Saturday, September 20, 2008

And Then He Sewed the Guy's Head Back On...

This is a story about my med school roommate. Not for him the cool, dark caverns of radiology -- he went into ear, nose and throat (ENT). While I learned about CT and ultrasound, he studied tympanoplasties and facial reconstruction. While I battled barium enema blow-outs, he struggled with snot, or as he called it: DIMPS and IMPS (dessicated inspissated mucopurulent secretions and inspissated mucopurulent secretions).

After a stint in the Air Force, I headed for the hushed groves of academic radiology. My roomie got out of the Navy about the same time, and headed for a solo practice in the foothills of the California Gold Country. He shared call with the only other ENT in town, and his practice started out fairly slowly and routinely.

This all suddenly changed during dinner one night, with a page from the emergency room. The ER doc was direct and to the point:
ER: Come here, quick!

ENT: Why? What's up?

ER: Don't ask questions! Just get your ass down here!
The suspense grew as as my friend drove across town to the ER.

Awaiting him there was a local crazy dude, who had tried very hard to saw his own head off with a chainsaw. With the luck that is often bestowed on drunks and crazy dudes, this guy had managed to miss his spinal cord and major blood vessels, while severing just about everything else holding his head on.

Most residencies don't cover this specific clinical situation. However, my friend made a, shall we say, heads-up job of it anyway. After his initial shock, he took charge of the ER, stabilized the bobble-headed crazy dude and proceeded to sew his head back on. Where it apparently stayed.

As you can imagine, this single incident made my friend's surgical reputation for life. As the word spread among other patients and other doctors, his practice grew pretty fast.

We could all tell war stories about defining moments in our own practices, when one good or bad call made a noticeable difference in our professional reputation. However, it's humbling to me just how often my stock rises or falls on some other non-clinical basis. Little things like the following have sometimes made more difference to my practice than years of CME:
  1. playing with a surgeon in a musical jam session
  2. my son dating an oncologist's daughter
  3. getting stranded by weather in an O'Hare bar with a colleague I rarely see at home
This social karma can pay off in the form of referrals, which are important to any specialist. These are particularly critical for radiologists. No matter how spectacular a barium enema we give a patient, it doesn't affect our bottom line (so to speak) nearly as much as impressing a fellow physician. As I mentioned above, this is contingent on a lot more things than clinical competence.

Social karma also makes it easier to weather turbulent times at work. Consider this simple stimulus/response situation. Suppose you miss a subtle torus fracture of the radius in a 10 year old boy, like the one shown below.

Someone you know pretty well will probably cut you some slack:
Man, that was a subtle fracture -- I didn't see it either. Kids' films scare the hell out of me.
However, to someone you don't know, you may now be:
That asshole radiologist who couldn't find his butt with both hands.
Given the choice, one would obviously prefer Door Number 1. Unfortunately, practicing Door Number 1 Radiology™ gets harder all the time.

In the old days of hospital-centered radiology, just about every physician in the hospital would drop by our department sometime during the day. This gave us lots of chances to work on those social skills that don't come naturally to people who work in the dark. However, these opportunities to schmooze with our clinical colleagues have dropped off considerably with the widespread adoption of teleradiology.

Nowadays, it's common for radiologists to work in freestanding imaging centers (we call them boxes), miles away from the hospital, reading X-rays across the internet. My department current reads images from about 16 sites around town, and we spend a lot of time calling reports to people we will never get to meet. We are left to squeeze any human warmth and interaction with these busy people into the interstices between bits of diagnostic information. This makes these little bits of humanity all the more important.

Of course, I could be wrong. A lot of radiology tasks are easily commoditized, and can be beamed to well-trained radiologists in the antipodes who are willing to charge a lot less than I do. I've already heard prospective radiology residents wondering if their future jobs will be siphoned off to some offshore radiology factory. Will the world all go WalRad, or will personal relationships forged with one's referral base keep at least some of that work at home? Beats the heck out of me.

While this all works itself out, I'll continue looking for heads to sew back on. In the meantime, I'll keep on reading cases, enjoying the physicians who still physically visit our department, and teaching our larval radiologists how to give great phone.


By popular demand (n=1), I have added an additional view of the wrist, with arrows pointing out the subtle buckles in the cortex that indicate the radial torus fracture. The discontinuity is best seen on the lateral view. Kids' bones are more flexible than those of adults, and often don't present with the classical linear lucency seen in fractured geezers (anyone over 21).


mcrislip said...

please to be putting an arrow on the fracture

The Samurai Radiologist said...

@ mcrislip: Good point. Consider it done.

Kim said...

You have my deepest respect - I can't see a fracture on xray unless the pieces are on opposite sides of the room.

We actually have our night films and CTs read by radiologists in Australia (and we're in California!).

It's always fun when we have to call them as they are so nice (and I'm a sucker for an Aussie accent : D! )

The Samurai Radiologist said...

@ Kim:

I'm a big fan of Australian radiology. Several of my fellows have been from there. Besides their swell accent, they have all been dauntingly smart and intimidatingly well-trained (even before falling into our hands).