Rad Rage

Flea is to Emergency Department as #1 Dinosaur is to Radiology.

It should be so simple. A patient with fever, productive cough, chest pain and rales on exam. I order a chest x-ray. I write a note that says, "CXR; r/o pneumonia." The patient goes to the hospital and gets the chest x-ray. So far, so good.

As it happens, this patient has been through a lot in his life (including throat cancer and asbestos exposure) that has left its mark -- lots of marks -- on his chest x-ray. The report comes back:

We do not have any previous studies for comparison. It is very important that we compare the current study with the previous study to determine any changes. This patient has extensive asbestos-related pleural changes and calcifications in both lower pleural surfaces. There is also nodularity in the left mid lung fields which needs to be compared with previous chest x-ray to ensure stability. If this is new, then a CT of the chest would be indicated. There does appear to be subtle infiltrate in the right lower lobe, which may represent an early right lower lobe pneumonia.

As it happens, I have reports on this patient's chest x-rays going back to the early 1990s at the same hospital. Therefore the films described in those reports are all -- say it with me -- at the hospital. With a choice of a CT of the chest or comparison with old films, guess which one has no radiation or contrast exposure, is completely independent of patient compliance and doesn't cost nearly as much? I'll just get them to do a comparison with the old films.

I call the film room. I give the patient's name, date of birth and medical record number. I tell the clerk that I would like the radiologists to please compare the current chest x-ray to the old films that they (should) have in their files. The clerk asks for the patient's date of birth (again.) I give it (again.) I am told that I need to put my request for comparison with old films in writing. I am given a fax number to fax it to. I write the following (after writing the patient's name, date of birth and medical record number):

Please compare CXR of 10/6 to previous films. I include dates of 3 most recent previous films going back to 2001. Previous reports attached.

I fax not just this note but the report from the most recent previous CXR. Hey, I'm trying to be helpful. Maybe there's some secret code number somewhere on the report that will help them find the film more easily.

I wait.

A week later I call the file room back. They never got the fax. I send it again. This time I call to confirm that they got it. They did. I ask when I can expect to see the comparison. They tell me they have to find the patient's old film envelope; then the radiologist can dictate an addendum to the report.

I wait.

Another week later I call back. Monica, the film room clerk, and I are now on a first name basis. She lets me know that the films are in the radiologist's pile and I should see the addendum in 2-3 days.

I wait.

The following week I call my friend Monica, who promises it will be faxed to my office by the end of the day.

The next day, the addendum reads (essentially) "No change from previous films." Time elapsed: 1 month to determine that my patient has all kinds of nasty-looking pleural shit that is stable, and a new superimposed RLL pneumonia (for which I treated him) and from which he is now clinically recovered.

Just in time for the followup chest x-ray to make sure that infiltrate cleared. Keep in mind this is a guy with asbestos damaged lungs who stopped smoking for about 5 minutes after he was diagnosed with his throat cancer (ok, it was maybe about 2 years) so there's always the possiblity that the new infiltrate dscribed last month wasn't actually pneumonia but something bad like a lung cancer.

(Deep sigh.) Ah, but this time I have learned my lesson. My note for the CXR reads:

CXR; please compare to study of 10/6 to determine resolution of RLL infiltrate in patient with known abnormalities on CXR.

Six days ago he had the film done. Three days ago it was read. Yesterday it was dictated. Today I saw the report:

PA and lateral views of the chest were performed and compared to a previous study done on 10/6. Again noted is extensive asbestos related pleural changes with calcified pleural plaques as well as increased density in both lower lung fields especially in the left perihilar region. While this has not significantly changed since October, I would like to compare these findings with older chest x-rays which we will attempt to obtain. Once the previous chest x-rays are available, additional recommendations will be made.

AS YOU CAN SEE, NOT ONE WORD ABOUT THE RIGHT FUCKING LOWER LOBE!

Fay Wray is to King Kong as Monica the film room clerk is to #1 Dinosaur.

I call the film room. I tell Monica what the problem is. She is so good at her job that I actually keep a civil tongue in my head. She is also a fucking miracle worker: about two hours later, the radiologist -- the VERY SAME RADIOLOGIST THAT ACTUALLY READ THE FILM even (after supposedly having read my note) -- calls me back! I surprise myself at the civility of my tone (after listening to her tell me why they can't find the older films anymore and these two are so abnormal she really wants to compare them to the older ones) as I ask, "What about the RLL infiltrate? Is it still there?"

Finally finally finally it turns out that the two films are identical. The likelihood is that it wasn't really an infiltrate from 10/6 at all but rather all pleural based stuff, as he has very extensive bibasilar changes. But the bottom line is that now what he needs is a CT of his chest. (Very. Deep. Sigh.)