Why H&P When You Can Just CT?

Dr. Centor is at it again, with more bashing of the Emergency Department, this time because we order too many CTs. He cites this great study, by my friends/colleagues Jarone and Jonathan at my own institution, showing that CT imaging has risen in our own ED over time. And why has use of CT gone up? According to Dr. Centor, an academic hospitalist, it’s due to (his words, not mine):

  • Emergency physicians practice in the “fog of war”.
  • It appears that too often CT scanning takes the place of a careful history and physical examination. This can occur when the emergency physician is drowning in patients.
  • I believe that emergency physicians need more inpatient experiences to better understand the natural history of disease.

Okay, first, Fog of War. I like this. I agree. We are, I’d argue, the only physicians who are really comfortable managing the acutely ill undifferentiated patient. You never know which way a case is going to go, you never know what the labs are going to show, so you make sure you have that 2nd line, and you change your pathway as things develop. The Fog of War is lifted once you get your workup done (that’s called hindsight bias).  

But these two other points? Wowzers. Just so everyone knows–Emergency Physicians actually do go to the same medical schools as Internists, before we get turned to the dark side. We learn how to take a history and physical–really, we do! Despite what my colleagues may think, I am not a scan-ordering, button-pushing monkey.* I actually care deeply about radiation risk–and do not scan when I think it’s safe not to–and it’s a little offensive to assume that I simply scan because it’s easier. Yes, it’s really difficult when it’s busy. But just because a patient has, say, chest pain, and it’s busy, that doesn’t mean I just start CTing willy-nilly. Just because it’s busy and you have a headache, you still get evaluated for your type of headache; if I’m not worried about mass, subarachnoid, bleed, or tumor–you get my regular headache meds, not a scan. (The scan doesn’t fix the headache!)

Here’s a sampling of the patients I’ve CT’d recently:

  • Seizing AIDS patient
  • Elderly woman on coumadin, minor head injury, GCS 15, neuro exam normal
  • 3rd-visit bounceback with back pain radiating to the right lower quadrant, tender to palpation, vomiting, no prior CT
  • New onset facial droop 1 hour ago
  • Demented man with a head injury, two sycopal episodes with head injury
  • 75 year-old lady with a good story for kidney stones and a family history of them, but never had them before

And a few who I haven’t:

  • Hypotensive guy who I resuscitated, had been complaining of epigastric abdominal pain, but never tender on exam. (I instead performed my own bedside ultrasound of his gallbladder, aorta, heart, IVC, and FAST exam.)
  • 24 year-old woman with on-and-off tension headaches associated with stress and her cigarette smoking, who wanted one “just to be sure”
  • 23 year-old guy with a classic story for kidney stones and blood in his urine

It’s funny that Dr. Centor would want me to have more internal medicine training; he states that “In the late 70s I spent a couple of years working in emergency rooms,” which, I gotta say, would make me argue that he needs more recent Emergency Medicine training, not the other way around. Sounds like he has no idea how EPs practice, besides knowing there’s a lot of crowding in our departments. I’d love to hear how more internal medicine training would make me image less as an Emergency Physician.

Some thoughts on CT: Just like the fog of war, hindsight bias is 20/20. When that CT comes back negative, and you have to continue your hunt, then it’s really easy to say “Wow, the dumb ER doctor scanned another patient for no reason.” (The patients with the head bleeds don’t go to medicine, they go to neurosurgery, that’s why medicine teams see patients with negative head CTs all the time. Selection bias.)

CT changes disposition frequently–and frequently from “admit” to “discharge.” CT takes many-a-patient who, in the 70s, when Dr. Centor was practicing in the ED, would have been admitted for observation or more testing, and allows us to safely discharge a patient. The tender belly now gets a CT instead of serial abdominal exams; the patient on coumadin with a fall gets a CT instead of serial neuro exams and close observation; the trauma patient gets their liver laceration visualized and gets serial hematocrits in the SICU instead of being taken to the operating room. Or the stable patient with a penetrating neck injury, who gets a CT angiogram instead of an angiogram, EGD, bronchoscopy, barium swallow, and SICU admission. Inpatient teams don’t frequently see these benefits, because we frequently discharge the patients who would have otherwise been admitted. Again, selection bias.

Finally, I actually find that it’s the inpatient medicine teams and consulting services that won’t see or accept a patient on their service without a CT. They want the patient completely tucked away; they want the diagnostics completed before admission; they want all the answers when we don’t even have them, either. Some examples:

  • Ortho patients with comminuted fractures: CT for “pre-op planning”
  • Mid-face cellulitis patients with a small amount of fluctuance, ENT Consult doesn’t want a CT: medicine asks “What’s the CT show? Why didn’t you CT them yet?”
  • Short of breath patient, I don’t think it’s a PE: Medicine asks, “Can you just do a CTA of their chest before they go upstairs?”
  • Kids with chronic nosebleeds, per ENT: “Can you CT them and we’ll follow-up in clinic? We don’t need to see the patient today.”
  • Altered, blown pupil, per Neurosurgery: “We’ll come down after we review the CT.”
  • Urology, on kidney stones: “How big is the stone on CT? Where is it? Can you re-CT them, their stent may have migrated.”
  • Neurology, acute onset stroke patient: “Are they at CT yet?”
  • Surgery, 22 year-old female, great story for appendicitis, but without peritonitis: “It might be gyn-related, not appendicitis.”

Similarly, many more patients are coming through the Emergency Department now than before, frequently referred by another service. While yes, the patient is getting the CT in the Emergency Department, it’s due to a request from another service.

If anyone (including Dr. Centor) could diagnose these patients with just a “careful history and physical,” or if anyone would be willing to take the above patients on their service without some sort of imaging–please, come work here! We’d love to have you! But my guess is that no one would touch them with a 10-foot pole.

Shadowfax, another great EP, has his own response as well.

* Funny enough, we had a medicine resident rotate with us for a month, and at the end of the month, she told us, “Wow, you guys have a really physically exhausting job. Before this, my entire time on the wards, I thought you guys just sat at the computer and ordered tests and checked your email. But now I realize the reason I always saw you at the computer is because you were giving me signout while I was sitting there.”

Update: Dr. Centor responds.

  1. #1 by db - February 10th, 2011 at 17:29

    If you read my rant carefully, I clearly do not bash emergency physicians. I state clearly that you have a difficult job, made more difficult by the lack of adequate primary care in this country.

    I know that you work hard. But the data are clear, CT scanning is increasing. As your own experts state clearly, emergency medicine must study appropriateness to try to limit CT scanning.

    As I state in my second rant, emergency physicians span a spectrum. I know some who resort to testing (labs and CT scanning) rather than taking a history and doing a physical exam. I know some who order the 10th CT scan in the same year for irritable bowel disease.

    The increase in CT scanning is a fact. Perhaps all the CT scans are indicated, but talking with hospitalists from many different hospitals, you will hear many stories of unnecessary scanning.

    Obviously I am biased. I believe every adult physician should spend some time in internal medicine inpatient training. My students tell me clearly that they think they need more internal medicine. One of my 4th year students, who is matching in emergency medicine, told me he eschews any program that does not include internal medicine ward rotations. I am surprised that some programs avoid the inpatient setting.

    I apologize if you read my rant as an attack on emergency medicine. My attack was on the forces that lead to the relentless increase in CT scanning.

  2. #2 by seth - February 10th, 2011 at 21:53

    and every day, we deal with hospitalists and medical residents who “can’t admit the patient without labs,” who order or request CTs in the ED before they go upstairs, who ask “why don’t you ever give your acute CHF patients lasix?” and are bewildered when we explain that it’s for the same reason we don’t give beta blockers to our patients with MIs or PPIs for GI bleeds. And order IV antihypertensives for asymptomatic hypertension and question why we cool our patients after ROSC.

  3. #3 by sch - February 21st, 2011 at 22:56

    None of our surgeons will even look at an abd pain pt without
    a CT report at hand. Even the most obvious surgical indication
    of free air in the abdomen they want the CT, guess it is easier
    to plan your surgery if you know it is colon and not perf ulcer.
    Second driver is the bloody d-dimer. If you have a > 0.5
    and any hint of SOB or CP, the hospitalists want a chest CT before the patient is sent up. Blunt trauma (usually VC/4whlr)
    tends to get pan CT as well if the presentation is at all iffy.
    Never the less I agree, some discriminators are needed and
    the preschool head injury ones are helpful, and the better
    availability of abd US would make after hours abd conundrums
    less likely to result in CT especially in the legions of young
    ladies with their abd pains.

  4. #4 by healthy living - March 4th, 2011 at 19:22

    Yes, their jobs are indeed strenuous. But I agree with sch that they require CT even for the most obvious diagnosis. Getting CT’s prevents them from having a clinical eye I think.

  5. #5 by Pinaki Mukherji - April 11th, 2011 at 09:51

    Sadly, only the internists who don’t want more scanning and the ER docs who don’t order them will involve themselves with this debate.
    The admitting team that demands a pre-admit scan will not be corrected by their fellow internists (and they will continue to treat asymptomatic HTN with IV meds and give tons of lasix to skinny folks with APE). And the ED physicians will shake their heads taking signouts from colleagues on pts. who got an abd CT “because they’re 70.”

  6. #6 by Alex - August 4th, 2011 at 22:54

    The sad reality is that all trainings are not the same. They differ across state lines, counties, cities, and even down the street. One hospital may have a very good EM residency training program while their internal medicine program is poor while another, less than 3 miles away, have an awesome IM program and their EM training makes you wonder if EM was a good choice of residency. At my hospital, I’ve seen IM residents ask for chest x-rays on patients with lower extremity cellulitis but I’ve also overheard an EM resident admitting a patient for rule out ACS. “She has chest pain, poorly controlled DM (because her FSBS was elevated when she was triaged) and uncontrolled HTN (because she was in pain), so I’m going to bring her in for a full workup. My PCA is getting the EKG and labs right now.” Medicine is a practice because we take what we are taught with a grain of salt and internalize into our own individual practice. Everyone practices medicine the way they feel comfortable with. Some of it is due to poor training and some due to good or bad experiences. You can’t say apples are always better than oranges just because you had a few sour ones.

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