Coo-Coo or Contra Coup
I recently treated a very old and pleasantly demented gentleman who had slipped and fallen at home, sustaining a laceration to the back of the scalp. It was a witnessed fall, his second in less than a month, and there was no report of syncope or loss of consciousness. Other than the laceration, the patient was without complaint and neurologically intact, at his baseline mental status. He just wanted me to hurry up and close his wound so he could go home.
I briefly considered not ordering a CT scan; after all, his recent head scan (reflexively ordered by one of my risk-averse colleagues) was normal, he wasn't on any blood thinners, and he seemed to be OK. Apparently there are some ivory tower physicians who think we ER docs order too many imaging studies, and I heard them murmuring like a chorus in the back of my mind. Fortunately, I ignored them.
I'm certain that if I had NOT ordered a CT scan on this patient with a seemingly benign injury, the Multidisciplinary CT Scan Rationing Committee would have had a meeting with the Quality of Care Committee and they would have jointly supported my decision...even after his subdural hematoma and hemorrhagic cerebral contusions had become clinically apparent and possibly devastating. Maybe they would have even given me an award for my outstanding clinical judgment or my superior rationing of resources.
In the real world outside of academic conference rooms, nobody ever gives you a pat on the back for ordering fewer tests or practicing more cost-effective medicine. But one thing that academia and private practice have in common is that administrators in both arenas have a very low tolerance for missed or delayed diagnoses, particularly when the outcome is bad.
So we'll continue to order as many damn CT scans as we want. Personally, I'd rather order 1,000 "unnecessary" CT scans than face the question of why I didn't order the one that might have mattered.
I briefly considered not ordering a CT scan; after all, his recent head scan (reflexively ordered by one of my risk-averse colleagues) was normal, he wasn't on any blood thinners, and he seemed to be OK. Apparently there are some ivory tower physicians who think we ER docs order too many imaging studies, and I heard them murmuring like a chorus in the back of my mind. Fortunately, I ignored them.
I'm certain that if I had NOT ordered a CT scan on this patient with a seemingly benign injury, the Multidisciplinary CT Scan Rationing Committee would have had a meeting with the Quality of Care Committee and they would have jointly supported my decision...even after his subdural hematoma and hemorrhagic cerebral contusions had become clinically apparent and possibly devastating. Maybe they would have even given me an award for my outstanding clinical judgment or my superior rationing of resources.
In the real world outside of academic conference rooms, nobody ever gives you a pat on the back for ordering fewer tests or practicing more cost-effective medicine. But one thing that academia and private practice have in common is that administrators in both arenas have a very low tolerance for missed or delayed diagnoses, particularly when the outcome is bad.
So we'll continue to order as many damn CT scans as we want. Personally, I'd rather order 1,000 "unnecessary" CT scans than face the question of why I didn't order the one that might have mattered.
Labels: defensive medicine, health care crisis, links to greatness
posted by scalpel at 2:33 AM
31 Comments:
So you just order ct scans for everyone with only minor head injury??? That sounds like a crazy waste of resources to me.
Not necessarily, but such an approach can be justified. How much does a CT scan cost the hospital anyway? Not much. We're already open for business 24 hours a day. The scanner is warmed up and ready, and the CT tech is just surfing the internet. The Radiologist doesn't mind reading them either. Cha-CHING!
I whole heartedly concur; the massed choir of gainsayers who complain about "defensive" medicine, or "soft" referrals for CT become startlingly quiet when a patient like this mcomes back 2 weeks later with a GCS of 3 and finally gets the scan. I feel the same way about referrals for admission. I'd rather the criticism of a thousand of my colleagues for "unnecessary" admits than 1 grieving relative
In an ideal world, an excellent clinician should be able to charge more for his services. If I can make a diagnosis without ordering a $2,000 test, isn't my value to the patient worth an extra couple of hundred dollars compared to a less experienced doctor whose "cost to diagnose" is higher?
In our current system, it is not. I have very little incentive to NOT order CT scans. The only real disincentive to ordering abdominal CTs, for example, is the extra two hours they take. If they were quick, I'd probably order them on almost everybody with belly pain.
What incentive does a surgeon have to trust my judgment (or use his own) and skip the CT scan on an obvious case of appendicitis? None whatsoever, except as dictated by his personal schedule.
Hey.. Very true.. I remember one of our proffessor quoting this whatever you said.. He said the ct and such investigations which when not needed should be avoided.. The one who can do this is really a good physician.. Well in india. . Cost effectiveness really matters because many cant afford to have it..
Well one reason not to do the CT scan is the massive amount of radiation you expose the patient to. Also incidental findings on these ct's sometimes expose patients to additional tests with their own risks.
Those aren't really very convincing disincentives from MY standpoint.
The radiation argument is mostly theoretical, but if a patient were to actually suffer an injury the blame couldn't be localized to an individual scan or ER visit. It would be tough to prove that my CT scan caused cancer years later.
The incidental finding argument is more of an easily managed annoyance, usually just requiring a brief conversation, a little documentation, and recommendation for further testing long after my interaction with the patient is completed.
I agree that the easy way for you is just to order those ct's. But as a doctor I would expect you to make decision that are in the best interest of the patient, even if these are not always beneficial to you.
I probably order a head CT on about 75% of those over 70 with mild-moderate head trauma (presuming not on coumadin). One has to be a YOUNG 75 year old without a million medical problems and not frail for me to not order one. I have diagnosed dozens of cerebral contusions on old people with relatively minor injuries and hate to think what would happen to me in one of those review committees when they discuss my missed diagnoses.
So the course of treatment for this very old pleasantly demented man will change how?
Will the cost of the expensive tests use the last of this elderly man's savings?
Everyone in the field knows that his life course will not be improved by any knowledge gained from these tests. He's very old and frail and already demented.
From this patient's standpoint, what good came from the diagnostics?
Within the administrative oversight of the NHS Emergency Medicine Service in which I work (1 very large ED and 2 minor injury units serving over 1 million patients),I am always being rapped over the knuckles by the admin REMF's for the number of x-rays that I order;whilst the M&M stats simultaneously show that I "diagnose" the greatest number of fractures generally;and in relation to the amount of films-ordered;and the number-of-patients-seen/practitioner.But always,the x-ray is ordered because I think its going to improve the outcome.
If it were me (as the patient) I would want you to order whatever you feel or deem necessary, YOU are the doctor not the other "hoot" who's job is to " save $ when it comes to the point !!! Stacy
"He's very old and frail and already demented."
In this country, at this time, those aren't justifications for rationing medical treatment.
"From this patient's standpoint, what good came from the diagnostics?"
He maybe got to live a little longer than he would have otherwise.
Screw that, man. If they are over 70 or so and they take a whack to the head, they get spun. No way am I going to be on the hook for missing that. I don't need the stress, and I get to sleep that night.
I agree with the course of action on that patient, but what is your stance on kids?
Fellow colleagues of mine feel the need to scan every kid that has had a GLF and a bump on the head. It drives me out of my head, I just do not understand the logic behind it or lack there of. Especially since it is becoming common practice.
Chart review is sending my BP through the roof.
Old demented people get scanned, that's the rule. What if he was only "pleasantly demented" after the fall? You never know. Younger people get a discussion, more participation in their own care, and sent home with counseling about symptoms to watch out for.
Besides, just like there used to be an acceptible "negative appy" rate, you need to have some scans come back negative, otherwise you're missing stuff.
Well then make life easier for yourselves scalpel. Just have the CT scanner in triage and CT them all head-pelvis. Add on a rainbow panel and EKG and you are done.
Ahhhh ...
One of my favorite quotes comes to mind:
"When things go wrong, nobody thanks you for saving them money."
Its obvious that the people who don't want you doing the CT have never been sued for missing an injury like this.
Would you all change your minds if the patient was your child/spouse/parent?
If so, you're blowing smoke.
If you´re not seeing very many normal CXRs, head CTs or whatever other tests you´re not ordering enough - words of wisdom from a very experienced emergency physician.
I'd say it was good call. You had that gut feeling, which always ends up involving your butt when you ignore it.
Jon
Scalpel...what do you mean when you say "The radiation argument is mostly theoretical"?
Has anyone ever proven that CT scans have caused a single case of cancer?
Oh Scalpel...I WANT YOU TO BE RIGHT!!
Here's the way I look at it:
If I've never had a CT scan, I wouldn't worry at all about getting my first one. If I've already had 10 of them, then one more probably isn't going to make that much difference, but I might think twice about whether I really need it. If I've already had 30 of them, then I'm on borrowed time anyway, so I should be thankful for the extra time that modern medicine has extended my life (or improved its value).
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To be fair, as discussed at ER stories (http://erstories.net/?p=842#comments), there are some categories of patients for whom collaring and CT scans are warranted, even for a minor fall. Elderly patients, like the one you scanned, are one of these categories due to the risk of C-spine damage, brittle bones, and the possibility of dementia (unable to respond properly to help with the diagnosis).
The ivory tower folks like myself are more about identifying best practices because sometimes tests are overused and defensive medicine is practiced.
The key is defining best medicine, and making sure the people who translate studies to actual practice are aware that "best practice" varies by patient category.
what could possibly be an unnecessary test for a healthy 18 year old in a MVA but no neck pain can be necessary for an elderly patient who merely fell out of bed.
Sorry about the long post previously and is why I deleted it, but you could see why I get a little squirrelly anytime over use of radiologic tests come up.
Do like your theory though.
So there are no long term studies that definitively prove this concern?
Although logically...I can appreciate why the concern.
Someone told me I get more radiation flying from east to west coast than a CT. Then aren't frequent fliers at risk?
Other than the interesting stream of comments, my favorite thing about this post was your clever title. Much appreciated.
Scalpel I like your style, wish you were a Dr in the Er where I had a visit recently and needed a CT ordered that never was. I work in the hospital which is a true shame. was having sever chest pain, shortness of breath, No EKG changes, had had recent knee surgery, Hx of DVT to PE, All the Doctor wanted to ask was if my day had been to stressful. Thought I was having a panic attack which I had never had. Gave me morphine and sent me home. I went to another ER and had the CT and You guess it, which I had already figured since the pain was localized PE on the CT
heart and lungs my area of specialty. I didn't let it drop. its amazing to me how many doctors think women with chest pain are looking for attention, having panic attacks or are simply just having a stressful day. Giving me a fucking break. I've been in the medical profession for 20 years. Dr Doogie (my ER D0c)needs to go back to medical school and learn.
How much does a CT scan cost the hospital anyway? Not much. We're already open for business 24 hours a day. The scanner is warmed up and ready, and the CT tech is just surfing the internet. The Radiologist doesn't mind reading them either. This makes sense. So what is the problem? Is the patient (or his insurance) getting a high bill for this test? So the hospital is making too much profit from it?
nokomis@sonic.net
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