Teaching in Accident and Emergency Medicine: 10 Commandments of Accident and Emergency Radiology BMJ 1995;310:642-5 http://decode-medicine.blogspot.com/

1. The 10 Commandments of Accident and Emergency Radiology Adapted from BMJ 1995;310:642-5 http://decode-medicine.blogspot.com/

2. Treat the patient, not the radiograph If the condition is immediately life threatening treatment should be started straight away without waiting for a radiograph to confirm the clinical diagnosis. tension pneumothorax severely displaced fractured ankle

3. Take a history and examine the patient before requesting a radiograph Establish the mechanism and force of injury and use this information to deduce which resultant abnormalities are likely.

4. Request a radiograph only when necessary A useful investigation is one whose result (positive or negative) will alter the patient's management; many requested investigations do not.

5. Never look at a radiograph without seeing the patient, and never see the patient without the looking at the radiograph The doctor can correlate the radiological findings with the clinical examination, which helps to reduce the chances of missing an abnormality or perpetuating an error. If a patient re-attends, always look at any radiographs taken previously, or at the least obtain the radiologist's report. Do not accept the accident and emergency radiological interpretation written on the medical record.

6. Look at every radiograph, the whole radiograph, and the radiograph as a whole A common mistake is to focus immediately on severe abnormalities or on particular areas of the film. This may lead you to fail to inspect the whole film and consequently to miss additional abnormalities.

7. ABCs for Interpreting Radiographs A. Adequacy A. Alignment B. Bones C. Cartilage and Joints S. Soft tissues

8. Re-examine the patient when there is an incongruity between the radiograph and the expected findings

9. The rule of twos Two views at right angles Two joints include either end of the long bones Two sides to compare the normal and injured side Two occasions to repeat radiographs at a later date to show the abnormality (early callus or rarefaction) Two radiographs to compare with a known normal film

10. Take radiographs before and after procedures Removal of foreign body Reduction of dislocation or fracture

11. If a radiograph does not look quite right ask and listen: there is probably something wrong The final responsibility lies with the doctor, and not the radiographer, therefore never accept poor quality or inadequate films. It is important to seek senior advice and also to listen to the radiographer.

12. Ensure you are protected by fail safe mechanisms Quality control system for interpreting radiographs On reviewing the films, the doctor records the radiological diagnosis on the request (or return) card All emergency radiographs must be reviewed by a radiologist, and the report returned, within 3 working days. Many would now advocate immediate (within 24 hours) reporting as a good standard of practice The radiologist's report should state clearly whether he agrees or disagrees with the radiological diagnosis of the emergency doctor All radiographs must be reviewed if the report states disagree. The radiologist must contact the department at once if a serious injury has been missed