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CT Scans; the new physical exam

I work in a busy, medium sized emergency department. Because we’re busy, and because of the ridiculous burden imposed by EMTALA, lots of consultants don’t really want to come to the emergency department.

Can’t say I blame them, really. It’s often a thankless job, thanks in no small part to our legislators who made sure everyone has access to health-care, but conveniently forgot to pay the people who are doing the hard work and actually seeing the sick, dying, wounded, drunk, angry and annoying.

If I were in another specialty, I’d honestly consider going off the call schedule, opening a surgery center or any of the other options docs do to avoid hospital affiliation and EMTALA-mandated work.

However, we’re still stuck with the problem until we all unite together and insist on it being changed.  For now, people still come to the hospital and need care, need studies, need specialists.  For now, I have to sort through it all.

Which brings me to the point of this post.   A few nights ago I cared for a small child with abdominal pain and fever that began about 12 hours prior to arrival.  He had no vomiting or diarrhea, no cold symptoms, no urinary symptoms.  His knees were drawn up, and he was lying on his right side.  He was quite tender to exam, and showed guarding.  One year ago, he had an appendectomy.  One less thing to worry about.
His CT abdomen and pelvis, with contrast, was essentially negative.  His CBC, urine and electrolytes were normal.  I called the on-call surgeon and described the child and studies.  He told me that it sounded viral.  I admit, I hadn’t re-examined the child at that point.  I asked, and probably with the wrong tone, ‘So are you telling me that nothing bad can be wrong with this child?’  My surgeon friend became annoyed with me (not with the patient), and came to the department to do an evaluation.
What followed was a back-hall argument that turned out to be a little too loud.  I felt badly and apologized, and so did he.  But I tried to point out that in the emergency department, we are often faced with a conundrum:

Sick patient, worrisome exam, negative studies.

So, what do we do?  Now, I’m throwing this out to everyone, ER doc, FP, Internist, Hospitalist, Surgeon and all.  I’m not being sarcastic; I want to know.  Have we reached a place in medicine where the science of labs and imagining is sufficient to rule out dangerous etiologies without exam?  Have we reached a place where history and physical exam are simply vestiges of the old days of medicine?

I’m not a researcher, but many of you are.  Please give me your thoughts on this.  I don’t want to argue with anyone, and I don’t want to miss a diagnosis.  I also don’t want to cause already over-burdened specialists to have to come to the hospital when they needn’t.  But sometimes, frankly, I want another pair of eyes, another set of hands, another brain admittedly sharper than my own, to help make a decision.

And I’m just not sure the scanner qualifies.

What do you think?  If I’m all wet, if I need to quit my belly-aching and stop worrying, I need to know.

Let me have it!  And please forward this to other docs in other specialties as well.  Because it applies to cardiology, ENT, pediatrics, anyone who relies on any kind of lab-work or imaging.

Have a great day!

Edwin

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Edwin

9 Comments

TBTAM

2008-08-13 00:26:02 Reply

I don’t think CT is the end all and be all, especially with kids and older folks, whose bodies tend not to have read the textbooks, and when not every radiologic test is perfect.

A re-exam would have been helpful for you, as you suggest, but in the end we also have to go with our instincts. In this particular case, sometimes continued observation or even admission for observation and serial labs will go a long way toward deciding the right course of action. Because one important element of the diagnosis is time, and the evolution of symptoms over that time. And time is a luxury that you have very little of in the ER. (And which patients and lawyers don’t accept very well as an important element in the decision making process….)

A consultation is just what you’ve described it as – a request for a second pair of eyes and hands and another brain to help out when the you are uncomfortable in making a decision.

mamadoc

2008-08-13 01:30:16 Reply

I’m an FP, not a pediatrician or surgeon, but I think this would be a place for admission for observation and repeat labs as outlined above. Unless the parents are gold-plated reliable and you believe they’ll followup with their ususal doctor the next day (admittedly, a rare situation). If he’s better the next day, no harm no foul. If not, aren’t you glad you took your impression seriously? Sometimes you need to treat the patient, not the laboratory. And no, I don’t think you can call it viral without an exam.

Jonathan Dee

2008-08-13 01:48:32 Reply

I also struggle with knowing when to refer or consult and when not to. I’m not sure if anyone has studied this yet or not, but we should probably have a certain percentage of false-positive referrals to make sure we’re not missing an unacceptably high number of serious diagnoses.

I would second TBTAM’s reply.

Aaron

2008-08-13 04:03:37 Reply

I think this highlights a serious flaw in the specialty of EM as practiced in small and medium sized hospitals (especially single-coverage). In order to insert ourselves into the house of medicine over the years we told the surgeon – Hey, just let me be a specialty and we’ll see all of your post op complications, all of your acute presentations, and assume all of the risk of their dispositions. We won’t even bother you unless we’re really in a bind, and then over the phone we’ll allow you to try to talk us out of our own exam. Heck, maybe we’ll let you yell at us, treat us like we’re medical students, and project all of your unprocessed anger at us.

And, usually, we won’t yell back because we “need” you. We need you on the call panel and we need you for emergent surgery. Since the ER rarely “makes money” we have no power not to take the abuse… our contract (usually not owned by us, we gave that up to the greedy first EM generation) is in jeopardy. The surgeon does make money for the hospital so s/he can be quite belligerent before s/he gets reprimanded.

This applies, in spirit, to many other specialties we need “on-call.” If you are one of the kind/reasonable specialists then I applaud you and I’m sorry that we, too, are often imperfect and ridiculous. But, for each one of you there are 2 nut-jobs throwing insults over the phone. It may shock you that sometimes the consultant knows less about the unusual presentations of acute appendicitis than I do! I’ve just literally seen more walk through the door appy’s than they had seen during their training. How often does an appy walk in to a surgical clinic nowadays? Never. They come through me first.

Truthfully, don’t you think we should either stop being pansies and draw some boundaries or we should stop being EM docs and let the ICU and FP’s run the ED? Or we should close these little ER’s where the poor bastard working there fights for everything that walks through the door and consolidate to bigger centers with back up.

We’ve dug our own hole… does anybody remember what it was like before there were competent ER docs? Well, the orthopedist came in when there was an orthopedic problem, the surgeon for surgical problem, the OB for an OB problem, etc.. Much sleep was lost for them.

We have made ourselves rugs to be walked on. Let them hire “house docs” to be their interns. Maybe we should all move to Intensive Care medicine and start pulling some clout.

I’m a little bitter, I’m sorry. From the outside (and to EM docs that are in bigger centers with back-up) I must seem crazy. But try it… it really is sad what we put up with. Don’t we have any respect for ourselves? Do they know what you are doing for them, what interference you are running for them?

Ok, skewer me. I deserve it.

Andy Fragen

2008-08-13 15:59:36 Reply

As a consultant I look at it this way. If I’m on call and the ER doc wants me to evaluate a patient I come and do it. But as a surgeon I have to say that my general rule of thumb is the 80:20 rule. If there’s an 80% chance that I’ll need to operate on the patient before discharge then I’ll admit the patient. If I think that it’s only 20% then you’ll need to involve someone else.

However, what I really tire of is the triage doc mentality of some of the ER docs. Sometimes they seem to forget about the patient after they’ve consulted me. This is especially prevalent around end of shift when they don’t do a particularly good job of handing off this patient to their colleague and assume that I’m now taking care of the problem. Most of the time this is OK, but it fails utterly when my assessment is “No acute surgical problem.”

Erik

2008-08-13 21:44:57 Reply

Patient looks sick, labs look OK, radiology non-diagnostic.

Or the other variations: Pt looks great, labs look terrible. Imaging looks terrible, pt looks great.

In these cases we usually admit the pt for 24 to 48 hrs of observation. Most of the time we don’t actually do anything but repeat labs and watch closely.

But every once in a while we find something.

System works well in our community.

Robin

2008-08-15 02:12:16 Reply

As a patient who tries to stay away from the ED, I find your perspective refreshing. I try to stay away because I try to circumvent emergencies, not for any negative reason. However, recently I had no choice but to go to the ED with very severe abdominal, back, and flank pain. It was late, my PCP wasn’t in, and no urgent care centers were open.

When I arrived there, a gentleman kindly parked my car after helping me into the ED, and I was immediately taken into triage. I found myself in a “room” with one of the lovely gowns on within minutes. To make a long story short, after CT scan, blood work, urine tests, and various and sundry other things with a very competent (in my eyes) physician, nothing was conclusive. Yet, I was very sick and in pain.

Ultimately, he let me go home. I refused pain meds so I could drive. His instructions to me showed his frustration. He said he knew I was ill, that something was wrong, but he had ruled out any life-threatening illness, thus his job was done. He made me promise to see my PCP asap, and called the on-call physician from that office to advise her of the same.

I ended up at my PCP’s office on a Saturday after that with a doctor I don’t typically see, and he was skeptical. I won’t go into details here, but ultimately he apologized because I had a whopping infection, pylonephritis, which cultured for an ugly bug later.

The ED physician was right. I was ill. It just took another day for it to show. He knew it, but he couldn’t prove it. And in retrospect, all the water I’d drunk that evening probably diluted my urine. Maybe. Anyhow, it was with his encouragement and support I pushed to have more answers. Otherwise, I probably would have suffered silently for longer.

You can’t answer everything. I, as a patient, don’t expect you to. I’m just glad when you try and you support me and encourage me to get further evaluations if warranted. It was good to hear nothing “life-threatening” was found. It was good to know that someone was trying and had done all he could to help me within the given circumstances.

You can be my ED doctor anytime. It sounds like you did the same.

jb

2008-08-20 20:25:27 Reply

I’m a surgeon. I get along extremely well with ER colleagues, because I don’t give them a hard time when they call me. If it’s an inconvenient time, they are generally apologetic to bother me, even if it’s a clear cut surgical problem. They know that if it’s a surgical problem, or has a high likelihood of same, I’ll come and admit the patient. In this setting, however, I would balk at admitting. Normal labs, normal CT, history of appendectomy makes likelihood of acute surgical disease very small. Depending on the setting, it could be viral, inflammatory (too young for Crohn’s?), infectious- any number of non-surgical illnesses that a surgeon is not best equipped to handle. Why was a pediatrician not consulted? It would have been quite reasonable for a pediatrician to admit, evaluate for non-surgical lesions, ask the surgeon to consult, also get a GI doc involved, other specialties as indicated.
What did the child end up having?

Max

2008-09-06 21:26:20 Reply

Please keep these excellent posts coming.

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