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All of those "rule-out" tests.....


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Done more than a few chest CTAs to "rule out" dissections.  Rarely find them.  

 

Tonight, did one on a young(ish) healthy guy who had a great story for MSK back pain....except his back pain was severe.

 

Big Stanford A dissection.  Got him flown to where he needs to be to get fixed.

 

Note to self.....do more tests.

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I work with a doc I like to call "Capt CAT Scan" - even when it's obvious what is going on, they'll still scan them.  Almost snapped the other day when they scanned a patient of mine I'd handed over for an obvious urosepsis...who'd just finished a pile of radiotherapy.  She wanted to rule out a toxic megacolon that in fact turned out to be a bilat pyelo - when the abd exam showed no distention or anything else to go with that.  I'm all about nuking people if I think they need it, but you still have to use your noodle before you do it.  If your gut says something isn't right, so be it, especially if other things in Hx and exam point towards something being not right.  I've nailed more than my fair share of appy's simply because the pain pattern and physical exams said so, even if labs didn't.  If it walks like a duck, quacks like a duck, it usually isn't a swan.

 

SK

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Guy was from out of town on a hunting trip.  Stepped into a hole early that morning while hunting and felt a twinge in his back.  Hours and hours later he was holding the antlers as his buddy was skinning and his back (T5-T8 area) started hurting.  Absolutely normal exam.  Guy had a perfect story for this being MSK pain.  Just couldn't get his pain improved in the ED.....

 

Hx:  Former smoker, well controlled HTN.  Early 50s.  Very active guy.

 

I'll be doing more tests from now on.....

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Story is good for needing some sort of imaging - wouldn't have jumped straight to CTA unless an XRay showed something odd.  Having said that, I think the operative words are "...couldn't get his pain improved in the ED" - that warrants further looking into.

 

Had a 60 yo dude in a month or two ago that abruptly stepped into a shallow hole, had severe back pain as a result.  XRays at the hospital he went to previously showed multilevel compression fractures, no scan or labs done.  Of note he was also awaiting a haematology consult due to an odd anemia.  I did those in the ED showing disseminated multiple myeloma.  Key there is the story didn't add up to why a fit youngish fellow had minor trauma resulting something completely out of proportion.

 

SK  

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The big question is this - what is the NNN (Numbers Needed to be Nuked) to make it beneficial to all to scan every soul that walks through the door with a cold or even less on the off chance we'll fine someone with a sleeping dragon waiting for it's alarm to go off? 

 

SK

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Good pickup B2PA.  AD is very rare (about 2000/yr in a country of 319 million works out to just over five a day in the US), but serious and with significant morbidity & mortality if not caught.

 

Not sure I would have scanned him this guy with a great (classic?) story for musculoskeletal back pain but something in his description of pain or discomfort (or risk factors if he had any) obviously set off your 'Spidey-sense'

 

Caution with availability bias ("Note to self.....do more tests.") - of course this is always easier said than done. 

 

Had a 30-ish female several years ago with a little DOE and fatigue. She was a smoker and obese.  VS normal and was low-risk for DVT by Well's and PERC-negative.  Sent her home and she bounced back two days later with worsening DOE and had + CTPA. 

 

I was spring-loaded to CTPA the sh*t out of everyone for about 6 months after that!

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Good pickup!

 

I have personally seen and dx/caught 4 vertebral artery dissections in the last 9 months. For where I live there should only be about 8/yr for my areas population so I don't know if I have good or bad luck... I got a bit of flak initially but when the catch is there it is a big deal. Usually it is "gut" type of call. The kind where you don't exactly know why but something is wrong that isn't necessarily obvious. Those are both the scariest and potentially most rewarding moments in the ER for me.

 

Again good catch!

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I just picked up a copy of "The Laws of Medicine" by Siddhartha Mukherjee.  In it, he defines what he believes are some finite laws for what many consider an imperfect science.  His First Law is this "A strong intuition is more powerful than a weak test".  I think this whole topic here is about how many of us use our intuition in our day to day jobs.  I was briefly scanning another spot in the general forums about changing the length of med school or residency - unfortunately, I think taking away residency time for brand new baby docs is probably not a good thing for this very reason - our intuition as PA's or MD's is developed by seeing many different diseases and their various patterns of development and progression. 

 

Going back to my quip about NNN, you have to put a bit of brain power into what you're doing before you do it.  Granted, T-Spine pain for some people is something that demands imaging, however, I was trained to work in environments that didn't have ready access to laboratory/imaging testing beyond MAYBE an I-Stat, a urine stick, a glucometer and EKG machine.  I've seen more cases of thoracic facet syndrome than any of the zebras mentioned here so far.  I've also seen a lot of missed bony mets as well - that's where Hx and exam all come into play.  We've all been trained to listen, ask questions, touch, feel and manipulate and then decide what we should or should not order based on what we've gathered and on the probabilities of what we're looking for being there.

 

The problem lies these days with the fact that everyone seems to think they know more about doing our job than we do and always come in demanding shyte they don't really need.  Luckily in Canada we can look at many of them and say "NO...N-O", whereas in the US, patients are more like consumers than patients (please correct me if I'm offside there).  I always ask myself and the patient "Is this really going to change how I look after you?".  If the answer is yes, well then I have to order it.  If no, then I can either sit on it and see if things change or treat it like the quacking duck it probably is.

 

One last thing I'd like to finish with...my current SP, who was a surgeon in the South African Defence Forces, always says "the best four things to diagnose appendicitis are these..." and points to the pads of his index through little fingers. 

 

SK

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I just picked up a copy of "The Laws of Medicine" by Siddhartha Mukherjee.  In it, he defines what he believes are some finite laws for what many consider an imperfect science.  His First Law is this "A strong intuition is more powerful than a weak test".  I think this whole topic here is about how many of us use our intuition in our day to day jobs.  I was briefly scanning another spot in the general forums about changing the length of med school or residency - unfortunately, I think taking away residency time for brand new baby docs is probably not a good thing for this very reason - our intuition as PA's or MD's is developed by seeing many different diseases and their various patterns of development and progression. 

 

Going back to my quip about NNN, you have to put a bit of brain power into what you're doing before you do it.  Granted, T-Spine pain for some people is something that demands imaging, however, I was trained to work in environments that didn't have ready access to laboratory/imaging testing beyond MAYBE an I-Stat, a urine stick, a glucometer and EKG machine.  I've seen more cases of thoracic facet syndrome than any of the zebras mentioned here so far.  I've also seen a lot of missed bony mets as well - that's where Hx and exam all come into play.  We've all been trained to listen, ask questions, touch, feel and manipulate and then decide what we should or should not order based on what we've gathered and on the probabilities of what we're looking for being there.

 

The problem lies these days with the fact that everyone seems to think they know more about doing our job than we do and always come in demanding shyte they don't really need.  Luckily in Canada we can look at many of them and say "NO...N-O", whereas in the US, patients are more like consumers than patients (please correct me if I'm offside there).  I always ask myself and the patient "Is this really going to change how I look after you?".  If the answer is yes, well then I have to order it.  If no, then I can either sit on it and see if things change or treat it like the quacking duck it probably is.

 

One last thing I'd like to finish with...my current SP, who was a surgeon in the South African Defence Forces, always says "the best four things to diagnose appendicitis are these..." and points to the pads of his index through little fingers. 

 

SK

t-spine pain for all people demands imaging

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Here is my bit on CT imaging specifically, due to its ever increasing usage.

 

Multidetector CTs have improved greatly in the past 10-15 years. Single detector scanners (old) resulted in a much higher absorbed dose of X-rays. New MDCT scanners incorporate software controllers (AEC) that adjust tube current (beam energy, kVp) based on pt. metrics to produce high-resolution image reconstruction with less total X-ray exposure (effective absorbed dose, mGy). Dose technique is something that not all facilities routinely alter, nor are staff always trained in methods of dose reduction. (tube output, filtering, and phase/slice reduction)

 

What we should be looking at is the lifetime attributable risk (LAR) of developing a CT induced neoplasm. LAR is a product of scan frequency and total absorbed dose which increases inversely with decreasing age at time of exposure. Thus the threshold for CT scanning a 65yo is ideally lower compared to a 15yo. We probably will not do much to impact the LAR in older pts. Whereas younger pts., especially those undergoing multiple ionizing radiographic imaging studies for chronic conditions or treatment, are at a higher risk.

 

Check out the Image Gently Campaign for their recommendations on using ionizing scans in pediatric populations. http://www.imagegently.org

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This is the kind of stuff that keeps me awake at night after busy ED shifts - have had a couple good saves myself, but on the other hand I always wonder what I've missed!!!  I do appreciate threads like these and learning from the experience of others, though.

 

Curious on the vertebral dissections you mentioned below - traumatic/atraumatic, with what symptoms/how did they present, what caused your radar to ping and order the CTA versus all the other neck pain/HA that you don't scan?  

 

 

 

 

Good pickup!

I have personally seen and dx/caught 4 vertebral artery dissections in the last 9 months.

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T-Spine pain with red flags in history and/or exam demands imaging...which is what National Radiology guidelines up here reflect.  Personal experience is the patients and/or the ordering practitioner and/or some lawyer who couldn't get into medical school tend to demand more imaging vs what is wrong with them actually demanding it; a number of surveys and studies reflect that as well.  Don't get me wrong - I still will sometimes do a TTR (Therapeutic Trial of Radiation) on someone, but I'm generally fairly confident in my history taking and examination skills to really decide what, if anything, is warranted.  If I'm stumped or on the fence, I'll talk with an SP or go to the nukes directly and chat with them.

 

As for scanning kids, ironically, the scanner in my hospital is the most up to date in the province with regards to targeting and limiting exposure - it's actually safer to scan kids at my facility than it is at the major pediatric centre, since they've got a scanner older than Dirt's great grand parents.  There is a bit of a time sacrifice though, since the computer program is much slower at producing pictures when doing the peds scans due to the reduced radiation.  Despite all that, I wouldn't order one without talking to a pediatrician first unless it was dire straits.

 

SK

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T-Spine pain with red flags in history and/or exam demands imaging...which is what National Radiology guidelines up here reflect.  Personal experience is the patients and/or the ordering practitioner and/or some lawyer who couldn't get into medical school tend to demand more imaging vs what is wrong with them actually demanding it; a number of surveys and studies reflect that as well.  Don't get me wrong - I still will sometimes do a TTR (Therapeutic Trial of Radiation) on someone, but I'm generally fairly confident in my history taking and examination skills to really decide what, if anything, is warranted.  If I'm stumped or on the fence, I'll talk with an SP or go to the nukes directly and chat with them.

 

As for scanning kids, ironically, the scanner in my hospital is the most up to date in the province with regards to targeting and limiting exposure - it's actually safer to scan kids at my facility than it is at the major pediatric centre, since they've got a scanner older than Dirt's great grand parents.  There is a bit of a time sacrifice though, since the computer program is much slower at producing pictures when doing the peds scans due to the reduced radiation.  Despite all that, I wouldn't order one without talking to a pediatrician first unless it was dire straits.

 

SK

t-spine pain is a red flag in and of itself, i will not argue with you anymore, experience brings wisdom to some

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t-spine pain is a red flag in and of itself, i will not argue with you anymore, experience brings wisdom to some

 

He's got more content in two posts than you do in your entire history on the forum.  You're also the lunatic who said, "JMPA, on 13 Aug 2015 - 8:43 PM, said: a great example is RHO. the childs antibodies can intere act with the mother and cause substantial injury and even death in certain circumstances."  I had it saved in my feed as the most inane thing I have read on the forum.

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This is the kind of stuff that keeps me awake at night after busy ED shifts - have had a couple good saves myself, but on the other hand I always wonder what I've missed!!!  I do appreciate threads like these and learning from the experience of others, though.

 

Curious on the vertebral dissections you mentioned below - traumatic/atraumatic, with what symptoms/how did they present, what caused your radar to ping and order the CTA versus all the other neck pain/HA that you don't scan?  

Well, it was a mixed bag.  Let me see if I can recall the patients...

 

#1 - mid-20s female; hx of floaters (with negative work-up) came in with mild headache (non-SAH presentation) and unilateral neck pain after doing some weighted squats.  No fever or menigitis-like sx.  No CVA sx and vision was subjectively unchanged.  However, her visual sx seemed worsen a bit with neck flexion/extension.  The changes/worsening with flex/extension kind of started the pathway (this was the first one so it was still pretty zebra and relatively far down on the list of ddx)

 

#2 - 50s female, hx of HTN, elevated BP upon arrival with non-complaince, headache and subjective paresthesias (my gut just made the call to scan honestly)

 

#3 - middle aged individual s/p MVC with airbag as I recall. Hx of HTN (medication controlled), mild unilat neuro sx subjectively with increased sx/headache on head movements.  They came in without c-collar on (we put one on)

 

#4.  50-60s female with acute onset of unilat neuro sx with headache and neck pain.  Sx were worse with neck flex/ext and intermittent visual changes (floaters with questionable transient decreased unilateral peripheral vision loss), uncontrolled/non-compliant HTN with BP of 180/100 or higher upon arrival.  Neuro sx were largely subjective though one side was 4/5 vs 5/5 on the other (UEs only, LEs were normal)

 

Those are what I can recall of the patients; the zebra was the young female who was also the first.  I will admit that initially I treated her as an MS complaint and sx resolved with muscle relaxers but gave her very strict return precautions and told her that if they returned or changed to come back.  She did and we scanned her because the vision changes began to increased and were more prominent (though pain had completely subsided) and *bam* it showed a dissection.  The others were combination of sx and age as well as my gut saying to do so.  The concerning thing is how often are these missed?  I know that it is said that we are scanning too much and that we are arguably dx'ing more PEs that the body would otherwise likely correct (talking about subsegmental or small PEs) but still, you have to wonder how often it is not dx'd.  I approach headache/vision changes/neck pain without fever as possible dissections now.  I get that there is a bias, and I obviously do not scan a lot of them, but I definitely do consider it a bit higher in the ddx now.  Again, a lot has to do with your gut or the little voice in your head saying "Something is not right here..." or at least in my case it did.

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No matter how honed in your history and physical skills are or how intuitive or experienced one is, I think the scary part is when we do pick up on that case that any other day would've been missed. We can all agree that "aggressive imaging" is not the direction to steer medicine, and yes looking at NNT or numbers needed to diagnose vs false positives and radiation, one may be able to make a generalized statement. But we can all think of many negative scans however we've also all had that scan we got expecting it to be negative and finding something surprising on the read. It feels great to catch a dissection or bleed or any impending disaster when it's still early enough to intervene with an expected degree of success. But think of all the patients who walk in and out of a hospital being reassured that bounce back or expire some time later. I of all people do not ever want to practice out of fear (of missing every possible dx, or from litigation). But with modern imaging we have all had those patients where we get something as the OP said as a rule out, only to be surprised by the insidious result we receive. Sometimes out intuition saves us but the other side of that coin is that others times it does not.

 

There's no easy answer. From a whole population perspective we have learned that we're doing more overall harm in some regards than we are helping (eg the whole everyone has a positive d dimer fiasco). But In accepting that we can't work everyone up the most careful and detailed way because of radiation, time constraints, false positives etc, that there is some small degree of patients whom ARE going to be missed no matter how intuitive, experienced and skilled the PA or doc seeing them is.

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I'm on a roll. From last night

 

1. LOL put on steroids 2 days before for mild vasculitis, gets up from bed and falls. Husband says her dementia is worse in past 2 days. PE- a&o but off her game, has occipital hematoma. No thinners. I almost chalk up her mental state to baseline dementia worsened by steroid psychosis, but I scan her anyway....moderate SAH.

 

2. LOL fell (again) in nursing home. Again a&o, again off her game. Frontal contusion, no thinners. Scan shows moderate subdural.

 

Funny how things go in cycles....

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There's no easy answer.

 

I think the most interesting thing I read on this forum in the maybe two years I have been here was a PA who posted about how his ER uses an in-house calculated algorithm / flow chart to talk to low risk chest pain patients about going home or going to the floor for observation.  This helps the provider to avoid practicing fear-based or lawsuit-based medicine.  There's a term for it, patient-centered or some such happy thing.

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