What is Defensive Emergency Medicine?

So I read all the time that defensive medicine costs all this money (and depending who you talk to, it’s a lot of money or not that much), but I still don’t know when I’m practicing it or when I’m not. So I came up with a few scenarios and want you to vote on what you think. I’ll leave the poll open for the next week, and then post the results after that. Real cases we all see daily (I don’t necessarily practice this way, just giving examples!):

Scenario 1:

52 year-old woman with hypertension and dyslipidemia, got in an argument with her daughter, had 3 minutes of left-sided chest pain and “my left arm was numb,” with maybe some shortness of breath (“sometimes,” she says, which doesn’t really answer your question), self-resolved. Now in the ED feels fine, EKG unchanged and unremarkable from the last one. No prior stress test. You admit her for rule-out ACS. “This could be unstable and new angina!”

Scenario 2:

40 year-old male with a history of PE on coumadin, with three weeks of non-pleuritic 1/10 chest pain and shortness of breath. Gradual onset. EKG and chest x-ray are normal, and INR is therapeutic and perfect: 2.5! You CT angio the patient for pulmonary embolism. “If it’s a PE and he’s therapuetic on his coumadin, he needs an IVC filter!”

Scenario 3:

4 year-old male had a brief LOC after his brother opened a door quickly and hit him in the forehead. Healthy kid. Normal vitals, normal neuro exam, no signs of a basilar skull fracture. 2cm hematoma. PECARN suggests observation vs. CT. You CT the kid. “I would hate to miss a subdural in a 4 year-old, that’d be devastating!”

Scenario 4:

26 year-old healthy female with a day of vomiting, no diarrhea. Says she has abdominal pain, but belly’s not tender. Tachy 106, otherwise vitals are normal and she looks well. Plan is for fluids and reglan and re-assess. Your resident orders a CBC and BMP for some reason, and the WBC comes back 24.8. Patient feels a little better, is tolerating PO, and abdomen is still not tender. You order a CT scan of the belly anyway, “That’s a really high white count! I’d hate to send an appy home!”

Scenario 5:

36 year-old female with a history of anemia on iron with heavy vaginal bleeding, history of heavy periods. Not pregnant. 2 days of bleeding, says she’s going through 8 pads a day, this is heavier than her normal “heavy” vaginal bleeding. Well-appearing in the ED, BP is 130/66, HR in the 70s, no signs or symptoms of symptomatic anemia. Vaginal exam has some pooling of blood in the vault, no active bleeding from the os. Her prior hematocrit in the computer system from 6 months ago is 34.3. You order a CBC. “Maybe it will be really low and she’ll need a transfusion!”

Answer the survey.

  1. #1 by Nick - November 23rd, 2010 at 20:12

    Great scenarios, Graham! Except for #5 — what’s the defensive decision (ordering a CBC?)

  2. #2 by Canuck - November 24th, 2010 at 18:08

    In my neck of the woods, scenarios 2-5 would be defensive medicine.

    And luckily I don’t need to practise it 🙂

  3. #3 by JR - November 25th, 2010 at 18:16

    They are all defensive medicine in my opinion, maybe with the exception of 5 since there is little cost or harm in an H/H, except I would only order a whole blood Hgb and not a CBC

  4. #4 by Sonja Hodzic - November 26th, 2010 at 02:53

    Very good scenarios. According to my opinion, scenarios 2-4 are defensive medicine. What is the answer on the 5 scenario?

  5. #5 by Graham Walker, MD - November 26th, 2010 at 03:43

    Amended. Sorry–5 was if you order a CBC.

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