Posts Tagged ct scans

My Brilliant Feat

Did you ever have a moment of pure satisfaction at gaining a skill only to have it overshadowed by the reality of your situation?  I was working the day shift in the E.D., and it had started getting crazy as usual.  Between trying to efficiently manage and dispo my patients I was looking at CT scans and chest x-rays trying to rule out head bleeds, diagnosing pneumonias, and evaluating injured extremities.  Abdominal scans can still be challenging from time to time, so when I was looking at the scan of an elderly patient brought in with nausea and vomiting, I was talking out loud to the attending… “I see distended loops of small bowel, and I can’t see the cecum.  It looks like it’s higher than it should be and fuller;  maybe there’s an intussusception.  Possibly I also see some lesions in the liver as well…”  I had just finished my wet read of the scan when the attending read off the just-finished official CT read from the radiologist:  “Cecal intussusception most likely secondary to neoplasm with probable malignant metastases to the liver.”

For about two seconds, (ok maybe five), I jumped around in joy (ok, not literally jumping but I did pump the air with my fist), reveling in my diagnostic skill, my medical acumen, my attending saying, “You go, girl!”  (ok, maybe not those exact words, but that’s what I was hearing in my head.)  But, then I stopped;  suddenly aware of  the realization of this unexpected finding.  I was going to have to go talk to this very nice family and tell them that their loved one most likely had cancer.  They would have to be admitted for further work-up and biopsies, etc.  There would be a lot of questions about surgery and prognoses.  Some answers I would be able to provide, others I wouldn’t.  I’d be in the room for a while offering what little support I could and then arranging for surgery to admit, calling their primary, etc.

Some days reality just sneaks up on you like this.  Soberly, I went to go talk to the patient’s family, but in my head I could still hear a quiet applause as I left the work arena and headed to the patient’s room.

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Healing Our Health Care: Doing Less

Often in Emergency Medicine, we have multiple influences pushing us to do one thing, when we know the other is right for the patient. Part of it might be fear — of lawsuits, of bad outcomes — part of might be a demanding patient who “knows antibiotics always work for me,” part of it might be access to a new CT scanner, so “I might as well check.” But we all know of patients who’ve had one workup, which has led to another, which has led to some complication — a botched cath, a nosocomial infection — and you can’t help but wonder what if that workup had never been done, and was it really necessary in the first place? What if we were just chasing our tails with incidentalomas? What was our pre-test probability before the test, and even if the test is positive, how much did it really increase our post-test probability, anyway?

We’re in a tough place in the Emergency Department. People have come to us for evaluation, and our job is to Rule Out Badness ™. They’re in the Emergency Department, so we need to make sure they’re not having an emergency. Sometimes, however, I wonder if many patients weren’t better served at a walk-in clinic instead of a walk-in ED, where the mere lack of access to instant lab results and imaging studies might make for a better course of action (combined with watchful waiting as the workup progresses over days to weeks).

In last month’s EMRAP (2 hours of Emergency Medicine I look forward to every month), Jerry Hoffman, NEXUS Criteria creator and EP at UCLA-Oliveview talks about how he approaches these influences, and I think it’s absolutely worth 3 minutes and 53 seconds of your day:

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(Thanks to Jerry and Mel Herbert of EMRAP for their permission to use this clip!)

Sometimes Jerry’s methods don’t work — but for most people, most of the time, they will. Sure, it’s easier to write the script for cough medicines or order the CT scan than have a discussion, “teaching moment” or even argument with a patient or his parent — but if the two minute discussion saves the patient from a medication side effect they may come back for, or allows us a faster discharge with less brain radiation, then it’s probably worth it for both doctor and patient, right?

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