The Ill Prepared Study

Any examination can lead you astray or cause erroneous findings if it is poorly executed. Reasons may be the lack of experience of the examining physician, especially when dealing with less frequent clinical problems, or when performing a study that requires considerable technical skill but has not been performed by that particular physician in a while. When considering the choice of a radiographic modality, its particular operator dependence also needs to be taken into account. If your least-talented ultrasound technologist is on duty and is unwell because of a long night on the town the previous evening, you may need to consider doing the examination yourself or choosing a more objective method such as CT.

f Insufficient preparation of the patient, however, is by far i the most frequent cause of failed studies.

The responsibility for patient preparation lies mainly with the referring physician. If the patient is restless and unable to cooperate, sedation must be considered. Special preparatory measures have to be communicated and explained to the patient with sufficient care, making sure that the information is understood. A lady undergoing an ultrasound of the abdomen, for example, should preferably be fasting because an air-filled stomach hinders optimal visualization of the pancreas. A nervous older gentleman who is scheduled for an upper gastrointestinal study with barium and air followed by a small-bowel follow-through should also be fasting to allow for a good contrast coating of the gastric mucosa. Fasting in this context means: no breakfast, no coffee, no smoking, no tooth-brushing and, of course, no alcohol. For obvious reasons, the study should be scheduled in the morning hours and diabetic patients should be examined first and perhaps need to consider reducing their morning dose of insulin if applicable. Referring physician and radiologist have to cooperate well in these cases; mistakes and failures are more than irritating for the patient:

Patient Maggie Snatcher: Mrs. Maggie Snatcher (78) has been complaining about irregular bowel movements for some time. The rectal examination is normal but occult blood has been detected in her stool. You send your patient to radiology to get an air contrast barium enema (see p. 193), to exclude large-bowel pathology. You have, however, forgotten to properly inform and prepare Mrs. Snatcher. She has not been told to take a laxative the day before; she has eaten dairy products until the evening before instead of having only clear liquids and soups for two days prior to the examination. Radiologist Smith does not cancel the examination when he learns about her lack of preparation. He fights hard to make the best of it to spare the patient (and you) having to schedule another appointment. The examination takes three times longer than normal because every piece of fecal residue has to be differentiated from intraluminal tumor. Finally Smith surrenders, stating that no tumor can be found.

Four weeks later the examination is repeated after a textbook preparation and a plum-sized malignant polyp is diagnosed by Smith's special friend, Assistant Professor Newman. You should not be counting on any favors from Smith for a few months to come. And your credit rating with Mrs. Snatcher has also gone down the drain.

f A badly prepared study may cost you dearly in terms of i time, nerves, and friends at the very least. It will certainly ruin your day.

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