ordering tests

[costar]

What are your guys' thoughts on emerg doctors over investigating?

 

I always thought it was a bit over the top myself but then yesterday I saw an ectopic show up in emerg that was found on a 2nd U/S after the ER doc fought with the rad to get it last night at 1am. The first one 5 days ago was completely normal.

[A-Stark]

Emerg doctors over investigating? Usually they're more prone to pass on inadequately worked up consults.

 

All inpatients get too much bloodwork, though.

[rmorelan]

What are your guys' thoughts on emerg doctors over investigating?

 

I always thought it was a bit over the top myself but then yesterday I saw an ectopic show up in emerg that was found on a 2nd U/S after the ER doc fought with the rad to get it last night at 1am. The first one 5 days ago was completely normal.

 

You are always going to find examples going either way on the fringe with stuff like this. There should be some push and pull on both sides for imaging studies (which often are not benign - radiation is radiation after all).

[Lactic Folly]

Well, without overall stats, all anyone has is only a piece of the big picture. (I'm thinking of that study presented at CAEP a little while ago which found large variations in imaging requests among different ER docs.)

 

The radiology residents see all the negative scans ordered by ER. They don't see the patients who are assessed and sent home without imaging.

 

The internal medicine residents see the patients whom they've been asked to see as soon as it's clear the patient is a candidate for admission. They don't see the patients that ER has sent home (including those after negative imaging).

 

That is why there are guidelines - but until they protect against malpractice (or the fear of it), the impact of such guidelines may be limited, as there are always exceptional cases, even though it could be said that a reasonable standard of practice was followed.

 

(However, in costar's example, I believe the accepted course of action after a negative ultrasound and positive HCG *is* indeed to follow up in a week's time with repeat ultrasound. The differential for positive HCG + no intrauterine pregnancy + normal adnexae includes normal early pregnancy, completed abortion, and ectopic pregnancy. Not sure why it was a point of contention - was this a radiologist or a radiology resident?)

[rmorelan]

Well, without overall stats, all anyone has is only a piece of the big picture. (I'm thinking of that study presented at CAEP a little while ago which found large variations in imaging requests among different ER docs.)

 

The radiology residents see all the negative scans ordered by ER. They don't see the patients who are assessed and sent home without imaging.

 

The internal medicine residents see the patients whom they've been asked to see as soon as it's clear the patient is a candidate for admission. They don't see the patients that ER has sent home (including those after negative imaging).

 

That is why there are guidelines - but until they protect against malpractice (or the fear of it), the impact of such guidelines may be limited, as there are always exceptional cases, even though it could be said that a reasonable standard of practice was followed.

 

(However, in costar's example, I believe the accepted course of action after a negative ultrasound and positive HCG *is* indeed to follow up in a week's time with repeat ultrasound. The differential for positive HCG + no intrauterine pregnancy + normal adnexae includes normal early pregnancy, completed abortion, and ectopic pregnancy. Not sure why it was a point of contention - was this a radiologist or a radiology resident?)

 

that raises one area I think that gets ER into a bit of trouble with rads - I mean there are all these protocols and of course Rads know them backwards and forwards. Quite often people want to bypass those protocols and well Rads don't want to

 

On my first week I saw a psych resident argue with the on call rads for a head CT for head injury when a person fell from standing to the ground. There are a variety of reasons why that didn't follow the need for a scan but of course if you are the one with lingering doubts you may still want one.

[Lactic Folly]

On my first week I saw a psych resident argue with the on call rads for a head CT for head injury when a person fell from standing to the ground. There are a variety of reasons why that didn't follow the need for a scan but of course if you are the only with lingering doubts you may still want one.

Or if you have seen someone pass away from uninvestigated (until too late) intracranial hemorrhage after a seemingly vague history of head trauma, while admitted for workup of ?arrhythmia as a cause of falls... (as I have)

 

From the other resident's perspective, they are also likely irked because if it had been the daytime, at most centres the order would have been entered into the computer with a history of trauma, and the patient called down for their CT without any hassle.

[rmorelan]

Or if you have seen someone pass away from uninvestigated (until too late) intracranial hemorrhage after a seemingly vague history of head trauma, while admitted for workup of ?arrhythmia as a cause of falls... (as I have)

 

From the other resident's perspective, they are also likely irked because if it had been the daytime, at most centres the order would have been entered into the computer with a history of trauma, and the patient called down for their CT without any hassle.

 

Shouldn't do it in the day either of course.

 

I guess my point is internal med/ER whips out studies and policies all the time - the XYZ study says this, or the ABC study says that so we should use evidence based medicine for proper patient care. However if a radiologist whips out the Canadian CT Head Rules and it is like he/she is speaking a different language

[Lactic Folly]

Well, in this study, various ER departments tried to implement the CT Head rule, with apparent limited success:

http://www.cmaj.ca/content/182/14/1527.abstract

It would be interesting to see what they say about it in Ottawa (where the study originated).

[rmorelan]

Well, in this study, various ER departments tried to implement the CT Head rule, with apparent limited success:

http://www.cmaj.ca/content/182/14/1527.abstract

It would be interesting to see what they say about it in Ottawa (where the study originated).

 

See this is what I like - actually processing on the study/evidence etc - even if it means the current guidelines are shown to be wrong. I know at Ottawa the rads will block studies that fall outside of the rules to an obvious degree (as they did in the psych example I mentioned). Not to say they are inflexible.

[Satsuma]

Shouldn't do it in the day either of course.

 

I guess my point is internal med/ER whips out studies and policies all the time - the XYZ study says this, or the ABC study says that so we should use evidence based medicine for proper patient care. However if a radiologist whips out the Canadian CT Head Rules and it is like he/she is speaking a different language

 

Really? You think the Canadian CT Head Rules are like a foreign language to an emerg doc? You do realize Ian Stiell is an emerg doc, right?

 

Costar has no evidence for the broad statement that emerg docs over-investigate. And over-investigate with what - labs, imaging? And for what conditions - SAH, AMI, the patient who stubbed their toe? There are some things where a miss rate of even 5% is considered too high eg SAH. How is over-investigation defined in this statement?

 

Generalizations do not provide constructive ways to discuss things.

 

Emerg docs see undifferentiated patients, with limited time and limited information. The job of the emerg doc is to not miss life-threatening presentations. So unless we can sufficiently convince ourselves that nothing life-threatning is going on, we are going to investigate until we can convince ourselves that there is nothing life-threatning going on within reason (eg we are fairly certain we send home between 2-5% of ACS despite the 2 negative trops- but it's not like we can admit all CP to avoid missing everyone)

 

And personally, I'd rather be accused of over-investigating something that turns out to be benign then to be accused of missing something that killed a patient because I didn't investigate and sent them home.

[Lactic Folly]

Re-reading rmorelan's post, he technically said that radiologists and ER seemed to be speaking different languages, which I think is really the crux of the problem here, i.e. communication. Difficult to build those relationships leading to constructive solutions when all the stories that the residents tell each other are cases on call that are framed as adversarial from the start (request/accept/deny, rather than let's find the best solution for this patient, all things considered). Understandable though given the time pressures and stress involved, which is why we need to make more of an effort in calmer times for such discussion. Good that we have a variety of fields represented on PM101 (though I don't think we ever found an ob/gyn person for that poster who was looking).

[A-Stark]

Really? You think the Canadian CT Head Rules are like a foreign language to an emerg doc? You do realize Ian Stiell is an emerg doc, right?

 

Considering I first learned (and applied) said rules on emerg rotations (along with the Ottawa ankle/foot rules), and there were posters of both in EDs I've worked in, it's a fairly odd comment. I think sometimes we over-investigate, but that's because we do a lot of unnecessary blood work and tests for "baselines" that really aren't warranted.

 

Emerg docs see undifferentiated patients, with limited time and limited information. The job of the emerg doc is to not miss life-threatening presentations. So unless we can sufficiently convince ourselves that nothing life-threatning is going on, we are going to investigate until we can convince ourselves that there is nothing life-threatning going on within reason (eg we are fairly certain we send home between 2-5% of ACS despite the 2 negative trops- but it's not like we can admit all CP to avoid missing everyone)

 

And personally, I'd rather be accused of over-investigating something that turns out to be benign then to be accused of missing something that killed a patient because I didn't investigate and sent them home.

 

Yeah. On the other side of things, if every consult results in an admission, it stands to reason that certain patients were sent home who should have at least gotten some more workup or investigation. Consulting services tend to dislike more borderline consults, but it's usually a good idea to have more eyes on the case than fewer.

[rmorelan]

Really? You think the Canadian CT Head Rules are like a foreign language to an emerg doc? You do realize Ian Stiell is an emerg doc, right?

 

Costar has no evidence for the broad statement that emerg docs over-investigate. And over-investigate with what - labs, imaging? And for what conditions - SAH, AMI, the patient who stubbed their toe? There are some things where a miss rate of even 5% is considered too high eg SAH. How is over-investigation defined in this statement?

 

Generalizations do not provide constructive ways to discuss things.

 

Emerg docs see undifferentiated patients, with limited time and limited information. The job of the emerg doc is to not miss life-threatening presentations. So unless we can sufficiently convince ourselves that nothing life-threatning is going on, we are going to investigate until we can convince ourselves that there is nothing life-threatning going on within reason (eg we are fairly certain we send home between 2-5% of ACS despite the 2 negative trops- but it's not like we can admit all CP to avoid missing everyone)

 

And personally, I'd rather be accused of over-investigating something that turns out to be benign then to be accused of missing something that killed a patient because I didn't investigate and sent them home.

 

No I don't think they are a foreign language - I know they know them as well as any radiologist would but probably because they are busy and under constraints those are not always followed. Ideally the conversation would follow exactly along the lines of the rules - you tell a rads you have a patient that meets the criteria because of X,Y,Z and things go a lot faster. Order one and just say they hit their head and you are just begging for a follow up call and potential argument as the Rads ultra annoyingly then walks through the rules that of course you already know. If a rads just blocks a scan without bothering to listen and potentially bend the rules if appropriate based on the clinical judgment of the ER doc then he/she is being dumb as well. Either way both sides get annoyed and gah - more than one late night argument ensues and no one wins.

 

The trouble is over investigating ultimately will kill people - just not kill them right away (well usually not right away). This is where - and I think really it should be this way - there is a bit of conflict between the two services. Respectful conflict is actually ok at times.

 

We know that for every X number of scans we run we will give some one cancer statistically speaking. We know that cancer will have an associated mortality rate. We don't know who of course but we cannot ignore that even if it is a population effect. I meet one radiologist that actually has a counter he runs on this computer that ticks off, based on his particular area of scan, how many people will die as a result of the imaging he interprets - just a rather morbid way for reminding himself there are scanning risks, and of course to make a point graphically I hated that counter but it reminds me that CT scans kill people and we need to learn a lot more about how to minimize that effect vs reward, just like every other specialty is trying to reduce the chances of death from their procedures.

[A-Stark]

Re-reading rmorelan's post, he technically said that radiologists and ER seemed to be speaking different languages, which I think is really the crux of the problem here, i.e. communication. Difficult to build those relationships leading to constructive solutions when all the stories that the residents tell each other are cases on call that are framed as adversarial from the start (request/accept/deny, rather than let's find the best solution for this patient, all things considered). Understandable though given the time pressures and stress involved, which is why we need to make more of an effort in calmer times for such discussion. Good that we have a variety of fields represented on PM101 (though I don't think we ever found an ob/gyn person for that poster who was looking).

 

Oftentimes I find the "adversarial" issue comes up mostly when a tech or administrator cancels a study because a box wasn't checked off or some other paperwork thing wasn't done, even when it's already been approved by a radiologist.

[A-Stark]

We know that for every X number of scans we run we will give some one cancer statistically speaking. We know that cancer will have an associated mortality rate. We don't know who of course but we cannot ignore that even if it is a population effect. I meet one radiologist that actually has a counter he runs on this computer that ticks off, based on his particular area of scan, how many people will die as a result of the imaging he interprets - just a rather morbid way for reminding himself there are scanning risks, and of course to make a point graphically I hated that counter but it reminds me that CT scans kill people and we need to learn a lot more about how to minimize that effect vs reward, just like every other specialty is trying to reduce the chances of death from their procedures.

 

That's all well and good, except that the biggest issues tend to come not with CTs (relatively easy to get done) but MRs and, of course, labour-intensive ultrasounds. Or anything in IR. I had a CTU patient recently who needed a perc drain for his massive liver abscess, only for it to be delayed because his INR was marginally above their cutoff (of doubtful significance for bleeding in that context) and because some radiologist arbitrarily decided there might not be an infection after all.

[Lactic Folly]

Oftentimes I find the "adversarial" issue comes up mostly when a tech or administrator cancels a study because a box wasn't checked off or some other paperwork thing wasn't done, even when it's already been approved by a radiologist.

 

See - communication again.

 

Or anything in IR. I had a CTU patient recently who needed a perc drain for his massive liver abscess, only for it to be delayed because his INR was marginally above their cutoff (of doubtful significance for bleeding in that context) and because some radiologist arbitrarily decided there might not be an infection after all.

But to take the other side, would people say the same thing about a surgeon who didn't want to operate until coags were corrected, even though some thought the delay was unnecessary?

[rmorelan]

That's all well and good, except that the biggest issues tend to come not with CTs (relatively easy to get done) but MRs and, of course, labour-intensive ultrasounds. Or anything in IR. I had a CTU patient recently who needed a perc drain for his massive liver abscess, only for it to be delayed because his INR was marginally above their cutoff (of doubtful significance for bleeding in that context) and because some radiologist arbitrarily decided there might not be an infection after all.

 

I will buy that argument - the darn MRI is just a in demand resource they are under so much pressure not to use the darn thing any more as it is booked to the gills. What is annoying about is that MRI is the correct imaging study often but you just cannot get the silly thing done and it defaults back to the only other 3D scan of CT. At Western before I left there was a huge argument in the Rads department about that - resource limitation vs it being the right scan. It frustrated the heck out of some Rads that really wanted those to run all the time. Same with ultrasound - no tech after a certain point in the evening standardly, you can call them in but then it is overtime on a limited resource. In both cases there is back pressure on the department to contain costs. No one likes arguing from a cost perspective - it is a soul sucking exercise.

 

As for IR I am not as sure on that one (IR is its own world at times - still fighting for its place in things.)

[rmorelan]

But to take the other side, would people say the same thing about a surgeon who didn't want to operate until coags were corrected, even though some thought the delay was unnecessary?

 

yeah the do - all the time The CTU/ICU docs complain with the required surgery is delayed (often delayed again) sometimes a bit arbitrarily and they are still stuck on your ward for days longer - that is just born out of frustration that the patient won't really get better until the surgery is actually done.

[rmorelan]

Oftentimes I find the "adversarial" issue comes up mostly when a tech or administrator cancels a study because a box wasn't checked off or some other paperwork thing wasn't done, even when it's already been approved by a radiologist.

 

At least with some of the newer electronic ordering systems that happens less and less.

[A-Stark]

See - communication again.

 

I don't disagree, though they should not be able to cancel an approved scan without at least attempting to contact the referring physician. But when I want something done I always go down to talk to the radiologist and/or techs directly. They're getting to know me a little too well down in the scanner...

 

But to take the other side, would people say the same thing about a surgeon who didn't want to operate until coags were corrected, even though some thought the delay was unnecessary?

 

Depends on how much of a derangement there was, and whether it reflected actual coagulopathy vs. impaired synthetic function. And if someone needs an intervention, you can correct coags. There is always a tradeoff.

 

And, frankly, if IR wants to be making clinical decisions they should be around to come see patients in consultation, like the surgeons. If you want to be a technician, it becomes frustrating when you block clinical decisions that absolutely encompass these tradeoffs.

[rmorelan]

 

And, frankly, if IR wants to be making clinical decisions they should be around to come see patients in consultation, like the surgeons. If you want to be a technician, it becomes frustrating when you block clinical decisions that absolutely encompass these tradeoffs.

 

Some places in the states are like that - IR has their own wards etc and run it just like any other surgical discipline and do consults etc. Cannot say I disagree with that - you want to be treated like a surgeon then you got to go all the way.

[Lactic Folly]

And, frankly, if IR wants to be making clinical decisions they should be around to come see patients in consultation, like the surgeons. If you want to be a technician, it becomes frustrating when you block clinical decisions that absolutely encompass these tradeoffs.

Agree. I'm sure practices vary widely at present, but this is the direction IR is going, and should be going.

[HycrestJIT]

What are your guys' thoughts on emerg doctors over investigating?

 

I always thought it was a bit over the top myself but then yesterday I saw an ectopic show up in emerg that was found on a 2nd U/S after the ER doc fought with the rad to get it last night at 1am. The first one 5 days ago was completely normal.

 

Illness is a process that occurs over time. As a physician, you only see a tiny snapshot of that illness in the spectrum of its course. Thus, it serves as no surprise that the same test days later would find different things.

 

Welcome to the wonderful world of primary care .

[costar]

What speciality are you in Satsuma? If you do a nephro rotation, you'll quickly see how many contrast nephropaths get admitted. The nephrologist at our institution gave a talk about how many ER docs order contrast CT abdos on query AAA and send these old timers to nephro inpt ward.

Tests are not without morbidity and free of charge.

 

 

Really? You think the Canadian CT Head Rules are like a foreign language to an emerg doc? You do realize Ian Stiell is an emerg doc, right?

 

Costar has no evidence for the broad statement that emerg docs over-investigate. And over-investigate with what - labs, imaging? And for what conditions - SAH, AMI, the patient who stubbed their toe? There are some things where a miss rate of even 5% is considered too high eg SAH. How is over-investigation defined in this statement?

 

Generalizations do not provide constructive ways to discuss things.

 

Emerg docs see undifferentiated patients, with limited time and limited information. The job of the emerg doc is to not miss life-threatening presentations. So unless we can sufficiently convince ourselves that nothing life-threatning is going on, we are going to investigate until we can convince ourselves that there is nothing life-threatning going on within reason (eg we are fairly certain we send home between 2-5% of ACS despite the 2 negative trops- but it's not like we can admit all CP to avoid missing everyone)

 

And personally, I'd rather be accused of over-investigating something that turns out to be benign then to be accused of missing something that killed a patient because I didn't investigate and sent them home.

[Mourning Cloak]

Relevant to discussion (I think)

 

http://www.choosingwisely.org/wp-content/uploads/2012/09/Choosing-Wisely-Master-List_LQ1.pdf