Radiologists – The Who, What, Where, When, Why and How

The April, 2013 issue of the American Journal of Roentgenology has an article by Dr. Richard Gunderman discussing the who, what, where, when, why and how of being a radiologist.

It is a must read for every radiology resident and perhaps every practicing radiologist as well.

 

Why did the Potter’s Hand shake?

One more piece from Dr. Akhila Prasad, Sr. Specialist, Dr. RML Hospital, New Delhi that makes her think. You can reach her at akhil43 at yahoo.com. She earlier wrote the piece, “The Physician Buried Inside the Radiologist”.

 

A vessel of more ungainly make…

What! Did the Hand then of the Potter shake?

The Rubaiyat of Omar Khayyam.

 

Who among us radiologists, are not familiar with the sickening, sinking feeling we get when we are scanning a blissfully, happily pregnant woman’s abdomen and the various shades of grey slowly reveal to us, “Yes! The Potter’s Hand must have shaken while making this pot!”

This is about the number of times we have diagnosed some form of congenital anomaly on an antenatal scan! The mother is smiling and looking at us in anticipation, often in a blissfully ignorant, content state, lying in front of us, so trustingly exposing her pregnant belly carrying that magical life inside her!

We have to continue to maintain a poker face as if nothing is amiss and everything is fine and first try to figure out what the hell is happening on the screen, and having quickly figured out how the Potter’s Hand shook and having frozen all the shakings into eternity (images), comes the next issue of how to tell, what to tell and how to manage the patient!

Sometimes the patient guesses even before we say something, our body language perhaps or the facial expression or her own intuition…or the number of postgraduate students excited beyond imagination at the unimaginable cosmic mistake in front of them!

Thoughts of all kinds, all at the same moment, fleet past in our minds…to err is human, but here is where the Divine seems to have erred! Is it possible? How? But the results are in the front of us on the screen! “What was that unborn child’s fault dammit!” you ask yourself. It has not even come into this world yet, or committed any mistake and it has had to pay…like this?” your brain argues. “Karmic”, the word echoes somewhere in your brain, a general one-stop shop answer to every Indian problem! “Whose Karma?” immediately your brain asks. “The unborn body? Or the unborn soul? Or the previous birth body? Or the previous birth soul??…you don’t have any answers!

And by that time anyway you have more pressing problems at hand to handle! To handle the patient at hand! To handle her mother or husband standing next to you! To gently reveal to them that something is wrong! God forgot to put a head! Or He shortened a couple of limbs! He decided to put the baby’s abdomen into the chest! God!!! What do you say? How do you say it? And why doesn’t it get easier over the years? Why is it as troubling and as painful each time? And the irony is that despite what you feel inside, you automatically tend to stick to your professional training and duty and deal with it as if it is perfectly normal to have an abnormal unborn child. And so you write out the report and say, “Next!”

This brings us to one more core issue in our training. We must drill it into every resident’s head to mentally and morally treat every obstetric ultrasound after the relevant period of gestation, as a Level II study! The patient has come to us at this instance for a scan, after fighting God knows what odds and under what difficult circumstances. It does not matter whether the ultrasound form or receipt says, “Level II”! We have to scan her child head to toe, no matter what the form says, no matter whether it is her nth ultrasound…it has to seep into our very being, that we have to quickly and systematically declare normalcy or detect anything abnormal. The mother and the child both deserve that!

Managing a Pneumothorax – The Fear is Mostly in the Mind

Two weeks ago, in Beirut, I was speaking on the impact of modern imaging in pulmonary medicine, to a group of chest physicians from Egypt. The moment I started speaking on CT guided lung biopsies, a physician got up and started talking about the dreaded risk of pneumothorax. I have had similar reactions in other towns in India, including tier I cities like Delhi.

I explained to him that while a pneumothorax is not uncommon during CT guided biopsies, there are many ways to mitigate its seriousness; single puncture, minimal trauma, bleeding along the tract during withdrawal and arguably puncture side down for a few minutes are measures that reduce the severity and incidence of or prevent the occurrence of pneumothorax.

But even if a pneumothorax does occur, it is a slow event that takes its own time to increase, if it does. If a pneumothorax occurs during the procedure, it can be aspirated at the same time and more often than not, that cares of the problem and we can even continue with the procedure (Figure 1). In case the pneumothorax occurs after we have washed out as a delayed complication, then we can still aspirate it using an over the needle catheter. A recent video describing this procedure has been posted on The New England Journal of Medicine site. While this video shows the technique to be used in patients with spontaneous pneumothorax and describes a blind approach, we can use this simple procedure to aspirate under CT guidance as well and then check the status immediately on the CT scan table.

A and B show the start of a CT guided core biopsy of a subpleural nodule using a coaxial system. Since the nodule is immediately subpleural, the risk of pneumothorax is slightly higher than for a deeper nodule and C shows the developing pneumothorax. In D, the canula has been withdrawn into the pleural space and the pneumothorax was aspirated. E shows the biopsy continuing after the pneumothorax has been aspirated. It did not recur. Five minutes after the procedure, a scan in the supine position (G) shows a thin residual pneumothorax that was non-progressive.

A and B show the start of a CT guided core biopsy of a subpleural nodule using a coaxial system. Since the nodule is immediately subpleural, the risk of pneumothorax is slightly higher than for a deeper nodule and C shows the developing pneumothorax. In D, the canula has been withdrawn into the pleural space and the pneumothorax was aspirated. E shows the biopsy continuing after the pneumothorax has been aspirated. It did not recur. Five minutes after the procedure, a scan in the supine position (G) shows a thin residual pneumothorax that was non-progressive.

In the worst case scenario, an interventional radiologist should be able to put a tube in as well, despite the fact that the need to do this would be very low in experienced hands.

The Trust of Our Colleagues

In a recent issue of JAMA, is a short article by Dr. H. Esterbrook Longmaid that describes a moment when the doctor makes a diagnosis of metastatic prostatic cancer in another doctor, who has been a mentor and a teacher. It makes poignant reading.

I am reminded of the number of times I have had to break the news of some disease or the other to a colleague or junior or senior / teacher. So often, these doctors, even though they may not refer patients themselves, choose us because of the faith they have in us…that we will do the best we can when we perform the test, that we will break the news to them in the best possible manner and most importantly, we will maintain confidentiality regarding the results.

Each time a doctor comes to us in this manner, it should be a matter of pride that one of our colleagues who could have gone to anyone, has chosen you or me to come to, over others. And we should do our best to never undermine this trust.

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