Letter from the Editor

Article Outline

• Copyright

I remember the first day I was on-call in my first private practice job almost 35 years ago. At 5 or 6 o’clock, I went home, and waited for the phone to ring. I could get called in to read C-spine x-rays, do a barium swallow or IVP, or even a rare angiogram. But more often than not, nothing happened after 5 o’clock that involved me; just had to be available, basically.

Fast forward to the present. Whoa! What happened? Now instead of closing shop at 5 pm, we simply introduce the next shift and the next shift after that. The CT scanner spins all night long, the ultrasound techs are not left alone and no one wants to leave a horrific MR sitting in the stack until the next morning. Phones are ringing, images are downloading throughout the night. The radiologist is no longer the outsider. We are now in the middle of everything—which is good. But such a level of acuity when dropped in our laps requires us to adjust our practices.

The first article is an editorial by Dr. Daniel Saket, who is a radiology resident in a fine program in Philadelphia. Dr. Saket gives us an opportunity to see what worries those who will be the future of our profession—night call. How do we deal with the second and third shifts without outsourcing? He feels that outsourcing to Nitehawk should be reserved for smaller practices and that larger groups should deal with night call from within to maintain continuity with the clinical staff. Thus, more radiologists should be training in emergency radiology to provide this service to their groups. Larger groups, of course, are much better prepared to provide such call coverage.

In the next article, Drs. Chivonne L. Harrigal and William K. Erly discuss the topic of emergency imaging from a somewhat broader perspective, including solutions for academic institutions and community hospitals. They consider such matters as the role of sleep deprivation in diminishing performance, interpretation errors and the omnipresent legal issues.

Whatever solution individual groups may adopt, in my opinion as a practicing radiologist, they should try to avoid the double and even triple shift solution. After reading images for the 9-hour span of the typical radiology workday, tacking on an additional shift may not be the best way to proceed. When it comes to such detailed work as image interpretation, fatigue certainly does matter. Nitehawk radiologists are presumably fresh off of the Australian beaches or wherever. There are ways of mitigating the remoteness of the Nitehawk coverage with timely communications and of course a good Nitehawk service that provides timely and correct reading.

Now down to business. One of the controversies facing emergency room physicians is how to deal with cervical spine trauma. What sort of imaging is needed, if any at all? In their article, Drs. Bernhard Tins and Victor Cassar-Pullicino wade right into this very confusing and often controversial subject, discussing all the pros and cons of the various recommendations that are out there now. And they come up with a very reasonable set of recommendations of their own.

One of the conditions that we rarely considered back in the days before CTA, is blunt cerebrovascular injury (BCVI). In their outstanding review article, Dr. Dirk Stengel and his associates in Berlin review the literature on BCVI and discuss the impact of CTA. This is a more prevalent condition than was previously considered. Fortunately, we now have accurate tools to evaluate these key arterial structures.

One of the questions in the minds of everyone is the role of CT in evaluating chest pain during the day and off hours. Surely we already provide 24-hour coverage when looking for pulmonary emboli and aortic dissection. Now, with availability of MDCT, especially 64-slice scanners with cardiac gating, we have the ability to evaluate the coronary arteries, which is the final piece of the “triple rule-out” of chest pain. In their fine article, Drs. Jean Jeudy and Charles White discuss the various imaging options that are available to evaluate patients in the ER with chest pain. Most of their article focuses on the emerging role of CTA, especially in the evaluation of the coronary arteries.

There are a number of imaging options available when the abdomen sustains blunt trauma. First, of course, there is CT. In a wonderfully illustrated article, Drs. Joshua W Stuhlfaut, Stephan W. Anderson and Jorge A Soto, discuss the role of MDCT of the abdomen in the evaluation of blunt trauma. Most of this work was done on a 64-slice scanner, and as you would expect the images of bowel, solid organ, mesenteric and diaphragmatic injuries are outstanding. Getting such beautiful pictures does not just happen. It requires much attention to technical details and appropriate contrast timing.

There are those institutions, especially abroad, that rely more heavily on ultrasound to evaluate blunt abdominal trauma. Ultrasound is often more readily available and does not involve ionizing radiation or iodinated contrast material. Though most severe organ injuries present with some intraperitoneal fluid, some do not and require additional study such as CT. There is another way, and that has to do with using ultrasound contrast agents as described in an excellent article by Dr. Massimo Valentino and his associates. These new agents provide more robust diagnostic information in the organs at risk: the spleen, liver, kidneys and pancreas.

As I sit and read films, one knee radiograph after another, all of the soft tissues are hidden to me because the x-rays do not discriminate. MRI, of course, does a much better job, and is the most effective way of evaluating acute knee injuries. In a nicely written and illustrated article, Drs. Edwin H.G. Oei, Abida Z. Ginai, and Myriam Hunink discuss the MRI of traumatic knee lesions.

Finally, we are honoured to have Dr. Leonard Swischuk contribute a fine survey article on emergency imaging in the pediatric age group. For those of us who have to look at pediatric cases as a part of our practices, this is an enormously helpful article that covers much of the pitfalls. Personally, in my practice, I will keep it close at hand.

The emergency departments at hospitals around the country are being increasingly inundated. The triage lines from the ER often run into diagnostic imaging and that now happens throughout the day and the night. This issue is an attempt to cast light on some controversial subjects and to examine in detail a few common emergency imaging topics. I want to thank all of the authors for their fine contributions.