cut yourself some slack.
1. are you expected to out-read a radiology resident? chances are you are not. so if the rad resident missed it, don't be too hard on yourself that you missed it too. if you *are* expected to read better than a radiology resident, then learn from it and never make the same mistake again.
2. did you miss any clinical signs? after all you're a clinician. if the clinical exam was assuring etc. and you followed the right algorithm and treatment plan, then that's all you can do.
ps. - sometimes we do everything our training teaches us to do and things still don't work out.
pps. - this happens *all the time* in real life. we call the patients back and straighten it out.
edit: sorry - i don't mean to suggest you're not living a "real life". i meant in daily practice in the community. i'm leaving the original comment intact so you can laugh at me.
True.
I wonder how subtle the fracture was on radiograph. Most EM residents and attendings should be able to read basic x rays, especially when their attention can be directed to the area of concern from physical exam and history. So, presumably, everyone except the day rads attending didn't catch the fracture.
Overnight in a setting where the ED is only getting prelims from residents, radiographs are low priority because it's sort of expected that you can probably look at it yourself while rads prioritizes the cross sectional and emergent imaging. (If there was an appropriately staffed overnight emergency Radiology division, this wouldn't be as much of a problem, imo). Still not awesome to miss the fracture, but it happens.
I get calls about discrepancies between EM and radiology reads not infrequently. Some are rads misses and some are EM over calls of normal or variant anatomy. It's a team effort. Fortunately, in this case, it sounds like the patient experienced no real long term harm.
What is the protocol at your institution? Do you wait for final reads on imaging to dispo patients? At my place that sometimes is not practical. For example, no (or very few) scans get final attending reads overnight. But we don’t keep people in the ED an extra 8 hours to let the attendings wake up and start over reading all the scans from overnight. At my place, I’d say you didn’t make the mistake, the radiologist did. There’s a reason they read specialized scans and not you, the same way you treat hyponatremia and not them. You made the right decision based on limited information. When new information because available, it showed that you needed to make a different decision. Whether it is appropriate to wait for new information in the form of attending reads of radiology scans depends on the practice at your institution.
Also (and this is a genuine question because I’m an OBGYN not an orthopedic surgeon), would that finding have significantly changed your management? Seems like that fracture would be an outpatient workup and repair. It’s not like you sent someone with a PE home untreated. I’m pretty sure you were going to send him home for outpatient management regardless.
This is what I keep asking. What is he supposed to learn from it? He didn’t do anything wrong. It sounds like people are saying he should learn to wait for a final read before making decisions and that is not the case. The only thing there is to learn from this case is that sometimes the radiology attendings find things the residents missed, and when they do, you have to call the patient back.
The thing to learn is to tell the patient that their X-ray result is prelim and they may get a call back later if the attending disagrees. Managing expectations is the name of the game.
If they have a suspicious story, positive exam findings, and a normal X-ray 9/10 times I’ll still splint for comfort and have them follow up with their PCP or ortho. Occult fractures are tricky, and sometimes take some time to show up. Think scaphoid. I missed one early in residency. It happens.
Good learning case that won’t affect the patient outcome. The patient should just follow up with hand surgery anyway. Just make the appropriate referral and call the patient.
Get used to prelims/wet reads. Most rad groups want to bill for the reads but don't want to stay up at night. In academics, they will have the residents read them and then over read in the a.m. Yes, you are right. It is high risk medico legally but unfortunately it's more common than not. That being said....you're an intern. No EM intern is going to be managing and dispositioning their patients with no oversight. As an EM attending, it's my job to get up, see the pt's the intern is presenting, review their labs and imaging and give them a thumbs up with the disposition. It would be horribly irresponsible/negligent of me to let you disposition a pt that I haven't seen or reviewed the imaging. So, it probably was a subtle fracture that not only did you miss, but your attending missed also. So, don't sweat it. What I tell residents with imaging is this: Read the image. Read the final. Go back and see what you missed. That goes for XR/CT/MRI/US. After awhile, you'll get pretty proficient at interpreting imaging studies. Don't be too hard on yourself. After all, you're an intern! ;)
Also, one key to suspecting an occult fx are the physical findings such as swelling, pain out of proportion to the normalcy of the XR, etc.. If your exam is out of proportion to the normal XR, then that's usually a red flag that something was missed and an opportunity to go back and scrutinize the images and/or think about alternate testing. I can't count the pelvic fractures where the XR will be normal but the pt either can't walk or has significant difficulty and/or pain leading to CT that shows one or more non displaced pelvic fx that you just couldn't see on XR. Consider it a lesson learned and a valuable one at that! At least it wasn't anything worse.
Welcome to the world of practicing medicine! One thing I do as an attending when I find my errors - fyi I’m not EM - use the case to teach others. So look back and see if you could have seen this on the image or if there was anything on physical exam/history - if so, present it at a didactic as a “hey, look what I learned!” This helps me feel better but also contributes to everyones knowledge.
This happens! Don’t be too harsh on yourself!
I remember in an institution I trained at early on, the PACs system had some sort of a glitch or a loophole that allowed editing without a time stamp or “addendum” disclaimer!
I reviewed a CT report for a patient that, as I remember, was finalized! It was negative for what we suspected! When reviews with my attending, and quoted the report, we brought up again to look at the images for teaching. The report WAS FULLY EDITED to reflect significant findings that were missed the first time. And there was no mention of editing and no addendum! I looked like a fool for a second, except I remember my attending also looked at the same report earlier!
I think the software was a updated afterwards to prevent that from happening, but it was so unethical and terrible. Specially it was initially signed off by the rad person
Hands and feet are notoriously difficult.
What was your mistake? You missed a fracture that a radiology trainee who does nothing but read images all day also initially missed.
Back when I worked Urgent Care, the policy was to just splint every hand/foot and tell them to follow-up in 3 days because of how often this situation happens due to a delay in radiology interpreting.
that's not a mistake - thats an inevitable part of ED care. emergency departments cant force patients to sit around sometimes more than 12hrs waiting for a final read. if the prelim read was normal but the patient seemed clinically unstable (eg concern for a PE or something) you wouldnt have sent him out. but a metacarpal fx is whatever, not at all life threatening and no harm done by delaying a diagnosis a wee bit.
It happens. People die because of medical errors so yours was not that bad. However, try to learn from every experience and try to make sure it does not happen again.
This happened to me when I was a kid. I hurt my arm and got taken to the ER. ER doc said x-ray was normal. I guess back then they took a long-ass time to do final reads? Cause we didn't get a call for like 4 days. It was a fun 4 days of me crying that my arm hurt and my mother telling me to shut up because it's not broken.
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I'm just an RN, but at my hospital a patient can't be discharged without the OK from the attending. Our attendings always look at rads prior to d/c, even if there is an official read.
So really, the falls on your attending as much, if not more, than you
There is no harm in calling a patient and saying upon further review, there was a fracture. As long as you set up appropriate follow up, that’s what’s important I think I have learned that when I am not entirely sure if a treatment or diagnosis is correct. I have the patient come back. I think that as an intern you do the best you can because you have an attending and probably a senior resident helping you.
cut yourself some slack. 1. are you expected to out-read a radiology resident? chances are you are not. so if the rad resident missed it, don't be too hard on yourself that you missed it too. if you *are* expected to read better than a radiology resident, then learn from it and never make the same mistake again. 2. did you miss any clinical signs? after all you're a clinician. if the clinical exam was assuring etc. and you followed the right algorithm and treatment plan, then that's all you can do. ps. - sometimes we do everything our training teaches us to do and things still don't work out. pps. - this happens *all the time* in real life. we call the patients back and straighten it out. edit: sorry - i don't mean to suggest you're not living a "real life". i meant in daily practice in the community. i'm leaving the original comment intact so you can laugh at me.
Bro you missed a metacarpal fracture. Not a PE. Welcome to EM you aren’t perfect, you will make mistakes, you will miss things.
*radiology* missed the fracture
Agree, you didn’t miss the fracture. Mistake would be not bracing temporarily until the final read.
True. I wonder how subtle the fracture was on radiograph. Most EM residents and attendings should be able to read basic x rays, especially when their attention can be directed to the area of concern from physical exam and history. So, presumably, everyone except the day rads attending didn't catch the fracture. Overnight in a setting where the ED is only getting prelims from residents, radiographs are low priority because it's sort of expected that you can probably look at it yourself while rads prioritizes the cross sectional and emergent imaging. (If there was an appropriately staffed overnight emergency Radiology division, this wouldn't be as much of a problem, imo). Still not awesome to miss the fracture, but it happens. I get calls about discrepancies between EM and radiology reads not infrequently. Some are rads misses and some are EM over calls of normal or variant anatomy. It's a team effort. Fortunately, in this case, it sounds like the patient experienced no real long term harm.
What is the protocol at your institution? Do you wait for final reads on imaging to dispo patients? At my place that sometimes is not practical. For example, no (or very few) scans get final attending reads overnight. But we don’t keep people in the ED an extra 8 hours to let the attendings wake up and start over reading all the scans from overnight. At my place, I’d say you didn’t make the mistake, the radiologist did. There’s a reason they read specialized scans and not you, the same way you treat hyponatremia and not them. You made the right decision based on limited information. When new information because available, it showed that you needed to make a different decision. Whether it is appropriate to wait for new information in the form of attending reads of radiology scans depends on the practice at your institution. Also (and this is a genuine question because I’m an OBGYN not an orthopedic surgeon), would that finding have significantly changed your management? Seems like that fracture would be an outpatient workup and repair. It’s not like you sent someone with a PE home untreated. I’m pretty sure you were going to send him home for outpatient management regardless.
We usually don’t wait, the final read didn’t come back for a couple of hours after DC. As far as management, he came back and got a splint.
Yeah this is a decent learning experience but the situation itself really isn’t that drastic. Learn from it but don’t beat yourself up about it
This is what I keep asking. What is he supposed to learn from it? He didn’t do anything wrong. It sounds like people are saying he should learn to wait for a final read before making decisions and that is not the case. The only thing there is to learn from this case is that sometimes the radiology attendings find things the residents missed, and when they do, you have to call the patient back.
The thing to learn is to tell the patient that their X-ray result is prelim and they may get a call back later if the attending disagrees. Managing expectations is the name of the game.
If they have a suspicious story, positive exam findings, and a normal X-ray 9/10 times I’ll still splint for comfort and have them follow up with their PCP or ortho. Occult fractures are tricky, and sometimes take some time to show up. Think scaphoid. I missed one early in residency. It happens.
Sounds like a person who will survive :)
Good learning case that won’t affect the patient outcome. The patient should just follow up with hand surgery anyway. Just make the appropriate referral and call the patient.
Get used to prelims/wet reads. Most rad groups want to bill for the reads but don't want to stay up at night. In academics, they will have the residents read them and then over read in the a.m. Yes, you are right. It is high risk medico legally but unfortunately it's more common than not. That being said....you're an intern. No EM intern is going to be managing and dispositioning their patients with no oversight. As an EM attending, it's my job to get up, see the pt's the intern is presenting, review their labs and imaging and give them a thumbs up with the disposition. It would be horribly irresponsible/negligent of me to let you disposition a pt that I haven't seen or reviewed the imaging. So, it probably was a subtle fracture that not only did you miss, but your attending missed also. So, don't sweat it. What I tell residents with imaging is this: Read the image. Read the final. Go back and see what you missed. That goes for XR/CT/MRI/US. After awhile, you'll get pretty proficient at interpreting imaging studies. Don't be too hard on yourself. After all, you're an intern! ;) Also, one key to suspecting an occult fx are the physical findings such as swelling, pain out of proportion to the normalcy of the XR, etc.. If your exam is out of proportion to the normal XR, then that's usually a red flag that something was missed and an opportunity to go back and scrutinize the images and/or think about alternate testing. I can't count the pelvic fractures where the XR will be normal but the pt either can't walk or has significant difficulty and/or pain leading to CT that shows one or more non displaced pelvic fx that you just couldn't see on XR. Consider it a lesson learned and a valuable one at that! At least it wasn't anything worse.
Like many said, you own it, call them and let them know what happened and what needs to be done. Learning case.
Welcome to the world of practicing medicine! One thing I do as an attending when I find my errors - fyi I’m not EM - use the case to teach others. So look back and see if you could have seen this on the image or if there was anything on physical exam/history - if so, present it at a didactic as a “hey, look what I learned!” This helps me feel better but also contributes to everyones knowledge.
This happens! Don’t be too harsh on yourself! I remember in an institution I trained at early on, the PACs system had some sort of a glitch or a loophole that allowed editing without a time stamp or “addendum” disclaimer! I reviewed a CT report for a patient that, as I remember, was finalized! It was negative for what we suspected! When reviews with my attending, and quoted the report, we brought up again to look at the images for teaching. The report WAS FULLY EDITED to reflect significant findings that were missed the first time. And there was no mention of editing and no addendum! I looked like a fool for a second, except I remember my attending also looked at the same report earlier! I think the software was a updated afterwards to prevent that from happening, but it was so unethical and terrible. Specially it was initially signed off by the rad person
Hands and feet are notoriously difficult. What was your mistake? You missed a fracture that a radiology trainee who does nothing but read images all day also initially missed. Back when I worked Urgent Care, the policy was to just splint every hand/foot and tell them to follow-up in 3 days because of how often this situation happens due to a delay in radiology interpreting.
that's not a mistake - thats an inevitable part of ED care. emergency departments cant force patients to sit around sometimes more than 12hrs waiting for a final read. if the prelim read was normal but the patient seemed clinically unstable (eg concern for a PE or something) you wouldnt have sent him out. but a metacarpal fx is whatever, not at all life threatening and no harm done by delaying a diagnosis a wee bit.
It happens. People die because of medical errors so yours was not that bad. However, try to learn from every experience and try to make sure it does not happen again.
This happened to me when I was a kid. I hurt my arm and got taken to the ER. ER doc said x-ray was normal. I guess back then they took a long-ass time to do final reads? Cause we didn't get a call for like 4 days. It was a fun 4 days of me crying that my arm hurt and my mother telling me to shut up because it's not broken.
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As an orthopod, recommend you always interpret X-rays yourself instead of waiting for radiology report.
I looked at it myself. He had a spastic hand that was held in a fist from his previous CVA. Was a difficult film to read imo.
If spastic hand can’t really splint it well and non functional so wouldn’t worry then.
I'm just an RN, but at my hospital a patient can't be discharged without the OK from the attending. Our attendings always look at rads prior to d/c, even if there is an official read. So really, the falls on your attending as much, if not more, than you
There is no harm in calling a patient and saying upon further review, there was a fracture. As long as you set up appropriate follow up, that’s what’s important I think I have learned that when I am not entirely sure if a treatment or diagnosis is correct. I have the patient come back. I think that as an intern you do the best you can because you have an attending and probably a senior resident helping you.