CDU 3-3527
PACS 3-8448
Operator 0
Security 3-8500

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ED/NF Survival Guide

I. Responsibilities

A. Prelim all studies on ED patients

B. Prelim all CTPAs and call important findings to service CT tech should call to give you a heads up on all CTPAs, but occasionally you won’t get a call, so it wouldn’t hurt to occasionally check the chest CT queue for any missed inpatient CTPAs

C. Prelim any “stat” inpatient studies done overnight that the service calls you about

1. These don’t always have to be real detailed if there is a specific concern (i.e, RP bleed, free air, PTX, etc.)
2. Type the major findings you tell the service in the Ibox, so the section finalizing the study the next day knows what you told the service
3. You will, at some point, be bombarded to look at multiple inpatient studies by both physicians and nurses. Don’t feel obligated to look at everything immediately- you will miss important findings if you try to rush through them all. Just kindly ask for the pt’s name and MRN, and tell them you will look at it as soon as possible and get back to them
4. Probably the lowest priority are the studies residents want you to prelim for them prior to rounds the next morning. I often don’t get to these until the wee hours of the morning, at which time I page the resident to tell them my impressions

D. You will occasionally be asked to look at studies from an outside facility, for which there has to be a report somewhere, but you won’t have access to it; just do your best. Also, our department will never give an “official” read on an outside study, if anyone asks

E. Protocol CTs as necessary

II. How the ED is broken down

A. OSU Main (3-7080)

1. In addition to the main OSU ER, there are two special areas called Fast-track and the CDU
2. Fast-track (3-4010) patients are seen by an ED attending only, and are usually there for more straightforward problems
3. CDU (3-3527) stands for Clinical Decision Unit (I think), and is an observation area for patients while a decision is made regarding disposition

B. OSU East (7-3414)

III. When to call a tech in

A. MRI

1. Neuro

a. In the setting of acute stroke, when the stroke neurologist has been called to evaluate for potential lytic therapy. Emergent MRI/MRA is otherwise not part of the routine w/u of stroke or TIA
b. Evaluation for cord compression or epidural abscess

i. Ask for specific symptoms and level of involvement to determine what level to scan
ii. For epidural abscess, ESR may be elevated, but doesn’t have to be (can also have nl WBC)

a. necrotizing fasciitis
b. occult hip fracture

1. V/Q Scan and GIB study are most common reasons to call in tech
2. Per Dr. Hall, the following are also appropriate indications:
a. Brain death study
b. Renal transplant scintigraphy
c. HIDA scan

D. Ultrasound
1. Tech available at OSU Main until 11pm Mon-Thurs, and usually from 8-12 Saturday morning
2. After these hours, tech on call for emergencies only
a. Usually only for scrotal US to r/o torsion
b. Transplant kidneys in peri-operative period
c. If you get a request that sounds reasonable, run it by attending

E. At OSU East, they call the Nuc Med and US techs in themselves

IV. Other emergent procedures/studies

A. LP under fluoro
1. For r/o SAH, meningitis, or pseudotumor w/ progressive visual changes
2. Service should try themselves first
3. Rad OD typically does these overnight rather than call in Neuro on call resident; just tell service you’ll do it when you have time (within next few hours)
4. We usually don’t dictate these since there is usually no attending; just be sure to write procedure note

B. CT myelogram may need to be done emergently (rarely) to look for epidural abscess in a pt that can’t get MRI- needs to be approved by Neuro attending

C. Swallow study
1. Usually to look for esophageal perforation
2. Can usually do limited study, just take a bunch of pictures in different projections

D. CTA
1. Rad OD has to approve all CTAs overnight
2. Different Neuro attendings have different thoughts on when and why these should be done. Here are some general guidelines:
a. In the setting of SAH, and need to eval for aneurysm; this is probably the most appropriate reason to do these overnight
b. Screening for aneurysm in setting of WHOL and negative head CT is not good reason for CTA
i. Service needs to do LP to r/o SAH
ii. If simply screening for aneurysm (ie, family h/o aneurysm), MRA is usually preferred, and this is not emergent

V. Miscellaneous

A. Pregnant patients
1. All studies on pregnant patients need to be approved by Rad OD.
2. Plain films usually no problem.
3. If CT absolutely necessary, can shield pelvis and get pt to sign consent.
4. CTPA v. V/Q – no definitive answer, can usually just do CTPA

B. CTPAs and central lines: really need to try to get peripheral IV. If no other options, can usually do through central line and reduce injection rate; just check w/ techs and make sure service knows it will be limited study

C. Occasionally, non-ED cases show up on ED queue. You will learn to recognize the ED attending names. Can also look up pt location on e-Results (under “Locate pt by”, then “Campus”; “ED census” will give you list of all pts in OSU Main ED (East not included); can also look under “Pt information” and “Visit hx” to see where pt is located)

D. Spare battery for Spectralink phone (6-5138) is in charger in chest RR

Incorrect Count

In all cases where there is a film taken while a patient is in the OR to look for a foreign body (incorrect sponge count, needle count, etc.), the policy is as follows:

1- The OR calls the rad tech, who immediately goes to the OR to take the film (study must be complete, ie include entire abdomen or area of interest, even if it takes more than one film)

2- Rad tech calls Rad OD to make them aware the study is complete, and also to give the number to call with the report

3- Rad OD MUST call an attending immediately, regardless of time, to get a final read!! (If during the day, call the attending reading abdominal plain films, if at night, the attending covering the ED at night is responsible, even if they have gone home)

4- Either the attending can call the OR, or the Rad OD can call with the final read.

Emergent MRI

The indications for emergent MRI studies for the ED are:

1. Necrotizing fasciitis of any limb.

2. Compartment syndrome of any limb.

3. Possible hip fracture.

4. Possible scaphoid fx in patient that may be lost to f/u.

5. R/O osteomyelitis can wait for the morning in most cases unless an abscess is associated with possible fasciitis.

The tech should always be called in for this

CONTRAST ALLERGIES

(this includes Betadine)

PREDNISONE 50 mg P.O. 13 hrs, 7hrs, & 1hr prior to procedure.

DIPHENHYDRAMINE (BENADRYL) 50 mg P.O. 13 hrs, 7hrs, & 1hr prior to procedure.

According to the ACR, an acceptable alternative is:
Methylprednisolone 32 mg P.O. 12 hrs and 2 hrs prior to procedure.

Along with 50 mg Benadryl 50 mg P.O. at bed time the night before.

If the study is emergent, consider Dexamethasone (Decadron) 4-8 mg IV and Benadryl 25 mg IV, wait 15minutes and then scan.

For patients with a history of delayed contrast reaction – The radiology department will discharge patients with a prescription for a Solu-medrol pack. Patient to follow the instructions on the pack.