C-spine CT on NEXUS??

[GeneralVeers]

I've had a rash of my PAs at several different facilities immediately jumping to CT cervical spine on young people in minor MVAs with some midline tenderness but otherwise low suspicion of injury. When I ask why they are doing CTs rather than just doing plain films they quote NEXUS. I've reviewed NEXUS, and it just recommends imaging, but I think they are getting it from this paragraph:

• There is also concern that NEXUS was derived and validated in an era when plain films were much more commonly ordered to assess for C-spine injuries. CT imaging of the C-spine is now much more common, and there is some evidence that computed tomography may identify CSIs that would be missed by NEXUS and/or the CCR.

Apparently some of the docs are telling them to just get C-spine CTs on all patients with midline tenderness after an MVA. To me that's a lot of radiation on the thyroid of young, healthy people. I don't do this in practice. Am I missing something?

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[jw3600]

Modern cars are so safe now that I rarely ever see any pathology from any of these low risk mechanisms MVCs. I do literally nothing for 95% of them except oral meds. Even radiographs are useless. Start treating your Cspine tenderness like a trauma surgeon:
You don’t ask if it hurts. You push hard on the spine and if they jump and objectively have signs of distress you call it tender. Patient reported midlne tenderness is doo doo.

 

[GeneralVeers]

Modern cars are so safe now that I rarely ever see any pathology from any of these low risk mechanisms MVCs. I do literally nothing for 95% of them except oral meds. Even radiographs are useless. Start treating your Cspine tenderness like a trauma surgeon:
You don’t ask if it hurts. You push hard on the spine and if they jump and objectively have signs of distress you call it tender. Patient reported midlne tenderness is doo doo.

Agree completely. I've never picked up a fracture on a young person who is walking, talking and able to move their neck. I agree that 95% of them NEED nothing and should go home. The reality is that my patient population demands X-rays for litigious purposes. I'd rather just order the placebo x-ray which of course will be negative and D/C them home than order a CT.

 

[Fox800]

Canadian C-spine rule is more sensitive and specific than NEXUS. Why are you still using NEXUS?

Why are you getting placebo x-rays? Either CT them or don't do imaging.

Canadian does not even have feature posterior cervical spine tenderness as a hard indication to image. If they LACK posterior tenderness, it's considered a protective feature, but 99.99999% of the time you get out of it because they ambulated after an MVC/fall or are sitting in the ED on arrival.

If the mechanism is low risk, they have at least one protective feature, and they can range their neck left and right, you're done.

 

[GeneralVeers]

Canadian C-spine rule is more sensitive and specific than NEXUS. Why are you still using NEXUS?

Why are you getting placebo x-rays? Either CT them or don't do imaging.

Canadian does not even have feature posterior cervical spine tenderness as a hard indication to image. If they LACK posterior tenderness, it's considered a protective factor, but 99.99999% of the time you get out of it because they ambulated after an MVC/fall or are sitting in the ED on arrival.

If the mechanism is low risk, they have at least one protective feature, and they can range their neck left and right, you're done.

I x-ray patients that I don't want to do anything for but who demand X-rays. I know they don't have a fracture, but I don't want to waste time, energy or a complaint arguing with them. X-ray is faster, cheaper, and gets them out of my department reasonably satisfied. It would possibly be unethical to do a CT scan on a person who has low probability for fracture.

 

[Fox800]

I x-ray patients that I don't want to do anything for but who demand X-rays. I know they don't have a fracture, but I don't want to waste time, energy or a complaint arguing with them. X-ray is faster, cheaper, and gets them out of my department reasonably satisfied. It would possibly be unethical to do a CT scan on a person who has low probability for fracture.

Fair. Sounds like you need to get your MLPs up to speed on Canadian and just end the ridiculousness up-front.

 

[GeneralVeers]

Fair. Sounds like you need to get your MLPs up to speed on Canadian and just end the ridiculousness up-front.

Problem is they have docs telling them to CT everyone who has any midline tenderness. We have all seen the young female who has all-over neck tenderness after a car accident. To me this is not midline tenderness and wouldn't warrant imaging.

 

[deleted859535]

You don’t ask if it hurts. You push hard on the spine and if they jump and objectively have signs of distress you call it tender. Patient reported midlne tenderness is doo doo.

Funny how this is also true for a whole lot of musculoskeletal and abdominal cases. I internally shake my head when I do an abdominal exam and have a family member chime in, "if it hurts, you need to tell the doctor!" No, no you do not unless I ask.

Agree completely. I've never picked up a fracture on a young person who is walking, talking and able to move their neck. I agree that 95% of them NEED nothing and should go home. The reality is that my patient population demands X-rays for litigious purposes. I'd rather just order the placebo x-ray which of course will be negative and D/C them home than order a CT.

This, overwhelmingly. Image and discharge. Easier for everyone.

 

[BoardingDoc]

As has been said already, but to reiterate: Canadian C spine only. I haven't ordered an Xray of the C-spine since I was a resident. I either CT my patients or I briefly explain the Canadian C-spine criteria to them and explain why they don't need a scan. If anything, I feel like a neck XR just opens you up to more liability.

Lawyer: Why did you order a neck xray?
MD: To look for a cervical spine injury
Lawyer: Surely you know that a CT scan is the preferred modality to do this
MD: Well, my suspicion for them having an injury was low and they were Canadian C-spine criteria negative
Lawyer: Then why did you order images at all?
MD: Well, as a screening test of sorts
Lawyer: So you DID think there might be an injury... I refer you to my previous question about why you didn't CT them.
etc. etc. etc.

 

[n2b8me]

I think trauma management is so streamlined because of our point and click EMR and to minimize litigation... which means majority of anything trauma at a trauma center is pan-scan.

a recent example who I saw for whiplash pain a few days after her accident...

20 something female rearended while driving. taken to trauma center. eval by trauma surgeon who documents a normal exam except some neck and back tenderness and something about the ATLS protocol.
full lab panels done. CXR, pelvis xr done.
CT cspine, chest, abd, pelvis done.
all studies negative.

I was thinking the same as you... am I missing something?

No. this is the new(ish) reality … AND she was probably dispo'd in a couple hours (glowing)

But I would have done like you too from the start, obligatory cspine plain films, some Toradol and dc.

 

[Groove]

For my MVA's, I utilize NEXUS and if they require imaging --> CT.

I rarely get XRs anymore, especially if they fail NEXUS (typically with mid-line tenderness). CT is superior to XR in every way and nobody is worried about radiation exposure in the context of trauma (6 mSv in this case...3.1mSv from background radiation alone during an average year. 0.06% thyroid cancer risk). CT was not a common imaging modality during the derivation of NEXUS and plenty of literature indicates CT over XR if they fail c-spine CDR (NEXUS OR CCR).

The study that many people love to quote showing increased sensitivity with CCR vs NEXUS was from early 2000s and is thought among many to be due to flawed study design and selection bias. (It was a Canadian study...did we really expect CCR not to be superior in the study results?)

In contrast to NEXUS, where the NLC had a sensitivity of 99.6 percent and specificity of 12.9 percent, in a subsequent Canadian study the NLC demonstrated a lower sensitivity of 90.7 percent and a higher specificity of 36.8 percent [28]. These discrepancies may stem from differences in study design. As an example, inclusion criteria differ for the two trials: the Canadian group excluded those under the age of 16 years and subjects with a Glasgow Coma Score (GCS) of less than 15, whereas these subjects were included among the NEXUS cohort. In addition, NEXUS investigators excluded all patients in whom radiographs were deemed unnecessary, while the Canadian investigators included such individuals. Thus, selection bias may account for the lower number of false negatives and true negatives reported in the Canadian study, potentially inflating both the sensitivity and specificity of the CCR. Finally, the prospective validation phase of the CCR study was performed in the same institutions in which the derivation phase was performed, raising concerns about improved performance due to familiarity with the rule [31].

Don't get me wrong...I'm all about utilizing evidence based CDRs to reduce health care costs and radiation exposure, but do you guys really expect your MLPs to apply these rules appropriately? How many of them would you trust to evaluate YOU or a family member during a trauma? I tell mine to always err on the side of caution. If they want to spin a MVA that I'm unable to see in person, then spin them up I say. I don't want them to miss anything and I simply don't trust them to apply NEXUS or CCR appropriately. The last thing I want to do is pound in their head that "imaging is BAD" for trauma and positively reinforce a minimalist mentality towards pt's with neck pain after a MVA. I trust myself to apply minimalism but not the MLPs. Sorry, it's just not worth the worry at the end of the day when I'm signing these charts.

The problem is that most of these pt's are hysterical and dramatic when they come in from a minor MVA. You so much as brush a fingertip against the back of their neck and they scream. For these people it's incredibly counterproductive to spend time trying to justify a way out of imaging. I spin them and discharge them if they are going to be dramatic. It's much less effort than trying to give them a "non opioid" analgesic, check back in an hour, re-examine their neck, try to assure them that they don't need imaging while their family member talks about a cervical fracture that a doctor missed in Uncle Johnny 10 years ago. Please.

The irony is that it's only EM that spends this much time trying to rationalize a way to reduce radiation exposure in trauma. The minute you call the trauma surgeon to evaluate your Bravo in the ER, the first thing they are going to ask is why the pt's hasn't been pan scanned.

 

[southerndoc]

My health system (>750,000 total volume annually between 10 ED's) has an official policy to CT to rule out cervical spine injury for suspected injury.

@Fox800 The reason why people still use NEXUS instead of Canadian c-spine rule is because of the word "Canadian." We tend to like our own system (metric system is case in point) and don't like "outsiders." I prefer Canadian rules for both head CT and C-spine. Love the Ottawa rules.

If they have paraspinal tenderness and are wanting an x-ray, I try to convince them. If they still want it, I just order an x-ray. Arguing with a patient gets you nowhere. If they have midline tenderness without a decent mechanism, then I order a plain film x-ray. This is especially true of those that walk in or EMS doesn't put a collar on who my gestalt is they don't have a fracture. If they have a decent mechanism/CCR positive, then they get a CT per our policy.

The literature is there that x-rays miss 15% of unstable C-spine injuries and CT is the preferred imaging modality. However, NEXUS and Canadian rules do not dictate which imaging modality to use.

 

[southerndoc]

Most of the data we have comes from atomic bomb survivors living several miles from the blast sites.

The UK looked at this (Pearce study) out of about 180,000 pediatric patients who had head CTs (pediatric was <22 years of age, different than most US definitions). They followed them for 10 years and found a 1:10,000 risk of leukemia. Meaning every 10,000 CT's ordered, there was 1 additional case of leukemia. Some argued that the 10-year follow-up time was too short. They extrapolated results to get higher risk rates, but the general consensus is that the benefits outweigh the risks when clinically indicated.

The problem is the number of unnecessary CT scans. Trauma activations frequently get pan-scanned just because they were a trauma activation. Physicians get a heightened sense of alarm when something comes in as an alert and tend to overtest.

 

[Groove]

CT C-spine
Male 25yo

An Additional Cancer Risk of 0.060340% is equal to 1 in 1657 chances.

Or said another way, a 99.93966% chance of having no effect of the above studies.
To help support XrayRisk.com please make a donation. Click Here.

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Comparison Doses​
Natural Background	3.1 mSv/year10	Domestic Pilots	2.2 mSv/year11
Average US Exposure	6.2 mSv/year10	7 Hour Airline Flight	0.02 mSv12
Chest x-ray (2 views)	0.10 mSv	Chest CT	7.0 mSv

Estimated Lifetime Risk of Death from Various Sources13​

Motor Vehicle Accident​	1% or 1 in 100 chances​
Drowning​	0.1% or 1 in 1000 chances​
Bicycle Accident​	0.01% or 1 in 10,000 chances​
Lightning​	0.001% or 1 in 100,000 chances​

Keep in mind, the overall lifetime risk of developing an invasive cancer is 37.5% (1 in 3) for women and 44.9% (1 in 2) for men regardless of imaging history. These statistics are averages and do not predict what is going to happen to you. They do not take into consideration individual risk factors including lifestyle (smoking, diet, exercise, etc), family history (genetics) or radiation exposure. The majority of cancers occur later in life and the average lifetime risk of dying from cancer is 25% (1 in 4).[/TD]

XrayRisk.com : Radiation Risk Calculator -- Calculate Radiation Dose and Cancer Risk

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You can also print these out and give to pt's.

 

[d2305]

I remember a list of rules for reading c spine x rays. I actually saw one (film only) that looked pretty normal, but had soft tissue edema only. I think he ended up with hardware.

 

[jw3600]

Has anyone actually seen C spine fractures from these low risk mech MVS. You know the ones I’m talking about. Restrained. No airbags. No intrusion. Self extricated. Ambulatory on scene. Car drivable. Yadda yadda.

 

[Dr Mantis Toboggan]

In old people for sure.

Has anyone actually seen C spine fractures from these low risk mech MVS. You know the ones I’m talking about. Restrained. No airbags. No intrusion. Self extricated. Ambulatory on scene. Car drivable. Yadda yadda.

 

[Groove]

Has anyone actually seen C spine fractures from these low risk mech MVS. You know the ones I’m talking about. Restrained. No airbags. No intrusion. Self extricated. Ambulatory on scene. Car drivable. Yadda yadda.

I had one less than a month ago though I'll admit they are rare. Late 30s/early 40s male, healthy, low speed MVC where he lost consciousness at the wheel and per EMS "rolled over a median, crossed a lane and came to a stop in grass on the other side of the road" with no reported impact and virtually no damage to the vehicle c/o neck pain. Restrained, no airbag, ambulatory, low risk features present per CCR. Some mild TTP to the c-spine though I was not that impressed. In fact, I was so non-impressed, I took him out of the collar and he could easily rotate 45 deg either side. CCR neg. NEXUS...technically positive, but extremely unimpressive exam. CT --> stable c-spine fx.

I'll admit these types of cases are extremely uncommon for me (low mechanism MVCs in a pt with no high risk features) and typically most of mine are due to sig whiplash mechanisms. Either the pt is drunk with excessive cervical muscle relaxation during the point of impact or they are unconscious with a flaccid neck during a whiplash mechanism (the above case).

 

[GeneralVeers]

r XR if they fail c-spine CDR (NEXUS OR CCR).

The study that many people love to quote showing increased sensitivity with CCR vs NEXUS was from early 2000s and is thought among many to be due to flawed study design and selection bias. (It was a Canadian study...did we really expect CCR not to be superior in the study results?)

In contrast to NEXUS, where the NLC had a sensitivity of 99.6 percent and specificity of 12.9 percent, in a subsequent Canadian study the NLC demonstrated a lower sensitivity of 90.7 percent and a higher specificity of 36.8 percent [28]. These discrepancies may stem f

In old people for sure.

Old people are different. CT scan all day long.

 

[RustedFox]

I don't order x-rays for patient appeasement.
It's Nexus or CT.

I pitch it to them in a manner as to say "we can clear you without imaging" and I make it clear that "x-rays are worthless in this situation; they miss up to 15-20% of fractures".

If they want an x-ray for litigious purposes, they can go elsewhere. I personally don't want to "feed the fish" and have them coming back for more non-urgent/non-emergent nonsense.

I also document in my chart (autotext FTW) the NEXUS c-spine criteria, and that a decision was made together with the patient after reviewing the criteria to abide by the recommendations and NOT proceed with c-spine imaging. That way, when they complain - the director simply reads the chart and says: "Welp. Another idiot who changed his/her mind and doesn't know what they want."

 

[GeneralVeers]

I don't order x-rays for patient appeasement.
It's Nexus or CT.

I pitch it to them in a manner as to say "we can clear you without imaging" and I make it clear that "x-rays are worthless in this situation; they miss up to 15-20% of fractures".

If they want an x-ray for litigious purposes, they can go elsewhere. I personally don't want to "feed the fish" and have them coming back for more non-urgent/non-emergent nonsense.

I also document in my chart (autotext FTW) the NEXUS c-spine criteria, and that a decision was made together with the patient after reviewing the criteria to abide by the recommendations and NOT proceed with c-spine imaging. That way, when they complain - the director simply reads the chart and says: "Welp. Another idiot who changed his/her mind and doesn't know what they want."

I agree with you. I wouldn't order X-ray if I seriously was concerned for fracture. In my suburban, entitled population it's not worth me arguing and having to respond to complaint letters. Too many complaints and I could be fired. If they demand the X-ray, I do it, then document "X-ray not indicated and patient has no indication for ANY imaging, but demanded the study be done. In the interest of patient satisfaction it was performed and was negative."

 

[southerndoc]

Old people are different. CT scan all day long.

As are people with rheumatoid arthritis and ankylosing spondylitis. Never verified the data, but our neurosurgeons say a history of cervical spine surgery with hardware increases your chances of fracture.

 

[southerndoc]

I agree with you. I wouldn't order X-ray if I seriously was concerned for fracture. In my suburban, entitled population it's not worth me arguing and having to respond to complaint letters. Too many complaints and I could be fired. If they demand the X-ray, I do it, then document "X-ray not indicated and patient has no indication for ANY imaging, but demanded the study be done. In the interest of patient satisfaction it was performed and was negative."

I documented something similar (not as direct) on a patient once. Anthem paid the emergency bill, but didn't pay for the x-ray or radiology read of the x-ray because I documented it wasn't clinically indicated but the patient wanted it done anyway despite notifying them it wasn't indicated. I got a phone call from the patient asking me to change my chart. I told her I wasn't changing it, that I told her at the time it wasn't indicated, and that there is nothing I can do if her insurance isn't going to pay. She threatened to not pay her bill. I told her she may want to talk to billing about it before it went to collections and ruined her credit. She was not a happy camper.

 

[bravotwozero]

That's frikkin' awesome guys. We might not be able to escape patient satisfaction scores, but looks like I can still hold patients responsible for their choices.

 

[thegenius]

I've had a rash of my PAs at several different facilities immediately jumping to CT cervical spine on young people in minor MVAs with some midline tenderness but otherwise low suspicion of injury. When I ask why they are doing CTs rather than just doing plain films they quote NEXUS. I've reviewed NEXUS, and it just recommends imaging, but I think they are getting it from this paragraph:

• There is also concern that NEXUS was derived and validated in an era when plain films were much more commonly ordered to assess for C-spine injuries. CT imaging of the C-spine is now much more common, and there is some evidence that computed tomography may identify CSIs that would be missed by NEXUS and/or the CCR.

Apparently some of the docs are telling them to just get C-spine CTs on all patients with midline tenderness after an MVA. To me that's a lot of radiation on the thyroid of young, healthy people. I don't do this in practice. Am I missing something?

I think it's potentially a tough call...largely based on judgement. I try to order XRs if I think it's low risk provided the pt's anatomy can give you an adequate xray. A good XR is fine in low risk neck injuries. Sometimes they are fat or have big shoulders and you can't see C7 or T1 well. Or they are so fat that there is so much soft tissue you can't make much of anything from the xray. If I can predict those...I will not order the xray and just kind of figure whether they need imaging.

I know NEXUS has midline tenderness...I think its stupid though (empirically). There are people who have normal necks and just gently touch their spinous process and they say it hurts. I call shenanigans. So now...I just gently touch them and say "is this really terrible, absolutely terrible pain? I don't want to know if it's mild pain"...they usually say no and I go on with my business. Basically....I don't ever use c-spine tenderness to evaluate whether someone needs imaging.

 

[thegenius]

As has been said already, but to reiterate: Canadian C spine only. I haven't ordered an Xray of the C-spine since I was a resident. I either CT my patients or I briefly explain the Canadian C-spine criteria to them and explain why they don't need a scan. If anything, I feel like a neck XR just opens you up to more liability.

Lawyer: Why did you order a neck xray?
MD: To look for a cervical spine injury
Lawyer: Surely you know that a CT scan is the preferred modality to do this
MD: Well, my suspicion for them having an injury was low and they were Canadian C-spine criteria negative
Lawyer: Then why did you order images at all?
MD: Well, as a screening test of sorts
Lawyer: So you DID think there might be an injury... I refer you to my previous question about why you didn't CT them.
etc. etc. etc.

Boo!!

Me: I order tests for low risk suspicion because [ there is probably a study at some point saying that it was OK to do ]

I was just deposed in court the other day. The lawyers were not that smart. Not that I really want to mess with that assumption.

 

[gro2001]

I use NEXUS and not Canadian C-spine, even though I don't hate Canadians. What I hate are rules that are difficult to use.

The thing people don't appreciate about clinical prediction rules, is that for them to have any validity, they have to be applied EXACTLY as they have been validated. So if a rule you like has an age cut off of 50, you don't actually know what the sensitivity and specificity is at 51. You'd think it'd be pretty similar, but it's entirely possible that the age cut off was chosen because there were a few patients in the derivation dataset in their early 50s who would have decreased the accuracy beyond the predetermined value.

To be Low risk by Canadian C-spine you have to:
-Be 65 or younger
-Have no paresthesias
-Have no high risk mechanisms
-Have presence of low risk features
-Able to actively rotate head 45 degrees left and right

Anyone remember what the high risk mechanisms are? Maybe you do, but every time I've asked a trainee who said they were C-spine negative, they couldn't accurately recount them. I personally tend to forget the bicycle and ATV ones and/or how many stairs they were allowed to fall down. For the record:

• Fall from ≥3 ft (0.9 m) / 5 stairs
• axial load injury
• high speed MVC/rollover/ejection
• bicycle collision
• motorized recreational vehicle

It's even worse for the presence of low risk features (which they must have one of):

• Sitting position in the ED
• ambulatory at any time
• delayed (not immediate onset) neck pain
• no midline tenderness
• Simple rearend motor vehicle collision (MVC)

Anyone remember what makes an MVC not simple?

• pushed into traffic
• hit by bus/large truck
• rollover
• hit by high-speed vehicle

No idea where to draw the cut off of small vs large truck.

Now, you can say that you'd remember them roughly and err on the side of scanning, but then you are using your gestalt and not the CCSR. Which may be similarly adequate, but you shouldn't have the false reassurance that you have the wisdom of Canada backing you up.

 

[BoardingDoc]

I use NEXUS and not Canadian C-spine, even though I don't hate Canadians. What I hate are rules that are difficult to use.

The thing people don't appreciate about clinical prediction rules, is that for them to have any validity, they have to be applied EXACTLY as they have been validated. So if a rule you like has an age cut off of 50, you don't actually know what the sensitivity and specificity is at 51. You'd think it'd be pretty similar, but it's entirely possible that the age cut off was chosen because there were a few patients in the derivation dataset in their early 50s who would have decreased the accuracy beyond the predetermined value.

To be Low risk by Canadian C-spine you have to:
-Be 65 or younger
-Have no paresthesias
-Have no high risk mechanisms
-Have presence of low risk features
-Able to actively rotate head 45 degrees left and right

Anyone remember what the high risk mechanisms are? Maybe you do, but every time I've asked a trainee who said they were C-spine negative, they couldn't accurately recount them. I personally tend to forget the bicycle and ATV ones and/or how many stairs they were allowed to fall down. For the record:

• Fall from ≥3 ft (0.9 m) / 5 stairs
• axial load injury
• high speed MVC/rollover/ejection
• bicycle collision
• motorized recreational vehicle

It's even worse for the presence of low risk features (which they must have one of):

• Sitting position in the ED
• ambulatory at any time
• delayed (not immediate onset) neck pain
• no midline tenderness
• Simple rearend motor vehicle collision (MVC)

Anyone remember what makes an MVC not simple?

• pushed into traffic
• hit by bus/large truck
• rollover
• hit by high-speed vehicle

No idea where to draw the cut off of small vs large truck.

Now, you can say that you'd remember them roughly and err on the side of scanning, but then you are using your gestalt and not the CCSR. Which may be similarly adequate, but you shouldn't have the false reassurance that you have the wisdom of Canada backing you up.

Mdcalc for all your rules until you know the criteria solid. And I guess we'll just agree to disagree about the difficulty involved in using Canadian cspine rules. Virtually all my mvcs are sitting up, or got out of the car themselves (low risk factor present), so there is rarely ever a need to determine if the mvc was simple as the rule only requires one low risk factor be present. The rest of the criteria are straightforward as well. MDcalc lays them out well. Even if you can't remember the criteria without having to go to the website first, I'd argue that 30 seconds looking it up is faster than getting and waiting for a CT read because you used Nexus on a patient with midline tenderness. You also have the ancillary benefit of not irradiating a patient and generating an unnecessarily large bill for them.

 

[TooMuchResearch]

I use Canadian. Agree pulling MDCalc, either before going to the room or in the room while talking to the patient, is easy to do.

Mdcalc for all your rules until you know the criteria solid. And I guess we'll just agree to disagree about the difficulty involved in using Canadian cspine rules. Virtually all my mvcs are sitting up, or got out of the car themselves (low risk factor present), so there is rarely ever a need to determine if the mvc was simple as the rule only requires one low risk factor be present. The rest of the criteria are straightforward as well. MDcalc lays them out well. Even if you can't remember the criteria without having to go to the website first, I'd argue that 30 seconds looking it up is faster than getting and waiting for a CT read because you used Nexus on a patient with midline tenderness. You also have the ancillary benefit of not irradiating a patient and generating an unnecessarily large bill for them.

 

[askamsky51]

I asked Jerry Hoffman about this exact thing. He told me this (paraphrasing): CT'ing everyone that comes in with neck pain is stupid. We wanted to design a study that supported common sense, and I think we did. We had to make strict definitions for research quality and reproducibility. If you think too hard into clinical decision tools then stop and use your common sense.

 

[miacomet]

I agree with you. I wouldn't order X-ray if I seriously was concerned for fracture. In my suburban, entitled population it's not worth me arguing and having to respond to complaint letters. Too many complaints and I could be fired. If they demand the X-ray, I do it, then document "X-ray not indicated and patient has no indication for ANY imaging, but demanded the study be done. In the interest of patient satisfaction it was performed and was negative."

Sounds like a crap job....

 

[GeneralVeers]

Sounds like a crap job....

Not really. That's most jobs today in middle class or upper class suburbs. Americans are very entitled and complainy. My job is to "satisfy" the patient and avoid complaint letters. I'll do most BS X-rays and blood work that they request but draw the line at MRI, CTs or narcotics.

 

[miacomet]

Not really. That's most jobs today in middle class or upper class suburbs. Americans are very entitled and complainy. My job is to "satisfy" the patient and avoid complaint letters. I'll do most BS X-rays and blood work that they request but draw the line at MRI, CTs or narcotics.

I work in a super high pt satisfaction job in a very high-income area, but admin is not malignant in the way you mention. Insane. I hope they are paying you the big, big bucks to provide non evidence-based medical care. I can't recall the last time I did C spine x-rays. CT or clear and home.

 

[RustedFox]

Not really. That's most jobs today in middle class or upper class suburbs. Americans are very entitled and complainy. My job is to "satisfy" the patient and avoid complaint letters. I'll do most BS X-rays and blood work that they request but draw the line at MRI, CTs or narcotics.

Yep.

This. All day long.

I really can't deal with these people anymore. I used to think that they didn't bother me; but they do. They take their toll.

I can't practice *good medicine* anymore.

I said this on here awhile back, but it bears repeating:

"I went 'full Veers'."

These folks can have what they want. I simply do not care anymore.

I used to have a canned speech about "the three biggest myths in medicine" and go around mythbusting and whatever.

I don't do that anymore. The muggles are so attached to their fixed-false beliefs.

 

[GeneralVeers]

Yep.

This. All day long.

I really can't deal with these people anymore. I used to think that they didn't bother me; but they do. They take their toll.

I can't practice *good medicine* anymore.

I said this on here awhile back, but it bears repeating:

"I went 'full Veers'."

These folks can have what they want. I simply do not care anymore.

I used to have a canned speech about "the three biggest myths in medicine" and go around mythbusting and whatever.

I don't do that anymore. The muggles are so attached to their fixed-false beliefs.

Right. It's far easier to do the BS placebo X-ray. It take me no time or mental energy to do. In the time that I spend arguing why a test isn't needed, I could go see another patient and make 4 more delicious RVUS.

 

[deleted859535]

Would definitely reiterate the above. Fun for me working with residents because, hey, EBM this and unnecessary testing that. Yes, those things are important. But sometimes, good Lord, just do the damn X-ray / strep swab / blood work.

 

[miacomet]

Right. It's far easier to do the BS placebo X-ray. It take me no time or mental energy to do. In the time that I spend arguing why a test isn't needed, I could go see another patient and make 4 more delicious RVUS.

Sure. If we are going to just be patient placaters, we SHOULD be replaced by cheaper midlevels. And you make a great argument for not getting paid in RVUs.

 

[GeneralVeers]

Sure. If we are going to just be patient placaters, we SHOULD be replaced by cheaper midlevels. And you make a great argument for not getting paid in RVUs.

If we weren't paid RVUs, then I would do the minimum work to maintain my job....just like socialism. We would still need midlevels then as productivity would be in the toilet.

At my Vituity job we are on a fixed rate and no RVUS. Some of the docs literally see 1 pt/hr and get away with it. When I ask why we can't switch to RVUS I'm told: "That's not part of Vituity's culture"

Patient placating is necessary at almost every job these days. I could practice 100% EBM and probably cut my ordering down 30%, but I would piss off a ton of patients in the process and I wouldn't have a job for very long.

 

[miacomet]

So, we had an issue with this with pediatric head CTs. Parents want them. They don't care about cancer or their kid's IQ, just their own need for reassurance. We came up with a clinical decision tool and share it with the parents, along with information about radiation risk. It's cut down our unnecessary head CTs by a huge percentage. I agree there are patients we can't convince, but I assume you are using something similar to help educate patients?

We are reimbursed based on using this, so it doesn't cut into our pay; quite the opposite. I would suggest your group come up with something similar if you haven't already. EBM is pretty important, although I agree x rays are low risk, but I think you do leave yourself at legal risk.

 

[GeneralVeers]

So, we had an issue with this with pediatric head CTs. Parents want them. They don't care about cancer or their kid's IQ, just their own need for reassurance. We came up with a clinical decision tool and share it with the parents, along with information about radiation risk. It's cut down our unnecessary head CTs by a huge percentage. I agree there are patients we can't convince, but I assume you are using something similar to help educate patients?

We are reimbursed based on using this, so it doesn't cut into our pay; quite the opposite. I would suggest your group come up with something similar if you haven't already. EBM is pretty important, although I agree x rays are low risk, but I think you do leave yourself at legal risk.

Pediatric head CTs are one thing, and I won't order them to placate parents. I go over criteria, and usually parents are receptive to not ordering.

We've come up with a protocol as a group for dealing wtih these low-risk studies which aren't indicated but are being demanded by patients: Order them

 

[thegenius]

Sure. If we are going to just be patient placaters, we SHOULD be replaced by cheaper midlevels. And you make a great argument for not getting paid in RVUs.

True dat. Test'n'Pills is all you need, run by a bunch of midlevels. They order a test, look up what the result means, and give you a pill. Don't need to be a doctor!

I think there is some master plan by the government and insurance companies to just phase out doctors overall except for the extreme subspecialists. Make it more complicated and burdensome to become a doctor, get patients to want more testing and cheaper access, and viola! You get midlevels who don't know a rash from a ketchup spill. But that's OK! They'll give you antibiotics anyway. Most of us can be replaced by midlevels and computers at this rate because we are doing less MDMing and more testing.

 

[thegenius]

So, we had an issue with this with pediatric head CTs. Parents want them. They don't care about cancer or their kid's IQ, just their own need for reassurance. We came up with a clinical decision tool and share it with the parents, along with information about radiation risk. It's cut down our unnecessary head CTs by a huge percentage. I agree there are patients we can't convince, but I assume you are using something similar to help educate patients?

We are reimbursed based on using this, so it doesn't cut into our pay; quite the opposite. I would suggest your group come up with something similar if you haven't already. EBM is pretty important, although I agree x rays are low risk, but I think you do leave yourself at legal risk.

Interesting...as I feel the parents I see in my population (which is generally low socio-mental-economic) seem to understand the notion of not getting a head CT on these kids. I can't remember the last time I got a CT Head for trauma on a kid. been a real long time.

Frankly, we should use the same gestalt for adults too. We over CT those, but then again most of them come in drunk, high, or with a finger up their own butt for some unexplained reason, and it just doesn't make any sense so we order the CT.

Me: "You hit your head earlier today. But why do you have your finger up your butt?"
Patient: "what....what you talking about? I feel fine. Can I have a soda?"
Me (in my head): he is crazy and I'm going to scan him

 

[Groove]

Interesting...as I feel the parents I see in my population (which is generally low socio-mental-economic) seem to understand the notion of not getting a head CT on these kids. I can't remember the last time I got a CT Head for trauma on a kid. been a real long time.

Frankly, we should use the same gestalt for adults too. We over CT those, but then again most of them come in drunk, high, or with a finger up their own butt for some unexplained reason, and it just doesn't make any sense so we order the CT.

Me: "You hit your head earlier today. But why do you have your finger up your butt?"
Patient: "what....what you talking about? I feel fine. Can I have a soda?"
Me (in my head): he is crazy and I'm going to scan him

Part of the problem is the system wide pressure to enhance metrics, decrease LOS and dispo, dispo, dispo. We tend to over scan patients who live in this vague indistinct clinical state where there are features in their history or exam that suggest the need to image or work up further but there are elements and barriers to the case that consternate us such as low IQ, lack of english fluency, intoxication, etc.. that if overcome might allow us to more comfortably minimize the work up but many times it's simply expeditious to "spin them, lab them and be done with it". I don't know about you but I really don't have time to sit there and pull teeth with some of these patients with multi-system complaints and melodramatic exams bordering on hysteria. If I walk in the room and identify a significant barrier that I feel can't be overcome in a timely manner, then I will work them up expeditiously (though not cost effectively) to definitively rule out any badness, disposition them in a timely manner and move on to the (hopefully) more straightforward patient during the next encounter.

That being said, I don't have to scan too many kids. I can typically spin PECARN in such a way to parents that they will follow my lead. I get good traction with the part about wanting to "minimize radiation in his/her growing brain so that they don't grow up with brain cancer later in life". The parents eyes will generally widen as I stress "BRAIN C-A-N-C-E-R" and they will start vigorously nodding before I've finished my line.

 

[deleted109597]

I prefer to stress the better studied linear decrease in IQ. "You wouldn't want your kid to not get into college would you?"

 

[Groove]

I prefer to stress the better studied linear decrease in IQ. "You wouldn't want your kid to not get into college would you?"

Heh! Maybe in YOUR patient population. The parents actually have to have a high enough IQ to recognize the benefits in harming said IQ for that method to work. Let's just say my patients are not the sharpest tools in the shed. Our payor mix reflects this btw, which is why we require a hospital subsidy.

I'll def use that one though next time I get some smart parents.