xray readings

Tuesday, October 4, 2011

Two weeks, two quarterbacks, two injuries and two x-rays that were difficult to read. Initial X-ray reports of Michael Vick’s injured hand suggested a broken bone, though further review (almost like instant replay) did not confirm the fracture. Ben Rothlesberger hurt his foot and his x-rays were inconclusive for a break. The MRI done the next day revealed a sprain. Good news for both players but certainly fans might wonder about who is reading the x-rays and how good they might be.

There is a winding road for a patient to get an x-ray. Usually a doctor examines the patient and needs more information to make the diagnosis or monitor treatment. The doctor usually writes a brief note to the radiologist indicating the clinical situation. It may be as simple as “chest pain” or “looking for pneumonia”. The image is taken by a radiology technologist/technician who is responsible for getting good looking pictures with the least amount of radiation. The ordering doctor often looks at the x-ray ad acts upon his interpretation. Behind the scenes, the radiologist also looks at the images and makes the final official report. This may happen in real time or the report may be delayed depending upon circumstances.

Reading an x-ray is a difficult job. The radiologist needs to know normal anatomy, variations of normal and unusual presentations of abnormal. They live in a world of black, white and various shades of gray and are at the mercy of a variety of people to do their job. They presume that the doctor who is examining the patient orders the proper pictures. A hand x-ray may show the wrist bones but not necessarily at the proper angle to see potential injuries. The technologist needs to take images that in focused, centered on the proper body part and include all the relevant anatomy.

All this background to reveal that reading an x-ray is an inexact science. Errors can happen routinely and there is an accepted miss rate of about 4%. Often the misses are not clinically significant but it’s important to appreciate the checks and balances in the system. The first reading by the ordering doctor often directs real time treatment. The secondary reading by the radiologist acts as quality control. The doc at the bedside may be interested in only one area of the film but the radiologist takes responsibility for all of it. Communication trails, paper, electronic and phone calls go back and forth to make certain everybody is on the same page.

When errors/misreads/discrepancies occur, it’s the patient that gets confused. Phone call explanations are less than satisfying and often the patient is asked to return for further views of the body part. It’s important to remember that the body is 3D but x-rays are 2D and multiple views allow the radiologist to reconstruct in his mind the body’s anatomy. CT scan and MRI are alternatives that are sometimes considered to get that 3D look, however they are susceptible to the miss rate as well.

Trying to come to grips with missed x-ray readings is a continual struggle for radiologists. Perfection is the goal but probably an unrealistic one. Uncertainty is not an expected consequence of getting a medical test. Blood tests are reported as indisputable numbers but x-rays are interpretations and not necessarily as black and white as the images on the screen. For Vick and Rothlesberger, the consequence of this lack of clarity was a few hours of diagnosis uncertainty. For other patients, it might be the difference between needing an operation and going home. For the radiologist, it’s trying to get the right answer all the time.

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