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ED Registrar (Proactive, patient advocate): Hey, how are you? Thanks for coming down.

ICU Registrar (Calm, relaxed, ready to negotiate): No trouble. What's cooking?

ED Registrar: Well, I've got this guy I was telling you about. The intern saw him about an hour ago when he came in with a fever and looking clammy. Apparently he was a bit off when his daughter spoke to him on the phone earlier today, so she called an ambulance to bring him here.

ICU Registrar: Smart daughter.

ED Registrar: Yeah. In here he's febrile, a bit tachy around 110 and I've had to give him 2 litre of crystalloid to prop up his blood pressure. So he's probably septic.

ICU Registrar: Mmmm.

ED Registrar: The source seems to be his belly. When I examined him, he's really tender in his right upper quadrant and probably a bit guarded too. His LFTs are a little off, with a mixed pattern and his Bili is around 30. The sonographer was in the unit so I asked her to have a quick look at him and she thought there was some fluid around his gallbladder. All the rest of his bloods, including renal and a lipase are fine, except his WBC count is 16, as you'd expect.

ICU Registrar: OK, seems fair enough so far ...

ED Registrar: Right, so we're just taking him around for a CT, 'cause I spoke to the Surgical on-call registrat and told him all this and he wanted a CT just to be sure. But I don't know if we really need to. What do you think?

ICU Registrar: $f*! ^#@

Question

So, once you've calmed down, what DO you think? CT or no and what is your objective reasoning to back up your response?

Answer

OK, this time, rather than outline a possible response and then bore you all to tears with clever deductive reasoning laced heavily with references and articles, go and listen to David Newman's excellent podcast on the truth about diagnostic testing. You can get it on his Smart EM website or go to iTunes and subscribe to the free Smart EM podcast.

Smart EM Smart testing: Back to basics podcast

Whether you work in ICU, ED, anaesthetics, medicine, surgery or even psychiatry, this is stuff you should think about. Like David says in the podcast, it is probably stuff you already know and do, even if you are not aware of it.

A couple of caveats though. The podcast caters essentially for a North American health system of emergency medicine, so if some of it seems a little obvious or blunt, remember that clinical practice can differ quite substantially in the U.S. where litigation rates are high, medical insurance policies dominate and the tendency to test first and question later is the norm. But the core of the message he presents is valid no matter where you work nad no matter what specialty you pursue.

Once you've had a listen to the podcast, have another think about what your response to the scenario above might be.

Comments  

 
#4 Matthew Mac Partlin 2013-01-19 21:38
Great points Gerard. I think you've summed up the salient deficiencies that plague us all at some time or another (and some of us all the time).

I particularly like you point about the "opportunity to correlate this diagnosis with the CT (or any test) findings" because this really is the role of most tests in clinical medicine.

I also agree with how despite an obvious frustration, you separate that from what the patient needs. no point in making the patient suffer for someone else's irritation.
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#3 Gerard Fennessy 2013-01-19 11:37
Hi Matt,

Great post to get me thinking on a number of levels.

(1) The SMART EM podcast is a good primer for PPVs, NPV, Sens, Spec etc. His comments on the usefulness of a WCC in acute cholecystitis is a great example of floccinaucinihi lipilification (it's a real word).

(2) The response from the surgical registrar is a frustrating one. It seems to me that this is a common way of saying "look, I don't want to switch my brain on right now, I want someone else to make the diagnosis."

If I was the surgical registrar, I would tun this diagnostic "problem" on its head, and call it an "opportunity" - an opportunity for me to talk to (shudder!) and examine an acutely unwell UNDIAGNOSED abdomen.

An opportunity to make my own diagnosis, and opportunity to correlate this diagnosis with the CT findings, and an opportunity for me to be wrong (...or better still, for me to be right - and for the CT to confirm it).
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#2 Gerard Fennessy 2013-01-19 11:36
(3) I also find it frustratingly common that the ICU registrars see the patient well before the specialist registrars. If they are sick enough to need ICU, they are certainly sick enough for the unit registrar to come in ASAP and lay hands on the patient.

IS that not fair enough? Should the ICU registrar say "well, they aren't needing inotropes, you don't have culture results, they don't need ventilation - call me back when you really need ICU." No way! So why do we put up with it from other units?

(4) Further, a CT abdomen is not without risks or costs. What is the age of the patient - is the risk of cancer in the future worth it?

What is the cost? Do I have a responsibility to spend public health dollars responsibly? If this CT-scan cost came OUT OF MY WAGES, would I still do it?

Anyway, I am digressing.
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#1 Gerard Fennessy 2013-01-19 11:33
(5) The diagnostic possibilities are still wide. Is the patient haemodynamicall y stable yet? Have they received their first dose of antibiotics yet? Have cultures been taken? Are big lines/long lines in?

Does he need a more formal ultrasound?

Is it something NOT liver/GB? Pneumonia? Perforation? AAA? Do we have our blinkers on?

What does his CXR show?

My plan...
Get the ABs in
Get some lines in
Resuscitate
CXR, more formal USS
Ask the ICU charge nurse for a bed
Ask the surgical reg to turn brain on, and lay hands on patient
Yes he needs a CT, but this should be concurrent with surgical review.
Be worried about this guy...

Cheerio!
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