In an era when new technologies and demands for increased clinical productivity have rendered direct contact between radiologists and patients less frequent than ever, it is important for radiologists to pause from time to time and consider the relationship between radiologic iages and the lives of the patients they depict.
Radiology is an image-based medical specialty, and in many ways, the most salient reality in a radiologist’s daily practice is the medical image. By whatever modality we produce images, they are the principal objects of a radiologist’s attention. We are educated and contribute to patient care largely in terms of our ability to create high-quality images, detect lesions, offer differential diagnoses, and make recommendations for further diagnostic evaluation. Yet there is a reality behind the images, that of the patient whose anatomy and physiology they depict. If radiologists lose sight of the connection between radiologic images and the afflicted human beings they depict, our level of professional commitment and fulfillment may suffer ( ).
Because the image does not tell the whole story about the human being it represents, the story behind the image can be as illuminating as the image itself ( ). In an era when new technologies and demands for increased clinical productivity are rendering direct contact between radiologists and patients less frequent than ever, it is important for radiologists to pause from time to time to consider the relationship between what we see in radiologic images and the significance of those same images to patients. To explore this relationship, we describe a particular clinical case from the neonatal intensive care unit (NICU) that juxtaposes these sometimes widely separate domains of meaning.
The clinical picture
Following unremitting labor, baby Grace was delivered by emergent cesarean section at 24 weeks’ gestation. Prior to delivery, the neonatologist gave her parents the option of resuscitating their daughter at delivery, informing them that there was a 30%–50% chance of survival if the fetus was delivered at 24 weeks. He counseled the parents that Grace could develop severe mental and/or physical disabilities, but might also lead a normal life. The neonatologist made it clear to the parents that the management plan could be altered to less aggressive interventions or even strictly palliative care, if the situation warranted. The parents opted for resuscitation.
Grace was received by the neonatology team immediately upon delivery. She was intubated and given surfactant. Her Apgar scores were 5, 5, and 6 at 1, 5, and 10 minutes, respectively, and she weighed 830 g. The first 4 days of her life were a medical roller coaster ride. On day 1 she was started on total parenteral nutrition and received a blood transfusion. Over the next several days her medical team struggled to stabilize her respiratory status, switching back and forth between conventional and oscillating ventilatory support. They encountered episodes of metabolic and respiratory acidosis, the development of pulmonary interstitial emphysema, and fluctuating blood pressures. A chest radiograph report from day 4 of life read:
Lines and tubes are in stable, standard position. No pneumothorax or pleural effusion are present. Persistent premature lung disease. Bubbly cystic lucencies bilaterally suggesting pulmonary interstitial emphysema. Impression: Interval development of findings suggestive of pulmonary interstitial emphysema.
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Clinical History: 24 week premature infant with probable germinal matrix hemorrhage. Comparison: None. Findings: There are very large bilateral grade IV germinal matrix hemorrhages. Both lateral ventricles are enlarged, the left more so than the right, producing some midline shift anteriorly to the right. The third and fourth ventricles are not well seen, although they do not appear enlarged. Impression: Very large bilateral grade 4 germinal matrix hemorrhages.
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The story behind the image
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Hard choices
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Lessons
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References
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