DB’s is Dead Wrong on ED CT Overuse

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).


Comments

  1. trenchy says:

    looks good so far.

  2. trenchy says:

    Oh the topic, Too many CT’s? That’s funny…

    1. SEVERAL specialists in my area will perform and read films in their office diagnosing an injury (usually a fracture) after I diagnosed a “sprain” without films. It invariably results in a patient complaint an dropped ER charges… even though we have plenty of evidence to show that the physicians are simply bilking patients.

    2. Patients are ROUTINELY referred to the ER for CT’s by PCP’s and specialists… particularly at late hours of the night when all the patient needs is an evaluation by a physician. The MD’s sending the patient apparently niether trust the EP’s evaluation skills nor want to get out of bed to do it themselves.

    3. Non- Emergency Physicians rarely see the initial presentation of the diagnoses that EP’s must make on a daily basis. Appendicitis, Pulmonary Embolism, Subarachnoid Hemorrhage, multi-trauma, kidney stones, and a vast array of other illnesses RARELY present to the outpatient setting and many PCP’s do not even understand the utility of CT in these presentations.

    4. Radiologists ROUTINELY suggest follow up CT for radiographic lesions.

    5. On a personal note, nearly every non-EP seems to have a problem with some portion of Emergency care and MANY jump at the opportunity to criticize the ER. I personally prefer to be criticized for being too careful than for missing, with 2 weeks of tests and retrospection, an “obvious” diagnosis…

    …screw ‘em!

  3. Speaking as a specialist….screw ‘em indeed! This is a complex issue, and not going to go away. As an old-fashioned surgeon, I prefer to simply take “obvious” cases of appendicitis to the OR directly, rather than waiting on a CT. When a patient with an “obvious” appy gets a CT before I am called, and I ask the ED doc why, they tell me that my younger colleagues (and those that are a bit lazier) insist on one. Oh well….screw ‘em!

  4. Goatwhacker says:

    Having worked in both ED and office-based medicine, in retrospect I can say I probably did order too many CTs out of the ED. I can think of four main reasons for this:

    1. Medicolegal – this goes without saying. While every doctor knows H&P is more important than imaging, the reality is that the public and by extension the courts place an almost mystic importance on testing. In the case of appendicitis I think many docs would consider a CT or US the standard of care, although I’ve seen appys missed and surgery delayed in patients with normal CTs.

    2. Temporizing – when the whole ED is crashing around you, ordering a CT is quick and easy (too quick and easy probably). ED docs are often proud of the ability to juggle many patients at once, temporizing and ordering tests is one way to do it. I’m not particularly proud of this reason but it happens.

    3. The CT is a heck of a good test – Compared to CTs when I started in residency (1985) CTs have become so good there is a temptation to over-utilize them.

    4. lack of longitudinal care – the ED is geared towards quick diagnosis and disposition. In my office I can tell patients I’ll be in the office all day and to let me know if they get worse. They can also call me at home for advice. In the ED you generally can’t provide this type of service and the administration frowns on you keeping a patient in the ED for a few hours to see how they do.

    A side note to Trenchy – of course I see appendicitis, PE’s and kidney stones in my office, why do you think I wouldn’t?

  5. Eddie Alexander says:

    With respect, two comments here:

    1. A baseline CT scan is required for pancreatits because clinical deterioration can then be observed radiographically by comparing another CT to the one obtained on admission. (e.g. for necrotizing pancreatitis )

    2. CVA (an inappropriate term in any event-what accident?) is A CLINICAL DIAGNOSIS..I’m sure you know this, but for everyone else, the CT is necessary to look for hemorrohage (about 12% of cases) and to avoid giving thrombolytic therapy to a bleeding stroke victim..
    Good post as always…

  6. First, I love Goatwhacker’s name.

    Seocnd, I am an IM hospitalist and I NEVER ask my residents for a CT scan result for a case of pancreatitis. If one was done in the ED, I tell them that I’m not even interested. Unless you are suspecting pancreatic necrosis (a rare thing) the CT doesnt help, and most likely will be negative for a wek. The vitals and labs and the patient tell the story.

    Additionally, I see a lot of CT’s for suspected colitis and diverticulitis. These are tough calls and I would never fault an ER doc for getting one for those.

    Can you just imagine if we didnt HAVE CT scans??? I’d rather have too many than too few.

  7. Trenchy says:

    Goatwacker; many, many private MD offices use the ER as a diagnostic center. If it takes more than the 15 minutes needed in the office they are sent to the ER, usually with a list of tests that they suggest with an “ER to evaluate and treat” note attached.
    Yesterday, I had referrals to evaluate for… “r/o fracture”, “r/o urospesis”, “r/o neurosphyllis”, “r/o angle closure glaucoma”, and “r/o appendicitis”. The neurosyphillis consult entertained us for some time.

  8. One of the tricky bits here in the north is that we don’t have CT scanners. Somehow that doesn’t prevent people walking into emerg with “this is the worst headache of my life”, “he just won’t stop having seziures”, and “I keep coughing up blood”.
    I always get a bit of a kick out of the irate calls that occasionally come back if the scan shows up negative. Trust me, when I send a patient thousands of kilometers in a medevac plane because they present clinically as an SAH, I am not ‘dumping a migraine on your service’ if they turn out to not be bleeding…..
    Sigh, at least my appis go straight to the OR….

  9. Habits can be hard to break. One of the problems with EDs is that a patient may come back again and again, yet be seen by someone different each time.

    I try not to have my migraine patients go to the ED, mostly because it doesn’t necessarily help overall management. It’s hard to see the sense in someone getting a CT of the head every time they come to the ED with a headache, even if it’s been once a week for the last month, and there is really nothing special about their headache each time.

  10. We have some docs that will order a chest CT on every 20 year old with a cough and “chest pain” (with deep breaths), even with no shortness of breath, no history of recent surgery nor risk factors for PEs etc, nor decreased O2 sats, to rule out a PE. I feel that is CT overuse. This is in addition to the heart monitor, troponins, etc. Other doctors in the department would never think to order a chest CT and expose the kidneys to the dye with such a benign presentation. These scans make for a long day at work, especially since I’m usually the one who has to explain their “indication”.

    My favorite all time Head CT was on a young adult who got whacked in the head with a chocolate egg on Easter and had no decreased LOC nor even marginal signs of anything except a lump on his head.

  11. I have one partner who (I swear to God) introduces himself as “Hi, I’m Dr Jones. what sort of CAT Scan do you need”

    The CT techs hate him.

    Sigh.

  12. Hear hear!

    “what’s the CT show?” I hear it EVERY SHIFT…multiple times, on pts that I didn’t initially scan.

    Last night…RLQ and flank pain, sounded like a stone in a new stoner. Uro wants CTs to confirm, then KUBs to follow. CT showed possible early appy. Call Surgery. Uhoh…noncontrast CT…”get a contrasted one, then call me back.” I tell him the guy’s creatinine is 1.6, how about they come lay hands on him first (which I already did; I didn’t make my CT decision based purely on his CC)? “OK, but our recommendation will be the same.” I suggest putting him in the hospital for serial exams.

    They come down, see him, ask for the CT. Busy night…4 hours later, CT’s done. Shows the exact same thing. So they put him in the hospital for serial exams.

    That’s 2 CTs, same pt, only one of which I did, and mostly b/c the Urologists want it for stones (glad I did, or I’d have missed the early appy.) And they ended up doing what I’d recommended anyway.

    Same night, same consultant…”I’ve got a lady here with an incarcerated hernia.” “What’s the CT show?” “I don’t need one…I can feel it.” “Well, I’ll be down when I can. Get the CT.”

    Kelly: Those docs you work with don’t know how to use other risk-stratifying tests, then. You don’t go “hmmm….PE…CT.” You risk stratify, and if they’re high enough risk, CT them. Same with head trauma. Sounds like you work in a practice of mighty scared physicians…

  13. jrobatc says:

    We also see a high number of patients who have no primary care physician. True there are some compassionate care networks for unattached follow up but many take months to get in. When I have a suspicious mass show up on a routine xray, I have no choice but to scan it or risk the patient being lost in the mire of hopeful outpatient follow up and delay treatment. An attorney tried to sue our group for a mass on an admitted patient that did not get worked up. The wet read from radiology was normal. The next day, after the patient had already been admitted the final read showed a suspicious mass. Weeks later the patient was found to have metastatic small cell and the attorney tried to pin delay of care on the ED. This was in a patient who had been admitted and had good follow up.

    Do we try to limit CT’s? Certainly, a good knowledge base in conjunction with an appropriate history and exam should go far with the risk stratification. However, we do see very ultradramatic patients who you can’t even touch without them screaming in pain, poor historians etc limiting our bedside abilities and forcing us to rely on tests which often times are, in retrospect, unecessary. There are also times where that small voice in the back of your head tells you to scan something and woe and behold, that PE with normal vital signs, rears it’s ugly head or in a recent case a realtively healthy 40ish midlevel provider who works at our hospital was found to have an extensive aortic dissection in a chest pain work up.

    Personally, I prefer to avoid extensive tests in general to increase throughput in the ER as well as to do my part to limit the overall burden of healthcare to those of us who are actually bearing the burden in the form of taxes as well as high premiums ($912.00 a month to purchase my own plan for my healthy family!) but I have to balance this with standard of care, proper work up, admitting MD expectations, and medical legal considerations as well.

    Finally, I dare say that were we to miss a diagnosis by not ordering a CT, those same non-ER MD’s who criticise us for ordering too many would criticise us for not oredering the CT in that case.

  14. However, we do see very ultradramatic patients who you can’t even touch without them screaming in pain, poor historians etc limiting our bedside abilities and forcing us to rely on tests which often times are, in retrospect, unnecessary.

    I doubt they were unnecessary, it’s just that when they come back negative it’s normal to ask ‘did I really need that test’ and the answer is yes, you did. (The other way is, had the test shown something actionable, would you still say it had been unnecessary)?

  15. jrobatc says:

    Good point GruntDoc. My experience has been that, in most cases, the ultradramatic are being so for secondary gain and rarely have any true findings. I give them the benefit of the doubt, especially since many have several risk factors and co-morbidities, but often I am reasonably sure I’m not going to find anything when I roder the tests.

    PS I love the site. I am a TrenchDoc refugee and recall Trenchy referencing your site as well as the recent reference to both of your sites in Annals.

  16. Unofortunately, I rarely call the surgeon for an appy withouth a scan. Prio to CT, surgeons were allowed (even expected) a 25-30% negative rate. With CT it’s now below 5% and any deviation from this percentage causes them trouble. I’ve also been burned twice now by terminal ileitis in young males without an IBD history. It’s all down to one thing, America: LAWYERS.

  17. Jen N. RN says:

    I watched a congessional hearing on CSPAN the other day about Emergency Medicine. They are actually entertaining the idea of passing legislation that makes it more difficult to sue ER Docs and personnel. It would be similar to prehospital stuff where the person has to prove “Gross Negligence.” Wouldn’t that be nice! The 3 ER Docs on there sure thought it was!

  18. Jen,

    Can you give me a citation, bill name, or anything else?

    Was it House or Senate?

    SF

  19. Jen N. RN says:

    Here is a link that to an article that talks about it….
    http://www.acep.org/webportal/Newsroom/NR/general/2007/062207.htm

    Here are a few excerts…
    …”The Government’s Response to the Nation’s Emergency Room Crisis” hearing is being held today by the U.S. House of Representatives Committee on Oversight and Government Reform, chaired by Rep. Henry Waxman (D-CA).

    In addition, U.S. Reps. Bart Gordon (D-TN) and Pete Sessions (R-TX) have introduced the Access to Emergency Medical Services Act of 2007 (H.R. 882) in the House of Representatives, and U.S. Senators Debbie Stabenow (D-MI) and Arlen Specter (R-PA) have sponsored a companion bill (S. 1003) in the Senate. This proposed legislation seeks to address the dangerous trends outlined by the 2006 IOM reports, including specifically the widespread lack of preparedness for disaster.

    Hopefully that gives you an idea of who is doing what. The whole hearing was really interesting and talked about just the sad state EM is in in general.

    Here is a link I found to buy the hearing from CSPAN….
    http://www.c-spanarchives.org/videolibrary/index.php?main_page=product_video_info&cPath=6_11&products_id=199372-1

  20. Capt Kirk says:

    Too many CT’s? I’ve had one radiologist tell me I did too many in the ER. But for r/o appy, I’ve been very surprised how many positive appy’s I’ve discovered when the history and exam pointed far away – RUQ pain (not preg), no fever, normal WBC, no RLQ tenderness or rebound – but CT positive for early appy! I’ve found and admitted 5 (FIVE) early appy’s in the last 2 months alone by using CT as a final screen rather than sending pt home with recheck in 12 hours. I have 20 years experience in emergency medicine, and I’m a good enough clinician to know it’s not my exam.

    On the other hand, all my general surg calls start with “… And what did the CT show?” I work mostly nights, and found most general surgeons will delay coming in by asking for the CT in the most obvious cases (17K WBC, fever 102, periumbilical pain moved to RLQ, pronounced rebound RLQ, etc.) So I start antibiotics and get the CT (delaying their need to come in and evaluate the pt by an hour or more), call them back, and they admit the pt and schedule the case for the morning! Surgeons at both hospitals I work at now are holding off surgery until 7 am on patients coming in after midnight. Good thing cardiologists haven’t followed with their STEMI pts.

  21. michiganemdoc says:

    Yo.

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