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Become a Scan Request Superstar

As a brand new doctor, even on your first day, your senior is likely to ask you to request a scan for one of your patients. Approaching the radiologist to approve this request can be a daunting mission - you might feel a potential for embarrassment and then maybe having to return to your boss, tail between legs, and admit that 'the radiologist wouldn't agree to it'. Rest assured, we have all been there, blank-faced in front of the radiologist, and the phrase 'ground, please swallow me up' springs to mind! Well, in an effort to avoid this scenario, here are three steps to help turn yourself into a Scan Request Superstar.

Step 1: Understand the 'What'

Be absolutely clear what it is you are supposed to be requesting. Do you need a CT with oral contrast? Or just IV contrast? A gastrografin follow-through or a gastrografin swallow? Or a gastrografin enema? Make sure you are also clear how urgent it is. Ask your senior if you are not sure of anything, and then move on to Step 2.

Step 2: Understand the 'Why'

Now that you know what you need to request, are you clear about why it is necessary? Broad reasons for requesting a scan include:

  • confirming a suspected diagnosis;

  • excluding an important diagnosis/differential diagnoses;

  • planning surgical procedures.

Be clear about how the scan might influence a patient's management - the radiologist is well-entitled to ask you 'what's the point?'

Examples of scans include a CT for a patient who is five days post bowel resection. Here we might suspect an anastomotic leak, and a positive finding might lead to percutaneous drain or laparotomy. Another example - a repeat CT head for a patient who already had this the day before following a head injury. "Why do you need another one?" the radiologist asks. Well, we may need to exclude new or progression of an intracranial bleed. If so, it may lead to craniotomy or transfer to a specialist centre, as examples of how it may influence management.

Another reason why you need to be clear on the reason for the scan is so that the radiologist can answer the right clinical question. Ultimately, if you aren't sure, ask your senior!

Step 3: Understand the Patient

There are clinically-related questions and there are imaging-related questions you need to be able to answer.

Clinically-related questions are those that relate the condition of the patient to the reason for the scan. In step 2 you clarified the reason why you need a scan for your patient. However, in step 3, you need to really understand why those clinical questions need to be answered. The background, the "why of the why" - what is it about the patient that leads you to ask the radiologist to answer your clinical question? Radiologists can be real sticklers, but they are so for a reason! Make sure you understand, to use our earlier example, why you suspect an anastomotic leak - is the patient febrile? Have their inflammatory markers recently increased? Do they have worsening abdominal pain despite being six days after their operation? Communicate the relevant history, examination and investigation findings clearly and confidently to the radiologist. Another example - you need a CTPA for a patient with a suspected pulmonary embolism (PE) - why does the history suggest PE? What is the respiratory rate and PaO2? Does the patient have any risk factors for venous thromboembolism? If you're not sure, then ask your senior before requesting the scan, and remember to be clear on the reasons why a particular scan might need to be performed urgently and communicate this clearly to the radiologist.

Imaging-related questions are those that are directly relevant to the actual performance of the scan itself. For example, "what is the patient's eGFR" and "how can the patient come down (i.e. chair or bed?)". The patient's eGFR reassures the radiologist that the patient's kidney function has been considered in the context of giving IV contrast, and that appropriate measures have been taken to address the risks of contrast nephropathy. If the scan also involves a procedure (for example, an ultrasound-guided percutaneous drain), then make sure you know the patient's platelet count and coagulation profile (i.e. INR) at the very least.

Conclusion: Opportunities for you and your patient

If you stick to these 3 steps, and ask your seniors when you're not sure, then you're likely to understand your patients a great deal more than if you were a passive player who is happy to just 'wing it' with the radiology department. Don't just wing it! You're better than that!

If you put these steps into practice, you might find yourself asking your seniors more questions - in return you're likely to receive valuable clinical teaching you wouldn't otherwise have received. Requesting scans is a great opportunity to represent and help your patient, as well as being a fantastic opportunity to learn.

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