Old folks just need CTs

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TrumpetDoc

TrumpetDoc

Full Member
10+ Year Member
There's a reason rules have age cutoffs and such. However a case yesterday was a 66y female. Remote trauma, trip an fall from standing hight. Hit head on left forehead. Nice size hematoma, scab, and lots of evolving eccymosis along face down neck. complaint of headache not severe but persistent. However headache came up later, her CC was the bruising solely.
No PMHx.
VS normal.
Takes only a baby ASA for prevention.
Exam except for above mentioned stuff, normal. Neuro exam normal including gait, only quirk is that she had trouble with date, but states thinks this is baseline.

I had flirted with no ct due to her looking so well actually. But her age/ASA, and persistent headache, well..you know.

Of course ct showed an area of IPH on opposite side with significant mass effect and beginning of shifting!
Her exam never changed.

Funny thing is... I wonder if the Ct had been negative, particularly in the coming future ...would it have been deemed unnecessary?
 
TrumpetDoc said:
There's a reason rules have age cutoffs and such. However a case yesterday was a 66y female. Remote trauma, trip an fall from standing hight. Hit head on left forehead. Nice size hematoma, scab, and lots of evolving eccymosis along face down neck. complaint of headache not severe but persistent. However headache came up later, her CC was the bruising solely.
No PMHx.
VS normal.
Takes only a baby ASA for prevention.
Exam except for above mentioned stuff, normal. Neuro exam normal including gait, only quirk is that she had trouble with date, but states thinks this is baseline.

I had flirted with no ct due to her looking so well actually. But her age/ASA, and persistent headache, well..you know.

Of course ct showed an area of IPH on opposite side with significant mass effect and beginning of shifting!
Her exam never changed.

Funny thing is... I wonder if the Ct had been negative, particularly in the coming future ...would it have been deemed unnecessary?
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If your discharge diagnosis was "headache" then yes, it would've been deemed unnecessary. However, the patient had a history of trauma. So if you included the trauma as part of your discharge diagnosis it would've been acceptable.

That's where I see medicine going. The smart docs are going to be able to keep practicing how they want to, but they're going to have to learn a bunch of non-medical information such as diagnosis codes in order to avoid penalization. That's going to bog them down and detract from the attention that they can devote to patients. All in the name of safety and efficiency!
 
elderly, head injury -> with rare exception, CT. With ASA onboard, no question.
 
dotcb said:
elderly, head injury -> with rare exception, CT. With ASA onboard, no question.
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👍👍

No question. I CT old people without HA all the time after minor trauma.

After awhile I've gotten to where my history and exam on an older person is almost less important to me than their complaint. What I mean by that is that I know what I'm going to order just by glancing at the chart - age, vs, cc.
 
I agree, and although my little voice said..."there's no way this could be bad, etc" I would scan this every time.
I wanted to illustrate the uselessness of clinical exam and eval in the elderly...
 
Saw one like this as a med student. 70yr old slipped on ice but sorta caught himself on his truck before hitting side of head.No blood thinners. Big knot, no loc/N/V, had a HA after. Guy didn't think anything of it. Called his PCP who set up an apt the next morning, PCP didn't see anything but sent him for outpt CT. Get this, guy goes for CT, leaves the outpt imaging center and goes dancing with his wife! Gets a call that he needs to go to the ED. He shows up saying that he is not really sure why they told him to come in, normal exam. We finally get the PCP on the phone and get the CT report sent over. Big bleed with shift. Guy did great however.
 
66 is young at my shop. And she'd probably be upset at you for calling her "elderly."

Of course, I see 90 year olds who've fallen off their bikes, so take it with a grain of salt and 25 of HCTZ!
 
I was just reading somewhere (I think Annals but can't prove it) that plavix is actually a major factor in GCS 15, + bleed on CT pts in some cases as big a factor as being on coumadin. There are places to save money in health-care, but trauma in the elderly isn't one of them (excepting perhaps the DNR, comfort-care only nursing home patient transported for eval after fall without signs of pain/discomfort).
 
EctopicFetus said:
BTW those CT rules (Which are crap) are for non traumatic HA.
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Anyone 65 and up doesn't get placed on a "rule" for me either,. I was just making light of the age part of rules in general. Even trauma CT rules were not meant for sub acute injury either.
 
Just for the sake of being argumentative 😀 I think there are a significant number of these elderly CT + patient who we don't do anything for. We watch and wait and re scan. Is that really better than go home and come back if you don't develop any symptoms?

I'm smarting over this because I had a 104 (seriously 104 😱) yo after a mechanical fall. She was transferred to my hospital for a Neurosurg consult. So I called neurosurg and admitted her. For the first time ever NSG came in 45 in later and told her that they would never operate on her under any circumstances because of her age. So then the patient and family wanted to go home. As I had already admitted her I couldn't just d/c them. They were really upset so I'll get a bad survey.

My neurosurgeons always complain about seeing asymptomatic bleeds and they never do anything so I wonder if they need to even be identified. I know this is "grumpy consultant bias" (which is the worst kind) but I wonder.
 
docB said:
Just for the sake of being argumentative 😀 I think there are a significant number of these elderly CT + patient who we don't do anything for. We watch and wait and re scan. Is that really better than go home and come back if you don't develop any symptoms?

I'm smarting over this because I had a 104 (seriously 104 😱) yo after a mechanical fall. She was transferred to my hospital for a Neurosurg consult. So I called neurosurg and admitted her. For the first time ever NSG came in 45 in later and told her that they would never operate on her under any circumstances because of her age. So then the patient and family wanted to go home. As I had already admitted her I couldn't just d/c them. They were really upset so I'll get a bad survey.

My neurosurgeons always complain about seeing asymptomatic bleeds and they never do anything so I wonder if they need to even be identified. I know this is "grumpy consultant bias" (which is the worst kind) but I wonder.
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Who accepted the transfer? If the first time NSx is hearing about it is after the bed is made and the house is all tidied up (figurative), then there is a broken link somewhere.

And I thought about this post from 5 years ago:

ERMudPhud said:
Later I learned that you are never too old for chemo. I saw a 98 year old demented lady with metastatic breast cancer with no PO intake for a week secondary to nausea from her chemo. I swear if they found a tumor on King Tut's mummy you could find an oncologist to give him chemo. Later when his kidney's were found to be non-functional you could find someone to dialyze him too.
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Apollyon said:
Who accepted the transfer? If the first time NSx is hearing about it is after the bed is made and the house is all tidied up (figurative), then there is a broken link somewhere.
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One of my partners did. But we have been told to accept every transfer no matter what. Our instructions are to say, Quote "Thank you Sir. May I have another." to anyone who calls.

It would be bad for us though to have the referring doc talk to a consultant and we have a policy against that. In the past it resulted in consultants refusing the transfers and/or refusing to see the patients once they were transferred.
 
docB said:
One of my partners did. But we have been told to accept every transfer no matter what. Our instructions are to say, Quote "Thank you Sir. May I have another." to anyone who calls.

It would be bad for us though to have the referring doc talk to a consultant and we have a policy against that. In the past it resulted in consultants refusing the transfers and/or refusing to see the patients once they were transferred.
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Well, if they refuse the transfer, then it's a done deal. It's a ****ty way to handle it, but it is being handled. Refusing to see them once they were transferred, though? That's bad juju.
 
docB said:
One of my partners did. But we have been told to accept every transfer no matter what. Our instructions are to say, Quote "Thank you Sir. May I have another." to anyone who calls.

It would be bad for us though to have the referring doc talk to a consultant and we have a policy against that. In the past it resulted in consultants refusing the transfers and/or refusing to see the patients once they were transferred.
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My old shop was like that as well. The admin didn't trust the consultants not to inappropriately turn down transfers, so everything was rubberstamped by the ED doc and sent ED-to-ED. NSx was the only specialty that had won the right to screen consults but that was only so they didn't catch an operative case while still in the OR. Many times we would accept transfers after the consultant had refused, which you can imagine made for fun calls on our end.
 
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