Bioengineer

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So I got into a somewhat heated discussion with my attending today about urine pregnancy testing. At some point in time during my residency I had a patient who was a young woman of childbearing age who was married and involved in a low speed MVC, wearing a C-collar, complaining of C and T spine TTP and L shoulder pain only. My attending wanted xrays of C and T spine, and left shoulder. Out of habit, I asked her if there is any way she could even possibly be pregnant and she said no. I asked her to explain. She stated that even though she was married, she had not had sex in months and has been having normal periods. Several reasons I thought she did not need a pregnancy test included: A. I don't think she is lying to me for no reason. B. These particular imaging studies haven't been proven to cause any harm to an unborn fetus. and C. Our hospital has a policy that any woman of childbearing age who can consent for xrays must sign a waver that she understands the potential risks to her unborn child should she choose to undergo radiological testing without a pregnancy test.

My attending basically told me that if he was the expert witness for the plaintiff that I would have no chance in court. He said if she had a child and the child had any type of deformity that I would get sued and I would lose and he based it on the fact that I was too cavalier to order a cheap urine pregnancy test.

What do you think? Do I have a defense? What has medicine come to if this is what my career will be about? This is not what I want my practice to be like. I try to be reasonable in my clinical practice. What am I missing?
 
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I'm just a resident as well and I completely agree with you. I have attendings that do the exact same thing in many cases which doesn't make a whole lot of sense to me. Call me naive, or just not jaded yet, but I feel like defensive medicine gets in the way of rational thinking and clinical judgement that medicine used to be about. Of course, now it's more about CYA and the thing is, I don't blame them.. it's just how society has changed.
 

KiloAxe

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In order to be considered medically negligent, you have to have duty, breach of duty, causation, and damage. The radiation exposure from xray is generally considered safe and I don't think they could actually PROVE causation in court. And given that the patient had to sign a waiver prior to the xray, I doubt they would even have a case. Personally, I don't get a UPT on everyone who is getting an xray.
 

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Our rad techs won't xray the abdomen, pelvis, hip, femur, chest, T or L spines of women between 10-60 without proof that they aren't pregnant or a signed waiver. I think you did all you needed to do, and your attending was just being a dick. It's ok, we all are sometimes.

The good news is that if you have someone who can't or won't pee on the backboard, or you have problems obtaining urine like the rest of us, you can use serum on a urine card and get the same results. If your lab nazis will let you do it.
 

Flopotomist

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In the "pick your battles" list, not sure why this would be one to choose. The cost of a UPT is tiny compared to a lot of the other tests we do all the time... why rock the boat for this silly thing? If a $8 test keeps the nurse, the rad tech AND the attending happy, I'll order it all day long.
 

AlmostJesus

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Our rad techs won't xray the abdomen, pelvis, hip, femur, chest, T or L spines of women between 10-60 without proof that they aren't pregnant or a signed waiver. I think you did all you needed to do, and your attending was just being a dick. It's ok, we all are sometimes.

The good news is that if you have someone who can't or won't pee on the backboard, or you have problems obtaining urine like the rest of us, you can use serum on a urine card and get the same results. If your lab nazis will let you do it.
Apparently, you can also use whole blood on a urine hcg card.
http://www.ncbi.nlm.nih.gov/pubmed/21875776
 

Dr.McNinja

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If a $8 test keeps the nurse, the rad tech AND the attending happy, I'll order it all day long.
If the $8 test takes 4 hours to perform, then it costs more than $8. As a resident, you aren't the one responsible for moving the department, so I agree, order away. As an attending, it's a battle I will fight if it isn't relevant.

Also, the whole blood thing was what I was trying to find earlier, and for some reason I could only find the serum data. Glad to see I wasn't crazy. Fingerstick with a couple of drops of blood is a way to speed this process up. Again, if you can get your lab to let you.
 
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if they have a uterus and have had a period in the last year, I get urine preg on virtually every female I see (i'm sure there are a few exceptions but I can't really think of them).
 

Arcan57

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Have you ever had a patient that couldn't possibly be pregnant (no sex, nl periods x years) have a positive pregnancy test? Maybe husband is deployed and she doesn't want to admit she's stepping out on him while he's overseas. Patients lie for a variety of reasons and sometimes for no reason at all. It's extraordinarily unlikely that a T-spine xray would cause any ill effects to a fetus, but it's likely that if there was something wrong (which is uncommon but not vanishingly rare) a jury would be willing to assess damages.

If they truly need a T or L spine xray (which I think is way overused in low mechanism MVCs because we take too damn long to clear people off the spine board), waiting for the pregnancy test is usually the smart move.
 

Tiger26

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If I'm getting labs already, I just get a serum preg since I know it will be drawn rather than getting to the end of the work up and finding out they didn't pee.

As for the not x-ray'ing thing without a preg test, the absurd thing is that kids born a few months premature get a daily chest x-ray while they grow in the NICU . . .
 

goodoldalky

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I agree with your attending here.

Several reasons:

1. Patients lie all the time. If it's about drugs or sex, they lie even more.
2. If the patient IS pregnant, depending on how far along she is (often hard to tell in my patient population secondary to BMI), she may need fetal monitoring or K-B testing.
3. UPT is fast, accurate, and has essentially no risk to the patient.
4. Whether it's necessary or not, all radiographic and trauma associations recommend abdominal shield for radiography in pregnant women.
 

Dr.McNinja

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Caveats, I practice in Texas, where the standard is willfully and wanton for malpractice.
For CT scans this isn't even a question. Nothing like documenting the iup on a CT. For the vast majority of xrays waiting for urine isn't necessary. CXR is the same as flying when it comes to radiation. That population isn't screened. L spine xrays, or any other near uterine studies, I'll get blood before urine. I really wish I worked at the ED the rest of you do where you get urine results quickly. Hell, I wish we could collect it before the 4 hour mark where the lab cancels it because they haven't received it.
Don't even get me started on how only doctors can "clear" off a spine board.
 
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Yes. Exactly. All patients lie, all the time. The one time you don't look is the time you get burned.
agree. I'm finishing residency now... 1st year I fought this battle. But, I quickly changed my tune after I had a couple women who say there's no chance and they aren't sexually active come back +... For the most part, if you are between 10-60 and have a uterus, I check.
 

RustedFox

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I got singed like this once when I was an intern. Patient swore up and down that there's no way she could be pregnant, and wouldn't pee for whatever reason. I told them to g'head and shoot the abdominal series.

Positive UCG.

Attending made me feel like less than a human being. It still bothers me a touch.
 

EM2BE

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agree. I'm finishing residency now... 1st year I fought this battle. But, I quickly changed my tune after I had a couple women who say there's no chance and they aren't sexually active come back +... For the most part, if you are between 10-60 and have a uterus, I check.
Only time I don't is if they are obviously pregnant.
 

logos

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At our institution she would get a CT, so we would do the preg if possible. For plain films I think asking the patient is adequate as the risk is approaching zero.

I have a great image of a pelvis where you can see the fetal head taken in our trauma bay. Sometimes you just need the xray and it dosent really matter if she is pregnant.
 

EctopicFetus

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A few points.. many as mentioned above.

1) all patients lie.. I have had virgins come up pregnant.. Miracles were happening..
2) you absolutely should check a preg.
3) where I work I just shield them.
4) if im worried about them (trauma wise) I dont care if they are pregnant.
5) we do tons of stupid things to keep the attorneys away.
 

Rendar5

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Question is how far do you go to check an hcg. I've had plenty of nonsexual women come up positive, and I can understand the need when it comes to spinal xrays. But head CT with abd shield? ankle Xray? finger Xray? I'm not entirely sure that a signed waiver and an abd shield is inferior to a upreg, honestly, as you would still order the test and shield them in those cases.

That said, I do agree with your attending in this case because this would not be a situation where you could cover your ass in terms of the patient lying by shielding them.
 

Apollyon

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+1. Stated lesbian, there with girlfriend who said, "It's impossible, I'm gay" and proceeded to pee HCG loaded urine into a pee cup. Confirmed with quant HCG and u/s.

Another immaculate conception. That Holy Spirit really gets around.
Saw that, too, when I was a resident. The non-pregnant partner was nonplussed, to make a gross understatement.
 

Arcan57

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Question is how far do you go to check an hcg. I've had plenty of nonsexual women come up positive, and I can understand the need when it comes to spinal xrays. But head CT with abd shield? ankle Xray? finger Xray? I'm not entirely sure that a signed waiver and an abd shield is inferior to a upreg, honestly, as you would still order the test and shield them in those cases.

That said, I do agree with your attending in this case because this would not be a situation where you could cover your ass in terms of the patient lying by shielding them.
It's likely going to vary by institutional rules. We just got our rules changed so chest xray, extremity xrays, and CT's neck and above could be done without a UPT and just shielding. In terms of pregnant lesbians, I told a woman she was pregnant and she said "that's impossible I've been in a committed lesbian relationship for 10 years". Got the quant back and it was 4, which was actually a negative for our lab.