint. No clinical history. I’m so used to it, but this lack of communication hurts the patient. Help me help you! The worst is when we get an abdominal/pelvic CT for ‘abdominal pain, unspecified’.” He continues, “Epic has made this communication crisis worse. The ED doc or PCP just clicks a worthless button and moves on. I can use Epic to read the doctor’s notes, but I shouldn’t need to do that. The MSK seat is not as bad as the abdominal seat as there are far fewer potential diagnoses.”

Statistics for the week… Study: 0 hours. Sleep: 9 hours/night; Fun: 2 nights. Example fun: Dog playdate at a local park followed by a dog-friendly brewery.

The rest of the book:

3 thoughts on “Medical School 2020, Year 4, Week 30 (Radiology, week 2)

  1. “Six scans come off one scanner in one hour… We are just getting slammed.”

    Don’t worry, AI will do all of that radiologist work within 5 years.

    • Have you been to a hospital lately? By memory, a NYC hospital pre-requirement for finger injury treatment: undress, put a hospital gown on, get into chair on wheels and be wheeled around by a certified technician whose the only job is to wheel patients around. I am sure that radiologists will enjoy pay hike for having extra skills to use AI technology.

  2. Radiologist complaining about lack of notes from examining doc…

    I would think it’d be a good idea for a radiologist to offer an unbiased opinion on what he sees in in the image. Pre-biasing a diagnostic test may lead to missing the real problem, and also makes radiologists lazy – they may skip looking at the whole image focusing only on the area which was reported as painful.

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