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Stanford University School of Medicine

On radiology reports: The case of Mr. X and the fistula

Sometimes, I sneak an elusive “I” into my radiology reports, a micro-defiance against a system that has little use for first person reflections.

Take the case of Mr. X, a man in his 40s, who got a CT scan for abdominal pain. I noticed gas in the bladder and focal wall thickening. Nine times out of ten, gas in the bladder is iatrogenic — meaning, a health care provider put it there, often by placing a catheter through the urethra.

In medical school, we’re taught, “When you hear hoof beats, think horses not zebras.” The most common diagnosis is usually the right one. But in the dark solitude of the radiology reading room, the mind can wander, to adventures in the Serengeti where zebras roam free, and I found myself thinking about a fistula, an abnormal communication between the colon and the bladder.

So, in the Impression section of the radiology report, I wrote quite boldly: “I believe this could represent one of two scenarios: If the patient recently had a Foley Catheter to explain the gas, then the bladder thickening could represent a mass, for which I recommend urology consultation. If the patient didn’t have a Foley, then the thickening could represent a colovesicular fistula.” With two words, I cast myself as the Gandhi of the radiology suite, leading a revolution in my mind. I believe.

Two days after I reviewed Mr. X’s scan, I followed up on his case. Sure enough, his medical team was focused on his abdominal pain. And no one was impressed by my fistula theory… if they’d read it at all. Brevity isn’t just the soul of wit, it seems.

Now, I hesitate to criticize these brave clinicians who deal directly with the blood, tears, and guts of every patient’s case. Something may look abnormal on a scan, but it could turn out to be nothing if the patient is the picture of good health.

And yet, there can be an advantage in my radiologist’s remove. I see only the evidence on the screen. It’s almost more intimate, seeing through a person’s skin to their insides. And when it came to Mr. X, things weren’t adding up.

So, feeling a bit like a meddling neighbor, I called the medicine attending and made the case for a fistula. She admitted that her team had been stumped on his case and would send him right away.

I felt a sense of validation. Finally, my voice would be heard.

My resident, on the other hand, felt differently. He realized that I had just volunteered him for the job of placing the rectal tube. No one likes receiving a rectal tube, and no health care provider likes putting one in.

Within the hour, Mr. X was in our department, clearly in pain.

After introducing myself and explaining what we were about to do, I thought of also letting him know that I read his CT scan, and that I put together the clues that would hopefully give us the answer to his pain. Here, I could assert my sense of belonging in his care. But, in face of his writhing discomfort, I decided against it. Besides, I didn’t exactly want him to associate radiologist with the jerk who gave me a rectal tube while I was in a lot of pain.

We performed the scan and my resident and I returned to our dark reading room. There, in clear black and white, was a colovesicular fistula. Now that the problem was conclusively identified, he would undergo surgery to solve it.

Even though Mr. X didn’t know the role I played in his treatment and even though I remained distanced, as I drove home that day, I felt a sense of job satisfaction that I hadn’t experienced in a long while.

This is part two of an essay; part one is available here

Ali Tahvildari, MD, is a radiologist at the VA Palo Alto and an affiliated clinical assistant professor at Stanford, where he also serves as associate program director of the radiology residency program. He is a member of the Pegasus Physician Writers at Stanford and enjoys writing fiction and poetry.

Photo by Elijah Henderson

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