Studies Say Too Many CT Scans

[docB]

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This story has been all over the media.

http://www.foxnews.com/story/0,2933,313698,00.html

They even single out EM as part of the problem.

CT scans became popular because they offer a quick, relatively cheap and painless way to get 3D pictures so detailed they give an almost surgical view into the body. Doctors use them to evaluate trauma, belly pain, seizures, chronic headaches, kidney stones and other woes, especially in busy emergency rooms. In kids, they are used to diagnose or rule out appendicitis.

So what do we do? The real world answer is nothing. We are punished severely for missing anything, especially in children, a group the article points out is disproportionally affected. There is little risk of getting sued for doing a scan that could cause cancer decades down the line. By the time it happenes the ordering doc will likely be retired if not dead and even then proving direct cause would be very difficult. So the incentive to order tests including CTs liberally will continue.

 

[DogFaceMedic]

Agreed. I do not intend to sacrifice my career on the altar of keeping costs down.

 

[EM2BE]

I haven't even started my career, and I plan to use them.

 

[WallowaWanderer]

I heard from a colleague (read: I don't know if this is really true) that other countries use a lot more MRI than we do here in the US. Maybe the medical community should be using more MRI. Are MRI's really that much more expensive? They are a lot slower - that's probably a problem. But, on the plus side the patient gets to listen to music and go inside that cool tube. Maybe the extra time and expense is worth it to avoid the exposure in kids.

It seems like, as a country, we want to "have our cake and eat it too." If we want the lowest possible miss rate then we're going to have to do a lot of imaging to catch that small percentage of cases that end up being something even though the clinical suspicion was low. Now, if we want all that without radiation exposure then that's asking a lot and it's going to cost more.

Just my $0.02.

 

[WallowaWanderer]

More thoughts -

It seems like the current situation is partly due to the malpractice climate and the article doesn't mention anything about the pressure on physicians to have a 0% miss rate. So, it seems like it is missing the big picture. And the whole atomic bomb thing - I mean, I realize that's the best we've got but how do we know whether small doses spread out over a lifetime would cause the same risk as one big dose at a single point in time.

And there aren't many surgeons out there who want to operate on a kid with a classic presentation of an appy before they see the CT scan, right?.

 

[Wackie]

And there aren't many surgeons out there who want to operate on a kid with a classic presentation of an appy before they see the CT scan, right?.

That's what I was going to mention. Everyone wants a CT done usually before they're even called.

 

[WilcoWorld]

I heard from a colleague (read: I don't know if this is really true) that other countries use a lot more MRI than we do here in the US. Maybe the medical community should be using more MRI. Are MRI's really that much more expensive? They are a lot slower - that's probably a problem. But, on the plus side the patient gets to listen to music and go inside that cool tube. Maybe the extra time and expense is worth it to avoid the exposure in kids.


Just my $0.02.

Not having looked at the numbers, I'm just speculating here. But I think that other countries likely have less pressure to image every head injury patient with "evidence of injury above the clavicles". As such, they order fewer CT scans. Thus the denominator in the ratio of MRI:CT will go down & the number of MRI's ordered will be relatively higher.

Speaking from experience, MRI's are much more difficult to obtain that CT's. MRI requires a patient to be motionless for considerably longer than CT, it also requires time consuming prescreening to avoid the very real potentially harmful effects of those 6 Tesla field strengths. Your patient can't be claustiphobic (which seems to have a high incidence among those patients forcing us to over-utilize imaging). And you need a radiologist comfortable reading them.

I would like better access to MRI, but I don't think that's the solution to the aforementioned problem. Realistic public expectations is the answer. Unfortunately, that doesn't exactly seem imminent.

 

[EctopicFetus]

So what do we do? The real world answer is nothing. We are punished severely for missing anything, especially in children, a group the article points out is disproportionally affected. There is little risk of getting sued for doing a scan that could cause cancer decades down the line. By the time it happenes the ordering doc will likely be retired if not dead and even then proving direct cause would be very difficult. So the incentive to order tests including CTs liberally will continue.

Co-sign.. come on now. All patients want tons of non-invasive tests. this wont change what happens one bit. I will say we dont CT kids here unless it is emergent and never for an Appy.

 

[EM2BE]

Co-sign.. come on now. All patients want tons of non-invasive tests. this wont change what happens one bit. I will say we dont CT kids here unless it is emergent and never for an Appy.

Haven't you found a way to make blood draws non-invasive yet? 😉

 

[WallowaWanderer]

Realistic public expectations is the answer. Unfortunately, that doesn't exactly seem imminent.

Yeah, we tried to get some of those installed in our ED, but I hear they've been on backorder for a really long time.

 

[MacGyver]

I heard from a colleague (read: I don't know if this is really true) that other countries use a lot more MRI than we do here in the US. Maybe the medical community should be using more MRI. Are MRI's really that much more expensive?

Yes, they really are that more expensive. To site an MR scanner is at least a 1.5 million dollar adventure. You have to build a special copper shielded room with huge vibration/shock isolators to keep building vibrations out of the room.

The magnet requires supercooled helium or nitrogen to cool the superconducting electromagnet, and furthermore it runs 24 hours a day, so its also a huge electric bill.

They are a lot slower - that's probably a problem.

True. Minimum 15 minutes.

But, on the plus side the patient gets to listen to music and go inside that cool tube.

There are a lot of claustrophobic people out there, far more than I thought there were. You can medicate them to some extent, but its hit or miss.

Maybe the extra time and expense is worth it to avoid the exposure in kids.

Kids have a very hard time with MR, and almost it always demands sedation to avoid motion artifacts.

 

[MacGyver]

Speaking from experience, MRI's are much more difficult to obtain that CT's.

True

MRI requires a patient to be motionless for considerably longer than CT

Very true

it also requires time consuming prescreening to avoid the very real potentially harmful effects of those 6 Tesla field strengths.

I dont think its that extensive. No medical electronic implants and no metallic implants consisting of iron, nickel, steel, or cobalt. Its a common misconception that everybody with any kind of metallic implant cant get MR imaging, but thats not true. Titanium implants and other non-ferromagnetic metals are perfectly safe.

Some of the smaller stuff: be wary of old tatoos that contain metallic inks, welders are a no-no because they have tiny iron filaments embedded in their corneas that can rotate under exposure to the RF pulses.

There's been a few case reports of people with hemochromatosis who have suffered ill effects in the scanner, but I dont think its an absolute contraindication.

BTW, where are you that you are using 6T field strengths for routine clinical imaging? I'd say 95% of all MR imaging is at 1.5T or 3T. The open scanners tend to run lower from 0.5T to 1.2T. I havent heard of any hospitals using a 6T scanner for routine clinical stuff. The higher field strengths are generally reserved for research protocols. Sometimes the higher fields are used for fMRI, but you guys dont use that in the ED.

I dont think the 6T field strengths are that much more dangerous than a 1.5T or 3T. As long as you do the prescreening appropriately, its not an issue. Sometimes people get burned with improper coil placement (e.g. loops of copper wire placed over the body) but thats a problem with all field strengths.

Your patient can't be claustiphobic (which seems to have a high incidence among those patients forcing us to over-utilize imaging).

This is a huge issue, probably the single biggest problem that prevents people from getting MR.

And you need a radiologist comfortable reading them

True, usually takes longer to get an MR read compared to CT.

I would like better access to MRI, but I don't think that's the solution to the aforementioned problem. Realistic public expectations is the answer. Unfortunately, that doesn't exactly seem imminent.

Agreed, we dont need more MR imaging, we need less defensive medicine and less of a litigious culture.

 

[Chronic Student]

We just got a new 3T scanner, it is the bomb (I feel like we are in the boonies, Oh wait we are) and the 1.5T that we have been using is still decent.

Now the open MRI is up to the quality of our old 1.5T which is extremely helpful with those who are really claustrophobic.

We used to get an anesthesiologist/anesthetist to give conscious sedation for those folks and we rarely have to do that now.

I recently had an MRI and I am not especially claustrophobic. That was an unpleasant experience. My shoulders hitting the sides of the tube was not fun and having the top of the tube an inch from my face was nice too.

I used to offer valium to people who expressed trepidation about the MRI. I now offer it as a routine due to my personal experience.

-Mike

 

[EM2BE]

I had one done several years ago. I don't remember feeling claustrophobic, but I think I also fell asleep (was sleep deprived for some reason).

 

[WallowaWanderer]

I had one done several years ago. I don't remember feeling claustrophobic, but I think I also fell asleep (was sleep deprived for some reason).

First I was claustrophobic, then I fell asleep. 😴

 

[anonymousEM]

I haven't read any of the articles that came out today but did hear the commentary on the radio this am. They were actually focusing here more on the advent of noninvasive CT screening (like the virtual colonoscopy etc) and stating that about 1/3 of the CTs done now are unnecessary. I think in EM most of what we order for is considered "emergent" and not "unnecessary" even if it is mostly because in our heart of hearts we know that it is a defensive medicine emergency for us...

Not to hijack this thread, but check out the other EM related clip I just saw on the news...now night shifts are on the list of things that cause cancer. I think I'll start requesting them off...medical necessity....

 

[Hard24Get]

I think in EM most of what we order for is considered "emergent" and not "unnecessary" even if it is mostly because in our heart of hearts we know that it is a defensive medicine emergency for us...

Here is a good one. We were sent a kid once with intermittent GERD with the promise from his PCP that he would get a CT scan 🙂rolleyes🙂. It actually looked for all the world like an anxiety disorder and there was certainly no good indication for CT. So we told him about the fact that the CT lends 100X the amount of potentially cancer-causing radiation as an x-ray and we felt the chance of detecting anything was low, but that we were happy to do one if he wanted. He refused! Nobody loses because the CT is documented as ordered but refused.

 

[southerndoc]

The thing that I've seen that works very well with patients (and parents if the patient is a kiddie), I explain the risk of radiation, the uncertainty of diagnosis without the CT, and then offer them a choice.

For example, if someone comes in with abdominal pain of unclear etiology, I explain that the CT scan of the abdomen will give them a radiation dose equivalent to 200-400 chest X-rays, tell them that I'm unclear what's causing their abdominal pain (and tell them what the possibilities are or what I'm thinking it could be), and then let them take part in the decision process. That way, it's a shared responsibility, and it seems to be one that patients love. I've received a few comments from patients appreciating how they were involved in the decision making process.

If it's a suspected appy, but too early to tell (like periumbilical pain, no fever, no white count, etc.), then I tell them it may be too early to diagnose on physical exam, but the CT may show it. If they want the CT, then I order it. If they want to wait to see if their abdominal pain worsens, then I discharge them with instructions telling them to return if pain worsens, changes character, if they develop fever, etc.

Not sure how this will stand from a legal perspective, but I do document the discussion in the chart.

 

[HokiMD]

That's what I was going to mention. Everyone wants a CT done usually before they're even called.

Every surgeon where I'm at currently does not care about a CT scan...the CT WILL MISS SOME, and studies have shown that getting a surgeon on board before a CT scan has better outcomes, and at our institution the surgeon wants on board asap, not waiting for a CT scan....

 

[docB]

Every surgeon where I'm at currently does not care about a CT scan...the CT WILL MISS SOME, and studies have shown that getting a surgeon on board before a CT scan has better outcomes, and at our institution the surgeon wants on board asap, not waiting for a CT scan....

But you understand that that is institution dependent. Where I am the surgeon will swear and hang up if the CT has not already been done.

 

[WakeMedHeel]

IMO, as much as we'd like to blame the lawyers (it's an easy excuse), a lot of the onus falls onto the EP. As a group, I think we lack physical exam skills, or rather, we rarely trust our physical exam and clinical judgement. Therefore we decide that we must confirm or rule out anything and everything with imaging.

I see people that come in with what appears to be a URI and would be a treated as such at a clinic, end up getting a CTPA. Patient's with simple gastroenteritis, get a CTAB/Pel because we "just want to make sure we're not missing anything."

At our institution our CT utilization has increased 25 percent over last year!!!

I'll admit, I'm occasionally guilty as the rest, but I really make a practice of trying to avoid, what I deem to be an unnecessary scan. I'll even argue with the surgeons - and have called an attending at home in the middle of the night on a classic appy where the resident was being lazy. Lawyers are surely part of the equation, but to completely place the blame on the legal system is irresponsible and just another way to try and pass the buck.

 

[TeleoDeum]

From a pediatric standpoint, we try to be aware of the radiation risks (our radiologists are great about staying on our butts to not do unnecessary CT). There is a growing body of literature that can help guide our clinical decision making. The AAP is currently reviewing a meta analysis about the utility of CT in pediatric head injury. Hopefully, this will yield an evidence based alogorythm for selecting high risk kids for intracranial bleeding and edema, and allow for more careful observation periods without the CT.
As for CT abd for appy, there is some good pediatric surgical literature that suggests getting the surgeon involved before the scan to perform an exam and make a determination. The alogorythm calls for surgical evaluation of the belly, with CBC, UA, +/- acute abd series xray (for pneumonia, obstructive pattern, or appendicolith). In cases of obvious appy, to the OR. In cases of obvious low risk, no appy, home or admit to Peds. In indeterminate cases, admit to Surgery for IVF and serial exams every 4 hours. If it is an appy, it should clincially declare itself. After 4-8 hours, if still unsure, the surgeon has the option of CT. The risks of negative exp lap versus radiation exposure have to be weighed.
I realize that this is not realistic in some locations, but both surgeons and parents should be made aware of the potential long term risks of radiation exposure for potentially unwarranted CT scans. Unfortunately, I believe that in the future we will be forced to have patients/parents sign an additional radiaton exposure consent.
Anyway, just some thoughts...

Greg

 

[Hercules]

Good discussion. EMRAP has been hammering this topic quite frequently in the past year. I take southerndoc's approach and have the same experience. If I don't really think a kid needs a CT to r/o appendicitis I'll explain the risks, usually talk the parents into watching, and then document the hell out of it. As for Head CT's in pediatric head trauma, I've been doing fewer and fewer. If you're looking for good studies to help you decide not to image in minor trauma, take a look at NEXUS-2. They had ~2000 pediatric head injuries and there was a pretty decent clinical rule that came out of it.

 

[southerndoc]

One article I read stated that we should use ultrasound more and that it was used more often in other countries. What the article failed to mention is the slight problem we Americans have with our obesity epidemic. What works in a country where the majority of patients are thin does not work where you can't see intestines by ultrasound because of too much adipose tissue.

I'm wondering how my practice will change when I am in a community with no in-house surgeon. Will I be forced to CT someone with fever, white count, right lower quadrant tenderness with rebound, positive Rovsing's, and a positive psoas sign?

 

[ERMudPhud]

I'm wondering how my practice will change when I am in a community with no in-house surgeon. Will I be forced to CT someone with fever, white count, right lower quadrant tenderness with rebound, positive Rovsing's, and a positive psoas sign?

Yes, and then watch as the surgeon waits 6 hours to take the patient to the OR in the morning.

 

[docB]

Yes, and then watch as the surgeon waits 6 hours to take the patient to the OR in the morning.

Or tells you even after the positive CT abdomen at 11pm (I am not making this up) "Groan! Fine! Admit to medicine. Start antibiotics and have interventional radiology put a drain in it and I'll see it tomorrow."

 

[docB]

IMO, as much as we'd like to blame the lawyers (it's an easy excuse), a lot of the onus falls onto the EP. As a group, I think we lack physical exam skills, or rather, we rarely trust our physical exam and clinical judgement. Therefore we decide that we must confirm or rule out anything and everything with imaging.

I see people that come in with what appears to be a URI and would be a treated as such at a clinic, end up getting a CTPA. Patient's with simple gastroenteritis, get a CTAB/Pel because we "just want to make sure we're not missing anything."

At our institution our CT utilization has increased 25 percent over last year!!!

I'll admit, I'm occasionally guilty as the rest, but I really make a practice of trying to avoid, what I deem to be an unnecessary scan. I'll even argue with the surgeons - and have called an attending at home in the middle of the night on a classic appy where the resident was being lazy. Lawyers are surely part of the equation, but to completely place the blame on the legal system is irresponsible and just another way to try and pass the buck.

I disagree. This is not a question of our physical exam or diagnostic skills. It's a question of being able to prove to a consultant what is going on or to a future lawyer what isn't. I know it's a URI but if that patient dies from anything really but particularly a PE in the few weeks following her visit her family's lawyer will kill me with the "But doctor, isn't there a simple test you can do to see if there's a blood clot in the lungs? Hmmmm. And by not doing that test you killed my client's loved one."

I have a colleague right know who is being sued for not starting a patient on prophylactic antibiotics for an uncomplicated lac. The lac got infected and the patient eventually got osteo. EBM is on his side. Have you ever tried to explain what a prospective randomized controlled study is to the kind of *****s who sit on juries? Another colleague lost a big award for not starting an uncomplicated kidney stone on antibiotics. Again, try to explain EBM to a jury and all they hear is Charlie Brown's teacher, Waaa waa waa waaa waaaa wa. All they know is that you're supposed to get antibiotics for everything and CTs answer all diagnostic questions. The plaintiffs even have a shiny slick talking "expert" there convincing them that they're right.

Fix med mal if you really want to reduce the number of scans.

 

[VFTW]

The problem is not with you EM providers being poor diagnosticians, because you're not. The problem is all based on defensive medicine.

 

[Wackie]

All they know is that you're supposed to get antibiotics for everything and CTs answer all diagnostic questions.

And doctors are money trees that get paid too much for what they do...though, they'd expect exceptional error-free service if you got paid as much as teachers with the exact same payouts they currently receive when suing.
But you know, doctors are trained at searching rectums for foreign bodies so they should be able to find and pull something out of there...

 

[EM2BE]

And doctors are money trees that get paid too much for what they do...though, they'd expect exceptional error-free service if you got paid as much as teachers with the exact same payouts they currently receive when suing.
But you know, doctors are trained at searching rectums for foreign bodies so they should be able to find and pull something out of there...

I still don't understand how people who receive free care (go to free health clinic) can still sue a dr. And the dr has to pay malpractice insurance for the few hours they work at the place. Any explanations?

 

[MacGyver]

I have a colleague right know who is being sued for not starting a patient on prophylactic antibiotics for an uncomplicated lac. The lac got infected and the patient eventually got osteo. EBM is on his side. Have you ever tried to explain what a prospective randomized controlled study is to the kind of *****s who sit on juries? Another colleague lost a big award for not starting an uncomplicated kidney stone on antibiotics. Again, try to explain EBM to a jury and all they hear is Charlie Brown's teacher, Waaa waa waa waaa waaaa wa. All they know is that you're supposed to get antibiotics for everything and CTs answer all diagnostic questions. The plaintiffs even have a shiny slick talking "expert" there convincing them that they're right.

I agree with you that juries are stupid but the real villain here is the hired gun "expert" witness *****. These are the scumbags with MDs behind their name who are selling out their profession to the lawyers. Without these "experts" none of these cases has any teeth to it whatsoever.

So what we really need to do is start punishing these ****** who go on the stand and claim that its against standard medical practice to not give abx wtih all lacs. We need to censure the idiot who claims that your colleague broke a standard of practice when he didnt give abx for kidney stone.

This lawsuit madness would end overnight if doctors werent so greedy. They're not happy with their $100 an hour clinical work so they sell out to the lawyers so they can make $400 per hour as an "expert"

So please, tell your colleague to leak the names of these "expert ******" who testified against them so we can all shun them, get them kicked out of their professional organizations, etc

I want their ****ing names.

 

[southerndoc]

MacGyver, AAEM and ACEP have censored emergency physician members who have given false testimony as expert witnesses. However, I don't think they are censoring enough.

It really means a lot when an expert witness on the stand is asked "have you ever received any sanctions from a professional society?" "Yes, I was censored by the American College of Emergency Physicians." "Why is that?" "They claim I provided false testimony."

Expert testimony from that expert: worthless.

 

[docB]

I still don't understand how people who receive free care (go to free health clinic) can still sue a dr. And the dr has to pay malpractice insurance for the few hours they work at the place. Any explanations?

You have to understand that everyone but us likes the current situation with EMTALA and med mal combining to screw us. The politicians like it because it creates an entitlement for free care without them having to go on record voting to raise taxes. It's another unfunded federal mandate. The patients like it because they get free care and might hit the jackpot. The lawyers like it because they hit the jackpot on every case. The doctors hate it? Those rich greedy bastards? Screw 'em.

 

[docB]

Hijacking a little here so apologies to the OP (oh wait...)

Defensive medicine isn't just ruining medicine. It's ruining the whole society. It's not just doctors that practice defensive medicine either. The cops don't want to be liable for maintaining drunk tanks so all the drunks are delivered by EMS at great cost to the EDs. Employers don't want to be liable for employee injuries so every bump and scratch has to go to the ED "just to get checked out." Businesses don't want to be liable so every slip and fall has to go to the ED. Schools tell parents to go to the ED to get doctor's notes saying that a child is not contagious before they're allowed back (what child isn't contagious?). It's the same with day care (what day care isn't contagious?). Employers demand that their workers get work notes and return to work clearences.

Think of the resources we would save if these patients did not go through the EDs.

 

[EM2BE]

You have to understand that everyone but us likes the current situation with EMTALA and med mal combining to screw us. The politicians like it because it creates an entitlement for free care without them having to go on record voting to raise taxes. It's another unfunded federal mandate. The patients like it because they get free care and might hit the jackpot. The lawyers like it because they hit the jackpot on every case. The doctors hate it? Those rich greedy bastards? Screw 'em.

I'm glad I did find out at least I understood what was going on and it was correct. I used to try to stay out of politics as much as possible, but that's less and less every day. I also thought going into med school that I would offer a day or 2 at a free health clinic because I was able to use them growing up and I wanted to give back. Unfortunately, because you have to pay them to be there and see patients, it seems fruitless (with the exception of the few who might really appreciate the help. If I weren't married at the time and my loans were paid off, I'd still be tempted, but if I am married, the hubby probably wouldn't understand my thoughts in wanting to do it.

 

[pseudoknot]

I'm glad I did find out at least I understood what was going on and it was correct. I used to try to stay out of politics as much as possible, but that's less and less every day. I also thought going into med school that I would offer a day or 2 at a free health clinic because I was able to use them growing up and I wanted to give back. Unfortunately, because you have to pay them to be there and see patients, it seems fruitless (with the exception of the few who might really appreciate the help. If I weren't married at the time and my loans were paid off, I'd still be tempted, but if I am married, the hubby probably wouldn't understand my thoughts in wanting to do it.

In Virginia, there is a state program whereby doctors working in free clinics are immune from suit and malpractice coverage is provided by the state for free. I'm not sure if such a thing exists elsewhere. Nor can I tie this into CT scans, but oh well.
http://www.trs.virginia.gov/Drm/clinic_volunteers.asp

 

[angel80]

I'm an IM resident who wandered into this forum and found this thread interesting. I definitely have seen an overabundance of tests ordered (not just by EM, but IM, surgery etc.) I think that part of it has to do with the fact that as physicians, we rely so much on testing now, that our physical exam skills have become poorer, and don't trust our clinical judgement as much as people used to in the past. The main issue though, as people have mentioned, is that we are all trying to cover our own behinds. That being said, as of right now, EM docs don't have to answer to anyone about their decisions to order tests. There's nothing stopping the practice. In IM, especially in Primary Care, we have the insurance companies on our back. They keep databases of physicians, know exactly how many CT/MRI/US etc you ordered, know how many times you prescribed expensive brand name antibiotic A vs. generic antibiotic B, know what bloodwork you order on patients, etc. I've seen these spreadsheets. If they decide that you spend too much money, you lose bonus money, or they may even decide that you get dropped as a physician in their network. As a PCP, you even get this info about the consultants in the area, and if you routinely consult the more "expensive" consultants, you lose money from the insurance companies. This practice by the insurance companies is expected to get even worse. So we are stuck between a rock and a hard place, trying to save our butts, but not get blacklisted by insurance companies. I think that this is going to spill over more into the hospitals as well, and I wouldn't be surprised if somewhere down the line, insurance companies stopped paying for their patients to go to certain ERs because those ERs are known for spending more money and ordering more tests than other ERs.

 

[docB]

...and I wouldn't be surprised if somewhere down the line, insurance companies stopped paying for their patients to go to certain ERs because those ERs are known for spending more money and ordering more tests than other ERs.

We already have a situation where one grup of hospitals dropped it's contracts with the predominant local HMO and now all those pateints are sent to the other hospitals.

 

[WakeMedHeel]

I disagree. This is not a question of our physical exam or diagnostic skills. It's a question of being able to prove to a consultant what is going on or to a future lawyer what isn't. I know it's a URI but if that patient dies from anything really but particularly a PE in the few weeks following her visit her family's lawyer will kill me with the "But doctor, isn't there a simple test you can do to see if there's a blood clot in the lungs? Hmmmm. And by not doing that test you killed my client's loved one."

I have a colleague right know who is being sued for not starting a patient on prophylactic antibiotics for an uncomplicated lac. The lac got infected and the patient eventually got osteo. EBM is on his side. Have you ever tried to explain what a prospective randomized controlled study is to the kind of *****s who sit on juries? Another colleague lost a big award for not starting an uncomplicated kidney stone on antibiotics. Again, try to explain EBM to a jury and all they hear is Charlie Brown's teacher, Waaa waa waa waaa waaaa wa. All they know is that you're supposed to get antibiotics for everything and CTs answer all diagnostic questions. The plaintiffs even have a shiny slick talking "expert" there convincing them that they're right.

Fix med mal if you really want to reduce the number of scans.

Like I said, it's an excuse. If you don't believe it's a PE and you've documented it appropriately then you shouldn't order a CTPA to cover for the lawyer. IMO, it's the worst possible medicine.

Our fastest and most clinically astute attending IMO, doesn't get sued (he's been doing it for 20 years), moves the department faster than any I've seen, and rarely orders scans. He trusts his clinical judgement and documents everything appropriately.

Sounds like your colleague did everything right. My mentor in med school, had a great piece of advice for me when I asked him about a very similar situation. His answer: "You're going to get sued. Do what you think is right and document it. You'll be able to sleep at night knowing you did the right thing even if the scumbags disagree." If you're going to listen to every horror story about lawsuits you'll never be able to practice effective medicine.

Lawyers are part of the problem, this I'll readily agree...but I think we use them as an excuse. We can do better.

 

[docB]

Like I said, it's an excuse. If you don't believe it's a PE and you've documented it appropriately then you shouldn't order a CTPA to cover for the lawyer.

Then you better be right 100% of the time. If a young patient with a lifetime of earnings ahead of the drops dead on you you're done.

 

[WakeMedHeel]

Then you better be right 100% of the time. If a young patient with a lifetime of earnings ahead of the drops dead on you you're done.

Maybe...maybe not.

 

[MossPoh]

I'd take that stuff with a grain of salt. A huge amount of CTs are ordered from the ER versus other areas. I'm in radiology research and it is interesting to see /hear the reasons WHY. A fairly common reason/excuse was that the cost of the actual ct is cheap for the hospital but a big money maker when billing out and it is also used for c.y.a.(Which with litigation in the states is understandable) I can say that many radiologists do get frustrated with the blitzing of CTs, especially with such detailed histories as "patient complains of worst headache of life", or anything along those lines. I'm not saying any of these are specific reasons, nor researched exclusively...just observations. I have noticed when doing a system analysis that even in a small hospital in a rural community on a monday morning there were about 25 CTs on the list and about 19 stemmed from the ER. I am not sure how they can really quantify that the CTs are the REASON for increased rates of cancer...seems to be a ton of variables with that.

 

[southerndoc]

Moss, I've had NUMEROUS private attendings send patients to the ED to get a CT instead of ordering it themselves. It circumvents the requirement for the patient to get pre-approval from their HMO. So, the disproportionate amount of CT's ordered from the ED isn't always the ED physicians fault.

Secondly, as the acuity of patients presenting to the ED is higher than the acuity presenting to a primary care physician's office, it is to not be unexpected that an ED would order more CT's.

Finally, "such detailed histories" often go unread by radiologists. I used to write specific things such as "LLQ pain x 36 hrs, fever, WBC=16" on the requisition order. I would get aggravated when the radiologist would call asking what side the pain was on, if the patient had a fever, etc. They apparently fail to read the clinical indication for the diagnostic imaging, at least at my hospital.

 

[MacGyver]

MacGyver, AAEM and ACEP have censored emergency physician members who have given false testimony as expert witnesses. However, I don't think they are censoring enough.

It really means a lot when an expert witness on the stand is asked "have you ever received any sanctions from a professional society?" "Yes, I was censored by the American College of Emergency Physicians." "Why is that?" "They claim I provided false testimony."

Expert testimony from that expert: worthless.

Alas, I wish it was that simple.

The expert ****** can use their lawyer cadre against the specialty boards too. They can sue the boards, stating that their sanctions resulted in a loss of income and the ability to ***** themselves out to the lawyers.

Docs can also sue state medical boards who vote to discipline them or revoke their license.

Its absolute bull****.

 

[Faebinder]

Dude.. This is such BS. We should give the Fox news writer the option not to get scanned in the ER and just die from "random" causes.

One day I will invent the "Mobile" ICU. All the patient's bed will be mechanically rotating like a round turning restraunt and there is this one room where they will move into and get auto CT scanned. That way each pt is scanned daily without effort.

If they want to make CT scan safer then they should go invest in making MRIs cheaper. Otherwise... scan ahead!

 

[Jeff698]

In addition to Southerndoc's reply about why most CTs originate from the ED....

The ED is where undifferentiated patients go. They come in to us with a huge differential and we narrow it down by investigating the really nasty possibilities.

We've created a test in the CT that, like it or not, give us the answer much of the time when Osler himself wouldn't have been able to get it.

One of the reasons physicians today (and don't give me this crap about it just being EM physicians) aren't focusing on physical exam findings is because, as we research the sensitivity/specificity/PPV/NPV of different findings, we realized they suck. We can either spend lots of time perseverating on the presence/absence of a finding with the sensitivity of a coin toss or we can order a test with 98% sensitivity.

So...what would Osler do?

Who cares. What would the evidence support?

BTW, if my patient tells me they're having the worst headache of their life, it came on suddenly during sex... they're getting a CT scan. To not get it is unresponsible. Most physicians would understand "worst HA of life" to be shorthand for "I believe the pretest probability of SAH is sufficient that it must be further investigated with a CT Head and, if negative, an LP"

Take care,
Jeff <- fully aware that a CT is not always indicated.

 

[docB]

I'l second or third the fact that most CTs are ordered from the ED because the patient's are on their initial workups. In fact most of the internists in my houses won't admit someone before any CT they might conceivably ever need has been done. Otherwise they might have to call a consult on their own.

 

[southerndoc]

I'l second or third the fact that most CTs are ordered from the ED because the patient's are on their initial workups. In fact most of the internists in my houses won't admit someone before any CT they might conceivably ever need has been done. Otherwise they might have to call a consult on their own.

I hate it when the internists want CT's for pyelonephritis and pancreatitis. It never fails I have to defend not ordering a CT. If they want it they can order it from the floor. If I thought the patient had a stone or hemorrhagic pancreatitis, then I would order it.

 

[Jeff698]

I hate it when the internists want CT's for pyelonephritis and pancreatitis. It never fails I have to defend not ordering a CT.

Even better is when you're resistance is weak and you order the scan. You then have to defend GETTING the scan to the radiologist.

The sum of that defense is "here's the internists pager number".

Sometimes you just can't win.

Take care,
Jeff

 

[BMW19]

Do CT's really increase to the overall cancer risk by 2%! That is a crazy # to believe. It is stated in the NEJM article.

I personlly have people in my family that have been CT'd several times just for sinus issues! How much could the actual overall lifetime individual risk increase? That would be a hard # to quantify

BMW-