Saturday, January 19, 2008

If You Do, Or If You Don't....2/6

Enough traffic has come back on the ER/CT issue that it gets its own post. One video tracker lists the 'reports' that are on the news channels. I solicited the following from some of those in the field:

Years ago, it was often said that radiology and lab was used to "rule out" this or that ailment because the doctor's didn't know how to make a clinical diagnosis. As a kid, I had right lower stomach pain and the family doctor did a simple blood test, pressed on the area that was hurting and told my parents to get me to the hospital ASAP and the surgeon would be waiting to take my appendix out. Today, it's lot's of lab work, plus a CT and then surgery. I think we can thank in large part of this particular dog and pony show to trial lawyers for driving up the price of a simple diagnosis. That's a whole different topic for another time!

On the plus side, CT has eliminated so many x-ray studies I couldn't count them. The numbers must be huge. Plus, the difference in radiation dose in a minimally invasive CT versus an angiogram (name your study) has to be significantly lower. And, many of these exams are performed on an outpatient basis eliminating lengthy hospital stays while recovering from such procedures. The diagnostic results are far, far superior to the "old" methods and techniques once touted as leading edge technology.

In a nutshell, CT may be over used by some physicians as a CYA defense, but on the whole, it's such a valuable tool that it has become the standard of care in medicine.
CT is a great thing. It lets us see into areas of the body that "the sun don't shine". And that's good. However, the over-use of radiation in any form is not. If you go into the ER, and I mean virtually any ER, and you have a cold, headache, miscellaneous pain, or trouble with your bowels (too active, or not enough), you will have an X-ray, and/or a CT. And, if you go there the next day, or a week later, the likelihood is that you will get the exact same treatment.

It doesn't mean that the treatment you will receive is bad, it just means that an emergency room is for EMERGENCIES. So, that's why you are directed to follow-up with your family physician. Without knowing you, the ER performs the same general screening time after time.
All xrays and lab tests are overused in the ER. I know this because I have a good friend who is a board certified ER doc and he would tell you: ER docs are the whores of the hospital. They are hired to do the dirty job that staff physcians don't want to do (ER coverage) but when the fecal matter hits the rotating blades, the staff docs won't hesitate to let the ER docs hang in the wind. So to cover their bottoms, they order more lab and xray, CT, etc than they really need, because it all comes down to our lawsuit happy society. CT is a great tool and it is over used, but it's either that or lawsuits every day and no more ER docs to cover.

Links to further reading:
Consumer Reports
The Washington Post
US News and World Report
Common Good
Sign My Cast


Anonymous said...

This is not a good time to try and sell a hospital or hospital company. They must buy some time and the best way to do that is to declare a "study". Don't really have to do a thing...just look at stuff. Buy a few capital items that you have to buy anyway to keep the locals off your ass and be attractive later when the market is better. not be diverted by the B.S...if it looks like a duck, quacks like a duck, then it's probably a duck (quack, quack!)

Anonymous said...

Ok, lets explore. 21 year old WM presents to ER with right lower quadrant pain for 2 days. Today has fever to 101 degrees F. Perfectly healthy all of his life, on no medications and no allergies. Saw his Doc 2 days ago and was placed on Cipro. It is Friday night and his local Doc is not on call. You are the ER doc. Physical examination reveals stable vitals with temp to 100 degrees F after one dose of Tylenol.Exam is normal except for rebound tenderness in the Rt. lower quandrant of the abdomen. The general surgeon on call happens to be in the ER seeing the 3rd patient of the night and planning to take yet another patient to the OR for emergency cholecystectomy. CBC ordered shows a WBC of 14,500 with a left shift and UA is normal. ESR is elevated to 30. You are in a level 1 trauma center. Oh, by the way, this young man is the son of the local trial attorney who loves to sue doctors. Your turn.

Anonymous said...

RLQ pain x2days, 14,500 WBC, 101 temp,and rebound...a touch more history, and probably a CT. How was the onset of pain...after eating? Characteristics? Assuming the rebound was at McBurney's point....

He'd be a surgical service referral, and the surgeon would make the call. Depending on the CT...if he'd eaten anything...the surgeon might hold until the AM and bump into the first slot...but that's his decision.

Anonymous said...

Interesting, it took you one whole sentence to mention CT.
Agreed, this is a surgical case until otherwise determined and only physical exam or xray imaging would be of sensitivity sufficient to declare this. Think back 50 years ago, I know you may be too young, but try. No CT. Went on physical exam and standard xray(low sensitivity). Rule of thumb used, if 50% of appendectomies aren't normal, your not doing enough surgery. Think this would fly with your insurance company or Medicare today? More to the point, walk out in the parking lot and look for the Parasitic Plaintiff's attorneys and run this by them. Either way, CT scans have simply become "standard of care" and if not done will be critical in cross examination.

Anonymous said...

I could have held back a couple...but why bother. An upright film would indicate if it had ruptured, but little else. My concern would be a CT on every bellyache that walks in the ER.

We rapidly create an excessive standard of care by our own over-reactions to the possiblity of litigation.

We are creating a situation in which a single payer reimbursement will be inevitable. And the government does so well in social programs.....

Woot said...

Well the problem will only be solved by capping medical malpractice suits. Like the slick shysters will let that law pass! Until it does...or heck freezes over, CT all belly pains for possible appy...still better than cutting them open to find a healthy appendix!

Technobabble said...

BTW, thanks for printing my all time fave Fqar Side cartoon!!!! All it needs is "Radiology" over one door and "X-Ray" over the other! LOL!!!!

Anonymous said...

Newest thing I've seen is doing CT's to rule out fractures on extremities. Usually you do this when the plain films show no break but the patient continues to have pain a few days afterwards. Now they are doing it in the ED every time they don't see an obvious break on the films.