CAdamsPAC Posted September 6, 2012 Share Posted September 6, 2012 As an 11 y/o boy I woke up one morning with the worst pain of my life in my rlq. Parents took me to the pediatrician who drew labs and sent me to the ER. WBC count was sky high and the pediatric surgeon said "it's his appendix". An hour later my appendix was out, looking pink and healthy. The pathology report came back and described a healthy, noninflammed appendix. Had there been imaging available then it would have ruled out the need for an unnecessary surgery. Of course this was done before laparoscopy so I have a 2.5" surgical scar on my belly. Moral of the story: Sometimes clinical suspicion is very high but still wrong. For every 99 successes you have 1 failure. If your expectation in medicine is to be 100% correct, you are in for major disappointment and frustration in your career . Link to comment Share on other sites More sharing options...
Guest JMPA Posted September 7, 2012 Share Posted September 7, 2012 Appendectomy risks far outweigh ct risks. You go have an guess and good luck appendectomy and i will have a ct scan pre-surgically. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 7, 2012 Moderator Share Posted September 7, 2012 Appendectomy risks far outweigh ct risks. You go have an guess and good luck appendectomy and i will have a ct scan pre-surgically. but do you want want one every month for 6 yrs like some of our pts get? those folks are headed for big time cancer in their later years.... Link to comment Share on other sites More sharing options...
MedicinePower Posted September 7, 2012 Share Posted September 7, 2012 If your expectation in medicine is to be 100% correct, you are in for major disappointment and frustration in your career . The entire point of my post is to demonstrate that nothing is 100%. Not sure how you could read it any other way. Link to comment Share on other sites More sharing options...
fuma102 Posted September 10, 2012 Share Posted September 10, 2012 This whole CT causes CA thing is way overblown. an abd/pelvis is like adding 3 years worth of radiation you get just from walking around town. http://www.radiologyinfo.org/en/pdf/sfty_xray.pdf Urology & radiology requested a KUB the other day in place of a kidney stone protocol CT. similar levels of radiation according to radiology websites, yet somehow they want to play pin the cancer on the PA. whatever. general rule for myself gets broken down to the following: new onset in >40 gets labs & a CT. Ive had a few CA's and a few renal abscesses. under 40 with a compelling story and UA suggestive gets 1 round of pain meds- if relieved, no CT. if Im doing 2 rounds of meds or they have a clean UA, they get labs & CT. I see no use for sono as it (A) doesnt tell me size and (B) its a waste of my time. over 40 you miss other stuff. So you find out they have huge unilateral hydro... and? we should be more worried about proper hydration before & after IV contrast for contrast induced nephropathy- this is a much more common issue (& will debilitate you sooner!) that may be more likely to result in a winning lawsuit. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted September 10, 2012 Share Posted September 10, 2012 The entire point of my post is to demonstrate that nothing is 100%. Not sure how you could read it any other way. The fact that you state you can't see how someone may have a different take on a statement is quite telling. The practice of medicine is an art developed with both academic opportunities, clinical experience producing "that feeling in your gut" telling you what needs to be done. Link to comment Share on other sites More sharing options...
RetNavyPAC Posted September 10, 2012 Share Posted September 10, 2012 ...especially in patients who have no desire to eat, a classic signal with a great PE... That's indeed what all of us were taught, but actually (and I just learned this a couple of years ago) the presence or absence anorexia has been demonstrated to be essentially useless in predicting the presence or absence of appendicitis. Andersson RE, Hugander AP, Ghazi SH, et al. Diagnostic value of disease history, clinical presentation, and inflammatory parameters of appendicitis. World J Surg. 1999;23(2):133-140. PubMed PMID: 9880421 This was brought home last year when I saw a 9yo boy brought in by his mother for "He says his belly's hurting bad!" while the lad was munching on some McDonald's fries. Son of a gun had a 10mm appy on RLQ US! Link to comment Share on other sites More sharing options...
RetNavyPAC Posted September 11, 2012 Share Posted September 11, 2012 This whole CT causes CA thing is way overblown. An Abd/Pelvis is like adding 3 years worth of radiation you get just from walking around town. I have to agree with fuma in that the cancer risk is has been overblown. It is not negligible to be sure, and we need to be judicious in what we order (especially in kids), but there is now "radiation phobia" - especially on the part of rad techs and some radiologists & primary care providers. I've had techs initially refuse and primary docs question my sanity when ordering a CXR on a pregnant woman. Even after I trot out the evidence (estimated fetal exposure from a maternal PA & LAT CXR is <0.0001 mSv - and that's UN-shielded!) the cognitive dissonance is almost too much for some. Link to comment Share on other sites More sharing options...
Ho0v-man Posted September 11, 2012 Share Posted September 11, 2012 Not a PA, but i am a CT tech. You really should be using IV contrast in the ED when they don't have hematuria. Oral contrast is only necessary when the pt is really thin. If you forego IV contrast you may miss subtle inflammatory changes or small abscesses. It's not just about being positive or negative. It's a crazy expensive test that exposes the pt to a lot of radiation. It's important to do it right the first time. Link to comment Share on other sites More sharing options...
MedicinePower Posted September 11, 2012 Share Posted September 11, 2012 The fact that you state you can't see how someone may have a different take on a statement is quite telling. The practice of medicine is an art developed with both academic opportunities, clinical experience producing "that feeling in your gut" telling you what needs to be done. I don't think you're fully understanding. I am highlighting that there can be multiple outcomes to a single set of variables. Why are you badgering me? Link to comment Share on other sites More sharing options...
maryfran123 Posted September 11, 2012 Share Posted September 11, 2012 Few comments here: RC said: "Agree totally.. .. Surgeons no longer read Cope's early diagnosis of the acute abdomen... " RC you will be happy to know my docs actually reference this text regularly and bring the book into our morning report to read from it on certain cases as an education tool for our surgical residents. They get especially uptight when a pt has focal or diffuse peritonitis c/w appy and either the ER or Surgical resident ask for the CT scan anyhow! Our hospital has a partnership with GE and our CT scanners have a special program to use lower than typical doses of radiation. How much lower I am not exactly sure. Re: cancer risk and CT, despite how strong the evidence is or is not, JCHAO is making a big deal about it. See their sentinel alert letter here: http://www.jointcommission.org/assets/1/18/sea_471.pdf From a trauma perspective, we are currently re-evaluating our use of CT scans, particularly in the pediatric population and developing new CMG to limit CT scans in kids. just my $.02 :D Link to comment Share on other sites More sharing options...
CAdamsPAC Posted September 11, 2012 Share Posted September 11, 2012 I don't think you're fully understanding. I am highlighting that there can be multiple outcomes to a single set of variables. Why are you badgering me? Whaaaaaaaaaaaa! I hope you don't ever work with some of the Surgeons I've worked with since you have such thin skin. Don't get into the game if you can't take being bumped into. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted September 11, 2012 Share Posted September 11, 2012 Few comments here: RC said: "Agree totally.. .. Surgeons no longer read Cope's early diagnosis of the acute abdomen... " RC you will be happy to know my docs actually reference this text regularly and bring the book into our morning report to read from it on certain cases as an education tool for our surgical residents. They get especially uptight when a pt has focal or diffuse peritonitis c/w appy and either the ER or Surgical resident ask for the CT scan anyhow! Our hospital has a partnership with GE and our CT scanners have a special program to use lower than typical doses of radiation. How much lower I am not exactly sure. Re: cancer risk and CT, despite how strong the evidence is or is not, JCHAO is making a big deal about it. See their sentinel alert letter here: http://www.jointcommission.org/assets/1/18/sea_471.pdf From a trauma perspective, we are currently re-evaluating our use of CT scans, particularly in the pediatric population and developing new CMG to limit CT scans in kids. just my $.02 :D It great to hear that clinical medicine education still happening! Testing because you can isn't smart. or good medicine. Link to comment Share on other sites More sharing options...
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