Download Emergency Radiology

Louisiana State University Health Sciences Center - Shreveport
Radiology Residency
Emergency & Trauma Radiology
I.
Orientation:
A. The ER radiology faculty consists of Dr. Abbie Kemper-Martin.
B. Emergency radiology operations
i. Role of the radiologists in emergency care:
a. Efficiency should be optimized. Make radiology as “hasslefree” for our clinicians as possible.
b. The key is MANAGE! Your principle goal should be to
learn to manage the patient flow (triage and assessing the
completeness and adequacy of radiographic studies “online” in order to eliminate the need of “calling back”
patients for further imaging), manage the technologies
(computed radiography, computed tomography, etc.),
manage the flow of information (consulting, results
reporting, etc.) and manage the core knowledge necessary
to effectively practice radiology in the emergency
department.
c. YOU are responsible for assuring continuity of patient care
in radiology with special attention to obtaining and
conveying information regarding on-going and anticipated
cases during “shift” change hand-offs and between the
various radiology subspecialties. At the completion of your
shift duties, update your colleagues of on-going and
expected diagnostic or therapeutic examinations.
C. Report distributions: Immediately report all unknown or unsuspected
important findings verbally to a member of the patient’s team of
caregivers. Report with whom you spoke and when in your dictated
report!
D. Accessing clinical information: 1.) Review prior radiographs and reports
on the PACS system. 2.) If necessary, request prior radiographs from the
file room. 3.) Consultation with the emergency docs.
II.
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Responsibilities of the resident
A. Our evaluation of your performance will include assessment of:
i. Core knowledge demonstrated in review of clinical and teaching
cases.
ii. Reliability, independence and initiative in “running” the service
iii. Interpersonal, consultative and case presentation skills
iv. Management success.
B. Service hours and educational format.
i. Monday – Friday: 08:00a.m. to 04:00 p.m.
ii. Most instruction will be performed on a one-on-one basis between
the emergency radiology staff and the resident.
iii. Either the emergency radiology staff or the appropriate resident
will present a monthly interesting case/missed case conference for
the department.
iv. The emergency staff on a monthly basis will provide teaching
conferences.
v. Residents are to attend all scheduled departmental conferences.
vi. Residents are encouraged to spend time with the technical staff to
learn radiographic positioning of the projections included in our
most commonly requested conventional radiographs and in the
most common CT studies.
C. Reading:
i. Main text: Stern – Trauma Radiology Companion
ii. Selected chapters in supplemental texts. (Rogers – Radiology of
Skeletal Trauma; Harris & Harris – The Radiology of Emergency
Medicine; Osborn – Diagnostic Neuroradiology)
Educational Goals and Objectives:
First and Second Year Radiology Residents (PGY 2 – 3)
Patient Care:

Participate in the real-time integration of clinical and imaging data in the
formation of the treatment plan.
Before the junior resident begins to take overnight call, they must be prepared
to develop a patient management plan based upon available information
(including radiography, ultrasound, CT, MRI). The assimilation of information
from electronic reporting databases is an essential component of this process.
3) Counsel patients concerning exam preparations.
4) Perform exams responsibly and safely, assuring that the correct exam is
ordered and performed.
5) Demonstrate exam specific radiation doses and ALARA
6) Oversee customized imaging workups.
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Medical Knowledge:
By the completion of the first year, residents are expected to demonstrate
knowledge of normal anatomy and recognition of abnormal imaging findings in
life-threatening or unstable conditions, such as:
* Cervical spine, pelvic and extremity fractures
* Pneumothorax
* Free fluid within the abdomen
* Signs of active bleeding
* Acute intracranial hemorrhage and cerebrovascular accident (CVA)
* Common causes of non-traumatic acute abdominal pain (e.g.
appendicitis, diverticulitis)
* Pulmonary embolism in uncomplicated cases
2) Demonstrate understanding of the principles of research project design and
implementation .
3) Demonstrate a clinically appropriate diagnostic treatment plan.
4) Demonstrate the ability to use all relevant information resources to acquire
evidence based data.
5) Demonstrate the proper use of radiological equipment.
Interpersonal and Communication Skills:
The resident must be directly available at all times while assigned to the ED.
Absences from the reading room should be coordinated with the attending
radiologist or other resident to the ED.
All residents rotating through the ED are expected to appropriately
communicate and document in the patient record urgent or unexpected radiologic
findings.
The resident is expected to communicate discrepancy reports and alterations
between preliminary (i.e. resident) and final (i.e. attending) interpretations
according to department protocol.
Produce radiologic reports that are accurate, concise and grammatically
correct.
Communicate effectively with all members of the health care team.
6) Demonstrate skills in obtaining informed consent, including effective
communication to patients of the procedure, alternatives, and possible
complications.
7) Demonstrate the verbal and non-verbal skills necessary for face to face
listening and speaking to physicians, families, and support personnel.
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Practice-Based Learning and Improvement:
The resident assigned to the ED is expected to:
* Identify, rectify and learn from personal errors.
* Efficiently use electronic and print resources to access information. The
resident is both asked to and expected to utilize access to on-line
informational databases, as well as appropriate textbooks to expand
their fund-of-knowledge in as close to a real-time manner as possible
whenever confronted by unfamiliar diagnoses or entities.
2) Help teaching of medical students, peers and other health care professionals.
Professionalism:
The resident assigned to the ED is expected to:
* Demonstrate respect for patients and all members of the health care
team
* Respect patient confidentiality
* Present oneself as a professional in appearance and communication
* Demonstrate a responsible work ethic with regard to work assignments
* Place the interest of the patient first and appropriately consult attending
radiologist on call when necessary for assistance
2) Demonstrate sensitivity without prejudice on the basis of religious, ethnic,
sexual or educational differences, and without employing sexual or other types of
harassment.
3) Demonstrate knowledge of issues of impairment
Systems-Based Practice:
Demonstrate knowledge of how radiologic information is integrated with the
other parts of the health care system in the treatment of the patient. The
radiologist, as a member of both the Department of Diagnostic Imaging and the
Emergency Department, is in a unique position to help patients and clinicians
navigate through the complexities of both areas.
Demonstrate knowledge of trauma imaging protocols.
3) Demonstrate ability to design cost-effective care plans
4) Demonstrate knowledge of funding sources
5) Demonstrate knowledge of reimbursement methods
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Third Year Residents (PGY 4)
In addition to those listed for second year residents, third year radiology residents
have the following objectives:
Patient care:
Integrate clinical history and imaging findings to provide a diagnosis or an
appropriate differential diagnosis.
Provide an appropriate management plan for the patient based upon the
above.
Medical Knowledge:
Further refinement of observational abilities and knowledge base with
application into an appropriate differential diagnosis of:
* Bowel disorders (e.g. ischemia vs. infection vs. neoplasm)
* Focal diseases of solid organs
* Focal brain lesions
* Secondary signs of CVA and herniation
* Diffuse and focal lung diseases
Knowledge of classification systems for:
* Solid organ injury
* Facial fractures
* Pelvic fractures
* Cervical spine fractures
Imaging protocols for trauma
Interpersonal and Communication Skills:
Teach first year residents and medical students emergency radiology
Provide consultation on imaging findings to emergency department staff
Practice-based Learning and Improvement:
Identify, rectify and learn from personal errors
Efficiently use electronic and print resources to access information. The
resident is both asked to and expected to utilize access to on-line informational
databases as well as textbooks to expand their fund of knowledge in as close to
a real-time manner as possible whenever confronted by unfamiliar diagnoses or
entities.
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Professionalism:
Act as a role model for medical students and junior residents.
2) Demonstrate altruism
3) Demonstrate the broad principles of biomedical ethics
4) Demonstrate principles of confidentiality with all information transmitted during
a patient encounter.
Systems-Based Practice:
Demonstrate knowledge of cost-effective imaging evaluation in the emergency
Department.
2) Demonstrate knowledge of the regulatory environment
3) Demonstrate knowledge of basic management principles such as budgeting,
record keeping, medical records, and the recruitment, hiring, supervision and
management of staff
Fourth Year Residents (PGY 5)
In addition to those listed for third year residents, fourth year radiology residents
have the following objectives:
Patient Care:
Demonstrate knowledge of medical and surgical treatment of diseases and
how treatment options may guide imaging.
Medical Knowledge:
Further refinement of detection abilities in subtle or complex cases.
2) Master your radiology knowledge in preparation for the boards and your
practice.
Interpersonal and Communication Skills:
Function independently as a consultant to the emergency department
attending staff.
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Practice-based Learning and Improvement:
Identify, rectify and learn from personal errors.
2) Efficiently use electronic and print resources to access information. The
resident is both asked to and expected to utilize access to on-line informational
databases as well as textbooks to expand their fund of knowledge in as close to
a real-time manner as possible whenever confronted by unfamiliar diagnoses or
entities.
3) Demonstrate critical assessment of the scientific literature.
4) Help teaching of medical students, peers and other health care professionals.
Professionalism:
Demonstrate respect for patients and all members of the health care team
Respect patient confidentiality
Present oneself as a professional in appearance and communication.
Demonstrate a responsible work ethic with regard to work assignments
5) Demonstrate honor and integrity: avoid conflict of interests when accepting
gifts from patients and vendors.
Systems-Based Practice:
Demonstrate knowledge of cost-effective imaging evaluation in the emergency
Department.
2) Demonstrate knowledge of basic management principles such as budgeting,
record keeping, medical records, and the recruitment, hiring, supervision and
management of staff.
Resident Evaluation:
1. The monthly electronic rotation evaluation form will be completed by the
attending radiologists who have had interaction with the resident.
2. 6 Month evaluation reviewed with the Program Director.
3. OSCE twice per year.
4. ACR In-Service exam
5. ABR Board exams
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CURRICULUM
I. The Brain and Spine
Cerebral Contusion
Diffuse Axonal Injury
Epidural Hematoma/Hyperacute Intracranial Hemorrhage
Acute Subdural Hematoma
Chronic Subdural Hematoma/Acute Rehemorrhage
Linear Skull Fracture
Depressed Skull Fracture
Delayed Post-traumatic Intracranial Hemorrhage
Child Abuse
Gunshot Wound to the Head
Acute Dissection: Internal Carotid Artery
Acute Intracranial Hemorrhage: Intraventricular Hemorrhage
Acute Intracranial Hemorrhage: Subarachnoid Hemorrhage
Nontrauma/Nonhemorrhage: Diffuse Anoxic Changes
Herniation: Uncal
Herniation: Subfalcine
Herniation: Upward (Cerebellar Hemorrhage)
Facial Trauma: Orbital Floor Fracture
Facial Trauma: Tripod Fracture
Facial Trauma: LeFort Fracture
Cervical Spine Injury: Dens Fracture
Cervical Spine Injury: Jefferson Fracture
Cervical Spine Injury: Atlanto-Occipital Dissociation
Cervical Spine Injury: Transverse Atlantal Ligament Injury
Cervical Spine Injury: Traumatic Spondylolisthesis of the Axis
Cervical Spine Injury: Hyperflexion Fracture/Burst Fracture
Cervical Spine Injury: Unilateral Overriding Facet
Cervical Spine Injury: Bilateral Overriding Facet
Thoracic/Lumbar Spine Injury: Burst Fracture
Thoracic/Lumbar Spine Injury: Flexion/Distraction Fracture
Thoracic/Lumbar Spine Injury: Extension/Distraction Fracture
II. The Torso
Scapulothoracic Dissociation
Scapula Fracture
Rib Fractures
Sternoclavicular Dislocation
Sternal & Manubrial Fractures
Airway Rupture/Laceration
Esophageal Rupture/Laceration
Esophageal Intubation with Gastric Perforation
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Traumatic Aortic Injury: Chest Radiography
Traumatic Aortic Injury: Computed Tomography
Injury to the Brachiocephalic Vessels
Myocardial Contusion
Cardiac Perforation and Rupture
Acute Traumatic Hemopericardium
Hemidiaphragm Injury
Pulmonary Contusion
Pulmonary Laceration
Pulmonary Laceration: Traumatic Pneumatocele
Pulmonary Laceration: Pulmonary Hematoma
Lung Injury: Blast Effect
Barotrauma
Aspiration of Foreign Body
Near Drowning
Intraperitoneal Fluid in Trauma
Extraperitoneal Fluid in Trauma
Intraperitoneal and Retroperitoneal Gas
Active Bleeding: Findings on CT Scan
Liver Injury
Biliary Injury
Splenic Trauma
Pancreatic Injury
Gastrointestinal and Mesenteric Injury
Duodenal Injury
Extraperitoneal Colonic Injury
Adrenal Hemorrhage
Renal Injury
Renal Laceration with Urinary Extravasation
Ureteral Injury
Bladder Injury: Intraperitoneal Rupture
Bladder Injury: Extraperitoneal Rupture
Urethral Injury
Trauma to the Gravid Uterus
Testicular Trauma
III. Upper Extremity
Clavicle Fractures
Acromio-clavicular Joint Dislocation
Shoulder Joint Dislocation
Humeral Fractures
Epicondyle Injury
Elbow Dislocation
Radial Head Fractures
Radius and Ulna Shaft Fractures
Carpal Fractures
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Carpal Dislocations
Metacarpal Fractures
Phalangeal Fractures
IV. Pelvis/Lower Extremity
Pelvis Apophyseal Avulsions
Lateral Compression Pelvic Fracture
Anterior Compression Pelvic Fracture
Vertical Shear Pelvic Fracture
Pelvic Ring Disruption and Arterial Injury
Sacral Fracture
Anterior Hip Dislocation
Posterior Hip Dislocation
Posterior Wall Acetabular Fracture
Transverse Acetabular Fracture
Both Column Acetabular Fracture
Intracapsular Femoral Neck Fracture
Occult Hip Fracture
Stress-Insufficiency Fracture of the Femoral Neck
Intertrochanteric Femur Fracture
Subtrochanteric Femur Fracture
Femoral Shaft Fracture
Supracondylar Fracture of the Femur
Patella Fracture
Tibial Plateau Fracture
Tibial Spine (Anterior Cruciate) Avulsions
Avulsion of the Posterior Cruciate Ligament Insertion
Segond Fracture
Patellar Dislocation
Knee Dislocation
Tibial and Fibular Shaft Fractures
Tibial Stress Fracture
Tibial Plafond Fracture
Ankle Mortise Injuries
Cuneiform Fracture
Calcaneal Fracture
Talus Fracture
Talar and Subtalar Dislocations
Tarsal Navicular Fracture
The Nutcracker Fracture of the Cuboid
Lisfranc’s Fracture Dislocation
Metatarsal Fracture
Toe Injuries
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EMERGENCY/TRAUMA RADIOLOGY
EXPECTATIONS
1ST year:
- learn how to manage the emergency radiology section in preparation for call. e.g.
how to triage studies appropriately when resources become limited, how to obtain
and relay information to the ordering clinicians,
- learn what views of the most commonly ordered exams constitute a normal study.
e.g. spines, cxr, abdomen, pelvis, extremities
- begin to recognize pathology and learn appropriate descriptive terms for dictation
purposes.
2nd year:
- to become more proficient in the above tasks.
- to be able to recognize more subtle patterns of injury.
3rd year:
- to have reviewed either in actual practice in the ER, from teaching files or texts
each of the curriculum cases listed in the attached guide.
4th year:
- to demonstrate independence and accuracy in reading films and managing the ER
section.
- to obtain an understanding of the pathophysiology of trauma and how it relates to
imaging findings.
EMERGENCY RADIOLOGY
ROTATION 1:
Knowledge based objectives – at the end of the rotation the resident should be
able to:
1. Identify normal anatomy of the bones, chest, abdomen and pelvis as seen on CT
and plain film.
2. Identify and describe common variants of normal.
3. Demonstrate a basic knowledge of radiologic interpretation as it relates to
emergency radiology.
Technical skills – at the end of the rotation the resident should be able to:
1. Given a chest, abdomen, bone or pelvis film or CT distinguish normal from
abnormal structures.
2. Dictate a report that is brief and understandable.
3. Communicate verbally with the referring physician and house staff about
radiographic findings.
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Decision-making and value judgment – at the end of the rotation the resident
should be able to:
1. Make decisions about when to alert the house staff to the immediacy of a
condition that is apparent on the radiograph.
2. Determine when to request that a repeat exam is needed because of technical
inadequacy.
ROTATION 2:
Knowledge based objectives – at the end of the rotation the resident should be
able to:
1. Discuss various common fracture patterns and acute conditions of the chest.
2. Discuss the most commonly encountered acute abnormalities of the chest,
abdomen and pelvis as seen on cross sectional images.
Technical skills – at the end of the rotation the resident should be able to:
1. Recognize and describe the most commonly encountered acute abnormalities on
plain film and CT.
2. Dictate with clarity and accuracy more complicated reports.
Decision-making and value judgment – at the end of the rotation the resident
should be able to:
1. Determine which cases can be interpreted and dictated independently and which
cases require the assistance of a faculty radiologist.
ROTATION 3:
Knowledge based objectives – at the end of the rotation the resident should be
able to:
1. Discuss the mechanisms of injury and commonly associated injury patterns seen
in the multi-trauma patient.
2. Correlate clinical data with radiological findings.
Technical skills – at the end of the rotation the resident should be able to:
1. Read routine ER films with a high level of accuracy and efficiency.
2. Supervise the performance of emergency CT scans.
3. Perform and interpret emergency ultrasound exams.
Decision-making and value judgment – at the end of the rotation the resident
should be able to:
1. Demonstrate a high degree of accuracy in interpreting and dictating cases,
identifying those cases with which assistance is needed.
2. Consult, with confidence, with primary care physicians and surgeons in regard to
most emergently obtained imaging procedures.
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References:
Association of Program Directors in Radiology (www.apdr.org)
Tampa General Hospital, ER Dept. Goals
Emergency Radiology Core Lectures: Abbie Kemper-Martin, M.D.
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Emergency Radiology operations
Brain trauma
Spinal trauma
Fractures and dislocations
Chest trauma
Gastrointestinal emergencies
Genitourinary emergencies
Vascular emergencies
Pelvic emergencies
Pediatric emergencies
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