Sunday, April 30, 2006

The Case of the Missing Hole...
A Doctor Dalai Mystery

I'm on call tonight, and I've read about 200 studies since 8AM. Does wonders for the attitude. Imagine my joy (or lack thereof), when I received the following call from one of our hospitals:

"Uh, Dr. Dalai? This is Joe Tech from NorthSouth Hospital. I have another CT PA gram for you, and also a renal stone CT. Oh, and Dr. Feckless in the ER wants to know if we should scan a chest without or with contrast. Why does he want it? Well, he sees a hole in the lung on a chest X-ray, and he wants to scan it......"

Only the names have been changed to protect the innocent (ME!!!). The chest X-ray in question is anonymously reproduced below:

See the "hole"? It's in the region of the left axilla, and it is a bloody artifact caused by crossing of breast and arm shadows. Hole, indeed.

My response to Joe Tech was at first angry and then practical..."Is Dr. Feckless going to call in the surgeons based on the CT finding? No, don't repeat that....repeat the chest X-ray with the arms out of the way, and if the, ummm, hole is still there, THEN we'll do a CT." The repeat is found below. Voila! No hole!

This sad tale is wonderfully illustrative of how the ER thinks. Or doesn't as the case may be. The slightest twinge deserves the full court press. The slightest question is to be answered with a $1000 CT scan. In the middle of the night, of course. So, I have to get off my anti-self-referral bandwagon and get on my anti-scan-for-no-good-reason bandwagon. Hey, maybe they are the same bandwagon? Anyway, this knee-jerk ordering of a very expensive test is yet another reason imaging costs have skyrocketed out of sight. One of my partners very seriously states that the ER depends on us because we provide the diagnosis for them, because we have become so good at reading CT's, and because CT's have become so much better with multi-slice technique. Balderdash. The ER is just palming off their triage duties onto us. Order a scan of the affected area and see a few more victims while it's being done. And order scans on the new victims while we're at it.

This practice has got to stop, just as much as self-referral must be curbed. I keep backing into the conclusion that socialized medicine is going to do that for us, whether we like it or not. Hope I'm wrong. In the meantime, let me read the next 10 negative CT's.


Anonymous said...

How about 5 negative PE stduies in 4 weeks....I saw it this week on a 31 year old female.

When you bring this up to them (the ER docs), they ask if you are on a crusade against radiation...

What happened to good medicine? The lawyers and the money involved has destroyed it.

Anonymous said...

10 CTPA's yesterday one positive...every other patient just had pneumonia or pleural effusions...can't convince the er and floors anymore what to do

Anonymous said...

As a prelim intern displaced by hurricane K, I've seen this sort of thing in each of the 6 hospitals I've worked in over the past year. No one knows what to do with incidental findings on all sorts of studies. At Charity (God rest her soul) we called this the VOMIT syndrome. Victim of Modern Imaging Technology - the people who come in as level I trauma, get a whole body scan, and then get the million dollar work up for some insignificant finding. In medical school there isn't much focus on radiology except for the basics of the CXR. Maybe things would change if there was more focus on rads in med school. Of course, that still doesn't change the decline in clinical skills - Osler must be turning in his grave nowadays. I've seen it work both ways though. I've been cursed in the middle of the night for calling in rads to do a CT on a guy with chest pain and a h/o vasculitis with an aortic graft. Turned out he did have a leak and it did change the patient's management. Overall though, I'd say there are many more unwarranted studies. Maybe its easier to be more cavalier and conservative when your an intern and your liability is less? Maybe tort reform is part of the answer to end the practice of medicolegal medicine and return things to clinical medicine?

Anonymous said...

Just think what you response would have been if you had to drive in to see the "disappearing hole"? :-)

Thank heaven for PACS.