By Dr. Barry Julius, AuntMinnie.com contributing writer

July 17, 2017 -- Every year around the beginning of July, I see some of the most haunted radiology resident faces -- right around 10 p.m., just after the attending evening shift ends and the resident night shift begins. It is almost always a second-year radiology resident who happens to be beginning his or her first night of call. What if I miss something important? What if I say something stupid? Will I be able to handle the intensity? Will I fall asleep? And, most importantly, will I kill someone?

The answers to these burning questions are only unlocked after the resident takes the first night of call. It is only after this event that the resident and the program director know whether or not this person can handle the burdens of being a radiologist. Everything in the first year leads up to this point: the precall quiz, the intense reading, the conferences, and the studying. It's crunch time.

Dr. Barry Julius
Dr. Barry Julius of RadsResident.com.

Just before the first night of dreaded call, my famous last words are, "You begin the night as a boy or girl, and you will end the night as a man or woman." Why do I say that? Because I think there is truth in that statement. Until you have the responsibility of independently making decisions for patients, you can never be a full-fledged radiologist. It's like all of those ancient traditions in religions and cultures, such as hunting that first wild boar, the confirmation, the bar mitzvah, etc. You are now allowed to function as an independent, freethinking human being who can make decisions on your own. Until that point, you are merely an observer, not an active participant.

Because call is such an intense and important experience, there are multiple things you must do to make it valuable and safe. I am going to enumerate eight simple golden rules of night call that I wish I knew prior to beginning those fated first nights. I urge that you follow this advice to enrich your education in a safe manner. Do not invoke the wrath of your fellow staff members and program directors in the morning by breaching these rules!

1. Look at every film with this in mind: What will kill the patient and what is common?

If you look at every film with these thoughts in mind and you have done the prerequisite work to get to call, you will not severely harm any of your patients. When you look at a chest film, always think pneumothorax. When you look at a female pelvic ultrasound, always think ruptured ectopic. When you look at a CT scan in a patient with right lower quadrant pain, always think acute appendicitis. And so on and so forth. Thinking about badness will prevent undiscovered horribleness in the morning.

Likewise, when you look at films, always think about the most common diagnoses first, and you will be right much more often than wrong. For instance:

  • Opacity on a chest film -- pneumonia, not Hampton's hump
  • Restricted diffusion on a brain MRI -- infarct, not ependymoma
  • Abnormality on a gastrointestinal (GI) bleed scan -- primary GI bleed, not Meckel's diverticulum with bleeding gastric remnant

I can guarantee your attending will look at you funny if you come up with too many zebras!

2. Always, always, always maintain your search pattern in every study.

In the radiology world, one of the main ways to miss something is to not look for it. There are going to be times in the middle of the night when the pressure may seem insurmountable and you need to deliver an answer that very second. A team of four angry surgeons comes down and asks, "What is going on with the film?" and needs to know now! An inpatient resident shoves a chest film in front of your face and says, "What's going on here?" The emergency medicine doctor is calling incessantly to get a read on that CT chest for dissection.

In each of these cases, I don't care how emergent and immediate they need the answer, always step back and go through your search pattern. This is a cardinal mistake that everyone makes at one point or another. Avoid it! Step back and tell them to give you a moment. Go through each organ or region in a rigorous manner. You will look a hell of a lot less stupid than if you blurt out a diagnosis/finding, only later to realize it was wrong because you hadn't thoroughly analyzed the study.

One of the worst feelings is having to find the doctor who just left your department with the wrong answer -- a doctor who is getting ready to do surgery that is not needed or to discharge a patient who needs to stay in the hospital!

3. If there is no harm to the patient, it is easier to do the study than to fight it.

This is one piece of sage advice that most residents take a while to learn. At nighttime, you will have limited time for everything. You are going to be pulled in 14 different directions at once. You are going to get calls from the emergency department, the floors, the surgeons, etc. And oftentimes, these events will happen all at once. So, if there is a study that is reasonable, just do the study. You will spend more time and energy trying to prevent a study from being done than by just completing it.

Of course, if the study is going to do significant harm to a patient, then, obviously, avoid it. However, that is the exception rather than the rule. That fluoroscopy study to rule out a foreign body that you try to block after the resident ordered it? I can guarantee it will come back hours later when you are exhausted or have lots of things going on at once. So, just do the study!

4. Don't let your temper get the best of you; you will hear about it in the morning.

There are going to be times when you encounter a curt gynecologist; a rude surgeon; a loud, demanding resident; and so on. You, yourself, are likely going to be grouchy and tired as well. It may seem like a good idea to talk back to that person in a similarly rude and unprofessional manner. Or, you may want to take a swing at one of these annoying chaps. Don't do it.

One of the most common complaints we get at nighttime is a letter written by an attending or resident saying that a radiology resident was unprofessional and handled a situation poorly under pressure. This will come regardless of whether the radiology resident is right or wrong. And often, it will stay in the resident's file/record. Don't let that be you!

5. Resident matters are best handled by residents. Attending matters are best handled by attendings.

At night, there are going to be times when an attending radiologist is needed. Make sure you don't get in over your head: Call your attending when necessary. The worst thing you can do is to perform a procedure that your attending should have done or make a phone call that should have been handled by your attending, only to find out that the wrong thing happened. It will become the talk of the town among the department -- and not in a good way.

A brain scan always needs to be read by an attending because of litigation issues. An intussusception reduction should always be done in the presence of a radiologist. And so on and so forth.

Likewise, if there is a resident issue at night, try to handle it yourself. If someone asks you whether or not to give contrast, make that decision. If a resident comes down to ask a question, answer it. You will only learn how to make the smaller decisions by playing the role of a radiology resident.

6. Ask for help if you can't handle something.

There are going to be times when the job may be too much for one person (e.g., a disaster happened with every patient getting a full-body CT scan). There are going to be questions that can only be answered by an expert (e.g., a subtle abnormality on an emergent neuro CT angiography). And there are going to be administrative issues that can only be handled by your chairman or program director (e.g., the MRI scanner broke -- should we recommend sending patients to another hospital?).

If there are issues such as these that come up at nighttime, make sure to call the appropriate channels going from lowest to highest in command. If it's a patient question that you aren't sure about, ask your chief resident. If he or she can't answer the question, you may want to ask the assigned attending on call. And up the chain it goes.

If you decide to handle everything yourself and it is inappropriate for your level, you can almost be certain of repercussions in the morning. So, please, ask for help when it is needed and appropriate!

7. Always answer your beeper/phone/pager.

Occasionally, we hear about a resident who was caught sleeping or not answering his or her pager at night. Unfortunately, those residents will often get written up in the morning for lack of timely dictation, etc. Remember to jack up the sound on your beeper/phone/pager. And take all calls!

8. Look at the films. Don't rely on the ER or nighthawk reads.

Being on call is the time to remove the umbilical cord and develop independence from your mentors/attendings. Therefore, make sure you do not repeat a dictation or reading that is already present. You should do everything from scratch, although you should look at their reads afterward.

It also looks really silly when the resident dictation matches the nighthawk dictation verbatim; this hints that the resident may not have looked at the films. When I am on in the morning, I appreciate the extra set of eyes from a resident checking the cases, even though others have looked at the studies. And it's not infrequent that our residents catch important findings that the nighthawk didn't notice. So, please, do your own independent reads/dictations!

Follow the golden rules

Call is a difficult but integral part of raising a radiology resident right. It is a time of trials and tribulations. You can and will make it through this harrowing trial, as long as you follow the golden rules.

Good luck!

Dr. Barry Julius, founder and chief editor of RadsResident.com, has been an associate radiology residency director at Saint Barnabas Medical Center since 2009. RadsResident.com is designed to be a credible, reliable, and informative site dedicated to radiology residents, students, program directors, and physicians interested in other radiology residency topics, with an emphasis on day-to-day residency information that is not covered on most educational sites. Topics include surviving a radiology residency, residency learning materials/books, financial tips, and jobs.

The comments and observations expressed herein are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.


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