The little things that make you age...

Discussion in 'Emergency Medicine' started by TrumpetDoc, Feb 14, 2017.

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  1. DissocativFugue

    DissocativFugue 7+ Year Member

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    Don't worry about it. It's the surgeon who has the problem. Not you. We have this one ortho doc who gets irate if there is a Ct ordered for a pelvis/hip fx and no plain film prior and will ask us to order one in addition. It's insane, unnecessary, egotistical and I mentally just chalk it up to some undiagnosed axis disorder of needing to feel superior. No matter what we do someone else will gripe and it's life. Do what you think is right and write your reasoning and all the rest is just noise.


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    TrumpetDoc likes this.
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  3. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 10+ Year Member

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    Regarding CT ---> plain film. The ortho buddy that I have has told me that it's far easier to size up the hardware he needs in the OR by a plain film. This may not be egoism after all.
     
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  4. Birdstrike

    Birdstrike 5+ Year Member

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    This is true. Now that I do over 80% of my work on patients with spine issues, constantly looking at MRIs, CTs, plain films and fluoro, despite the fact that CT and MRI typically give you more visual information than plain x-ray, plain films (fluoro or otherwise) do give you info MR and CT don't always give you for very specific situations, and quicker. Sometimes the complexity and 3D images can cloud the picture. Like your example, if you want to size up hardware, pedicle screws for example, it's much easier to do so with AP and lateral plain films, since you'll be comparing that directly to the fluoro (which is a 2D plain x-ray) in the OR. They want to know, "What does the hardware look like on AP and lateral?" To pull up a CT or MRI and try to assess that on cross sections, axial views, etc, makes the job more difficult, not less so, and might not even allow them to perform their surgery properly or confidently. Not to say that surgeons can't be arrogant and taunting at times to those in the ED, but sometimes a request that seems a little odd, redundant or unnecessary, may not be.
     
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  5. BoardingDoc

    BoardingDoc Don't worry. I've got my towel. 7+ Year Member

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    I have had the same experience. We rotate with orthopedics for a month during residency and this issue came up then. While counter-intuitive, there are definitely advantages to having plain films as opposed to cross sectional imaging. One of the few ortho injuries that I routinely get CT for is tibial plateau fractures (after suspecting it / seeing it on XR) as those are generally benefited by having a CT in the op-planning stage. Almost everything else is plain films.
     
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  6. DissocativFugue

    DissocativFugue 7+ Year Member

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    Thanks for the insight. I'm glad I didn't voice my opinions then and just ordered the plain films. I still am sort of baffled that the recons and saggital views and coronal views don't give enough information. However I can understand that it may be easier and more translational to the intraoperative environment. For now I'm labeling your advice as "alternative facts" much like the GOP.


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  7. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

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    Seriously? At least to me, it is quite clear as to why the plain films are better than the CTs, in the listed situation.

    As far as the political thing, huh?
     
  8. DissocativFugue

    DissocativFugue 7+ Year Member

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    It was an elderly person who had already had missed fx on plain imaging before due to osteoporosis. Hit her head and needed to go to ct anyway. This is what led to me ordering the way I did. If you don't understand my politics comment feel free to PM me.


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  9. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

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    I thought you were just trying to be humorous. I will not be PMing you; irony is you opened the door - you, for some reason, injected the politics. For you to bring it up, then say you'll only discuss it over PM is rich.
     
  10. DissocativFugue

    DissocativFugue 7+ Year Member

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    It was only a joke but I wasn't sure what you didn't get about it. Anyways it's not pertinent to the thread.


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  11. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

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    Yeah, not pertinent to the thread - but you brought it up. Maybe it's just because I'm a little tired at work, but that sounds a bit passive/aggressive.

    Good luck with your endeavours.
     
  12. DissocativFugue

    DissocativFugue 7+ Year Member

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    I didn't mean any ill will towards you or others. Sorry if I offended you. I really didn't mean to come off passive aggressive.


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  13. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 10+ Year Member

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    This was my precise logic. "She's on the table anyways, so I might as well CT that hip." CoolOrthoGuy was like - "Naw, bro - I gotta size up the hardware on the one good image; the x-ray. Make my job easy for me, plz?"
     
  14. ERCAT

    ERCAT

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    I had a patient who had right lower abdominal pain for three weeks. No fevers or anorexia, completely benign abdominal exam. I am saying no tenderness whatsoever. The only thing that set me off is she said, "It hurts in my right lower abdomen like heck when I walk around in heels!" I was a new PA and talked to my attending at the time who scoffed at me for having a gut instinct to order a scan. I ordered it anyway. Walked by her about an hour later and, not even turning away from her computer screen and typing furiously, she says angrily, "Call surgery. Patient in 15 has an acute appendicitis."

    Even had a kid who was getting on his bike traveling not even 1 mph when he braked and knocked his chest into the handle bars. Came in with chest pain. No belly tenderness. He had a mean liver lac. We had to air transport him out of there and he tried to leave AMA. When I asked why he said, "The only thing that will make me happy right now is a chicken burrito! I am starving!"

    Other kid, healthy 29 year old. Scraped his calf when stepping on a ladder a week ago and came in with calf pain. His calf was swollen so I just ordered the damn ultrasound and - DVT. I asked him, "Hey - have you had any chest pain? Cough? Problems breathing?" He said, "No... well, I guess last week I felt a sharp pain in my chest for a few seconds but that was it and didn't think anything of it." Big central PE on CTA.
     

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