Anyone bored enough to help?

[smq123]

But, what's with the Dr. Osler remark? Is that supposed to be a signal that you want to engage in a few rounds of namecalling or ridicule? Do you need me to trash you in a few message in some kind of dysfunctional forum codependency?

It was called "sarcasm."

I wouldn't have bothered with a few rounds of ridicule. I would have flagged your post in which you called me a killjoy, and you evidently called me a "dark cloud" for no other reason than the fact that I don't buy your proposed model of healthcare.

How you could honestly think that a medical student would think that getting a sexual history is more important than asking about MI's is beyond me.

Because you not only SAID it....but you went on and on in an extremely lengthy post about it!

Dude, there is a SERIOUS lack of self-awareness on your part.

I'm going to make mistakes, and I'm not going to worry about it neurotically.

I didn't worry about it neurotically when I was an MS2. That's how I got blindsided when I was an MS3!

Seriously, some people who loved MS1 and MS2 really turned around and hated MS3. I was the opposite, though. Despite having to change the way I talk and think, I've actually liked MS3 and MS4, for the most part.

Secondary hypertension is thought to be found in about 5 to 10 % of HTN cases. That's not a small number and not unusual. We have already agreed that there is a limit to what can be considered here. It is a balancing act, but anyone who sees a lot of hypertension cases (like you now and eventually me) will run into secondary hypertension cases from time to time. If you aren't seeing them, then I would start to wonder why you weren't.

Seen a couple of cases of secondary hypertension - not due to renal artery stenosis. Hyperthyroidism, usually, and a LOT of preeclampsia. A few people with renal disease - hereditary renal disease. One pheo, I think, while I was on surgery. That's about it.

If you saw patients with HTN every single day of your career, then you could expect to see 5-10%. Generally, though, it's kind of diluted in among the other types of patients that you see, and not that huge of a deal.

Even though they are very rare, I would nevertheless briefly consider it in the DDx and look for "panic attacks," episodic hypertension, palpitations, headache, sweating, angina, patients with FH of VHL, MEN-2. Although the 24 hour urine collection is inconvenient, the test is readily available and relatively inexpensive. There are plasma catecholamine tests available also if the urine test is not desired.

Once again, I think the the order of things to do while seeing patients isn't very clear to you. Which is fine, since you haven't done rotations yet.

If you want to break it down into steps:
1) Take a good H&P. That goes without saying, to the point where I think it's idiotic of med schools to keep insisting that you write that down as a step. It's even more irritating that that's the catchphrase that they pound into your head in MS1 and MS2 - because, as an MS3, if you say, "Well, I'd take a good H&P first," your attending will roll his eyes, and say, "Well, DUH. I was hoping for a better answer."

Ask the patient to characterize any symptoms of HTN - panic attacks, episodic SOB, episodic CP, etc. Any other unusual symptoms, etc. ROS, etc. Family history, etc., etc. Current meds, allergies, any underlying comorbidities. Physical exam - acanthosis nigricans, PMI, etc., etc.

2) Order the Chem 7. Maybe a TSH, since abnormal thyroids ARE quite common - much more common than renal artery stenosis.

3) Have the patient try a week or two of whatever you want to start the patient on. Make a followup appointment for the patient.

4) Talk to the patient about how the medication worked. Look over the lab results, and look over any abnormalities.

THEN, if the patient reports other symptoms, or that the medication isn't helping, and the labs are really weird, THEN you'd consider a 24 hour urine collection. Considering it beforehand is like using a shotgun to kill a mosquito.

When it comes to the ultrasound machine, I wouldn't have to buy it if it was otherwise available and not being used.

I'm not sure why, but you don't seem to understand how difficult that would be.

Let me use an analogy that anyone can understand. Let's say that you don't have a car, but your neighbors have one - a very expensive SUV. Your neighbor is a licensed driver and has actually raced semi-professionally. He knows how to handle a car.

One day you go to your neighbor and say, "Hey. I'm not really a good driver - not even an officially licensed driver - but I'd kind of like to use the car to drive to the movies. I don't really know how to drive it, but I taught myself a few things. Can I borrow it?"

Do you think your neighbor is going to loan his car to someone who rarely drives, is (admittedly) not very good at driving, and doesn't even really need to use it?

It's the same with an ultrasound machine. You can't just borrow one because it's "lying around." The value of that, in the eyes of the people who own one, is minimal, and they'd just tell you that they'll scan your patient themselves.

Also, I believe that proper training is essential, but that proper training in using an ultrasound machine does not require a radiology residency as some here seem to suggest. I wouldn't suggest buying it for "unofficial scans" unless it was pretty cheap relative to the payoff that can be expected and I found it to be very useful in detecting conditions that were otherwise missed.

...

And just how do you know that "proper training in using an ultrasound machine does not require a radiology residency"?

If you're a family med physician, or in IM, you won't be good at doing complicated ultrasounds. You just won't. You will lack even the basic training that ultrasound techs get. Bladder studies, echos, liver scans, etc. - reading even basic ultrasounds is challenging enough. Anything more complicated, and you'll be just as ignorant as the patient is about what you're seeing.

How expensive do you think the ultrasound machine is compared to managing thousands of seriously ill patients ... who are seriously ill because their condition was not diagnosed earlier? How many seriously ill patients who presented with say, premature kidney failure, would it take to justify a $60 test? My impression is that there are certain patient populations that are at higher risk for various conditions where a scan with an ultrasound machine would be justified.

<sigh> Despite the heart-tugging plea to "Think of the patients!," you're still not being logical.

Okay. I don't know what school you go to, but I get the impression that they are teaching students about the "big gun" diagnostic tests....and neglecting the everyday tests that people use that, actually, have a pretty good sensitivity rate.

If a person presents with possible signs of premature failure, you'd see it in the Chem 7, and the urine dipstick, both of which are easy and fairly cheap tests. The creatinine and BUN would be sky-high, and there would be proteinuria. If the patient really on the fast track to ESRD, he'd be dumping protein into his urine.

If that were the case, then yes, I'd get a renal ultrasound. But ONLY BECAUSE there is a JUSTIFIABLE reason to get one. You need some proof that there is a disease process going on. Otherwise, you're just hunting blindly in the dark for something that might not even be there.

Saying, "Well, my patient is at a moderate risk of kidney damage," is not a good reason to get a renal ultrasound.

Renal ultrasounds are too expensive, and too difficult to interpret by the average person, to use as screening tools.

My suggestion is that we look at the need, cost, and benefit in numerical terms rather than our emotional affinity to making such a change or whether it's the way it's always been done before.

For example, it's my understanding than even preventing even a single patient from needing dialysis would easily pay for a $25,000 ultrasound machine and its maintenance.

You know, I am getting a little irritated by the fact that you insist that the rest of us are defending the current standard of practice because of "emotional affinity to the way it's always been done before," or because we're, essentially, money grubbers. It's even MORE irritating because you honestly DO NOT HAVE A CLUE about what you're talking about! You're making a sweeping generalization about people's motivations, based solely on your own assumptions about the practice of medicine.

a) Some tests are simply too expensive. Just because I refuse to use an expensive, difficult to perform test to screen patients, does NOT mean that I don't care about them, or that I'm willing to give them poor care. It means that I'd rather use a cheaper, easier to use test that has a pretty good sensitivity rate! Which is exactly what the Chem 7 is!

b) Furthermore, how far are you willing to go to pick up EVERY single patient who might have an unusual case of hypertension? Fine, so let's say that you do renal ultrasounds on everyone....until one day you hear about a patient that you scanned, and was fine....but still had refractory HTN? And then you realized that your ultrasound missed that one person's case? Ultrasound isn't sensitive enough!

So then you escalate to CTA...until you hear about one patient that the CTA failed to diagnose!

So then you escalate to MRA....until you hear about one patient that you missed.

So then you escalate to renal artery biopsies.....

When are you going to draw the line?

---

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[LadyWolverine]

You want to hit people in the face because they disagree with you and have a different perspective, and you're only human in that respect. People beat and kill people all the time that they disagree with ... just visit any big city hospital's emergency room. Some spouses also beat one another physically and it's very unfortunate and unnecessary (and a big problem despite being illegal). I'm not suggesting you will give in to that desire. I suggest talking things out rather than resorting to violence, but that's a discussion you should have with your therapist.

Seriously, what the hell is your malfunction, man? I disagree with you because you are WRONG, not simply because you have a different perspective. I am inclined to think you just like starting pointless arguments for the sake of making stupid, tangential comments like these that somehow make you feel better about yourself for "putting me in my place." Don't patronize me. It's abundantly clear that you're going to be one of those 3rd-year students who consistently pisses off his residents and attendings because he thinks he knows better and "cares more about patients" than anyone else. Where do you get off being so condescending? Do us a favor and spare us all the sanctimonious rhetoric about "The Future Of Medicine" and how you will provide "better patient care" because you're not afraid to order a bazillion expensive tests that will cost the patient (or the taxpayers) huge sums of money to look for that 0.001% chance. Most of us have heard it all before from our more naive classmates. And if you order an echocardiogram to look for RAS, be prepared to be laughed at by the cardiologist.

 

[45408]

Yes it is!

Now we have some intelligent conversation going on Prowler style. Reminds me of talking to my two year old.

I guess I should act offended to go with the requisite berating of the intelligence .... ;-)

I like the multiple low blows as you pretend to be above that. You just posted this:

But, what's with the Dr. Osler remark? Is that supposed to be a signal that you want to engage in a few rounds of namecalling or ridicule? Do you need me to trash you in a few message in some kind of dysfunctional forum codependency?

And then compare my intelligence to a 2-year old's. Of course, you ignored the much more substantial posts that highlight how little you apparently understand about this subject, and you went for the low-hanging fruit. Congrats. My respect for you has substantially fallen throughout the course of this thread.

 

[TMP-SMX]

Kids these days. Can't we all get along?

 

[45408]

How expensive do you think the ultrasound machine is compared to managing thousands of seriously ill patients ... who are seriously ill because their condition was not diagnosed earlier? How many seriously ill patients who presented with say, premature kidney failure, would it take to justify a $60 test?
.....
For example, it's my understanding than even preventing even a single patient from needing dialysis would easily pay for a $25,000 ultrasound machine and its maintenance.

The key factor is the NNT - number needed to treat. The US already spends more per capita on health care than any other developed nation, and we don't even cover everyone. Your suggested solutions, quite honestly, are terrible ones. The last thing that we as a nation can afford to do is provide MORE tests and MORE imaging, and then try to also provide that to MORE people. We're already straining the limits of Medicare, and it's clearly forecasted to get much, much worse. It's also well-documented that some states, such as New York, spend substantially more money on increased testing and diagnostics, and they don't even have improved outcomes to show for it. It's just that more tests are done.

 

[OncoCaP]

It was called "sarcasm."

I wouldn't have bothered with a few rounds of ridicule. I would have flagged your post in which you called me a killjoy, and you evidently called me a "dark cloud" for no other reason than the fact that I don't buy your proposed model of healthcare.

Well, ok then Einstein. Let's see what you have to say.

Sure,



Because you not only SAID it....but you went on and on in an extremely lengthy post about it!

Again, it's context. If someone said "drop" your bag of fertilizer here, you would have no problem dropping it to the ground with a thud. If someone said, drop the patient off over there, you wouldn't literally push them off the bed at that location. You understand from the context. If someone says "the most important thing when you drive to my house is not to miss the turn at 2nd street because it comes up quickly" you wouldn't assume that not getting in an accident is somehow irrelevant. Context imparts meaning. I was talking about drug compliance and an issue I was concerned about in that respect. It doesn't preclude asking about MI's.

Dude, there is a SERIOUS lack of self-awareness on your part.

Perhaps. But perhaps not. I think you just like to argue about irrelevant stuff, and I'm fine with that.

(lots of good comments deleted).

When it comes to the car analogy, I would suggest that proper training (a license) would be required. If that wasn't possible, then I wouldn't recommend it. Also, I wouldn't borrow the care to haul firewood. I would make sure there is some kind of important benefit, such as perhaps taking a sick child to a doctor.

The reason I know that it doesn't require a radiology residency to properly use an ultrasound machine is that radiology techs use them all the time. I'm not suggesting that the radiologist provides no value, just that the radiologist isn't required for many ultrasounds that are done (like when you look at babies routinely).

<sigh> Despite the heart-tugging plea to "Think of the patients!," you're still not being logical.

Okay. I don't know what school you go to, but I get the impression that they are teaching students about the "big gun" diagnostic tests....and neglecting the everyday tests that people use that, actually, have a pretty good sensitivity rate.

If a person presents with possible signs of premature failure, you'd see it in the Chem 7, and the urine dipstick, both of which are easy and fairly cheap tests. The creatinine and BUN would be sky-high, and there would be proteinuria. If the patient really on the fast track to ESRD, he'd be dumping protein into his urine.

If that were the case, then yes, I'd get a renal ultrasound. But ONLY BECAUSE there is a JUSTIFIABLE reason to get one. You need some proof that there is a disease process going on. Otherwise, you're just hunting blindly in the dark for something that might not even be there.

Saying, "Well, my patient is at a moderate risk of kidney damage," is not a good reason to get a renal ultrasound.

Renal ultrasounds are too expensive, and too difficult to interpret by the average person, to use as screening tools.

I actually agree with you on this one. I dumped the idea of doing a renal ultrasound for the RAS a few messags back. It should be in there when I came to that conclusion. I can find it if you want me to. For one thing, it seems to too many false RAS positives in the general HTN patient population even in the hands of a skilled operator. The poor patient goes into surgery and it turns out the flow was OK. I've been told previously (by people I respect) that that's how they check for RAS. After doing a little more reading about it, I'm not so sure its a good test for screening normal risk patients. We agree on what tests should be done on the HTN patient as far as I know and I'm comfortable holding off on the 24 hr urine as well.

You know, I am getting a little irritated by the fact that you insist that the rest of us are defending the current standard of practice because of "emotional affinity to the way it's always been done before," or because we're, essentially, money grubbers. It's even MORE irritating because you honestly DO NOT HAVE A CLUE about what you're talking about! You're making a sweeping generalization about people's motivations, based solely on your own assumptions about the practice of medicine.

I'm not making sweeping generalizations. Anyone who has been paying attention knows that our medical system is broken and does not serve the interests of the public adequately. There are many reasons for that, and I'm open to discussion. I have my ideas and it doesn't bother me if you don't agree with them. One of my key points is that it costs too much to do a simple test. If a kid faints at a soccer match, they call an ambulance, take him to the hospital. Cost $1500. The EMTs determine there is nothing wrong, but take him to the hospital. Then in the ER they run a bunch of tests and find nothing. Cost $1500. Turns out the kid has a family history of fainting when nervous. Nothing cardiac. No sudden death. No arrhythmias. Kid goes home. Kid needs note from doctor that he's fit to play soccer. Goes to pediatrician, cost $200. Pediatrician refers to pediatric cardiologists for evaluation cost $2000. End of the days, found nothing. Idiopathic syncope, non-cardiac. Cost to family that makes $50K per year is ... $5200. Benefit to patient: none. Take a different kid. This one has type 1 diabetes but doesn't know it. He's having problems concentrating in school but can't get a a doctors because his parents can't afford to take him. They don't have $5200 dollars lying around. He goes on a bikeride on a trail, falls down and no one knows where he is. Parents are self-employed and have no insurance; can't afford it. They make too much to qualify for gov't programs. By the time they find him, he's a coma and does not recover. This kind of thing happens every day. Why? On the one hand we are so worried about lawsuits that what used to be "nothing" just give him a little fresh air. Parents had the same problem. Now costs $5200 to give an idopathic diagnosis with no treatment. Meanwhile many people can't afford this and suffer as a result. I could go on if you want to explore this further. I told you about the hemachromatosis patient who bounced aroudn without a true diagnosis for 20 years. This stuff happens every day. Physicians aren't perfect. The system is broken, life goes on. If want statistics about this kind of thing for the U.S. I can provide it. As an aside, even if both these patients had insurance it wouldn't necessarily mean the patients weren't paying for it somehow when they buy insurance, for example.

So what's the solution? If you have one, I'm certainly open to hear it. My point is that, first of all, when a patient shows up, we should consider what it might be with a DDx. We pretty much agree on this. Just treating common things as common is not a good idea if you could go from 90-95% accuracy to 99.99% for another $50 or something similiar. It's totally worth it because another appointment is going to cost $200. If that requires another $50 test, it's still a small cost compared to missing something and having to make another doctor's appointment (which would be way more expensive). As we discussed, some of the items in the DDx can be screened with tests we would do anyway or no extra cost PE items that, while difficult, are something an experienced physician should be able to do and a medical student will eventually be able to do well.

I know, what about the ultrasound machine? I'm not suggesting we use it for RAS in normal-risk HTN patients. Instead, let's say that the physician was concerned about a patient's liver and liver labs were borderline, but the patient could not afford to have an expensive ultrasound done for that (didn't have $1500 lying around). If the physician knew how to use the ultrasound machine (was trained, compentent enough to detect large/obvious abnormalities), he might look at the patient's liver and find a tumor or abscess, or something like that clearly needed to be treated with some quick checking. He could explain to the patient that he found something that concerned him. He doesn't know what it is but that further evaluation is necessary because it could be something very serious and shoudl be done even if it would place a huge cost burden on the patient. In this case, the physician could have saved the patient's life.

What I'm complaining about is that this is an issue and by suggesting that a patient should just try something common and come back, you could actually be costing the patient more money. In doing so, you could reduce the quality of care that the patient gets. By not even considering the issue, you are ignoring a serious problem we face with our medical system ... an issue you could potentially do something about, particulary as you get further in your career. By supporting the system and encouraging a kind of piecemealing of the treatment, you could be increasing the cost and making the problem worse. If you don't have any choice, there is nothing you can do. However, it's when you defend the system that I object.

The second thing is with respect to new or novel tests or tests done to a lower quality by a physician, tech or whoever to reduce cost. I agree we should look at the cost-benefit. Let's not do more tests if we cannot show the benefit in improved health and mortality at a cost that our patients can afford. I'm completely open to looking at the numbers in black and white. Once again, you are quick to dismiss the suggestion with something like "you don't know anything" about cost or whatever. The costs in the medical system are vast and many of them are known to people who deal with the system. You don't need to be an MS3 to know what the costs are (and even then you might not necessarily know). Rather than saying "you don't know" if you see a problem, explain your side. I see you did that in your last message and I like that. Show me how you are really making things better or at least have some sympathy for those who don't get the care they need because of issues with the system we have.

a) Some tests are simply too expensive. Just because I refuse to use an expensive, difficult to perform test to screen patients, does NOT mean that I don't care about them, or that I'm willing to give them poor care. It means that I'd rather use a cheaper, easier to use test that has a pretty good sensitivity rate! Which is exactly what the Chem 7 is!

Perfect!

b) Furthermore, how far are you willing to go to pick up EVERY single patient who might have an unusual case of hypertension? Fine, so let's say that you do renal ultrasounds on everyone....until one day you hear about a patient that you scanned, and was fine....but still had refractory HTN? And then you realized that your ultrasound missed that one person's case? Ultrasound isn't sensitive enough!

So then you escalate to CTA...until you hear about one patient that the CTA failed to diagnose!

So then you escalate to MRA....until you hear about one patient that you missed.

So then you escalate to renal artery biopsies.....

When are you going to draw the line?

We agree with your current approach to the HTN patient. Before you didn't take the RAS (dismissed it as unusual) unless the labs jumped out at you. I think you are more open to considering that than you were or maybe I just understand where you are coming from better. Either way is fine with me.

We went from arguing whether RAS should be considered in the DDx during the initial patient to seeing that we could consider it with really no extra cost. This could potentially improve the accuracy of diagnosis another 5% or so. Improvements like this add up. I also learned a lot about what you do and how you deal with these patients. I enjoyed that. Thanks for explaining it.

In terms of "drawing the line" if I could prevent a certain number of patients per year from going into renal failure to the point where they needed dialysis, I might be able to justify an ultrasound machine, it's maintenance and associated training for that. The costs for dialysis are quite high. Maybe I would try to get a grant for that or use existing equipment under certain circumstances. That's the kind of thing I'm thinking of. From what I can tell, ultrasound has a lot of potential in diagnosis. I wouldn't be interested in it if it just raised cost by $25K and had no proven benefit. Doing a study to see if it would have a benefit would also be fair game in my opinion.

 

[LadyWolverine]

We agree with your current approach to the HTN patient. Before you didn't take the RAS (dismissed it as unusual) unless the labs jumped out at you. I think you are more open to considering that than you were or maybe I just understand where you are coming from better. Either way is fine with me.

We went from arguing whether RAS should be considered in the DDx during the initial patient to seeing that we could consider it with really no extra cost. This could potentially improve the accuracy of diagnosis another 5% or so. Improvements like this add up.

I must be missing something. smq never said that you don't *CONSIDER* RAS in the differential. Of course you "consider" it. You entertain all kinds of crazy notions in your ddx. Conidering doesn't cost you any money. It also doesn't really prove anything. The exercise then becomes how to most wisely use your (limited) resources to determine the most likely etiology. Listening for abdominal bruits doesn't cost you any money (although I'm not aware of the diagnostic value of "auscultating for bruits" - for all I know, the sensitivity and specificity are around 5%, just like the worthless Kernig's and Brudzinski signs that they make 2nd years memorize when learning about meningitis - tests that are routinely performed but have little to no real diagnostic value). Doing a good physical exam, looking at the vital signs, and maybe running some basic labs are a good use of resources. Sending a patient for renal ultrasound with only a dx of HTN is not.

You need more solid proof to rule out or confirm diagnoses, and there is currently NO WAY to confirm RAS without incuring extra costs. What smq said was that, compared to essential HTN, RAS is a highly unlikely etiology for HTN and thus doesn't warrant a renal ultrasound, UNLESS you treat the patient for ET and it is refractory. Then it may be worth taking a closer look, and going down the path that inevitibly is more expensive. Why are you acting like you are "schooling" the clinical students when it is obvious that you don't know the first thing about managing chronic problems like these in the outpatient setting?

 

[OncoCaP]

The key factor is the NNT - number needed to treat. The US already spends more per capita on health care than any other developed nation, and we don't even cover everyone. Your suggested solutions, quite honestly, are terrible ones. The last thing that we as a nation can afford to do is provide MORE tests and MORE imaging, and then try to also provide that to MORE people. We're already straining the limits of Medicare, and it's clearly forecasted to get much, much worse. It's also well-documented that some states, such as New York, spend substantially more money on increased testing and diagnostics, and they don't even have improved outcomes to show for it. It's just that more tests are done.

I'm happy to have a normal conversation with you if that's what you are interested in. If you want me to talk to you like a 2 year old kid, I can do that also, but I don't think that's in anyone's interest.

Now to your point. Here's where I'm coming from. If a test costs $1500 and we do 100,000 of these tests per year, that's a lot of cash changing hands. No argument there. If those $1500 tests are a model of efficiency and we have the lowest cost individual who is competent enough to do the test with an acceptable (i.e., very good) level of accuracy and we need all the information in those test then I say, way to go, hurray! I have nothing further to say on that.

On the other hand, if you are often looking for a tumor, abscess, etc, the size of a grapefruit and you just cannot palpate the thing because it's in or under the liver, near other organs, etc and with the help of an ultrasound device the thing is obvious as fireworks on the 4th of July to pretty much anyone with an 1/2 day of training then I'm interested in seeing how we could get the same result for let's say $200 in cost rather than $1500, especially if we do a lot of these test. I'm even more interested in the $200 test if it means that patients are going to get it because they can't afford the $1500 and would simply go undiagnosed until they were beyond saving. As long as we don't routinely do both tests (i.e., the $200 test had a high false positive rate as if often the case when a new diagnostic is added), then I would be interested in it, otherwise not. In some cases it is a liability fear that causes a physician to order a $1500 test when a $50 test might do but not be as difficult to defend. In cases like that I would want assess how much of a liability risk there really is. Information about lawsuits and settlements can be difficult to obtain due to the sensitive and often confidential nature of those activities. In some cases, the best we can do is trace back where the information came from and whether it is reliable.

I know of physicians who have been sued for doing nothing wrong (in fact, the main physician reluctantly agreed to do the procedure in the first place because it was difficult but potentially very beneficial) but the patient did very poorly and the relatives received a lot of different accounts of what happened and finally sued because they trusted no one. In that particular case just making sure that the family was told one coherent and accurate story could have avoided the whole thing. No amount of imaging or expensive tests would have helped. I have seen other cases where lawsuits were dismissed because the physician had documented and delivered appropriate care without a lot of expensive tests. I do respect the fact that legal liability is a huge problem and needs to be treated with great care.

In my previous life, I worked with companies that did, among other things, signal analysis. We would pick information of interest out of what looked like garbage data that was completely incomprehensible to a human. With this kind of technology we were able to take information that no human could understand and turn it into information that a gal with a GED could use to generate literally millions of dollars in additional profits for our clients. This wasn't healthcare, but there are some similiarities here. Based on what I saw in that field, I'm hopeful we will see some interesting developments with ultrasound imaging capability, cost, and usability (that don't require years of training to use) and thus allow better care. I could be wrong, but my hope is that what I have seen provide great benefits in other fields would provide excellent, inexpensive benefits in medicine also. There are some papers about how ultrasound follow-up or screening provides better outcomes for certain groups of patients. They don't talk much about cost, and I see that as a problem, much as you clearly point out.

More to the above discussion, I agree with smq on the approach to the HTN patient. I was just pushing to have RAS in the DDx (and even Pheos if certain classic symptoms are there). She wanted to push those back for a future appointment unless labs came back out of line. My main point there is that we should do what we can with the information we have and I get the sense that there isn't much argument about. Listening for pathological abdominal bruits is apparently difficult and that's an issue in terms of screening.

Why do I bother with these long-winded arguments? It's interesting to me and I feel like learn a lot. It gives me a chance to bounce some ideas off people as well. Some ideas I have are good and some are not so good. I'm having fun with it.

 

[OncoCaP]

I must be missing something. smq never said that you don't *CONSIDER* RAS in the differential. Of course you "consider" it. You entertain all kinds of crazy notions in your ddx. Conidering doesn't cost you any money. It also doesn't really prove anything. The exercise then becomes how to most wisely use your (limited) resources to determine the most likely etiology. Listening for abdominal bruits doesn't cost you any money (although I'm not aware of the diagnostic value of "auscultating for bruits" - for all I know, the sensitivity and specificity are around 5%, just like the worthless Kernig's and Brudzinski signs that they make 2nd years memorize when learning about meningitis - tests that are routinely performed but have little to no real diagnostic value). Doing a good physical exam, looking at the vital signs, and maybe running some basic labs are a good use of resources. Sending a patient for renal ultrasound with only a dx of HTN is not.

You need more solid proof to rule out or confirm diagnoses, and there is currently NO WAY to confirm RAS without incuring extra costs. What smq said was that, compared to essential HTN, RAS is a highly unlikely etiology for HTN and thus doesn't warrant a renal ultrasound, UNLESS you treat the patient for ET and it is refractory. Then it may be worth taking a closer look, and going down the path that inevitibly is more expensive. Why are you acting like you are "schooling" the clinical students when it is obvious that you don't know the first thing about managing chronic problems like these in the outpatient setting?

If I understand her correctly, she advocates working with a more limited DDx than you would 1st or 2nd year for efficiency & practicality's sake. She has a good discussion of that in one of today's messages. Early on in the argument, she was convinced that RAS shouldn't even be on the radar (although she did order a test with some sensitivity for it) and went so far as to call it a zebra that we shouldn't even be thinking about (at least that was my understanding of what she was saying ... point being I don't think we have any disagreement about this anymore). She didn't want look at the other aspects of the RAS screen. She seems more open to it now because there is a way to screen for it that has minimal cost and RAS is reported to be as common as ~30% in certain patient populations.

In terms of how valuable the abdominal bruits are. Here's what it said in the article I mentioned earlier on RVHT:

"Abdominal bruits have a prevalence of 6.5% to 31% in the healthy population,[34] and a prevalence of 28% in patients with all-cause hypertension.[35] However, in patients with angiographically proven RAS, the prevalence ranges from 78% to 87%.[33] Two studies have investigated the sensitivity and specificity of finding a systolic-diastolic abdominal bruit in the diagnosis of RAS.[33] Sensitivity ranged from 39% to 63%, with specificity of 90% to 99%. Thus, the presence of a systolic-diastolic bruit is highly suggestive of RAS and should be screened for, while the absence of a bruit does not exclude RAS."

I didn't go back and read the original papers referenced in that article, but those numbers are almost certainly for well-trained experienced specialists and not MS2's or MS3s. However, checking for abdominal bruits is commonly advocated by the published experts whose papers I looked at. If we learn how to use this screen, (together with the other factors I mentioned previously and not not not, I repeat, not ultrasound) we might pick up a secondary hypertension that we otherwise would miss.

I'm not schooling anyone. When it comes to the clinical stuff, I'm quoting published experts (specialists) in these fields who disagree with some of the points that have been made on this thread. If you don't like the information you can argue with those cardiologists and nephrologists about it (send them an e-mail perhaps). I'm discussing this issue because I'm interested in the subject matter.

Your personal opinions on the likelyhood of RAS are vague and mildly interesting to me. I would find them much more interesting if they were from some kind of published or quotable source (someone board certified perhaps) and if your opinions were in line with published guidelines. If you are just repeating what you are being told to do, that's fine, but it's not necessarily very interesting to me and if it doesn't agree with published articles on this, I'm not sure I trust it. If you had some kind of published source from an expert in in hypertension, it might quote actual numbers or reference how and where they go there information.

I'm not suggesting that everything around here should be sourced. When opinions don't agree (particularly if you disagree with a published factoid) that's when I get interested in sources. Take care.

 

[smq123]

One of my key points is that it costs too much to do a simple test. If a kid faints at a soccer match, they call an ambulance, take him to the hospital. Cost $1500. The EMTs determine there is nothing wrong, but take him to the hospital. Then in the ER they run a bunch of tests and find nothing. Cost $1500. Turns out the kid has a family history of fainting when nervous. Nothing cardiac. No sudden death. No arrhythmias. Kid goes home. Kid needs note from doctor that he's fit to play soccer. Goes to pediatrician, cost $200. Pediatrician refers to pediatric cardiologists for evaluation cost $2000. End of the days, found nothing. Idiopathic syncope, non-cardiac. Cost to family that makes $50K per year is ... $5200. Benefit to patient: none.

A full cardiac workup isn't really a "simple test."

It's kind of unfair to nitpick, because this is actually a really bad example. You'd have to be the worst doctor in the world to ignore pediatric syncope. Pediatric syncope (especially syncope with exertion) can a very bad warning sign, and must always be extensively investigated. Usually it's nothing but vasovagal syncope, but it could very well be a sign of a severe vascular defect, or even a seizure disorder.

Unlike the HTN case study mentioned in the OP, peds syncope is actually kind of dangerous. The underlying causes of moderate HTN usually aren't things that can kill you right away. You won't die of a pheochromocytoma in a month or two, and renal artery stenosis isn't an emergency. However, the underlying causes of pediatric syncope actually MIGHT kill you in a week or two - the possibility of having a patient die of sudden cardiac death is really frightening.

This is one of the things that I didn't like about the field of pediatrics, incidentally. "It might be a sign of something totally normal....or it might be a sign of something that can kill your child instantaneously!!!" That constant swing between the two extremes drove me crazy after a while.

Take a different kid. This one has type 1 diabetes but doesn't know it. He's having problems concentrating in school but can't get a a doctors because his parents can't afford to take him. They don't have $5200 dollars lying around. He goes on a bikeride on a trail, falls down and no one knows where he is. Parents are self-employed and have no insurance; can't afford it. They make too much to qualify for gov't programs. By the time they find him, he's a coma and does not recover. This kind of thing happens every day.

It costs $5200 for a kid to go see a doctor and get a simple fingerstick?

You're comparing the costs of a major cardiac/neurological workup to a simple fingerstick. That doesn't really bolster your argument.

Before you didn't take the RAS (dismissed it as unusual) unless the labs jumped out at you. I think you are more open to considering that than you were or maybe I just understand where you are coming from better.

I think you're finally understanding where I'm coming from.

The problem is a question of timing and priorities. It's not that renal artery stenosis NEVER crosses your mind. It's just that you don't pull out the big diagnostic tests to specifically look for it unless you suspect that it might be the cause. But until then....I wouldn't really think about it or worry about it.

If the physician knew how to use the ultrasound machine (was trained, compentent enough to detect large/obvious abnormalities), he might look at the patient's liver and find a tumor or abscess, or something like that clearly needed to be treated with some quick checking. He could explain to the patient that he found something that concerned him. He doesn't know what it is but that further evaluation is necessary because it could be something very serious and shoudl be done even if it would place a huge cost burden on the patient. In this case, the physician could have saved the patient's life.

What I'm complaining about is that this is an issue and by suggesting that a patient should just try something common and come back, you could actually be costing the patient more money. In doing so, you could reduce the quality of care that the patient gets. By not even considering the issue, you are ignoring a serious problem we face with our medical system ... an issue you could potentially do something about, particulary as you get further in your career. By supporting the system and encouraging a kind of piecemealing of the treatment, you could be increasing the cost and making the problem worse. If you don't have any choice, there is nothing you can do. However, it's when you defend the system that I object.

<sigh> And again, you're using the exception to define how you think people ought to practice.

What I don't think that you've realized that, generally, when you order a test, you should have an idea of what you're looking for. Furthermore, if possible, you should combine tests. In this example of a patient with lab signs of liver disease, an ultrasound is looking for signs of fibrosis, and for how far that fibrosis has infiltrated into the tissue. Are the bile ducts patent? Are there signs of cholestasis? Many radiologists would also use the opportunity to do a liver biopsy....something that you, even if you're mildly competent in liver ultrasound, are absolutely NOT capable of doing.

Once again, this is not a good idea. You're going to do really rudimentary scans on your patients, on the "off-chance" that you get an incidentaloma? That's just flat-out bad medicine.

By suggesting that the "patient try something and come back," you will effectively address the majority of your problems...and free up more time to take care of your other, more challenging patients. Why is it so hard for you to understand that you should start out with the most statistically likely diagnosis, and then work your way up to the least? And why do you keep insisting that people should routinely order more complicated expensive tests, because of the "off-chance" that they'll find something? It's a silly suggestion.

We're not defending the current system because we're so enamored with it, or because it's perfect. It's because your suggestions are even dumber, and do the patients an even bigger disservice. THAT's why we "defend the current system."

 

[smq123]

Early on in the argument, she was convinced that RAS shouldn't even be on the radar (although she did order a test with some sensitivity for it) and went so far as to call it a zebra that we shouldn't even be thinking about (at least that was my understanding of what she was saying ... point being I don't think we have any disagreement about this anymore). She didn't want look at the other aspects of the RAS screen.

No, no. Once again you misunderstood.

And the misunderstanding may come because the way that med schools teach students to narrow down their DDx is really inaccurate.

As I explained before, by refusing to do a renal ultrasound or a 24 hour urine right off the bat, I am NOT necessarily discounting renal artery stenosis. What I AM saying is that I don't have enough reasons to suspect renal artery stenosis to the point where I would WANT To order a renal ultrasound or a 24 hour urine....so I wouldn't order one until I had further proof that it might be the cause of the patient's HTN.

You seem incapable of making the distinction. Just because I don't jump to order certain diagnostic tests does NOT mean that I've discounted ANY OTHER diagnoses. Your inability to grasp this is really frustrating.

You're going to hate your surgery rotation, I have to say. Even when a code blue is called, trauma surgeons don't run to them. They walk fast, but they definitely don't run. It's not because they don't recognize the importance of a code blue, but it's because they realize that there is very limited value in sprinting to a code. It's the same thing here. It's not that I don't realize that there are other causes of hypertension, but there's very limited value to rushing to do the more exotic diagnostic tests right away.

And LadyWolverine - thank you for so eloquently summarizing what I was attempting to say!

 

[LadyWolverine]

Your personal opinions on the likelyhood of RAS are vague and mildly interesting to me. I would find them much more interesting if they were from some kind of published or quotable source (someone board certified perhaps) and if your opinions were in line with published guidelines. If you are just repeating what you are being told to do, that's fine, but it's not necessarily very interesting to me and if it doesn't agree with published articles on this, I'm not sure I trust it. If you had some kind of published source from an expert in in hypertension, it might quote actual numbers or reference how and where they go there information.

I'm not suggesting that everything around here should be sourced. When opinions don't agree (particularly if you disagree with a published factoid) that's when I get interested in sources. Take care.

I don't really care what you find interesting and what you don't. I am not here for your entertainment. Furthermore, any monkey can copy and paste excerpts from research articles in an attempt to make his or her point with "evidence" to back it up. Good for you. (On that note, where is your so-called evidence that radiologists are replaceable by techs? You know what? Forget it. It's really not worth arguing about anymore.)

For your own sake, I truly hope that you are not this condescending in person. From what I've experienced this year, it does not bode well for you in this field.

In the meantime, as I continue to encounter acutal patients in clinic with HTN, I'll keep on doing my same old physical exam (which, oddly enough, includes auscultating for bruits in both the neck and abdomen ). I also have yet to see a single case of RAS diagnosed while in the outpatient clinic or on the wards. I have, however, seen a decent number of negative renal u/s's.

 

[Scaredshizzles]

The key factor is the NNT - number needed to treat. The US already spends more per capita on health care than any other developed nation, and we don't even cover everyone. Your suggested solutions, quite honestly, are terrible ones. The last thing that we as a nation can afford to do is provide MORE tests and MORE imaging, and then try to also provide that to MORE people. We're already straining the limits of Medicare, and it's clearly forecasted to get much, much worse. It's also well-documented that some states, such as New York, spend substantially more money on increased testing and diagnostics, and they don't even have improved outcomes to show for it. It's just that more tests are done.

That's because all other countries copy what we do and make generic versions of all the meds and procedures we use. God bless the US of A.

 

[Scaredshizzles]

I don't really care what you find interesting and what you don't. I am not here for your entertainment. Furthermore, any monkey can copy and paste excerpts from research articles in an attempt to make his or her point with "evidence" to back it up. Good for you. (On that note, where is your so-called evidence that radiologists are replaceable by techs? You know what? Forget it. It's really not worth arguing about anymore.)

For your own sake, I truly hope that you are not this condescending in person. From what I've experienced this year, it does not bode well for you in this field.

In the meantime, as I continue to encounter acutal patients in clinic with HTN, I'll keep on doing my same old physical exam (which, oddly enough, includes auscultating for bruits in both the neck and abdomen ). I also have yet to see a single case of RAS diagnosed while in the outpatient clinic or on the wards. I have, however, seen a decent number of negative renal u/s's.

That's because the risk factors for RAS are the same as those for atherosclerosis and HTN. Since even patients with 1 kidney or less than a full functioning kidney can have near normal creatinine levels, it is not an easy diagnosis to make. ACEi/ARBs might be useful for RAS, but so many patients with HTN get treated with an ACEi anyway, it begs the question when to bother looking for RAS and if it will make a difference. Obviously if the patient is starting to have elevated creatinine levels, you're going to do some sort of renal scan in any case.

 

[Scaredshizzles]

You know, and I know, that that kind of crap doesn't work when you're in the clinic or on rotations. If you say to your team, "Lasix is a bad choice for hypertension because of x, y, and z," you better have something to back it up. Otherwise, they're going to assume that you created that on the spur of the moment, and they're going to assume that you're full of BS.

Actually if I thought that lasix was a first line choice for essential hypertension they would think I was full of ****. I would say at this point thinking that you should treat isolated hypertension with lasix is not even a common misconception, it is a rare misconception. The studies that have shown that other medications are a better choice are so ominipresent that it would be silly to ask someone to bring in the 200 studies that have been done that show this, it is very commonly accepted at this point.

 

[45408]

One of my key points is that it costs too much to do a simple test. If a kid faints at a soccer match, they call an ambulance, take him to the hospital. Cost $1500. The EMTs determine there is nothing wrong, but take him to the hospital. Then in the ER they run a bunch of tests and find nothing. Cost $1500. Turns out the kid has a family history of fainting when nervous. Nothing cardiac. No sudden death. No arrhythmias. Kid goes home. Kid needs note from doctor that he's fit to play soccer. Goes to pediatrician, cost $200. Pediatrician refers to pediatric cardiologists for evaluation cost $2000. End of the days, found nothing. Idiopathic syncope, non-cardiac. Cost to family that makes $50K per year is ... $5200. Benefit to patient: none.

Clinical judgment was pretty much omitted from your example. Faints at soccer match + family history of fainting = enormous concern of hypertrophic cardiomyopathy. I saw a patient in clinic on Wednesday with HCM, and all she did was stand up rapidly from a squatting position (while dancing at a roller rink), and she fainted. Benefit to patient of advising her not to do anything that elevates her heart rate: prevention of death. No, I'm not being melodramatic - her risk of death is very real.

Even still, fainting is a pretty significant event. It's pretty abnormal to lose consciousness. There are some instances in which if it happened to me, I might disregard it, but as a physician, I'd pretty much always investigate it in the absence of a very obvious cause.

 

[45408]

That's because all other countries copy what we do and make generic versions of all the meds and procedures we use. God bless the US of A.

It's also because the state of Ohio has more MRIs than all of the UK. Want your gall bladder out? Head to a private ER with biliary colic, and you could get it out tomorrow. In the UK? Maybe early next year.

 

[OncoCaP]

A full cardiac workup isn't really a "simple test."

It's kind of unfair to nitpick, because this is actually a really bad example. You'd have to be the worst doctor in the world to ignore pediatric syncope. Pediatric syncope (especially syncope with exertion) can a very bad warning sign, and must always be extensively investigated. Usually it's nothing but vasovagal syncope, but it could very well be a sign of a severe vascular defect, or even a seizure disorder.

Unlike the HTN case study mentioned in the OP, peds syncope is actually kind of dangerous. The underlying causes of moderate HTN usually aren't things that can kill you right away. You won't die of a pheochromocytoma in a month or two, and renal artery stenosis isn't an emergency. However, the underlying causes of pediatric syncope actually MIGHT kill you in a week or two - the possibility of having a patient die of sudden cardiac death is really frightening.

This is one of the things that I didn't like about the field of pediatrics, incidentally. "It might be a sign of something totally normal....or it might be a sign of something that can kill your child instantaneously!!!" That constant swing between the two extremes drove me crazy after a while.





It costs $5200 for a kid to go see a doctor and get a simple fingerstick?

You're comparing the costs of a major cardiac/neurological workup to a simple fingerstick. That doesn't really bolster your argument.

I understand the difference between a cardiac workup and a finger stick (which was also done in this case, by the way, because EMT's around here look at several possibilities for what might be wrong). I am suggesting is that most families can't afford to pay $5200 for every kid who faints or has a similar worrisome symptom and expect to survive financially, which is pretty much happening now in terms of medical costs exceeding our country's ability to pay. By all means, check the kid out. Do the finger stick, listen to the heart, do the ECG. Monitor them. Figure out a way to do it in a way to keep the cost down without compromising the care. Maybe it involves taking the results from the emergency room ECG and sending them to the specialist rather than repeating the thing again. If you can consider a couple of differentials without adding a lot of cost (relative to another office visit) and without a lot of time to the office visit, then I would suggest we do it. If there is nothing we can do, then we can't. What the family can afford should be considered in the care we provide. A lot of families are being priced out of the care that they need. If we could maybe refer from the emergency room to the pediatric specialist rather than having to go through the pediatrician, maybe that could reduce the cost. Maybe if the ECG and vitals are normal, the child can be monitored in the ER for a few hours and then sent home (especially since the wait time in the ER is about 8 or more hours anyway).

I think you're finally understanding where I'm coming from.

The problem is a question of timing and priorities. It's not that renal artery stenosis NEVER crosses your mind. It's just that you don't pull out the big diagnostic tests to specifically look for it unless you suspect that it might be the cause. But until then....I wouldn't really think about it or worry about it.



<sigh> And again, you're using the exception to define how you think people ought to practice.

What I don't think that you've realized that, generally, when you order a test, you should have an idea of what you're looking for. Furthermore, if possible, you should combine tests. In this example of a patient with lab signs of liver disease, an ultrasound is looking for signs of fibrosis, and for how far that fibrosis has infiltrated into the tissue. Are the bile ducts patent? Are there signs of cholestasis? Many radiologists would also use the opportunity to do a liver biopsy....something that you, even if you're mildly competent in liver ultrasound, are absolutely NOT capable of doing.

Once again, this is not a good idea. You're going to do really rudimentary scans on your patients, on the "off-chance" that you get an incidentaloma? That's just flat-out bad medicine.

For those cases where the patient can afford to get the care you are talking about, I'm perfectly content to do all the usual stuff and pulling in all the various specialists. What I'm referring to is when the patient cannot afford the care you think they should have. We would like to do a $5000 liver workup, but, there is no money for that. So, what do we do? Do we send them home until they come up with $5K? People are going without care because they cannot afford it. When patients have no insurance and are unable to pay in full up front, they may be turned away except in life-threatening circumstances. But then when they do receive care they are stuck with a bill they cannot pay anyway and it prevents them from getting care that they might otherwise be able to afford. The choice is not between doing it "right" and doing it in an inferior way. If they money is there, then let's go for it .... What I'm referring to is the fact that medical costs are beyond what the U.S. can afford to pay. This means that many Americans do not even get the bare minimum of preventative medical care and then present with very serious, extremely expensive conditions that then must be treated to some extent, creating horrendous financial pressures. That garden variety HTN case can turn into an extremely expensive heart problem, which if prevented will actually save money.
With the costs of the current medical system, we cannot insure everyone. By spreading a problem over multiple office visits, the cost to the patient goes up and compounds the problem.

By suggesting that the "patient try something and come back," you will effectively address the majority of your problems...and free up more time to take care of your other, more challenging patients. Why is it so hard for you to understand that you should start out with the most statistically likely diagnosis, and then work your way up to the least? And why do you keep insisting that people should routinely order more complicated expensive tests, because of the "off-chance" that they'll find something? It's a silly suggestion.

I'm totally in favor of considering the most likely diagnosis. What I'm not in favor of is ignoring less likely diagnoses if screening for them is very inexpensive and not time consuming. By giving them the usual treatment and having them come back if there is a problem, we increase the cost relative and thereby decrease access to care. In addition, it increases the chance that a patient will present with a disease at a more advanced stage, which also increases direct and indirect costs to the patient. I suggest that we identify those procedures that can be performed by a non-specialist with training and use that to save money and increase access to care.

We're not defending the current system because we're so enamored with it, or because it's perfect. It's because your suggestions are even dumber, and do the patients an even bigger disservice. THAT's why we "defend the current system."

It's only "dumber" because you are unclear on the concept that something better but unaffordable is not better. If I need a car to get to a job that is not on a bus route and can only afford a used Chevy and the sale of anything cheaper than a 2009 Mercedes "E" class is prohibited because anything less does not similarly protect the occupants in the event of an accident, I don't benefit. I don't benefit because I can't afford the Mercedes. No one is doing me a favor. Similarly, someone providing used Chevies (if it were legalized, say) is not dumber or a disservice to me because now I can get to my job even though the safety features on the Mercedes E class blow the used Chevy away. The off chance of an accident doesn't justify me not being able to afford any car. Once you recognize that, you will see the fallacy in defending the current system. I'm not suggesting that you are in a position to do much about it, but you have a choice as to whether or not to defend what we are doing relative to less expensive alternatives.

I'm also not suggesting that there aren't other even better ways of improving our system. What I am suggesting is that costs for American medical care are excessive in part because we have a lot of specialists that make the quality of care "better" but less affordable, decreasing access to care and not getting care is among the worst possible options. We should use specialists. I'm not saying get rid of them. There are many things that require them. However, let's think critically about what does and does not require a specialist with an eye toward improving access to care.

 

[OncoCaP]

Clinical judgment was pretty much omitted from your example. Faints at soccer match + family history of fainting = enormous concern of hypertrophic cardiomyopathy. I saw a patient in clinic on Wednesday with HCM, and all she did was stand up rapidly from a squatting position (while dancing at a roller rink), and she fainted. Benefit to patient of advising her not to do anything that elevates her heart rate: prevention of death. No, I'm not being melodramatic - her risk of death is very real.

Even still, fainting is a pretty significant event. It's pretty abnormal to lose consciousness. There are some instances in which if it happened to me, I might disregard it, but as a physician, I'd pretty much always investigate it in the absence of a very obvious cause.

I totally agree we should address such a worrisome symptom. I would like see if we can manage & diagnose this for under $5200, particularly if the patient only lost consciousness very briefly and is back to "normal" (alert, oriented,etc.) quickly and it turns out not to be HCM. I'm open to ideas other than mine, of course.

 

[Scaredshizzles]

I totally agree we should address such a worrisome symptom. I would like see if we can manage & diagnose this for under $5200, particularly if the patient only lost consciousness very briefly and is back to "normal" (alert, oriented,etc.) quickly and it turns out not to be HCM. I'm open to ideas other than mine, of course.

The odds of syncope being cardiac in a child w/ no history of cardiac disease and normal physical exam is of course very low. Dehydration +/-hot weather/peripheral vasodilation +/- any psychological factors would most likely account for vasovagal sycope. (I would call this vasovagal or "neurocardiogenic" as opposed to idiopathic; unfortunately there is no good test to confirm vasovagal, tilt table testing has at best 50% se 50% sp. A history of a preceding prodrome for a couple of minutes and/or a controlled fall in the history would be a little reassuring; a negative history of seizures and lack of tonic-clonic jerking/incontinence/tongue biting/post-ictal state would also be reassuring in terms of no need for a neuro work up).

HOWEVER, the bottom line is that if this were your kid and your kid liked to play sports and your kid has an episode like this where he essentially collapses while playing sports, you would want the full work up, and you might even begrudgingly spend 10% of your annual income on it.) The good news is that if it happens again in the near future, you don't have to repeat the echo. I would say if anything, the cardiology consult was unnecessary prior to the echo, BUT, if the insurance won't reimburse the echo without a cardio consult first, what can you do?

 

[OncoCaP]

The odds of syncope being cardiac in a child w/ no history of cardiac disease and normal physical exam is of course very low. Dehydration +/-hot weather/peripheral vasodilation +/- any psychological factors would most likely account for vasovagal sycope. (I would call this vasovagal or "neurocardiogenic" as opposed to idiopathic; unfortunately there is no good test to confirm vasovagal, tilt table testing has at best 50% se 50% sp. A history of a preceding prodrome for a couple of minutes and/or a controlled fall in the history would be a little reassuring; a negative history of seizures and lack of tonic-clonic jerking/incontinence/tongue biting/post-ictal state would also be reassuring in terms of no need for a neuro work up).

HOWEVER, the bottom line is that if this were your kid and your kid liked to play sports and your kid has an episode like this where he essentially collapses while playing sports, you would want the full work up, and you might even begrudgingly spend 10% of your annual income on it.) The good news is that if it happens again in the near future, you don't have to repeat the echo. I would say if anything, the cardiology consult was unnecessary prior to the echo, BUT, if the insurance won't reimburse the echo without a cardio consult first, what can you do?

True. I could spend 10% of my income and life would go on. I'm not exactly in the average income bracket, however. I just can't fathom how families who don't have a lot of disposable income deal with this; they can't pay and then they have the creditors chasing them as if they were criminals. This particular case didn't include an echo (apparently unnecessary based on the chest X-ray and ECG). This was just ECG, glucose, and vitals done by the EMT's. ECG in the ER; they did a chest X-ray and ECG for the ped cardiologist and that was it. The pediatric cardiologist never even saw the kid. The EMT, ER doc, and pediatrician all listened to the kid's heart with their steth. No murmurs. Regular rate and rhythm. No family history of cardiac. No PMH of cardiac. I think a tech did everything at their specialist's office and they never saw a physician, and so at least the clinic is saving money that way (but I'm not sure if they are passing on the savings to the patient's family). Like you say, maybe dehydration / vasovagal. For an average family to spend that kind of cash and be told that they really don't know what it was but it's non-cardiac so the kid is cleared to play based on an ECG and chest X-ray. It appears that don't do echos unless they see something on the ECG. Maybe they do it differently where you are. If it was my kid I would have wanted an echo also, which was not done in this case.

 

[45408]

and you might even begrudgingly spend 10% of your annual income on it.

That's a ton of money. If your household income is $60,000 before taxes, you're taking home around $1800 every two weeks. A $5200 expense could completely wipe out your savings, if you even bothered to have any.

If the docs tell the family "It's not a big deal, there's no need to work it up further," I'm pretty sure they wouldn't argue to spend $5200.

 

[Scaredshizzles]

That's a ton of money. If your household income is $60,000 before taxes, you're taking home around $1800 every two weeks. A $5200 expense could completely wipe out your savings, if you even bothered to have any.

If the docs tell the family "It's not a big deal, there's no need to work it up further," I'm pretty sure they wouldn't argue to spend $5200.

I mean I think it is adequate to send the kid home with just the EKG. A normal EKG and physical exam pretty much rule out significant outflow impairment even if the kid has hypertrophic cardiomyopathy. The reason to get an echo would be a) because then a cardiologist would read the echo as opposed to just about anyone reading that EKG even if they are really bad at reading EKGs--- although picking up LVH on an echo isn't exactly rocket science, but I could see someone missing atrial enlargement on an EKG as a possible signifier of some sort of congenital condition....and b) because even with HCM that is of the non-obstructive form (no murmur, relatively less LVH----can be LVH at the apex or anywhere non-septal), you still have an underlying predisposition to arrhythmias.....the echo would not pick up the arrhythmia (holter monitoring/longer term monitoring would), the echo would however increase your sensitivity over EKG/physical exam in identifying potential HCM.

 

[Scaredshizzles]

But then there are some people who will say if the kid didn't slam his face into the ground, it is not likely arrhythmogenic syncope. And there is some truth to that.

 

[45408]

But then there are some people who will say if the kid didn't slam his face into the ground, it is not likely arrhythmogenic syncope. And there is some truth to that.

Well, it would certainly matter if somebody said "Oh, he fainted," but then I found out that he got light-headed and dizzy, and kind of stumbled down to the ground without ever losing consciousness.

Couldn't a vasovagal syncope result in hitting the ground pretty hard too?