Yesterday, Dr. Centor (whom I respect as a calm voice of rationality) went off the rails and joined the ED bashers with this:

Ask almost any inpatient clinician and you will hear that the ER does too many CT scans. I understand why they do them – but I disagree with the philosophy. They do CT scans in the hopes of decreasing malpractice suits.

Prior to CT scans, we diagnosed appendicitis clinically. Some patients have clear signs and symptoms; other patients have more confusing presentations.

Umm, “too many” depends entirely upon where you’re standing in the physician continuum. Let me tell you why we order CT scans, from the perspective of the grunt level EM physician.

We see the entire panoply of the human condition (as it applies to medicine), and have the terrific joy and challenge of sorting it out into recognizable bits. Without being dramatic, it’s not much like medical school taught us the physician-patient interaction would be. It’s entertaining but challenging, and more than a few of our patients have a limited education and vocabulary, and are literally unable to express themselves in terms that most ‘regular office’ patients can routinely display. In fact, some of them can do little more than yell “It hurts” and point at their bellies in the most vague way. Laying hands on their abdomens is usually a fruitless exercise in discerning hopefully whether the pain is from the upper or lower portion, to better guide the lab and radiologic / sonographic evaluations.

As for appendicitis: we’ve all, every one of us, had a case that was a Slam Dunk appy, we were so happy we’d made the diagnosis clinically we called the surgeon, who asked the following: “What’s their white count, their UA, and their CT show”? We’ll tell them (deflated a little, don’t they trust us?) that we don’t have a CBC back yet, the patient couldn’t pee now without extraordinary coercion, and why do a CT on a perfect case (?) to be told “call me back when you have them, and don’t do this again”. So, we learn: work everyone up, then call. It’s not only the ED docs who are responsible for increased use of scans.

Want to admit a patient with pancreatitis to the Internal Medicine service? “What’s the CT show?” is the admitting teams’ question. Us: Didn’t get one; had it before, has it again, patient states it feels just like their last pancreatitis flare-up. “Get a CT and call me back” is the usual refrain, and another ED doc gets dinged for an ‘unnecessary CT’, and the admitting team can cluck about the number of scans ordered in the ED. It’s not only the ED docs who are responsible for increased use of scans.

Finally, yes, we order a decent number of marginal CT’s, and it’s not just because we’re afraid of suits (we are*), it’s because all of us have several cases of What the Heck(!) they have What(?) from a CT that might, in retrospect be seen to have been more CYA then CVA, but find significant pathology. (My speciality is finding renal cell CA in patients that it’s not expected in, 3 so far). (Nobody gripes about those CT’s, by the way; a positive CT is a ‘goodCT’, even if in retrospect it wasn’t solidly indiated).

It’s like everything else in medicine: more complicated than it might seem on the surface.

*EM docs are sued at fairly high rates, and not because we’re stupid or negligent as a group or specialty. We’re sued because a) we have an interesting population of patients with varying disease, co morbidities, presentations and expectations, b) nobody loves their ED doc, especially when they get the bill, and c) we’re easy scapegoats for the next doc who’s only too glad to shift any potential liability to the ED doc (see b).