radiology angry at the ED

[allylz]

Hello there!

Apologies in advance if this is a dumb question. I have to assume that since I am an MS4, it is going to be dumb.

I'm doing a radiology rotation right now and all the attendings keep saying to me "you're going to be an emergency doctor, so remember this: if you have a reason for a patient's symptoms, don't order another imaging study". This has been said a number of times, for example, in reference to a patient who is short of breath, whose chest x-ray shows CHF, who then gets a chest CT ordered for 'rule out PE'.

Another example occurred today - a young patient with diagnosed DKA, getting an abdominal CT for 'rule out appendicitis'. The attending noted "DKA can cause abdominal pain. So why order a CT looking for appendicitis?"

At first I assumed that it was either done because the EP was looking at the patient and clinically they looked like appendicitis, with RLQ pain and peritoneal signs and so forth, or because they were covering themselves legally by checking for something life-threatening despite the fact that the symptoms could be explained by the diagnosis of DKA.

However, it occurred to me that if the patient didn't look particularly like appendicitis clinically, then couldn't we just treat the DKA first and see if the abdominal pain went away? Or, if the patient showed all the clinical signs of appendicitis, my understanding is that you can diagnose appendicitis without any imaging study (I seem to remember this from a step 2 boards question, but I suppose it probably doesn't reflect reality)....

What's the deal? Should I listen to these radiologists bashing the ED, or are they just full of it?

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[GeneralVeers]

Hello there!

Apologies in advance if this is a dumb question. I have to assume that since I am an MS4, it is going to be dumb.

I'm doing a radiology rotation right now and all the attendings keep saying to me "you're going to be an emergency doctor, so remember this: if you have a reason for a patient's symptoms, don't order another imaging study". This has been said a number of times, for example, in reference to a patient who is short of breath, whose chest x-ray shows CHF, who then gets a chest CT ordered for 'rule out PE'.

Another example occurred today - a young patient with diagnosed DKA, getting an abdominal CT for 'rule out appendicitis'. The attending noted "DKA can cause abdominal pain. So why order a CT looking for appendicitis?"

At first I assumed that it was either done because the EP was looking at the patient and clinically they looked like appendicitis, with RLQ pain and peritoneal signs and so forth, or because they were covering themselves legally by checking for something life-threatening despite the fact that the symptoms could be explained by the diagnosis of DKA.

However, it occurred to me that if the patient didn't look particularly like appendicitis clinically, then couldn't we just treat the DKA first and see if the abdominal pain went away? Or, if the patient showed all the clinical signs of appendicitis, my understanding is that you can diagnose appendicitis without any imaging study (I seem to remember this from a step 2 boards question, but I suppose it probably doesn't reflect reality)....

What's the deal? Should I listen to these radiologists bashing the ED, or are they just full of it?

The answer is the radiologists are right, and wrong. Remember they never get to see the actual patient. For the most part EPs do a great job of ordering the correct and appropriate studies, however their are a few who like to cover themselves legally, so will rule out "badness" in a patient with a ton of inappropriate test. We have an attending like that, who will hunt down a diagnosis of PE on patients with demonstrated asthma, CHF, or cocaine intoxication just to protect himself.

 

[beyond all hope]

Every service occasionally bashes on another service. And every once in awhile, we praise other services as well.

DKA can cause abdominal pain. However, often DKA has a trigger which is a deadly disease itself - MI, PNA, etc. Pneumonias can be caused by obstructing masses, or mask PEs (seen them both). Also remember lots of people die WITH PEs not necessarily FROM PEs.

Occasionally, a person can have more than one kind of deadly pathology - I've seen DKA, sepsis, renal failure, UGIB, alcohol withdrawl and ICH in the same patient. Old/sick people stack up morbidity and disease without dying or getting better, so often you can't stop with just one Dx.

Young/healthy people will come to the ED with only one problem and once you find it you're usually done.

 

[BKN]

Hello there!

This has been said a number of times, for example, in reference to a patient who is short of breath, whose chest x-ray shows CHF, who then gets a chest CT ordered for 'rule out PE'.

Mostly they're full of it. Sometimes the EP is being nuts, more often he's got a reason.

To use the example above.

1. 70% of PEs have been missed since the beginning of the autopsy era. May be getting a little better with multi-slice scanners, but I haven't seen any evidence.
2. The risk factors for DVT and PE are summarized by Virchow's triad (stasis, hypercoaguability and endothelial damage).
3. CHF is the biggest cause of stasis.
4. Thus many, if not most of those missed PEs are in patients with CHF.

So a CHFer has a PE and comes in short of breath. CXR shows failure (as expected) and the Doc makes a diagnosis of exacerbation, treats accordingly. Maybe the patient gets better (probably will if he made it to the hospital with his PE), maybe he doesn't. Then he has his next one and dies. Clinical cause of death-CHF. If an autopsy isn't performed, the real diagnosis is never made.

I'm not saying that I do a CT on every CHF exacerbation, but my index of suspicion is high.

 

[deleted109597]

We had to argue for 30 minutes for a CT PE protocol on a 16 year old girl.

But then it was negative. She still had an A-a of 46.

 

[margaritaboy]

Someone might have said this above, but a PE can be a cause of CHF exacerbation. So having an CXR that is consistent with CHF is fine, but it says nothing about PEs and if there is suspicion then further studies would be warranted.

Infections of any kind can precipitate DKA in type one diabetics. Whether a CT of the abdomen is warranted would depend on that patient's presentation and history, i.e. did they have RLQ abdominal pain and vomiting in spite of taking their usual doses of insulin?

Every service has something to say about the others.

 

[Farbar]

I really hate the in-fighting between specialties. Sure, sometimes studies are ordered that may not be necessary but this cuts both ways. I had a pregnant patient with signs of renal stones. My attending wanted an US to make sure she did not have hydro and send her home after lots of hydration and appropriate pain control. I, as a 4th year, am not qualified to say if this was best but I had to explain to the rads resident that we were not keen on sending our pregnant patient for a renal protocol CT. And yes, she was aware the patient was pregnant. I must have so much to learn.

 

[docB]

However, it occurred to me that if the patient didn't look particularly like appendicitis clinically, then couldn't we just treat the DKA first and see if the abdominal pain went away? Or, if the patient showed all the clinical signs of appendicitis, my understanding is that you can diagnose appendicitis without any imaging study (I seem to remember this from a step 2 boards question, but I suppose it probably doesn't reflect reality)....

That would be a bad idea. If you're worried about appy in a DKAer and your plan is to treat the DKA to see if the symptoms resolve you will be allowing the appy to progress and perf while you treat the DKA. How long should you give it? 8 hours? 12 hours? Too long to sit on an appy.

As for diagnosing appy without imaging, yes, we should be able to get a surg consult on exam alone. We generally can't. That's a surgery vs. EM battle for another thread. In this case though, like you said, you have another reason for the pain so no surgeon is going to cut the pateint based on the exam alone. You have to image to see if it's really an appy causing the DKA or abd pn from the DKA.

 

[kungfufishing]

Just dont mask that CT scan with morphine

 

[mikecwru]

I suggest you open the door to the reading room, let the light in, and watch the radiologist immediately burst into flames.

mike

Hello there!

Apologies in advance if this is a dumb question. I have to assume that since I am an MS4, it is going to be dumb.

I'm doing a radiology rotation right now and all the attendings keep saying to me "you're going to be an emergency doctor, so remember this: if you have a reason for a patient's symptoms, don't order another imaging study". This has been said a number of times, for example, in reference to a patient who is short of breath, whose chest x-ray shows CHF, who then gets a chest CT ordered for 'rule out PE'.

Another example occurred today - a young patient with diagnosed DKA, getting an abdominal CT for 'rule out appendicitis'. The attending noted "DKA can cause abdominal pain. So why order a CT looking for appendicitis?"

At first I assumed that it was either done because the EP was looking at the patient and clinically they looked like appendicitis, with RLQ pain and peritoneal signs and so forth, or because they were covering themselves legally by checking for something life-threatening despite the fact that the symptoms could be explained by the diagnosis of DKA.

However, it occurred to me that if the patient didn't look particularly like appendicitis clinically, then couldn't we just treat the DKA first and see if the abdominal pain went away? Or, if the patient showed all the clinical signs of appendicitis, my understanding is that you can diagnose appendicitis without any imaging study (I seem to remember this from a step 2 boards question, but I suppose it probably doesn't reflect reality)....

What's the deal? Should I listen to these radiologists bashing the ED, or are they just full of it?

 

[turtle md]

Just dont mask that CT scan with morphine

 

[Whisker Barrel Cortex]

Its definitely a little bit of both, coming from the dark side of things (the dark is not so bad when the alternative is nasty flourescent lighting. Its not like you guys work out in the sunlight).

Of course I understand the need to "rule out" things that may kill the patient. I also understand that we are not the ones seeing the patients and their clinical presentation. I don't object to the innumerable negative head CTs that are ordered. The one you find that has a bleed or mass will definitely benefit. I actually would think that the CT on a patient with DKA and no known etiology and abdominal pain is reasonable since an appy could precipitate DKA.

However, it is obvious to me and to pretty much every radiologist out there that there are some ED physicians that are way off to the upper end of the bell curve when it comes to the volume of studies they order. I can tell how busy a night is going to be and how many negative studies there will be just be finding out who the attendings are that night. I think this is the mark of an insecure doc who doesn't trust his clinical examination and acumen. We have asked to track the positive or negative study rate for ED docs, but this has been met with resistance from the ED docs.

Also, the lack of history taking or even a brief review of the patients chart by many ER docs is very disturbing. I should never have a rule-out cholecystitis on a patient status post chole, but I have. I should never have a 3rd rule out calculi CT on an 18 year old within a 2 month period when the other two scans showed that there were no calculi, but I have. Although I understand the fast pace of the ED, taking a better look at the patients history prior to ordering a $1000 scan and exposing a young patient to more radiation isn't too much to ask, or is it?

Although I repect BKN's opinions on the topic, in my experience, when I tell a clinician that the CXR shows CHF and a PE CT is requested anyway, they are invariably negative. I don't believe I've seen a single positive in this situation (although I have heard of 1 case from a fellow resident). The question becomes, how many negative studies on low risk patients is acceptable with the cost of this CYA approach to the medical system.

 

[waterski232002]

I should never have a rule-out cholecystitis on a patient status post chole, but I have.

You are right... for the most part, it's probably due to a poor H+P and lack of attention on physical exam. However, most of the patients where I work (urban indigent population) often deny having CHF but are on dig + lasix; deny having HTN but are on toprol, lisinopril, and norvasc; and deny having had any operations but are s/p appy, chole, and hyst based on old records and evaluation of healed abdominal incisions. Lap chole inscisions may be ambiguous, especially when about 5% of my population has either been stabbed, burned, or shot at some point in their life. And go figure, these tend to be the same pts that are drunk, poor historians, and refuse to cooperate during an H+P. And then there's the set of patients who don't know what kind of surgery they've had done b/c as they say "you're the doc... you tell me". So it's not totally fair to say that you should NEVER get a CT to r/o cholecystitis on a s/p chole patient.

Again, you don't evaluate the patient... you just get the 1 liner on the rec. But for the most part, you are definietely right, this should not happen. And certainly should NEVER happen if the patient KNOWS they've had their gallbladder removed or has a diagonal incision on their RUQ.

 

[GeneralVeers]

I've actually had some Mexican patients who told me they had their gallbladder removed in Mexico. They'll come in for RUQ pain and vomiting, and have a big midline scar on their abdomen. In two patients with this history I stuck the ultrasound probe on their RUQ and could see a gallbladder with stones.

 

[waterski232002]

I've actually had some Mexican patients who told me they had their gallbladder removed in Mexico. They'll come in for RUQ pain and vomiting, and have a big midline scar on their abdomen. In two patients with this history I stuck the ultrasound probe on their RUQ and could see a gallbladder with stones.

I wonder if they had an ex-lap and were s/p splenectomy from trauma.... and just didn't know what the difference was.

 

[GeneralVeers]

I wonder if they had an ex-lap and were s/p splenectomy from trauma.... and just didn't know what the difference was.

Just pointing out that history and physical can be misleading. That's why I always stick the ultrasound probe on RUQ pain, unless they are good historians and had surgery in the U.S.A.

 

[waterski232002]

I know... I totally agree. Too bad I suck at RUQ US.

 

[Ceez]

You are right... for the most part, it's probably due to a poor H+P and lack of attention on physical exam. However, most of the patients where I work (urban indigent population) often deny having CHF but are on dig + lasix; deny having HTN but are on toprol, lisinopril, and norvasc; and deny having had any operations but are s/p appy, chole, and hyst based on old records and evaluation of healed abdominal incisions. Lap chole inscisions may be ambiguous, especially when about 5% of my population has either been stabbed, burned, or shot at some point in their life. And go figure, these tend to be the same pts that are drunk, poor historians, and refuse to cooperate during an H+P. And then there's the set of patients who don't know what kind of surgery they've had done b/c as they say "you're the doc... you tell me". So it's not totally fair to say that you should NEVER get a CT to r/o cholecystitis on a s/p chole patient.

Again, you don't evaluate the patient... you just get the 1 liner on the rec. But for the most part, you are definietely right, this should not happen. And certainly should NEVER happen if the patient KNOWS they've had their gallbladder removed or has a diagonal incision on their RUQ.

sounds like a language barrier problem (poor understanding of the medical lingo also). some patients will say that they don't have HTN b/c they're well controlled on their meds and technically don't have high blood pressure. most ppl will not lie about their surgeries. but if you ask a new immigrant if they've had a "appendectomy or cholecystectomy," they will likely give you an answer (albeit a wrong one) rather than risk looking stupid.

also, if a non-english speaking patient "tells" you that they've had their gallbladder removed and you then see gallstones on an RUQ UTz, then you've taken an inadequate history.

 

[waterski232002]

There is no english barrier with my patients... cultural barrier, yes. 99% of my patients are african american and severely impoverished and uneducated. The majority really don't know their medical problems, don't know why they take their medicines, and don't have a clue why they have been operated on, nor do some of them care. They wait until they are septic before coming to the ER.

And technically, if the patient is on antihypertensives, than they DO have high blood pressure (it's just controlled). Even if they're not on any anti-hypertensives they may still carry a diagnosis of HTN (it may be diet controlled). Similarly, you can have diabetic patients who are not on any oral meds or insulin... it may be diet controlled as well, or more likely just undiagnosed.

But I understand what you're saying.... it can be difficult to tease out a good history.

 

[docB]

However, it is obvious to me and to pretty much every radiologist out there that there are some ED physicians that are way off to the upper end of the bell curve when it comes to the volume of studies they order. I can tell how busy a night is going to be and how many negative studies there will be just be finding out who the attendings are that night.

I can tell you that in the private world (and some parts of the academic world) being the guy who is "on the upper end of the bell curve" of ordering stuff will get you noticed by Utilazition Review. If it stays bad you'll get "counseld" to reduce your usage and may eventually be shown the door.

 

[docB]

I wonder if they had an ex-lap and were s/p splenectomy from trauma.... and just didn't know what the difference was.

They probably got a sham operation and a hefty bill.

 

[docB]

also, if a non-english speaking patient "tells" you that they've had their gallbladder removed and you then see gallstones on an RUQ UTz, then you've taken an inadequate history.

How do you figure? If a patient lies to me (I had my gall bladder out. No doctor I never did no drugs. I only had 2 beers) how have I taken an inadaquate history?

If your point is about translators then all I can say is that ever since that glorious unfunded federal mandate (no not EMTALA, the one about translators) I've got literally dozens of translators in the ED just waiting to help me out .

 

[DrQuinn]

Although I repect BKN's opinions on the topic, in my experience, when I tell a clinician that the CXR shows CHF and a PE CT is requested anyway, they are invariably negative. I don't believe I've seen a single positive in this situation (although I have heard of 1 case from a fellow resident). The question becomes, how many negative studies on low risk patients is acceptable with the cost of this CYA approach to the medical system.

I have had two. Both patients came in, BNP ~1000. I still checked for PE. I lovenoxed. I scanned both. Both had PE's. Both were intubated in < 24 hours after admission, became hemodynamically unstable, then coded and died. It happens. Out of the hundreds of CHFers I've admitted, I've done the PE workup in maybe 5% of them (noncompliance is a wonderful thing for CHF). As BKN said, CHF is probably going to be one of the biggest risk factors for PE in the future. It ain't in the textbooks cause its a relatively new "philosophy," but think about those Class 3/4s who sit around all day, and have universally "low flow states." Setup for a nice PE, which'll throw 'em in "AECHF."

Q

 

[BKN]

also, if a non-english speaking patient "tells" you that they've had their gallbladder removed and you then see gallstones on an RUQ UTz, then you've taken an inadequate history.

NOT! I work in an ED where the average education of the non-english speakers is the 2nd grade. And they make up about 50% of my patients. They are unfortunately bi-illiterate. They often have little information about disease, anatomy and well being. Even with most of our docs being spanish speakers and with almost entirely bilingual nursing staff to translate, the information can be very hard to get.

So the message to those of you who see only 1 immigrant a shift is that his/her educational background and understanding may be far poorer than you're used to, even in an inner city hospital. You've got to go slow, find somebody who speaks the language and consider the possiblity that the patient is covering for the fact that he didn't understand the question at all.

 

[BKN]

Although I repect BKN's opinions on the topic, in my experience, when I tell a clinician that the CXR shows CHF and a PE CT is requested anyway, they are invariably negative. I don't believe I've seen a single positive in this situation (although I have heard of 1 case from a fellow resident). The question becomes, how many negative studies on low risk patients is acceptable with the cost of this CYA approach to the medical system.

Well I understand your concerns and respect your experiences, but I wonder how many times you've been in the situation as a resident? If folks at your institution are ordering this on every CHFer, then clearly they are on the high upper arm of the bell curve.

I don't know how often I do this, but DocB's 5% sounds about right. I haven't kept track, but I think I've found a clot about 50% of the time. Makes me wonder how many were in the group that I didn't scan.

 

[la gringa]

i speak medically functional spanish (would be hard pressed to have a discussion about televisions, economics, or politics!) so i rarely use a translator for everyday spanish. however, when i do need one, 80% of the time the translator is also having difficulty understanding the patient due to the patient's level of education and/or language abilities. heck a lot of americans don't know what a gall bladder is and a few spanish speaking pts look at you sorta funny when you say "vesicula biliar". they usually get "piedras" though... but that's not so specific!

 

[bartleby]

You know quite well that the finding of CHF on a chest xray does not consequently guarantee that there is no other pathology present. The fact that you have not seen a PE does not mean that you will not find one any more than me flipping a quarter fifty times and coming up with "heads" means that "tails" does not exist.

In my experience, when I tell a clinician that the CXR shows CHF and a PE CT is requested anyway, they are invariably negative.

If you do not look for PEs when indicated, you will not find them. Another poster in this thread reminds us that most PE's are diagnosed on autopsy. The current practice approach to the diagnosis of PE's has been well borne out by the literature and a single person's anectodal experience should in no way contravene good evidence-based practice.

Whose ass is being covered, anyway? Most often it is the patient's. A PE is a rather bad life-threat to miss, and its management & workup are quite different than the alternative diagnosis of CHF or pneumonia.

The question becomes, how many negative studies on low risk patients is acceptable with the cost of this CYA approach to the medical system.

 

[southerndoc]

I haven't seen any CHF patients with PE's, but that may be because I'm not as aggressively looking for them. I do consider it, but I only scan if there is a high probability.

I have, however, found a lot of PE's in COPD exacerbations. In fact, a recent study out of France demonstrated a 22% rate of PE's in patients hospitalized for "COPD exacerbation."

 

[Apollyon]

...a single person's anectodal experience should in no way contravene good evidence-based practice.

But going to the contravention is such a good time! (It's always 3 weeks after ACEP.)