I’m on call tonight, and I’ve read about 200 studies since 8AM. Does wonders for the attitude. Imagine my joy (or lack thereof), when I received the following call from one of our hospitals:
“Uh, Dr. Dalai? This is Joe Tech from NorthSouth Hospital. I have another CT PA gram for you, and also a renal stone CT. Oh, and Dr. Feckless in the ER wants to know if we should scan a chest without or with contrast. Why does he want it? Well, he sees a hole in the lung on a chest X-ray, and he wants to scan it……”
Only the names have been changed to protect the innocent (ME!!!). The chest X-ray in question is anonymously reproduced below:
See the “hole”? It’s in the region of the left axilla, and it is a bloody artifact caused by crossing of breast and arm shadows. Hole, indeed.
My response to Joe Tech was at first angry and then practical…”Is Dr. Feckless going to call in the surgeons based on the CT finding? No, don’t repeat that….repeat the chest X-ray with the arms out of the way, and if the, ummm, hole is still there, THEN we’ll do a CT.” The repeat is found below. Voila! No hole!
This sad tale is wonderfully illustrative of how the ER thinks. Or doesn’t as the case may be. The slightest twinge deserves the full court press. The slightest question is to be answered with a $1000 CT scan. In the middle of the night, of course. So, I have to get off my anti-self-referral bandwagon and get on my anti-scan-for-no-good-reason bandwagon. Hey, maybe they are the same bandwagon? Anyway, this knee-jerk ordering of a very expensive test is yet another reason imaging costs have skyrocketed out of sight. One of my partners very seriously states that the ER depends on us because we provide the diagnosis for them, because we have become so good at reading CT’s, and because CT’s have become so much better with multi-slice technique. Balderdash. The ER is just palming off their triage duties onto us. Order a scan of the affected area and see a few more victims while it’s being done. And order scans on the new victims while we’re at it.
This practice has got to stop, just as much as self-referral must be curbed. I keep backing into the conclusion that socialized medicine is going to do that for us, whether we like it or not. Hope I’m wrong. In the meantime, let me read the next 10 negative CT’s.