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Reflections |
1 From the Department of Radiology, University of Texas Medical School, 6431 Fannin, MSB 2.100, Houston, TX 77030. Received May 17, 2000; revision requested June 27; revision received August 7; accepted August 15. Supported in part by a grant from the John S. Dunn Research Foundation. Address correspondence to the author (e-mail: John.H.Harris@uth.tmc.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONREFERENCES |
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Index terms: Emergency radiology • Radiology and radiologists, history • Radiology and radiologists, socioeconomic issues • Reflections
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONREFERENCES |
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Emergency radiology is defined as the imaging, and imaging management, in acutely ill and injured patients. My experience in this regard includes a residency in radiology at the Hospital of the University of Pennsylvania under the chairmanship of Eugene P. Pendergrass, MD (1954–1957), where I was briefly introduced to acutely ill or injured patients; 24 years in the private practice of radiology with my father, John H. Harris, MD, and F. B. Markunas, MD, in a 100–150-bed hospital in Carlisle, Pa (1957–1979), where I really learned the radiologic manifestations of acute illness and injury; a 1-year hiatus at Michigan State University (1979–1980); and from 1980 to the present, the practicing and teaching of emergency radiology at Hermann Hospital, Houston, and the University of Texas-Houston Medical School.
As I remind residents, "there was radiologic life before computed tomography (CT) or magnetic resonance (MR) imaging." Imaging of acutely ill or injured patients occurred before emergency radiology—it simply was not called "emergency radiology" and not practiced with the degree of intellectual and technical sophistication with which it is practiced today.
The American medical literature published before and during the first 5 decades of the 20th century is replete with articles describing the radiologic features of acute entities such as hydropneumothorax (1), pulmonary edema (2), and skeletal injuries (3,4) and the indications for and roles of retrograde urethrography and cystography in the examination of male patients with pelvic ring disruption (5).
The majority of patients seen in private radiology offices and nonacademic hospital practices were acutely ill or injured. In contrast, most radiology residency programs then—like many such programs today—were affiliated with teaching hospitals at which emergency medicine had less than primary importance. Automobile access to many academic hospital emergency "rooms" was so limited that it discouraged ambulance traffic. Consequently, most radiology residents had little or no first-hand experience in performing imaging of acutely ill or injured patients.
Physician care in community hospital emergency rooms was, until the 1970s, provided by hospital medical staff members on a rotational on-call basis, and that in most teaching hospitals was provided by interns assigned to the emergency "room" with on-call resident support. In both of these settings, radiologic consultation was provided by a general radiologist to whom the radiographs were brought for interpretation. Therefore, because of a very limited emergent patient population and primarily generalist radiologic staffing, very little or no teaching of emergency radiology existed in academic programs. Notable exceptions to the limited emergency medical and trauma patient populations existed at the larger tax-supported hospitals such as Grady Memorial Hospital in Atlanta, Ga, Philadelphia General Hospital, Pa, Boston City Hospital, Mass, Cook County Hospital in Chicago, Ill, Ben Taub Hospital in Houston, Southwestern Hospital in Dallas, Tex, Detroit Receiving Hospital, Mich, and Harborview Medical Hospital in Seattle, Wash. At these institutions, emergency radiologic experience and teaching were an indistinguishable part of radiologic practice.
The Maryland Institute for Emergency Medical Services Systems (MIEMSS) was one of the first trauma specialty hospitals in the country. The first full-time radiologist at MIEMSS, Robert Ayella, MD, a personal friend and the country’s first radiologist with a practice limited to the major trauma aspects of emergency radiology, reported many of the basic tenants of emergency radiology that are still true today (6).
Through the 1960s, conventional radiography, augmented by linear tomography in most hospitals and by polydirectional tomography (7) (Fig 1) in most teaching institutions, was the definitive imaging modality for the evaluation of acutely ill or injured patients. Today, CT, and to a lesser degree ultrasonography (US) and MR imaging, have totally replaced conventional tomography. The supine abdominal radiograph, or KUB (kidneys, ureters, bladder), played a major role in the assessment of the patient with abdominal pain. This radiograph was carefully appraised for "gas, mass, stones, and bones." Radiographic signs of splenic injury were limited to those of a large left upper quadrant abdominal mass representing a splenic or extracapsular hematoma, namely, elevation of the left hemidiaphragm, left lower lobe atelectasis with or without a left pleural effusion, displacement of the splenic flexure, and with a large extracapsular hematoma, an extrinsic pressure (mass) effect on the greater curvature of the stomach associated with prominence of the gastric rugae (Fig 2).
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One of the most dramatic changes to occur in emergency radiology during the past 5 decades has been the progressive shift from diagnostic and therapeutic angiography for abdominal and pelvic trauma to the distinctly less invasive, less time-consuming, and more diagnostically comprehensive CT. Abdominopelvic CT is now routinely performed in most level I trauma centers before the patient leaves the emergency center and is the current standard of care for patients with abdominal trauma, particularly blunt abdominal trauma. Currently, patient management decisions are based largely on CT findings, and angiography is usually performed only for specific clinical signs of unidentified blood loss. CT classification and monitoring of hepatic and splenic trauma have led to greatly reduced operative management of these injuries. CT and US have largely replaced diagnostic peritoneal lavage, the sole purpose of which was to demonstrate hemoperitoneum. In some centers, emergency radiologist-angiographers (9–11) perform interventional procedures in acutely ill or injured patients.
The definitive imaging study for mechanical small-bowel obstruction used to be the "obstruction series," which included supine, erect (if possible), and each lateral decubitus radiographs of the abdomen and an erect radiograph of the chest. The definitive study for obstructive colon disease was a carefully fluoroscopically monitored enema examination performed with a "thin" barium suspension.
The role of radiology in the diagnosis of appendicitis was limited to the identification of secondary signs, such as an opaque appendicolith in the right lower quadrant (Fig 5), a mass effect on the medial aspect of the cecum or medial displacement of the cecum/ascending colon from the flank stripe by a mass (Fig 6), or extraluminal air in the paracolic gutter. An appropriate clinical history and physical signs were helpful, when provided. CT is currently the definitive modality for the examination of patients with ambiguous radiographic lower quadrant signs and symptoms and in whom appendicitis is high in the differential diagnosis. CT signs of appendicitis include thickening of the appendicular wall, appendix diameter greater than 6 mm, periappendicular stranding, inflammatory changes of adjacent structures, and a periappendicular mass with or without gas (Fig 7) (12). The sensitivity of CT with oral and rectal contrast materials for the detection of appendicitis ranges from 96% to 98%, and the specificity ranges from 83% to 89% (13,14). CT assessment for possible acute appendicitis is usually performed following the administration of oral, rectal, and intravenous contrast materials. CT, by depicting all other structures in the right lower quadrant of the abdomen and pelvis, provides the opportunity to evaluate for nonappendiceal causes of the patient’s symptoms when the appendix is normal by CT.
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Before the advent of CT, the diagnosis of adrenal injury could be inferred only on the basis of clinical and laboratory findings and confirmed angiographically. Now, the adrenal glands are clearly shown at CT. Mesenteric and intestinal injuries were suspected only on the basis of a positive diagnostic peritoneal lavage. Currently, these injuries are well shown at CT. The only radiographic sign of acute pancreatitis was the ubiquitous "colon cut-off" sign (Fig 11). CT readily depicts the changes associated with both acute and chronic pancreatitis.
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Currently, as a result of the work of many radiology groups (19–22), contrast material–enhanced transverse CT, preferably with helical or multisection scanning, has been determined to be as accurate as catheter aortography for the identification of acute traumatic aortic injury (Fig 14). The earlier "widened mediastinum" has been redefined to be indicative of the presence of a mediastinal hematoma, which, when present, necessitates contrast-enhanced transverse CT. At those institutions where a CT scanner is located in or adjacent to the emergency center, contrast-enhanced transverse CT can be performed as an isolated study following the identification of a mediastinal hematoma or, as initially proposed by Raptopoulos et al (18), as part of abdominal CT with intravenous contrast material. In this fashion, acute traumatic aortic injury can be identified while the patient is still in the emergency center, in a very short time (ie, 5–10 minutes), and without additional personnel.
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Pulmonary CT arteriography has largely replaced pulmonary angiography for the examination of patients suspected of having pulmonary embolism. At some institutions, pulmonary contrast-enhanced transverse CT is the initial study performed for suspected pulmonary embolism in patients with known cardiac or pulmonary disease, with abnormal chest radiographs, or who have undergone surgery.
The definitive imaging assessment of spinal injury, neoplasia, and abscess was tomography, which involved placing the patient on his or her side for sagittal evaluation of the posterior elements and retropulsion of fragments into the spinal canal. Myelography, which was initially performed with oil-based contrast material that had to be removed at completion of the examination and later by using water-soluble contrast material, provided maximal information regarding the emergent pathologic entities of the spinal canal (Fig 15).
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In the past, intracranial midline shift could be assessed only by determining the position of either the frequently calcified pineal gland or the habenular commissure. The advent of B-mode US (26) was a remarkable and much more reliable method of identifying midline intracranial structures and effective regardless of whether pineal calcification was present. Clearly, the cause of the shift could be surmised only on the basis of the clinical findings. In the 1940s–1960s, pneumoencephalography—the removal of cerebral spinal fluid and the introduction of air through a lumbar puncture—and cerebral angiography were the only, and definitive, imaging procedures for the detection of predominantly nontraumatic intracranial abnormalities. The development of CT into a clinically useful tool in the early 1970s completely replaced pneumoencephalography and greatly reduced and altered the indications for cerebral angiography. Currently, CT— typically without the administration of intravenous contrast material—is the imaging modality of choice for nearly all emergency center patients with nontraumatic intracranial signs and symptoms. An air-fluid level in the splenoidal sinus was an obvious sign of skull base fracture, but the absence of the air-fluid level did not exclude such a fracture.
Facial fractures were assessed by using the five-film "facial series" augmented by linear or polydirectional tomography. Today, CT with transverse and either direct or reformatted coronal imaging and sagittal imaging is the definitive examination for middle face fractures. However, there remains a very useful place for the five-radiograph study of the face, which includes Caldwell, straight anteroposterior, Waters, extended Towne, and submentovertical (ie, "jug handle") views, as the initial screening examination in patients with less than massive middle face trauma to provide a conceptual overview of the midfacial skeleton and comparative follow-up purposes.
Before 1990, appendicular soft-tissue injury was suspected only on the basis of the conventional radiographic sign of swelling or alteration of normal fascial planes. During the past decade, MR imaging has been used to demonstrate nondisplaced femoral neck fracture and/or substantial soft-tissue injury as an explanation of the symptoms in elderly patients after acute minor hip trauma and with normal hip radiographs. More recently, Fornage (27) observed the value of US for the detection of soft-tissue injury.
Any discussion of the evolution of emergency radiology to its current recognized status would be deficient if the role and influence of the American Society of Emergency Radiology were omitted. The practice of emergency radiology and the Society have grown as one.
The fortuitous coming together of several independent events that occurred in the 1960s through the middle 1980s culminated in the realization that there was a need for radiologists who were interested in and knowledgeable about acutely ill or injured patients. Establishment of the American College of Emergency Physicians and recognition of emergency medicine as a special body of medical knowledge by the American Board of Medical Specialties created, in the minds of most emergency physicians, the desire for radiologic peers to be analogous to neuroradiologists and neuroclinicians, pediatric radiologists, and pediatricians. The importance of the "golden hour" (28)—that is, the 1st hour after trauma—for the successful management of badly injured patients demanded prompt and informed radiologic patient care.
Early emergency physicians came from all walks of medical life without formal training in emergency medicine and with little or no training in radiology. At that time, a few radiologists, believing that better radiologically informed emergency physicians could better interpret the radiologic studies of their patients when a radiologist was unavailable, participated in the early American College of Emergency Physicians Scientific Assemblies. This experience prompted two interesting reactions for radiologists: First, but least important, radiologists were occasionally vilified for "teaching the ER docs to read their own films," and second, radiologists became aware of how critically important informed radiologic consultation—knowledge that was not taught in most radiology residencies—is to the care of patients in the emergency setting.
The regionalization of trauma services (29), advent of air ambulance services, improved functional design of ground ambulances, and improved education of emergency medical technologists (30) led to improved survival rates for trauma patients. These factors, in turn, led to the redesigning of emergency "rooms" into emergency centers or departments, the planning of which prompted the realization of the importance of "clinical proximities" similar to induction and recovery areas adjacent to the operating suite. Since approximately 50% of patients admitted to the emergency center require imaging, radiologic facilities, and in some instances entire radiology departments, were planned within or adjacent to the emergency center. The essentiality of CT for the evaluation of possible abdominal pathologic conditions established by Federle and Brant-Zawadzki (31) and Toombs and Sandler (32) led to the use of CT in patients in emergency centers.
The developments described created the need for radiologists interested in imaging of the acutely ill or injured patient. The deficiency of the supply component in this supply-demand equation was addressed by a few academic radiology departments in the form of formal emergency radiology courses such as those conducted by Boston City Hospital (Tufts University) under the direction of Jerome Shapiro, MD; Harvard/Massachusetts General Hospital under the direction of Robert A. Novelline, MD; the University of Virginia under the direction of Theodore E. Keats, MD; and Stanford University under the direction of James McCort, MD.
In the 1960s and 1970s, one of the most popular weekend symposium series conducted by the American College of Radiology emphasized emergency radiology. The Radiology of Emergency Medicine (33), which is, to my knowledge, the first text devoted to imaging of acutely ill or injured patients, was published in 1975, and the fourth edition was published in 2000 (34). The 15th of the American College of Radiology Professional Self-Evaluation and Continuing Education Program was the Emergency Radiology Syllabus, published in 1979 (35); the second Emergency Radiology Syllabus was published in 1997 (36). Dr McCort presented the first text on trauma radiology in 1966 (8). The first edition of Emergency Imaging of the Acutely Ill or Injured Child by Leonard E. Swischuk, MD, was published in 1979 (37), and the third edition was published in 1994 (38).
Didactic teaching and identifiable clinical experience in emergency radiology has been scant. The responses of a 1991 (39) survey of radiology chairpersons of 130/192, academic and nonacademic radiology departments that conducted radiology residencies, were affiliated with hospitals with designated American College of Surgeons level I, or equivalent, trauma centers, conducted under the auspices of the American Society of Emergency Radiology, indicated the presence of a designated emergency radiology section in less than 35%; radiology resident rotation in emergency radiology throughout the 4-year radiology residency in less than 66%; and that radiology resident rotation in emergency radiology ranged from 2 to 16 weeks in only 40%. Over one-third of the responding institutions did not provide an educational experience in emergency radiology. In over 80% of the responding departments, emergency radiologist coverage was rotated among all faculty or the "general" faculty.
The preliminary and incomplete results of the 2000 Survey of Clinical and Teaching of Emergency Radiology of 123 academic radiology departments conducted by the American Society of Emergency Radiology (40), with a response rate of ±40% to date, suggest that, currently, approximately 2.3 full-time equivalent emergency radiologists are assigned to the emergency center; 60% of the respondents indicated that there was a full- or part-time "emergency radiology medical director," and in 51% of the responding departments, emergency radiologists interpret emergency center studies, including CT and US images.
With respect to resident teaching in emergency radiology, the 2000 survey results suggest a substantial improvement since the 1991 study: In 36% of radiology departments, emergency radiology is taught as a separate section, 46% report that an emergency radiology curriculum is used, and 38% indicate that there is a "designated instructor" in emergency radiology.
Today, emergency radiology is internationally represented by the American Society of Emergency Radiology, which, founded in 1988 with 35 members, has grown to a society of over 450 members, including very active members from the United Kingdom, France, Italy, Germany, Holland, Sweden, and Japan. In March 2000, the American Society of Emergency Radiology conducted its 11th annual scientific meeting, with approximately 250 registrants. The Society sponsors Emergency Radiology–A Journal of Practical Imaging, a bimonthly journal devoted to imaging of acutely ill or injured patients that in 1999 had approximately 1,000 United States and international subscribers, including 224 institutional subscribers.
Fellowships in emergency radiology are offered at Massachusetts General Hospital and Brigham and Women’s Hospital in Boston, MIEMSS of the University of Maryland in Baltimore, Jackson Memorial Hospital of the University of Miami, University of Texas-Houston Medical School, and Harborview Hospital of the University of Washington in Seattle.
The American Society of Emergency Radiology has been recognized as a radiologic subspecialty, having met the criteria for a seat in the Council of the American College of Radiology. Emergency radiology has been recognized as a unique body of radiologic knowledge by Radiology through the creation of the section of emergency radiology on the editorial board, with associate editors John H. Harris, Jr, MD, DSc, Stuart E. Mirvis, MD, and Robert A. Novelline, MD.
The increasing awareness of the importance of emergency radiology as a distinct body of radiologic knowledge both nationally and internationally, coupled with the growth of the American Society of Emergency Radiology and its current dynamic leadership, portends an exciting and clinically useful future for this emerging radiologic subspecialty.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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TOPABSTRACTINTRODUCTIONREFERENCES |
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