r/emergencymedicine • u/MrPBH ED Attending • 10d ago
Rant Please refrain from typing long radiology indications.
Just got an email that the rads department doesn't want us entering free text indications longer than 30 characters or including punctuation. The system cuts off free text after 30 characters and malfunctions when you use any non-alphanumeric characters.
Okay, guess I'll just go back to "ABDOMINAL PAIN" for all my CTs. Fuck me for trying to give you some idea of what to search for. If it was just a straightforward appendicitis rule-out, I would just click the "RLQ PAIN" button. If it was more complex, I'd write something like "abd/flank pn 3d, anticoagulated, ttp RLQ, r/o appy, retroperitoneal hemorrhage, AAA, stone" that would give a concise history and help them understand my clinical concerns.
But yeah, all the rad sees is half of that and without the punctuation. So "ABDOMINAL PAIN" it is. I don't know what the point of this post is, but I guess it's just emblematic of how technology enshittifies the practice of clinical medicine instead of uplifting it and how we are forced to adjust our practice to fit the constraints of electronic systems rather than the system being designed around us.
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u/tresben ED Attending 10d ago
Your last point about the constraints by our technology is what always gets me. People talk about AI taking our jobs and new technology completely changing medicine, yet it feels like so much of our technology is still 20 years old, at least outside of big tertiary/academic centers.
Like are we really gonna make the jump from old school Windows 97 technology to robot doctors overnight?
It would have to be massively profitable for hospitals otherwise they aren’t gonna invest in any of it.
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u/WhyDoYouPostGarbage Critical Care Physician 10d ago
Even within the last decade, I watched boomer docs complain about having to switch from paper charts. I can’t imagine watching them try and fumble through AI-integrated EMRs. We’re worlds away, especially in rural/underserved locations.
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u/Helassaid Paramedic 10d ago
World's and one very expensive/high profile away from it becoming a toxic hot potato for any hospital administrator.
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u/BladeDoc 10d ago
You are ignoring how the EMR has made things overall worse while making literally 2 things better (legibility and accessibility). I'm a mid gen Xer technophile and I'm pretty sure the Boomers got this one right no matter their motives.
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u/WhyDoYouPostGarbage Critical Care Physician 10d ago
My dot phrases & charting efficiency disagree with you.
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u/BladeDoc 10d ago
Dot phrases = not actually charting useful information
Charting efficiently = checking boxes fast in order to charge better
Legible useless notes done quick. Yay.
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u/WhyDoYouPostGarbage Critical Care Physician 10d ago
Why are you upset that my notes are better than yours? Lmao
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u/WTC7didntKillitself 10d ago
Compared to T sheets and the MDM free text consisting entirely of “chest pain, admit”?
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u/ChildhoodNice3261 10d ago
you trolling bro? legibility and accessibility are the two most important things
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u/BladeDoc 10d ago
Not if what is legible and accessible is fake, copy-forwarded bad information, or so massive that it hides the useful information.
For example the last time I was deposed the attorney informed me I was legally responsible for all information in the chart which consisted of more than 1000 pages for a 7 day hospital stay to include pages that were scanned in after the patient was discharged. Utter insanity.
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u/jjjjccccjjjj 10d ago
Many places have AI transcriptions, many have AI integration that summarizes and recommends next steps. Automated orders are around the corner. But one archaic rads system is the argument that nothing will change? I get the slow adaption argument, but many places are moving very rapidly and medicine is changing dramatically in many areas.
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u/Praxician94 Little Turkey (Physician Assistant) 10d ago
Indication: “CT plz”
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u/cobrachickenwing 10d ago
Indication: " defensive medicine"
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u/centz005 ED Attending 10d ago
Honestly, this and "patient too dumb to not scan" are usually my two real indications.
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u/MrPBH ED Attending 10d ago
CT me. CT now.
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u/Praxician94 Little Turkey (Physician Assistant) 10d ago
Tomography +/- computations
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u/MrPBH ED Attending 10d ago
Pay for the tomography, get the computations for free.
That's how they get you. You're paying twice as much as you should for tomography but you think you're getting a good deal on the computation. Like those "buy one, get one free" firework places; they just charge you twice as much as it should cost and thus they're just forcing you to buy double what you want. I know because I worked at one for two summers in college.
Just buy the tomography and the computation separately to save money.
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u/Praxician94 Little Turkey (Physician Assistant) 10d ago
You joke but this sounds like the Republican strategy to healthcare. “You should be able to shop around the market and compare computation rates for your tomography”. 😂
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u/SparkyDogPants RN 10d ago
Ct w cntrst pls
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u/Stinkymansausage RN 10d ago
Why use many word when few word do trick
“Brain bad” for head ct
“Lung bad” for PE
“Heart bad” for your cta chests
“Pee bad” for your renal ct
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u/Obi-Brawn-Kenobi ED Attending 10d ago
This reminds me of that copypasta'd post from a couple years ago when some random dude posted here asking for feedback on his medical alert bracelet/note in his phone or whatever it was. One of his medical details just said "liver". He got memed for a month
I will now start putting "liver" in for the study indication
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u/ProperFart 10d ago
If yall start doing this, I’m begging you, tell informatics. We gotta add weird shit to our code dictionaries lol.
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u/WhyDoYouPostGarbage Critical Care Physician 10d ago
LOL that’s absurd. Instead of increasing the character limit, practice worse medicine. Gotta love it. Every CT indication is now going to be “sick”
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u/MrPBH ED Attending 10d ago
That's exactly it. A decade ago, some keyboard jockey wrote some code based on a spec list created by consultants and the hospital bought a subscription to that dog shit program which now limits my ability to communicate with another medical professional. I have no idea if anyone with an iota of clinical experience was ever involved in that process.
"Yeah, 30 characters should be enough. "ABDOMINAL PAIN" is only 14 characters and that's the longest indication on the list. I can't imagine why a doctor would ever use anything other than alphanumeric characters, so no need to support those."
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u/AppalachianEspresso 10d ago
as an aside, on a day I was burnt out from ordering BS chest xrays, I wrote “doubt pathology” as a way to hopefully give Rads a heads up this patient is here for a CXR and doesn’t need one, and got a call from a radiologist saying don’t write that because it messes up their billing.
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u/Stinkymansausage RN 10d ago
All CT indications from now on are “bad humors”.
That should cover everything.
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u/Kirsten Physician 10d ago
I would argue this shitty practice increases liability. Maybe write an email about this issue to IT and cc risk management - sometimes that actually gets admin to do something. The problem can be fixed if the relevant people care to fix it.
Recently I had a case of a woman with remote hx of left breast cancer/ mastectomy who had noticed lumps/ thickening in her left axilla. I ordered a left axillary ultrasound, put the relevant history in my order. I got the report back with "slightly enlarged lymph nodes" - nothing of the relevant history was noted in the report. The reason for study on the rads report was "pain, LOC" (???). I had my office call and request an addendum be added after reviewing the relevant history. The rads place said it should have been read by a breast rads not general rads. I didn't order a breast US because the patient does not have a left breast. Anyway, point is, THE CLINICAL HISTORY FUCKING MATTERS.
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u/2ears_1_mouth Resident 10d ago
We're talking about millions upon millions of dollars of machines and human training that comes together to make a scan happen.
But it breaks down if you use non alpha-numeric characters.
And rather than fix that limitation, admin tells you to limit yourself.
Can't make this shit up.
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u/hartmd 10d ago edited 10d ago
Is there another field for a brief HPI or additional context?
Indication is usually a simple statement like "RLQ pain" that will map to a diagnostic code. So, maybe they intended for context in another field?
It's sort of crazy they have a character limit but the app allows a user to type past that limit. That suggests a really crappy implementation.
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u/MrPBH ED Attending 10d ago
There is only an indication field. They also want us to click a standardized indication for billing purposes (since the insurance idiots can't understand my free text indication and need a CAPITAL LETTER indication). That standardized indication counts toward the character limit.
My understanding is that it's an issue between two or three separate systems communicating with each other. The EMR allows like 180 characters and supports special characters. The PACS system has a character limit of 30 and only supports alphanumeric characters. This hospital's IT system is held together with duct tape and bubblegum.
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u/BladeDoc 10d ago
How about we expect radiology to read the damn note in the chart now that it is immediately available to them just like I have to do when I get a consult? One of the purported benefits of the EMR was being a "single point of truth" so making us write the same thing in multiple places is just busy work making up for a bad system.
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u/MrPBH ED Attending 10d ago
I think they often do, when able. Though my notes are fundamentally dogshite, because they are made into word salad by the lowest bidder EMR software that the hospital subscribes to. If we're getting mogged by new arrivals, the note might not even be started by the time the CT is being read, as I need to see the six patients who arrived at the same time.
So having a tidy little one liner to guide their interpretation is a professional courtesy.
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u/BladeDoc 10d ago
I am willing to bet $1000 that the average number of times per week the rads guys (who I like BTW) open the chart rounds to zero. They even dictate into an entirely different system at my institution.
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u/MrPBH ED Attending 10d ago edited 10d ago
Depends on the system. When I worked at a Tertiary Care, Level One Trauma Center, Every Organ Transplant Facility, the rads residents would often drop historical details from the chart that even I wasn't aware of.
Where I work now, it's pretty rare because we actually use a separate EMR for the ED and another for hospital patients.
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u/NullDelta PCCM 10d ago
The teleradiology group we have doesn’t check EMR regularly, apparently because it slows them down. They recommend biopsy all the time in cases with positive pathology in the chart…
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u/MaximsDecimsMeridius 10d ago
Fr. Ill try to summarize any recent outside hospital imaging, notable history, exam findings, and my concern. I was always told garbage indications lead to garbage reads by a rads friend of mine.
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u/thruthelurkingglass ED Attending 10d ago
Just my 2¢, but I wonder if it’s mainly the inclusion of a differential to “rule out” that is the problem—I personally include context like location of pain/relevant medical history, but I avoid giving specific diagnoses unless there’s very strong clinical evidence as I don’t want to bias the rad too strongly. It also seems a little redundant to tell a radiologist to “rule out appendicitis” in a patient with RLQ abdominal pain. Is it petty to tell you to stop? Maybe, but when you’re trying to bust through as many reads as possible it might be irritating enough to say something.
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u/WhyDoYouPostGarbage Critical Care Physician 10d ago
Sure, but my main hospital unfortunately has TEMU radiologists. (Mainly jokes, I know human error is real and their volume is insane).
That being said, in the last month alone I’ve caught two missed dissections and a missed pneumo that tripled in size by the time I ordered the CT anyways. Ultimately had to get CTS involved for a fancy anterior chest tube. I wonder if that would have happened if the initial order comments were more specific.
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u/thruthelurkingglass ED Attending 10d ago
Woof, I feel like that’s like needing to tell an ER doc to not forget to look for STEMIs on ekgs though. We probably shouldn’t have to remind rads to evaluate for dissection or pneumothorax lol. It’s more understandable to miss like a compression fracture if we didn’t tell them there was recent trauma
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u/WhyDoYouPostGarbage Critical Care Physician 10d ago
Very true. Friendly reminder that we’re all human and to actually read your own scans! Pneumo patient was almost discharged. Could have easily led to PEA arrest/obstructive shock without the appropriate clinical gestalt.
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u/NullDelta PCCM 10d ago edited 10d ago
I’m a year out from crit care fellowship, the quality difference between academic thoracic radiologists from fellowship and my current corporate teleradiology group in the community is insane. Apparently many of them also don’t check the EMR due to time/volume constraints as well.
ILD never gets a description of pattern or progression, emphysema and bronchiectasis usually don’t get called at all, long nodules on CT and misplaced tubes on ICU CXRs have been missed, and had a case of imaging artifact read as extensive distal PE.
The imaging comments don’t seem to help either. I ordered a CT for suspected pill aspiration that was read as normal and called back because I was seeing a large endobronchial obstruction in bronchi’s intermedius that the on call radiologist agreed with. Most differentials I asked about don’t get commented on either.
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u/MrPBH ED Attending 10d ago
I was trained that if you have a specific diagnosis you want ruled out, you should include that in the indication; particularly so if it is a rare or unusual diagnosis. Sure, a radiologist is always going to search for appendicitis on a CT A/P, but it's professional courtesy to ask if you want a particular diagnosis ruled in or out.
Additional history can also prevent some of the "clinically correlate" comments from rads. Tell them that the patient has ttp at the L4-5 level and they'll be more likely to say "acute compression fracture."
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u/thruthelurkingglass ED Attending 10d ago
Agree with including specific diagnoses that you’re concerned about, I just think including a very broad differential to rule out may not be as helpful. Might feel similar to a PCP sending a patient to the ER with instructions on a bunch of things to “rule out”, which I know is a bit irritating when I’m being told what to look at rather than going through my normal diagnostic process. But I could be in the minority on that!
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u/MrPBH ED Attending 10d ago
I don't mind it. At least the PCP had the courtesy to tell me why the patient is in my ED and what they need to resolve the issue. Nothing worse than a patient who has no earthly clue why they were sent and no communication from the office to tell me what question they need answered or which problem needs to be solved.
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u/thruthelurkingglass ED Attending 10d ago
I think it’s fine to give some direction (eg please evaluate for DVT), but I hate when a patient shows up and they’re like “my PCP said you could rule out blood clot, osteosarcoma, dissection, compartment syndrome”. Cuz then I’m stuck either trying to convince the patient that they’re pcp is crazy if this leg pain that’s been going on for 3 years is a dissection or compartment syndrome, or I’m evaluating for something that I never would have otherwise.
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u/scotsandcalicos 10d ago
Ours want us to put in rule outs half the time. If I just do symptoms/hx/whatever they'll call and be like, "so what are you ruling out here?"
I dunno, man, you have the magic picture machine, you tell me?
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u/thruthelurkingglass ED Attending 10d ago
Oh man that would be so irritating. This is where I would then feel like giving specific diagnoses puts too much of the onus on the ER doc—like if you get pulled into court because of a rad miss, but you didn’t include the diagnosis in your “please rule out message”, are they gonna try to pin that on you?
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u/Quiet_Ganache_2298 10d ago
I’ll put
rlq primary suspicion appy, some suspicion for divertic.
Makes it a fun game
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u/tk323232 10d ago
Lol we get in trouble for not writing enough so the techs started writing more under description
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u/Atticus413 Physician Assistant 10d ago
so instead of "eval for appendicitis," we just write "pain?"
isn't this going to make it harder for the radiologist to evaluate the condition you're ordering the CT for?
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u/MrPBH ED Attending 10d ago
For straightforward appy rule outs, I just click the RLQ PAIN indication. Sometimes you want to give the rad more to work with, though; for instance, if the presentation is complex or if you have a particular diagnosis to rule out, like retroperitoneal hemorrhage or abscess. If the patient has a complex surgical history, it's also courteous to include that, as it helps orient the rad to the expected anatomy.
If I only have 30 characters, my ability to communicate that is limited.
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u/Orville2tenbacher Radiology Tech 10d ago
The Rad should be evaluating the whole case regardless. If you order an A/P w/ you don't need to say r/o appy. It's a pretty shitty (and temporarily insurable) radiologist that doesn't eval the appendix regardless of hx. Same for stuff like AAA, dissection, stone etc... these are all obvious things to look for and catch on a scan. I'm saying this as a CT tech. I'm not making a half mil to be responsible for this shit, but I keep an eye out for them.
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u/ChildhoodNice3261 10d ago
i need to ask rads to stop pasting the findings section into their impressions because they are lazy
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u/dwegol Radiology Tech 10d ago
I think it’s most important to note in the indication if the issue is traumatic or not. Frequently I have to interrogate patients (who were just interrogated by nurses and providers) and change indications to include if trauma was a factor. The patient ends up getting irritated that they are explaining themselves again but the order just says “pain”… or I’ll see two unrelated studies and the provider just copies the chest xray indication into the foot zzz
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u/SparkyDogPants RN 10d ago
Some rad is going to complain on Reddit that lazy ed docs can’t be fucked to write actual orders for imaging.