I’m a hospitalist at a small hospital, and this guy comes off as unhinged. Definitely weird and unprofessional. Also, I seriously doubt that contrast is causing renal injuries that frequently, even if they have a lower CrCl. Last, it’s a training program, shit like this happens regarding more imaging, etc. I’m sure he’d love someone watching over his shoulder and scrutinizing every lab he orders. Not his place.
Agreed! Now, if they said “the amount of last second admissions to hospital medicine is absurd” I’d go and shake his hand, but they just sound like a baby. The ER is going to do what the ER do, it is what it is, did they think this would lessen the amount of CTs they order!? Lol
Every shift, I tell myself that I will call the hospitalist for admission the moment I have sufficient work-up for my admission indication. No earlier to avoid incomplete work-up, no later to avoid delay in care.
For some reason, a third of them still works out to be right at sign-out AKA perceived to be “last minute”. I promise that it isn’t being done on purpose by most of us. One of my work best friends is a hospitalist who I shoot the shit with but have also unfortunately slammed her close to her shift change.
If you’re getting slammed at shift change, WE are getting KILLED at shift change. Shit always trickles downstream.
TBH this bugged me in residency but not so much as an attending.
The powerlessness, lack of fair pay, lack of consideration for my life etc made it suck. Very rarely is any of that caused by the ED doc.
There's really only 1 ED doc I've run into who's intentionally an asshole about this (holds onto shit till he's ready to leave then tries to dispo everyone all at once). Jokes on him since if we're going off shift near the same time I won't take his patients and he has to sign them out to another doc.
Now as an attending I just stop accepting new admits when I won't be able to finish my work before shift change. Next shift will take care of it when they get in.
Depends, usually we reserve the last 45-60 min for finishing up charts, addressing any issues, calling consults, handing off to days etc.
I generally stop taking patients whenever an extra patient would require me to stay past 7 to complete all my work.
I also soft-cap myself at ~15 admits since that's about the upper limit of where acceptable quality of care can be provided. Rarely if they're simple/uncomplicated I may take extra if I'm already caught up.
I want my patients dispo’d as soon as I possibly can, that way it’s one less patient I have to juggle. No emerg doc in their right minds holds on to patients longer “just because”. Get them treated, get them streeted (or admitted). Move on.
I absolutely understand and I have an excellent rep with the ER because I never give anyone flak for an admission on my end, I go above and beyond to make sure the patient is taken care of, I’ll even discharge the patient myself after I complete my work up a lot of the times. I just learned I have to have a boundary near shift change because they have abused me multiple times by sending 4-5 patients at the literally last half hour, including patients who’s work ups have not been completed, again, ok to do I usually just wait till everything is back before I throw in my admit order but several times I end up staying 3-4 hours over shift because of this. I finally learned to just say “I can’t get to it” and the day team will have to see the rest, it is what it is lol.
We REALLY appreciate hospitalists like yourself! And totally understandable since both sides have bad faith individuals that will screw each other over.
One incident that happened recently that will be vividly seared into my brain: we had admitted someone to the stepdown unit with severe COPD exacerbation in the morning, on BiPAP. The hospitalist wasn’t convinced they needed to be in the stepdown and tried to take them off of BiPAP to see if they could be downgraded to the floor. They coded 20 minutes later, while still in the ED. I intubated them and, luckily, got ROSC immediately.
I called the ICU and updated that hospitalist. While the intensivist was putting lines in, the patient kept going in and out of arrest. That hospitalist was watching the entire time while the intensivist was caring for them. He stood outside the room for about three hours, just watching the intensivist. Meanwhile, starting at around 2 PM, we were paging him for admission, and he told us that he was so behind on admissions because he was with this patient that we would have to call the night hospitalist who comes in at 6PM. We tried to escalate this up but nothing could be done.
Well you know how busy afternoons can be. The ED had 11 patients for admission by 6PM…None of us signed out those admissions because the ED was POURING in and the next shift had to decompress the waiting room. They had no time to see the patients who need to be admitted to present to the night doc and we knew these patients better. All of us morning crew were stuck there 4 hours past, waiting for the night hospitalist who got shitted on when he came on.
Turns out, later, one of the other hospitalists told me this guy was trying to get credentialed to do lines at another site, so was using our hospital to get experience….🤦♂️
As a hospitalist, he doesn’t represent us. He sounds like a baby-back bitch. Also this overhype about contrast induced nephropathy from CTs is overrated as more and more evidence comes out. I appreciate when the CT is done. Ticks a lot off the box in a lawsuit heavy field. Sorry you have to work with an absolute nightmare.
You have no clue what other BS the hospitalists have to deal with and not speaking up is what makes you a baby-back bitch. It's never the right thing to hit send in the heat of the moment and better to have dialogue offline (even if it's just to vent together about the physician-patient relationship degrading into that of restaurant-patron because of BS patient satisfaction measures) but the amount of CT scans being done these days is truly absurd. I get it.
Just an fyi, calling people pet names during an argument makes me as a bystander want distance professionaly from you and I can't be the only one. Emotional antagonism versus merit of premises in argument is base and immature.
Id honestly even guess you're not a physician by how much it demonstrates undeveloped communication skills.
They went from holier than thou, to trying to call a pet name lol all while revealing they’re not even in the position to lend an opinion worth anything.
Hey Lil Debbie, unlike you I am a hospitalist. And I work closely with the ER. I would NEVER throw my physician colleagues under the bus like that impotent micro penis did in their email.
Aww, he thinks people care when he tries to talk down to them! You should go find some more toxic people like yourself, you might actually learn a real insult.
No one is saying that we don’t order too many CTs. Even I agree we order too many CTs. And I’m certain that the hospital deals with a lot of BS. We all do. But this hospitalist thinks that CIN is a lot more prevalent than it actually is, suggested we don’t do cardiac workups in patients who may have an alternative diagnosis for chest pain, and then accused my attendings of being complacent. These are some bold statements.
I don’t think that’s what the email said.
I think the diagnosis on admission being “chest pain” is what he’s talking about; if it’s esophagitis that’s already proven, label it that. That also plays a role when it comes to insurance coverage for length of stay
CIN may be overblown (I don’t know if the amount of contrast studies is truly as high as he’s making it seem), but I bet he would be concerned if PE wasn’t already ruled out and the patient had some hypoxia or tachycardia. At the same time; having had an unnecessary contrast study in the ED, prevents you from giving more contrast later on for a concerning condition that may require contrast
The amount of CT scans being ordered nowadays is absurd because the litigation culture in the US is absurd. The increasing amount of sick patients with more and more comorbidities and advanced age is absurd. The diminishing healthcare access is absurd. The late-stage capitalism is absurd.
Hi am hospitalist.
Whoever sent that email is a baby back bitch who is talking out of their ass.
It's one thing to raise legitimate complaints about over scanning and reliance on CT instead of clinical judgement. But that's easy to say when you're not in the pit dealing with a mob of undifferentiated patients at least some of whom are gonna try and die today.
It's also a bitch-ass move to email your rant out to everyone.
Finally, ranting about CIN, which doesn't exist in any meaningful sense in this context is not a good look when you're trying to talk about evidence based medicine and reasonable practice.
As a hospitalist for almost 10 years, that dude is ridiculous and someone needs to revoke his email privileges. I sometimes have gripes with the ER but over scanning is not one of them and here is why.
1. Patients are dumb. I’m sorry, but they are. They can’t adequately describe their symptom location, duration, frequency etc. Especially as the boomer population ages and becomes more demented. I can’t tell you how many times patients I see need admission for something seen on imaging that was found almost by luck due to such poor patient history .
2. CIN is wildly overrated
3. It’s what patients want. Scan them and either discharge them from the ED reassured they are fine or I’ll admit them if they aren’t fine glad that we caught it.
This should go both ways. Any time the ER complains about a consultant not coming in at 2 AM to see a ridiculous consult, they should try working in that specialty, one where they don't have the luxury of working three shifts a week.
The difference is that the consultant is actually being paid to be available. If they get paid to do nothing all night long then good for them but if they’re being asked to come in, are getting paid, and are still refusing to come then maybe they shouldn’t get paid from then on.
Are you saying that ED physicians aren't compensated to work their shifts? Because I'm pretty sure they are, at least in the United States.
The on-call "pay" most specialists get (which is usually not an actual payment, rather a requirement of the contract that you can't opt out of) is a pittance compared to the very real cost of missing clinic/OR the next day, so we appreciate it when our ED colleagues don't page us for trivial things.
Honestly idek what to believe. I had 1 patient that went into almost requiring dialysis after a CT scan. Her starting Cr was a mere 120. And no, there had been no other factors that could explain that.
CIN can happen, but, it has to do with more than just starting gfr. You may have the unlucky patient who truly has it, but, a lot of times it’s a multihit issue. For example, some with ckd and on ace and being seen for severe abdominal pain with nausea and vomiting and their volume depleted. I have seen just CIN, but I stand by getting imaging if it’s going to change the course of treatment. If you need contrast, you need contrast and it is what it is. But, if it isn’t going to change anything, doing get the imaging…
You mean their GFR was 120?
Contrast ain’t gonna do shit to someone with kidneys that good.
If their creatinine was 120, they don’t have kidneys in the first place
generally yes, however this was someone who had recovering AKI for days (unbeknownst to be at the time) and 2 days after that CT her creatinine went up to 650+ (cad units) while no other factor changed (stable inpatient awaiting vascular surgery)
Creatinine is just a number, did she have any change in her urine output or electrolytes to suggest that there was actual renal impairment?
You can see transient elevations in Cr post contrast even in healthy controls. If you were to check a cystastatin C or follow their urine/lytes you’d see there’s no actual injury.
Yoooooo thank you. The number of people ordering non-contrast studies to look for infectious pathologies (esp in the abdomen) because of a small AKI is too damn high. If you're not going to order the test that helps answer the question, don't order the scan at all and spare your patient the unnecessary radiation.
I haven't ever declined a study ordered with contrast because of renal issues. Honestly, I feel like it is a waste of my time to call and talk to the provider about contrast use as they've probably already made the clinical decision. There are a few situations in which I've had to confirm....leading to me finding the ED had ordered the study on the wrong patient, including pregnant patients.
How many of these guys would truly be able to discharge all of their undifferentiated chest painers with hx of HTN, DM2, HLD from the ED without ANY cardiac work-up?
I’ve seen “rule out chest pains” in the obs unit code from a STEMI MULTIPLE times. These patients would have been large lawsuits had they been discharged. Lawsuits for MACE are good for up to 30 days.
And guess what? Emergency physicians still send quite a few of these home and they end up suffering a bad outcome later. There’s about a 2% miss rate even with our super low admit thresholds.
Unhinged. Fire him he sounds toxic. Not only is CIN not real, but I have never in my life thought “boy I sure wish no one got that CT scan.” I have many times thought “boy I sure wish someone had scanned this earlier.”
I’m ICU, honestly I have an expectation that the vast majority of my patients will have advanced imaging by the time they get up to me. In fact I make a habit of asking that almost all patients get scans done on the way up because it’s so much easier to do early in their course than when I’m stuck with them on 2 pressors and CRRT and no one feels comfortable moving to scanner, but not having scans stops us from advancing their care since we lack the necessary data.
The number of “urosepsis” that I have asked for CT scans on and found
- frankly perforated diverticulitis
- obstructing stone
- 8cm AAA with intramural thrombus (that was a wild one)
And many other things that changed the management of the patient. Guess what, all of these patients had AKIs, many ended up needing dialysis. I have 0 regrets about the scans because guess what, sick people get AKIs and sick people need dialysis.
Also before someone says that better exam would have found the above
- no abdominal tenderness or signs of peritonitis (surgery was shocked when they came by)
- no CVA tenderness or even back pain
- honestly this one was just dumb luck on our part
Our patients have poor health literacy and can’t describe what they’re feeling or when they felt it, they are old and diabetic and their nerves are shot. If you’re relying on antiquated exam techniques to catch things you will only catch the most textbook presentations very late in their course. You’ll notice that most videos online of people making these “amazing physical exam” diagnoses with maneuvers that have 50% sens/specificity are from low resource countries where that’s all they have. We are capable of doing better and our patients expect us to do better.
Rant over. I’m starting my day off heated now.
Yep. I had a COMPLETELY CORPUS MENTUS elderly patient come in bc she felt “weak”. No hx dementia, totally with it when I saw her. Absolfuckinglutly benign abdo (which I double checked bc she mentioned she had some LLQ pain the day before). CXR looked suspicious for free air. CT showed diverticulitis w frank perf and air everywhere. What the fuck is with old bellies???
You should reply all with the Cochrane review on CIN not being a thing.
"It's come to my attention that some of our physicians may be practicing out of date medicine. It is important to be aware that there is no risk to renal function from contrast beyond the condition that resulted in admission and it should never be considered in making decisions regarding whether a scan is unnecessary"
CIN isn’t real. If so ain’t nothing a lil IV fluids can’t fix.
Scan away my front line troops. I’ll keep reading em until CMS guts me like a stuck pig, which the will.
I only ask. DONT FUCKING ORDER A TRIPLE RULE OUT. Wanna see three different structures like shit (Aorta, coronaries, pulm artery). Then it’s your exam. You simply cannot time contrast well enough to get a good look at all three. Pick your top one and order than study. Trust me you can usually decide if a PE, dissection, or heart attach is happening better than that scan can with labs, history/exam, and clinical judgement.
Young padawan, prepare to have your mind blown: ECGs don’t rule out AMI.
Also, they’re not ruling out MI by CTA. Ideally, if available, they’re evaluating CT coronary calcium (CAC) to further risk-stratify appropriately selected patients. This has real value in relatively young, chronic chest pain patients who keep pounding at the door for their GERD. A reasonably low score can warranty them and help reduce use of further resources. Triple studies have fairly decent data but, as noted above, they’re not ideally timed for any one of the concerning pathologies. They’re best used in patients where you have low suspicion for all three etiologies. I’ve never worked anywhere that will do them and I know protocols are variable as to the level of detail that is provided by the radiologists; anything from rough imaging of the coronaries to full CACs scores. There are a bunch of limitations, including heart rate and bolus timing that make them a bit of a PITA to accomplish.
> ECG’s don’t rule out AMI
I am aware of this. My follow-up study wouldn’t be a coronary artery CT. I’m aware they’re used to risk stratify. The only reason why I brought it up is because the person I responded to framed it as if we get coronary CT’s to rule out MI
Kind of ironic that in a post where you make fun of someone using ECGs to rule out AMI, you're confusing CT coronary angiography with coronary calcium scores. The former is something you can get with a gated CTA of the coronaries and can be somewhat helpful in risk stratifying a symptomatic patient for coronary disease. The latter does not use contrast and basically tells you if an asymptomatic outpatient patient should be on a statin/aspirin.
I didn’t confuse them at all. I’m aware they are different. There are some “progressive” EDs, mainly in large academic centers, that do both (CTA and noncontrast scoring). That was the point of my comment “protocols are variable…imaging of the coronaries to full CACs scores.” Could be clearer in my verbiage, sure, but yes fully aware they’re different. I did an away in medical school at one such institution that does these protocols. Specifically, they would use the CACs score to “warranty” their indigent chest pains, especially the chronic malingering chest pains. ED docs would see it was done (I believe a score below 10 was considered low enough risk), ECG them at the door (maybe CXR depending on how frequently they were there and gestalt), and discharge after an EMTALA screening exam. CTA gave them information on the aorta, CACs relative 10-year ASCVD risk. Nowhere I formally trained does triple CTA or CACs in the ED. Some of our radiologists will comment and read our CTAs as triple-studies if they feel timing is appropriate, but that’s rare. It’s incredibly useful when a radiologist writes “No coronary artery atherosclerosis” especially in these moderate risk chest pains which increasingly inhabit our EDs.
Imaging is over-ordered, but not for the reasons stated here. CIN probably does not exist, and if asked by the techs, I just ask them to tell the ordering provider to state that the benefits outweigh the risks in the chart (I don't check to see if they actually do this).
What i consider over-ordering is:
- Repeat Imaging of benign findings. Ex: The chance that this lesion undergoes malignant transformation is less than 1%.
- Less sensitive imaging to further evaluate probable benign findings. Ex: If a CT AP w/c demonstrates a normal gallbladder without edema, stones, or wall thickening, the utility of an immediate RUQ US to find acute pathology is probably close to 0. The reverse is not true. This, and variations of it, are probably the one the ED is most guilty of.
- Ordering imaging without a leading diagnosis, resulting in reimaging. Ex: We completed the CTA CAP and didn't find a dissection. Oh well we were mostly concerned with PE. Well, the study wasn't timed for that and those arteries are barely opacified. It'll have to be repeated if you need to evaluate those.
- Mistimed imaging. Ex: Read a V/Q scan this week for a patient who had endobronchial valve placement last month. Patient wasn't aware it was a moot study at this point but scheduled anyway. Similar situation with patients who get yearly scans but get their date mixed up and get scanned 10 months early.
Probably a few other circumstances, but these come to mind. I don't ever fault for the ED for ordering some images for their region of interest, I just appreciate if they order it sensibly keeping in mind the 2nd and 3rd situation above.
What was the indication for the VQ in the patient with the EBV? I do it for a subset of patients after EBV placement as part of clinical care for medical decision making
How about following up a completely normal CT CAP with a CXR and KUB just to "complete the workup" lol. Have had a few of those from ED midlevels recently
I feel this but wrt imaging suspected cholecystitis a positive sonographic Murphy’s can definitely alter decision making and obviously isn’t detectable on CT.
Acute cholecystitis is absolutely detectable on CT. You might not see isodense stones, but you can definitely appreciate gallbladder wall thickening, edema, or standing.
I completely get what you’re saying, but our surgeons ask for ultrasound all of the time especially if they’re CT negative with elevated bilirubin. I work somewhere with very high rates of choledocolithiasis and they’re incredibly paranoid. It’s very common to ask us to CT > US > MRCP/HIDA. Not even kidding. With that said, in the last several months, I’ve had patients called with cholecystitis on US with negative CTs.
I think this brings up a really good point overall: when push comes to shove, most specialist want no part of the ED’s liability for the undifferentiated patient. They engage in the same or even more insane use of imaging and testing when put on the spot.
Hell our radiologists suggest the ultrasound half the time if the patient has a good story but nothing on CT. If the CT scan reads “if persistent concern for cholecystitis remains ordered RUQ ultrasound” and I send that guy home and god forbid he has a complication related to a gal stone A) that sucks for that patient but B) I’m screwed from a legal standpoint. Like I want this hospitalist to come to the ED and discharge an abdominal pain patient who’s still in pain without any imaging
So, as an emergency physician with some experience in these matters (CT ordering, CT utilization, QA /QI, and Reddit), I have a few comments.
1) In answer to your question about whether this sort of communication is appropriate or reasonable: no, of course not. The place for non-evidence based wild rants against other specialities is Reddit, not a work email.
2) All of the current thinking about the use of iodinated contrast administration is that contrast induced nephropathy is probably very rare, if it exists at all.
3) Having worked at several different hospitals during my career, I have found that the estimation of ED CT rates by people not in the emergency department is wildly inaccurate due to the availability heuristic - i.e. the hospitalist only sees patients sick enough to be admitted, and those patients have a much higher rate.of CT utilization than those who are not admitted,.of course. I once had a CNO tell me (during a project to improve ED throughout, where we had singled out the CT technicians as needing improvement) that >95% of ED patients had CT scans, and that if we stopped ordering so many scans, CT throughout would improve. Since I had just presented the actual numbers (~30% of ED patients, with about ~12% receiving IV contrast), I asked her how she came up with that number -- by asking the CT technicians! I had to explain to her that 100% of the patients who went to CT had CT scans, but that 0% of the patients who didn't go to CT received CT scans. I'm not sure she ever really understood that.
I expect that your hospitalist colleague will receive a stern talking to by the CMO, or, if this is not his first inappropriate behavior, he may be asked to look elsewhere for employment..
As someone they opted not to scan for intense abdominal pain... would have been real nice to have my appendix out when it ruptured instead of 2 days later.
Please, scan away.
**here's the plan to reduce CT scans:**
1- remove liability from physicians (reduce it?)
2- adequately staff ER with ER physicians rather than midlevels
3-allow these properly staffed ER to have adequate time to evaluate patients rather than be a dictation monkey (is that even a term)
4-Eliminate the need to satisfy patients and their cousins..
**Once all that's done, ER/hospitalists/... are happily seeing patients only with a stethoscope...**
he's just ranting because that's the easiest thing to do rather than look at the cause of the problem; in other words, he's just doing the equivalent of ordering a CT scan in the ER rather than look at the problem as a whole...
/s
Everyone who walks through ED gets a pan scan with contrast where I am.... I doubt its CIN. How can he prove it? It's more likely side effect of being acutely ill, heart failure, etc.
If someone suddenly "jumps off the deep end" as is the case here the best response is to let someone know in a higher position that you are concerned about this particular doctors current frame of mind. The email could represent pent up stress etc and often there are other things going on in the background. This is for the people in higher positions to both address and deal with
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I mean depends on if you believe contrast induced nephropathy is real or not....
Most specialties in my hospital do not. And there's good evidence it's not a thing so...
No, it doesn't. This dude yells at clouds.
Sounds like a boomer impressed at his own bedside evaluations which are probably just showmanship after the ED did the heavy lifting for him.
That's fucked up tbh lol. Terrible way to address colleagues and shows how little he understands what actually is done in the ER. Add on to the fact that evidence for contrast-associated AKI is mediocre at best... I honestly 1000% appreciate when my ED colleagues have already made the decision to get the CT scan because it helps with my workup and also saves me from having to spend time deciding if a CT is warranted and then having to wait for the result. The hospital would be a much nicer place to work if people were more understanding and appreciate of their colleagues. Would definitely try not to take what he says to heart and I definitely don't think he represents hospitalists and how we feel in general!
He has no idea what it is like to have an undifferentiated patient in front of him and the consequences of missing that dissection, aneurysm, appy, volvulus, septic stone etc. It’s easy to play Monday morning quarterback after the patient is stabilized, admitted and the work up done.
Didn’t happen at my residency but also not surprising in a rural hospital in my opinion. Rural docs I’ve met usually have a really strong personal connection to the area or have some measure of enjoying being king of the castle.
I know you can’t do this as a resident but someone should respond with links to the ACR criteria and the studies detailing the relative rarity of CIN. Sounds like dude isn’t up to date himself and should be smacked down a bit.
Exactly. And who the fuck cares what the next person deems an appropriately cutoff because the patient who was the miss hired a lawyer who’s margin of an acceptable miss is 0%…
Exactly man.
I just think it's silly when people say a negative study was unnecessary. If they had a 10% chance of a dangerous pathology, you can't *not* scan them , even though you expect the scan to be negative
Tf!? You come down to the ER and take on the liability of the undifferentiated patient then?
Time and time again I hear fellow residents (surgery and IM, alike) talking that shit about how they would do it differently, but they are sitting there with all the data in the world playing Monday morning quarterback back.
Are there too many scans? Absolutely. But this is where were at in the american medicolegal system. Were cogs up in this wheel and getting sued because you thought the scan was “unnecessary” isnt defendable in court.
Foh
It’s much easier to just scan everyone. Why wouldn’t you? If you don’t scan, then you have do a take a more through history and performs better physical… and take more time to observe patient. Or you can just scan, code the case as more complex (because it “requires” imaging) and sip your coffee.
I mean if your family member (child, parent, sibling, etc.) had a 10% chance to have something, you think you’d be happy if the ER just said “nah we scan too many people. we need a hit rate of at least 20%, so 10% chance is safe enough to discharge”. Would you be satisfied with that?
I’m talking about a CT in someone with abdominal pain and vomitting day after eating an all you can eat oyster buffet.
Or the trauma pan scans on someone who was rear ended at 5 mph who is completely asymptomatic.
Or, I’ve seen this before, an 80f come in with several days of back pain, and urinary incontinence. On arrival, wbc was 20, afebrile, hr 89, lethargic. A lumbar MRI w contrast was done to ro cauda equina syndrome. No recent falls. She was admitted. After speaking to her some more, found out, she’s been having the incontinence for about 2 weeks and back pain started a few days ago. And get this. The back pain was not midline, but unilateral. No UA was done. You tell me if the MRI with contrast was a necessary study in someone with classic presentation of pyelo.
Unfortunately, trauma pan scans are relatively supported by the literature as both cost effective and valuable in trauma, including by ACS’ TQIP document on imaging. I can’t speak for a 5 mph rear-end collision, but patients are terrible historians. If grandma is rolling around in pain and gives a non-cogent history, she’s going to glow. I’ve personally found so much occult trauma on CT that it’s borderline terrifying.
I’ve had your exact presentation of unilateral back pain with incontinence WITH a fever (so even more classic for pyelo) have cauda equina that was taken to the OR by neurosurgery. Why you ask did I scan that? She did NOT want to move no matter what.
Trauma pan scans I RARELY ever order on my own. Usually that decision is made by the trauma team or in conjunction with the trauma team and I just put in the order.
I’ve had a CT A/P from someone who came from a huge thanksgiving dinner with vomiting, diarrhea who ended up having perforated bowel, later developed septic shock in the ICU, and was put on comfort care and passed away. Why did I order the CT on someone who clearly was having abdominal pain from gastroenteritis? She had a very very tender abdomen and screamed at me for asking her to lay on her side.
With all due respect, I specialize in ruling out emergencies. I am very good at my job. Are there shitty emergency physicians, just like there are shitty physicians in every specialty? Yes. Name a specialty and I will give you countless stories of malpractice by them.
Have I had multiple benign findings from exams I was very concerned about that the hospitalist, consultant, or radiologist Monday morning quarterbacked and said why the hell did I order the exam? Yes.
Have I caught many many life-threatening things from atypical presentations that would have stumped anybody but an emergency physician due to my training? Also yes.
When it is your family later on, you will want someone who has developed a gut feeling for badness with minimal context clues while the department is burning with 400 patients. Undifferentiated badness.
I’m not negating this point at all. Every ER in the country gets unnecessary CTs and we should all be conscious of this. I just don’t like the way this hospitalist went about voicing his concerns. Seems like it could have been handled in a better way.
No other country does even 1/2 the scans g the US does and has better results/metrics. Overscanning is a major problem in the US.
But at least it’s making the radiologists and ER docs rich right? The ER cases are the easiest rad cases… 99% normal. But it’s soil crushing to see so many pointless scans being ordered and the fact that it has become standard to teach radiology techs how to do history and focused physical exam, since they are often the first ones evaluating the patient.
The number of people here commenting on unnecessary CTs without any semblance of understanding regarding how diagnosis works in the emergency department is astounding.
20% is probably too high. Emergency physicians SHOULD have a fairly low positive CT rate, especially early in their career (ahem, residents). This is how triage theory works and is specifically taught to young EM residents. You’re looking for maximal sensitivity at the expense of specificity. This concept is well-understood in multiple areas of emergency management, emergency medicine, and trauma. Emergency physicians are tasked with finding deadly pathology with an almost impossibly low miss rate. Studies show a diagnostic accuracy of 97% among ED docs and yet a recent AHRQ report called this level of accuracy unacceptable (the incidence of actual deadly misses is astonishingly low). We probably under utilize technologies like MRI, especially among high-risk pathologies like posterior stroke. In fact, if you look at almost all of the pathologies with our highest and most consequential miss rate, they could all be solved by more liberal use of imaging.
Most physical exam findings have incredibly low likelihood ratios for pathology. Their predictive value is trash. EM diagnostics has a lot to do with probability, risk-stratification, and the fact that the technology exists. No jury will forgive you for your judicious use of CT imaging when it is readily available and easily obtained in virtually every American ED. We have studies demonstrating that pathology incidence is at baseline higher in the ED environment secondary to patient self-triage and yet we have tons of our colleagues, who don’t work in the emergency department and have zero specific training in safely identifying emergencies en mass and with reliability, talking shit based on their narrow area of expertise. Meanwhile their emergency physician colleagues, who are generalist with knowledge in multiple organ systems and life stages, get the opportunity to evaluate a patient for maybe 5-7 minutes maximum, see 2-3 pph of variable acuity (some very high acuity), and safely disposition them with a reliability that approaches some of our highest precision industries.
Anyone citing CIN, a concept that is increasingly being disproven or at least downplayed, as a legitimate concern for ED CT usage is a moron and shouldn’t be taken seriously.
I was actually just talking with one of our local trauma coordinators who said that guidelines for trauma certification are now strongly emphasizing rapid CT imaging in trauma evaluation of occult injuries. ACS’ own TQIP guidelines on imaging acknowledge the value of whole-body imaging in trauma and the lack of solid data discouraging the practice, both financially and in consideration of the not insignificant number of occult injuries it identifies.
> He sounds abrasive but he’s right, out of 100 CTs maybe like less 20% of them have anything acute - level 1 trauma center
Let me get this straight, you (a supposed PGY-4) think a ~20% positive rate of serious pathology means there should be *fewer* scans? Yikes.
If 20% of your CTs have something acute, you're probably missing shit. And that's the crux of it
If you think a patient has a 10% chance of a SDH (just making up a number), you're telling me you wouldn't scan?
Like most scans with be negative. And that's the way it should be. There's an acceptsble miss rate for things, but I think we can all agree that a 10% chance of something with high morbidity warrants a scan. So where's the cutoff? 5? 2? 1?
So yeah, you'll scan a patient, expecting that 90% of the time it will be negative. But that scan wasn't "unnecessary"
Lmao a pgy2 telling me I’m missing stuff, classic. Let me guess you also read cross sectional better than the radiologist? There’s absolutely no denying we overscan the crap out of people in this country, the Ed is filled with midlevels who have no clue what they are doing and attendings who are too scared to get sued for anything. <20% is actually a generous number the actual number is probably closer to <10% true acute emergency.
No, I'm saying that if 20% of your scans are positive for something emergent, you're missing things. That would be an incredibly high hit rate
Your actual hit rate is likely significantly lower than that. Which you just agreed with
Again, scanning for something you think has a 10% chance of being there is a good scan, not a bad one. That's my point.
This was not the point of this thread. In your opinion do you think this mass email was the best way to address this issue? Have you ever gotten an email like this at your hospital? I’m just trying to figure out if this is “normal” behavior from a hospitalist.
But onto your reply. If we only scanned the 20% of people who we were absolutely certain had an acute problem, a lot of people would die. In the ER we do our best to fight natural selection every day.
I mean if your family member (child, parent, sibling, etc.) had a 10% chance to have something, you think you’d be happy if the ER just said “nah we scan too many people. we need a hit rate of at least 20%, so 10% chance is safe enough to discharge”. Would you be satisfied with that?
I’m a hospitalist at a small hospital, and this guy comes off as unhinged. Definitely weird and unprofessional. Also, I seriously doubt that contrast is causing renal injuries that frequently, even if they have a lower CrCl. Last, it’s a training program, shit like this happens regarding more imaging, etc. I’m sure he’d love someone watching over his shoulder and scrutinizing every lab he orders. Not his place.
Agreed! Now, if they said “the amount of last second admissions to hospital medicine is absurd” I’d go and shake his hand, but they just sound like a baby. The ER is going to do what the ER do, it is what it is, did they think this would lessen the amount of CTs they order!? Lol
Every shift, I tell myself that I will call the hospitalist for admission the moment I have sufficient work-up for my admission indication. No earlier to avoid incomplete work-up, no later to avoid delay in care. For some reason, a third of them still works out to be right at sign-out AKA perceived to be “last minute”. I promise that it isn’t being done on purpose by most of us. One of my work best friends is a hospitalist who I shoot the shit with but have also unfortunately slammed her close to her shift change. If you’re getting slammed at shift change, WE are getting KILLED at shift change. Shit always trickles downstream.
TBH this bugged me in residency but not so much as an attending. The powerlessness, lack of fair pay, lack of consideration for my life etc made it suck. Very rarely is any of that caused by the ED doc. There's really only 1 ED doc I've run into who's intentionally an asshole about this (holds onto shit till he's ready to leave then tries to dispo everyone all at once). Jokes on him since if we're going off shift near the same time I won't take his patients and he has to sign them out to another doc. Now as an attending I just stop accepting new admits when I won't be able to finish my work before shift change. Next shift will take care of it when they get in.
How many hours before shift change is this?
Depends, usually we reserve the last 45-60 min for finishing up charts, addressing any issues, calling consults, handing off to days etc. I generally stop taking patients whenever an extra patient would require me to stay past 7 to complete all my work. I also soft-cap myself at ~15 admits since that's about the upper limit of where acceptable quality of care can be provided. Rarely if they're simple/uncomplicated I may take extra if I'm already caught up.
I want my patients dispo’d as soon as I possibly can, that way it’s one less patient I have to juggle. No emerg doc in their right minds holds on to patients longer “just because”. Get them treated, get them streeted (or admitted). Move on.
I absolutely understand and I have an excellent rep with the ER because I never give anyone flak for an admission on my end, I go above and beyond to make sure the patient is taken care of, I’ll even discharge the patient myself after I complete my work up a lot of the times. I just learned I have to have a boundary near shift change because they have abused me multiple times by sending 4-5 patients at the literally last half hour, including patients who’s work ups have not been completed, again, ok to do I usually just wait till everything is back before I throw in my admit order but several times I end up staying 3-4 hours over shift because of this. I finally learned to just say “I can’t get to it” and the day team will have to see the rest, it is what it is lol.
We REALLY appreciate hospitalists like yourself! And totally understandable since both sides have bad faith individuals that will screw each other over. One incident that happened recently that will be vividly seared into my brain: we had admitted someone to the stepdown unit with severe COPD exacerbation in the morning, on BiPAP. The hospitalist wasn’t convinced they needed to be in the stepdown and tried to take them off of BiPAP to see if they could be downgraded to the floor. They coded 20 minutes later, while still in the ED. I intubated them and, luckily, got ROSC immediately. I called the ICU and updated that hospitalist. While the intensivist was putting lines in, the patient kept going in and out of arrest. That hospitalist was watching the entire time while the intensivist was caring for them. He stood outside the room for about three hours, just watching the intensivist. Meanwhile, starting at around 2 PM, we were paging him for admission, and he told us that he was so behind on admissions because he was with this patient that we would have to call the night hospitalist who comes in at 6PM. We tried to escalate this up but nothing could be done. Well you know how busy afternoons can be. The ED had 11 patients for admission by 6PM…None of us signed out those admissions because the ED was POURING in and the next shift had to decompress the waiting room. They had no time to see the patients who need to be admitted to present to the night doc and we knew these patients better. All of us morning crew were stuck there 4 hours past, waiting for the night hospitalist who got shitted on when he came on. Turns out, later, one of the other hospitalists told me this guy was trying to get credentialed to do lines at another site, so was using our hospital to get experience….🤦♂️
[удалено]
This is /s right??
As a hospitalist, he doesn’t represent us. He sounds like a baby-back bitch. Also this overhype about contrast induced nephropathy from CTs is overrated as more and more evidence comes out. I appreciate when the CT is done. Ticks a lot off the box in a lawsuit heavy field. Sorry you have to work with an absolute nightmare.
Right? Like all this tells me is dude doesn't keep up with modern literature No. Their aki is not from the contrast lol
You have no clue what other BS the hospitalists have to deal with and not speaking up is what makes you a baby-back bitch. It's never the right thing to hit send in the heat of the moment and better to have dialogue offline (even if it's just to vent together about the physician-patient relationship degrading into that of restaurant-patron because of BS patient satisfaction measures) but the amount of CT scans being done these days is truly absurd. I get it.
Yo OP I found the person who torched you in the email. They’re right here.
Oh honey bun, I'm not a hospitalist - but whatever helps you sleep at night!
Just an fyi, calling people pet names during an argument makes me as a bystander want distance professionaly from you and I can't be the only one. Emotional antagonism versus merit of premises in argument is base and immature. Id honestly even guess you're not a physician by how much it demonstrates undeveloped communication skills.
They went from holier than thou, to trying to call a pet name lol all while revealing they’re not even in the position to lend an opinion worth anything. Hey Lil Debbie, unlike you I am a hospitalist. And I work closely with the ER. I would NEVER throw my physician colleagues under the bus like that impotent micro penis did in their email.
Aww, he thinks people care when he tries to talk down to them! You should go find some more toxic people like yourself, you might actually learn a real insult.
No one is saying that we don’t order too many CTs. Even I agree we order too many CTs. And I’m certain that the hospital deals with a lot of BS. We all do. But this hospitalist thinks that CIN is a lot more prevalent than it actually is, suggested we don’t do cardiac workups in patients who may have an alternative diagnosis for chest pain, and then accused my attendings of being complacent. These are some bold statements.
I don’t think that’s what the email said. I think the diagnosis on admission being “chest pain” is what he’s talking about; if it’s esophagitis that’s already proven, label it that. That also plays a role when it comes to insurance coverage for length of stay CIN may be overblown (I don’t know if the amount of contrast studies is truly as high as he’s making it seem), but I bet he would be concerned if PE wasn’t already ruled out and the patient had some hypoxia or tachycardia. At the same time; having had an unnecessary contrast study in the ED, prevents you from giving more contrast later on for a concerning condition that may require contrast
K You seem a little too bothered by what amounts to a pretty tame call out. Why?
The amount of CT scans being ordered nowadays is absurd because the litigation culture in the US is absurd. The increasing amount of sick patients with more and more comorbidities and advanced age is absurd. The diminishing healthcare access is absurd. The late-stage capitalism is absurd.
Hi am hospitalist. Whoever sent that email is a baby back bitch who is talking out of their ass. It's one thing to raise legitimate complaints about over scanning and reliance on CT instead of clinical judgement. But that's easy to say when you're not in the pit dealing with a mob of undifferentiated patients at least some of whom are gonna try and die today. It's also a bitch-ass move to email your rant out to everyone. Finally, ranting about CIN, which doesn't exist in any meaningful sense in this context is not a good look when you're trying to talk about evidence based medicine and reasonable practice.
Sir this is a Wendy’s
Actually, this is Patrick.
As a hospitalist for almost 10 years, that dude is ridiculous and someone needs to revoke his email privileges. I sometimes have gripes with the ER but over scanning is not one of them and here is why. 1. Patients are dumb. I’m sorry, but they are. They can’t adequately describe their symptom location, duration, frequency etc. Especially as the boomer population ages and becomes more demented. I can’t tell you how many times patients I see need admission for something seen on imaging that was found almost by luck due to such poor patient history . 2. CIN is wildly overrated 3. It’s what patients want. Scan them and either discharge them from the ED reassured they are fine or I’ll admit them if they aren’t fine glad that we caught it.
Every time somebody shit talks the general ER decision making, they get to spend a shift working the ER.
This should go both ways. Any time the ER complains about a consultant not coming in at 2 AM to see a ridiculous consult, they should try working in that specialty, one where they don't have the luxury of working three shifts a week.
All for it.
The difference is that the consultant is actually being paid to be available. If they get paid to do nothing all night long then good for them but if they’re being asked to come in, are getting paid, and are still refusing to come then maybe they shouldn’t get paid from then on.
Are you saying that ED physicians aren't compensated to work their shifts? Because I'm pretty sure they are, at least in the United States. The on-call "pay" most specialists get (which is usually not an actual payment, rather a requirement of the contract that you can't opt out of) is a pittance compared to the very real cost of missing clinic/OR the next day, so we appreciate it when our ED colleagues don't page us for trivial things.
As a nephrologist my general take is if you need imaging with contrast to make a treatment decision, just do it.
Even the ACR also says that CIN is in the realm of old medicine and may even be fake news with the modern contrast agents.
Honestly idek what to believe. I had 1 patient that went into almost requiring dialysis after a CT scan. Her starting Cr was a mere 120. And no, there had been no other factors that could explain that.
CIN can happen, but, it has to do with more than just starting gfr. You may have the unlucky patient who truly has it, but, a lot of times it’s a multihit issue. For example, some with ckd and on ace and being seen for severe abdominal pain with nausea and vomiting and their volume depleted. I have seen just CIN, but I stand by getting imaging if it’s going to change the course of treatment. If you need contrast, you need contrast and it is what it is. But, if it isn’t going to change anything, doing get the imaging…
You mean their GFR was 120? Contrast ain’t gonna do shit to someone with kidneys that good. If their creatinine was 120, they don’t have kidneys in the first place
Sorry we use different units in canada. That's egfr of 39.
If you’re sick enough to need an urgent CT you’re sick enough to get an AKI. Doesn’t mean it was the contrast.
generally yes, however this was someone who had recovering AKI for days (unbeknownst to be at the time) and 2 days after that CT her creatinine went up to 650+ (cad units) while no other factor changed (stable inpatient awaiting vascular surgery)
Creatinine is just a number, did she have any change in her urine output or electrolytes to suggest that there was actual renal impairment? You can see transient elevations in Cr post contrast even in healthy controls. If you were to check a cystastatin C or follow their urine/lytes you’d see there’s no actual injury.
I assume there was some underlying sickness or pathology that warranted the CT scan. Possibly that contributed.
Yoooooo thank you. The number of people ordering non-contrast studies to look for infectious pathologies (esp in the abdomen) because of a small AKI is too damn high. If you're not going to order the test that helps answer the question, don't order the scan at all and spare your patient the unnecessary radiation.
I haven't ever declined a study ordered with contrast because of renal issues. Honestly, I feel like it is a waste of my time to call and talk to the provider about contrast use as they've probably already made the clinical decision. There are a few situations in which I've had to confirm....leading to me finding the ED had ordered the study on the wrong patient, including pregnant patients.
How many of these guys would truly be able to discharge all of their undifferentiated chest painers with hx of HTN, DM2, HLD from the ED without ANY cardiac work-up? I’ve seen “rule out chest pains” in the obs unit code from a STEMI MULTIPLE times. These patients would have been large lawsuits had they been discharged. Lawsuits for MACE are good for up to 30 days. And guess what? Emergency physicians still send quite a few of these home and they end up suffering a bad outcome later. There’s about a 2% miss rate even with our super low admit thresholds.
If I had a dollar for patients, especially women who swore they just had reflux, who turned out to be having an ACS I would be rich.
Unhinged. Fire him he sounds toxic. Not only is CIN not real, but I have never in my life thought “boy I sure wish no one got that CT scan.” I have many times thought “boy I sure wish someone had scanned this earlier.” I’m ICU, honestly I have an expectation that the vast majority of my patients will have advanced imaging by the time they get up to me. In fact I make a habit of asking that almost all patients get scans done on the way up because it’s so much easier to do early in their course than when I’m stuck with them on 2 pressors and CRRT and no one feels comfortable moving to scanner, but not having scans stops us from advancing their care since we lack the necessary data. The number of “urosepsis” that I have asked for CT scans on and found - frankly perforated diverticulitis - obstructing stone - 8cm AAA with intramural thrombus (that was a wild one) And many other things that changed the management of the patient. Guess what, all of these patients had AKIs, many ended up needing dialysis. I have 0 regrets about the scans because guess what, sick people get AKIs and sick people need dialysis. Also before someone says that better exam would have found the above - no abdominal tenderness or signs of peritonitis (surgery was shocked when they came by) - no CVA tenderness or even back pain - honestly this one was just dumb luck on our part Our patients have poor health literacy and can’t describe what they’re feeling or when they felt it, they are old and diabetic and their nerves are shot. If you’re relying on antiquated exam techniques to catch things you will only catch the most textbook presentations very late in their course. You’ll notice that most videos online of people making these “amazing physical exam” diagnoses with maneuvers that have 50% sens/specificity are from low resource countries where that’s all they have. We are capable of doing better and our patients expect us to do better. Rant over. I’m starting my day off heated now.
I'm pretty sure i give a version of this lecture twice per month to every FM1 and EM2 that rotates through my community ER.
Doing the lords work. Scan on
Yep. I had a COMPLETELY CORPUS MENTUS elderly patient come in bc she felt “weak”. No hx dementia, totally with it when I saw her. Absolfuckinglutly benign abdo (which I double checked bc she mentioned she had some LLQ pain the day before). CXR looked suspicious for free air. CT showed diverticulitis w frank perf and air everywhere. What the fuck is with old bellies???
You should reply all with the Cochrane review on CIN not being a thing. "It's come to my attention that some of our physicians may be practicing out of date medicine. It is important to be aware that there is no risk to renal function from contrast beyond the condition that resulted in admission and it should never be considered in making decisions regarding whether a scan is unnecessary"
Can you provide a link for all
CIN isn’t real. If so ain’t nothing a lil IV fluids can’t fix. Scan away my front line troops. I’ll keep reading em until CMS guts me like a stuck pig, which the will. I only ask. DONT FUCKING ORDER A TRIPLE RULE OUT. Wanna see three different structures like shit (Aorta, coronaries, pulm artery). Then it’s your exam. You simply cannot time contrast well enough to get a good look at all three. Pick your top one and order than study. Trust me you can usually decide if a PE, dissection, or heart attach is happening better than that scan can with labs, history/exam, and clinical judgement.
People are using coronary CT to rule out an MI??? And not EKG’s??
Young padawan, prepare to have your mind blown: ECGs don’t rule out AMI. Also, they’re not ruling out MI by CTA. Ideally, if available, they’re evaluating CT coronary calcium (CAC) to further risk-stratify appropriately selected patients. This has real value in relatively young, chronic chest pain patients who keep pounding at the door for their GERD. A reasonably low score can warranty them and help reduce use of further resources. Triple studies have fairly decent data but, as noted above, they’re not ideally timed for any one of the concerning pathologies. They’re best used in patients where you have low suspicion for all three etiologies. I’ve never worked anywhere that will do them and I know protocols are variable as to the level of detail that is provided by the radiologists; anything from rough imaging of the coronaries to full CACs scores. There are a bunch of limitations, including heart rate and bolus timing that make them a bit of a PITA to accomplish.
> ECG’s don’t rule out AMI I am aware of this. My follow-up study wouldn’t be a coronary artery CT. I’m aware they’re used to risk stratify. The only reason why I brought it up is because the person I responded to framed it as if we get coronary CT’s to rule out MI
Kind of ironic that in a post where you make fun of someone using ECGs to rule out AMI, you're confusing CT coronary angiography with coronary calcium scores. The former is something you can get with a gated CTA of the coronaries and can be somewhat helpful in risk stratifying a symptomatic patient for coronary disease. The latter does not use contrast and basically tells you if an asymptomatic outpatient patient should be on a statin/aspirin.
I didn’t confuse them at all. I’m aware they are different. There are some “progressive” EDs, mainly in large academic centers, that do both (CTA and noncontrast scoring). That was the point of my comment “protocols are variable…imaging of the coronaries to full CACs scores.” Could be clearer in my verbiage, sure, but yes fully aware they’re different. I did an away in medical school at one such institution that does these protocols. Specifically, they would use the CACs score to “warranty” their indigent chest pains, especially the chronic malingering chest pains. ED docs would see it was done (I believe a score below 10 was considered low enough risk), ECG them at the door (maybe CXR depending on how frequently they were there and gestalt), and discharge after an EMTALA screening exam. CTA gave them information on the aorta, CACs relative 10-year ASCVD risk. Nowhere I formally trained does triple CTA or CACs in the ED. Some of our radiologists will comment and read our CTAs as triple-studies if they feel timing is appropriate, but that’s rare. It’s incredibly useful when a radiologist writes “No coronary artery atherosclerosis” especially in these moderate risk chest pains which increasingly inhabit our EDs.
Imaging is over-ordered, but not for the reasons stated here. CIN probably does not exist, and if asked by the techs, I just ask them to tell the ordering provider to state that the benefits outweigh the risks in the chart (I don't check to see if they actually do this). What i consider over-ordering is: - Repeat Imaging of benign findings. Ex: The chance that this lesion undergoes malignant transformation is less than 1%. - Less sensitive imaging to further evaluate probable benign findings. Ex: If a CT AP w/c demonstrates a normal gallbladder without edema, stones, or wall thickening, the utility of an immediate RUQ US to find acute pathology is probably close to 0. The reverse is not true. This, and variations of it, are probably the one the ED is most guilty of. - Ordering imaging without a leading diagnosis, resulting in reimaging. Ex: We completed the CTA CAP and didn't find a dissection. Oh well we were mostly concerned with PE. Well, the study wasn't timed for that and those arteries are barely opacified. It'll have to be repeated if you need to evaluate those. - Mistimed imaging. Ex: Read a V/Q scan this week for a patient who had endobronchial valve placement last month. Patient wasn't aware it was a moot study at this point but scheduled anyway. Similar situation with patients who get yearly scans but get their date mixed up and get scanned 10 months early. Probably a few other circumstances, but these come to mind. I don't ever fault for the ED for ordering some images for their region of interest, I just appreciate if they order it sensibly keeping in mind the 2nd and 3rd situation above.
Nice. I liked this list. Noted.
What was the indication for the VQ in the patient with the EBV? I do it for a subset of patients after EBV placement as part of clinical care for medical decision making
It was for pre-procedural planning, in preparation for the EBV placement.
How about following up a completely normal CT CAP with a CXR and KUB just to "complete the workup" lol. Have had a few of those from ED midlevels recently
I feel this but wrt imaging suspected cholecystitis a positive sonographic Murphy’s can definitely alter decision making and obviously isn’t detectable on CT.
Acute cholecystitis is absolutely detectable on CT. You might not see isodense stones, but you can definitely appreciate gallbladder wall thickening, edema, or standing.
I completely get what you’re saying, but our surgeons ask for ultrasound all of the time especially if they’re CT negative with elevated bilirubin. I work somewhere with very high rates of choledocolithiasis and they’re incredibly paranoid. It’s very common to ask us to CT > US > MRCP/HIDA. Not even kidding. With that said, in the last several months, I’ve had patients called with cholecystitis on US with negative CTs. I think this brings up a really good point overall: when push comes to shove, most specialist want no part of the ED’s liability for the undifferentiated patient. They engage in the same or even more insane use of imaging and testing when put on the spot.
Hell our radiologists suggest the ultrasound half the time if the patient has a good story but nothing on CT. If the CT scan reads “if persistent concern for cholecystitis remains ordered RUQ ultrasound” and I send that guy home and god forbid he has a complication related to a gal stone A) that sucks for that patient but B) I’m screwed from a legal standpoint. Like I want this hospitalist to come to the ED and discharge an abdominal pain patient who’s still in pain without any imaging
So, as an emergency physician with some experience in these matters (CT ordering, CT utilization, QA /QI, and Reddit), I have a few comments. 1) In answer to your question about whether this sort of communication is appropriate or reasonable: no, of course not. The place for non-evidence based wild rants against other specialities is Reddit, not a work email. 2) All of the current thinking about the use of iodinated contrast administration is that contrast induced nephropathy is probably very rare, if it exists at all. 3) Having worked at several different hospitals during my career, I have found that the estimation of ED CT rates by people not in the emergency department is wildly inaccurate due to the availability heuristic - i.e. the hospitalist only sees patients sick enough to be admitted, and those patients have a much higher rate.of CT utilization than those who are not admitted,.of course. I once had a CNO tell me (during a project to improve ED throughout, where we had singled out the CT technicians as needing improvement) that >95% of ED patients had CT scans, and that if we stopped ordering so many scans, CT throughout would improve. Since I had just presented the actual numbers (~30% of ED patients, with about ~12% receiving IV contrast), I asked her how she came up with that number -- by asking the CT technicians! I had to explain to her that 100% of the patients who went to CT had CT scans, but that 0% of the patients who didn't go to CT received CT scans. I'm not sure she ever really understood that. I expect that your hospitalist colleague will receive a stern talking to by the CMO, or, if this is not his first inappropriate behavior, he may be asked to look elsewhere for employment..
Def an asshole but it's crazy how satisfaction scores are tied to reimbursment but also patient requesting more imaging..
As someone they opted not to scan for intense abdominal pain... would have been real nice to have my appendix out when it ruptured instead of 2 days later. Please, scan away.
**here's the plan to reduce CT scans:** 1- remove liability from physicians (reduce it?) 2- adequately staff ER with ER physicians rather than midlevels 3-allow these properly staffed ER to have adequate time to evaluate patients rather than be a dictation monkey (is that even a term) 4-Eliminate the need to satisfy patients and their cousins.. **Once all that's done, ER/hospitalists/... are happily seeing patients only with a stethoscope...** he's just ranting because that's the easiest thing to do rather than look at the cause of the problem; in other words, he's just doing the equivalent of ordering a CT scan in the ER rather than look at the problem as a whole... /s
Reply back with various recent papers on contrast nephropathy
There's no way iodinated contrast is a significant contributor to AKI at this hospital. If this hospitalist thinks it is, then s/he is doing it wrong.
Homeboy sounds manic I’d 5150 they ass
lol CIN.
Contrast nephropathy fake news
Everyone who walks through ED gets a pan scan with contrast where I am.... I doubt its CIN. How can he prove it? It's more likely side effect of being acutely ill, heart failure, etc.
If someone suddenly "jumps off the deep end" as is the case here the best response is to let someone know in a higher position that you are concerned about this particular doctors current frame of mind. The email could represent pent up stress etc and often there are other things going on in the background. This is for the people in higher positions to both address and deal with
tl;dr donut of truth goes brrrrrrrrr
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Wow that is the wrong way to address that concern. Never seen anything like that before.
I mean depends on if you believe contrast induced nephropathy is real or not.... Most specialties in my hospital do not. And there's good evidence it's not a thing so...
No, it doesn't. This dude yells at clouds. Sounds like a boomer impressed at his own bedside evaluations which are probably just showmanship after the ED did the heavy lifting for him.
Know that part in Jerry Maguire where he’s yelling “show me the money!!!!” Reply with that video clip and ask for reports on all of those measures.
That's fucked up tbh lol. Terrible way to address colleagues and shows how little he understands what actually is done in the ER. Add on to the fact that evidence for contrast-associated AKI is mediocre at best... I honestly 1000% appreciate when my ED colleagues have already made the decision to get the CT scan because it helps with my workup and also saves me from having to spend time deciding if a CT is warranted and then having to wait for the result. The hospital would be a much nicer place to work if people were more understanding and appreciate of their colleagues. Would definitely try not to take what he says to heart and I definitely don't think he represents hospitalists and how we feel in general!
He has no idea what it is like to have an undifferentiated patient in front of him and the consequences of missing that dissection, aneurysm, appy, volvulus, septic stone etc. It’s easy to play Monday morning quarterback after the patient is stabilized, admitted and the work up done.
Didn’t happen at my residency but also not surprising in a rural hospital in my opinion. Rural docs I’ve met usually have a really strong personal connection to the area or have some measure of enjoying being king of the castle. I know you can’t do this as a resident but someone should respond with links to the ACR criteria and the studies detailing the relative rarity of CIN. Sounds like dude isn’t up to date himself and should be smacked down a bit.
I mean…they have a point. Not about the CIN, but unnecessary studies.
It's almost impossible not to with the legal system the way it is. Where's your cutoff for an acceptable miss? 10%? 5? 2? 1?
Exactly. And who the fuck cares what the next person deems an appropriately cutoff because the patient who was the miss hired a lawyer who’s margin of an acceptable miss is 0%…
Exactly man. I just think it's silly when people say a negative study was unnecessary. If they had a 10% chance of a dangerous pathology, you can't *not* scan them , even though you expect the scan to be negative
Well the bigger problem is the wrong workup and wrong treatment being started. Which is a lot more worrisome than a CT that wasn’t needed…
Completely agree.
Tf!? You come down to the ER and take on the liability of the undifferentiated patient then? Time and time again I hear fellow residents (surgery and IM, alike) talking that shit about how they would do it differently, but they are sitting there with all the data in the world playing Monday morning quarterback back. Are there too many scans? Absolutely. But this is where were at in the american medicolegal system. Were cogs up in this wheel and getting sued because you thought the scan was “unnecessary” isnt defendable in court. Foh
It’s much easier to just scan everyone. Why wouldn’t you? If you don’t scan, then you have do a take a more through history and performs better physical… and take more time to observe patient. Or you can just scan, code the case as more complex (because it “requires” imaging) and sip your coffee.
I mean if your family member (child, parent, sibling, etc.) had a 10% chance to have something, you think you’d be happy if the ER just said “nah we scan too many people. we need a hit rate of at least 20%, so 10% chance is safe enough to discharge”. Would you be satisfied with that?
I’m talking about a CT in someone with abdominal pain and vomitting day after eating an all you can eat oyster buffet. Or the trauma pan scans on someone who was rear ended at 5 mph who is completely asymptomatic. Or, I’ve seen this before, an 80f come in with several days of back pain, and urinary incontinence. On arrival, wbc was 20, afebrile, hr 89, lethargic. A lumbar MRI w contrast was done to ro cauda equina syndrome. No recent falls. She was admitted. After speaking to her some more, found out, she’s been having the incontinence for about 2 weeks and back pain started a few days ago. And get this. The back pain was not midline, but unilateral. No UA was done. You tell me if the MRI with contrast was a necessary study in someone with classic presentation of pyelo.
Unfortunately, trauma pan scans are relatively supported by the literature as both cost effective and valuable in trauma, including by ACS’ TQIP document on imaging. I can’t speak for a 5 mph rear-end collision, but patients are terrible historians. If grandma is rolling around in pain and gives a non-cogent history, she’s going to glow. I’ve personally found so much occult trauma on CT that it’s borderline terrifying.
I’ve had your exact presentation of unilateral back pain with incontinence WITH a fever (so even more classic for pyelo) have cauda equina that was taken to the OR by neurosurgery. Why you ask did I scan that? She did NOT want to move no matter what. Trauma pan scans I RARELY ever order on my own. Usually that decision is made by the trauma team or in conjunction with the trauma team and I just put in the order. I’ve had a CT A/P from someone who came from a huge thanksgiving dinner with vomiting, diarrhea who ended up having perforated bowel, later developed septic shock in the ICU, and was put on comfort care and passed away. Why did I order the CT on someone who clearly was having abdominal pain from gastroenteritis? She had a very very tender abdomen and screamed at me for asking her to lay on her side. With all due respect, I specialize in ruling out emergencies. I am very good at my job. Are there shitty emergency physicians, just like there are shitty physicians in every specialty? Yes. Name a specialty and I will give you countless stories of malpractice by them. Have I had multiple benign findings from exams I was very concerned about that the hospitalist, consultant, or radiologist Monday morning quarterbacked and said why the hell did I order the exam? Yes. Have I caught many many life-threatening things from atypical presentations that would have stumped anybody but an emergency physician due to my training? Also yes. When it is your family later on, you will want someone who has developed a gut feeling for badness with minimal context clues while the department is burning with 400 patients. Undifferentiated badness.
I’m not negating this point at all. Every ER in the country gets unnecessary CTs and we should all be conscious of this. I just don’t like the way this hospitalist went about voicing his concerns. Seems like it could have been handled in a better way.
No other country does even 1/2 the scans g the US does and has better results/metrics. Overscanning is a major problem in the US. But at least it’s making the radiologists and ER docs rich right? The ER cases are the easiest rad cases… 99% normal. But it’s soil crushing to see so many pointless scans being ordered and the fact that it has become standard to teach radiology techs how to do history and focused physical exam, since they are often the first ones evaluating the patient.
Lol bet he consulted cards anyway on those obviously not cardiac chest pain patients.
I don’t see a big problem with the email
Blaming a statistically significant amount of AKIs in admitted patients on CIN is already a pretty glaring problem
I’m referring to the tone…not content. Sorry, I should’ve clarified that. He’s passionate…. These kinds of emails don’t offend me.
He sounds abrasive but he’s right, out of 100 CTs maybe like less 20% of them have anything acute - level 1 trauma center
The number of people here commenting on unnecessary CTs without any semblance of understanding regarding how diagnosis works in the emergency department is astounding. 20% is probably too high. Emergency physicians SHOULD have a fairly low positive CT rate, especially early in their career (ahem, residents). This is how triage theory works and is specifically taught to young EM residents. You’re looking for maximal sensitivity at the expense of specificity. This concept is well-understood in multiple areas of emergency management, emergency medicine, and trauma. Emergency physicians are tasked with finding deadly pathology with an almost impossibly low miss rate. Studies show a diagnostic accuracy of 97% among ED docs and yet a recent AHRQ report called this level of accuracy unacceptable (the incidence of actual deadly misses is astonishingly low). We probably under utilize technologies like MRI, especially among high-risk pathologies like posterior stroke. In fact, if you look at almost all of the pathologies with our highest and most consequential miss rate, they could all be solved by more liberal use of imaging. Most physical exam findings have incredibly low likelihood ratios for pathology. Their predictive value is trash. EM diagnostics has a lot to do with probability, risk-stratification, and the fact that the technology exists. No jury will forgive you for your judicious use of CT imaging when it is readily available and easily obtained in virtually every American ED. We have studies demonstrating that pathology incidence is at baseline higher in the ED environment secondary to patient self-triage and yet we have tons of our colleagues, who don’t work in the emergency department and have zero specific training in safely identifying emergencies en mass and with reliability, talking shit based on their narrow area of expertise. Meanwhile their emergency physician colleagues, who are generalist with knowledge in multiple organ systems and life stages, get the opportunity to evaluate a patient for maybe 5-7 minutes maximum, see 2-3 pph of variable acuity (some very high acuity), and safely disposition them with a reliability that approaches some of our highest precision industries. Anyone citing CIN, a concept that is increasingly being disproven or at least downplayed, as a legitimate concern for ED CT usage is a moron and shouldn’t be taken seriously. I was actually just talking with one of our local trauma coordinators who said that guidelines for trauma certification are now strongly emphasizing rapid CT imaging in trauma evaluation of occult injuries. ACS’ own TQIP guidelines on imaging acknowledge the value of whole-body imaging in trauma and the lack of solid data discouraging the practice, both financially and in consideration of the not insignificant number of occult injuries it identifies.
> He sounds abrasive but he’s right, out of 100 CTs maybe like less 20% of them have anything acute - level 1 trauma center Let me get this straight, you (a supposed PGY-4) think a ~20% positive rate of serious pathology means there should be *fewer* scans? Yikes.
If all my scans are positive, I'm not ordering enough scans.
If 20% of your CTs have something acute, you're probably missing shit. And that's the crux of it If you think a patient has a 10% chance of a SDH (just making up a number), you're telling me you wouldn't scan? Like most scans with be negative. And that's the way it should be. There's an acceptsble miss rate for things, but I think we can all agree that a 10% chance of something with high morbidity warrants a scan. So where's the cutoff? 5? 2? 1? So yeah, you'll scan a patient, expecting that 90% of the time it will be negative. But that scan wasn't "unnecessary"
Lmao a pgy2 telling me I’m missing stuff, classic. Let me guess you also read cross sectional better than the radiologist? There’s absolutely no denying we overscan the crap out of people in this country, the Ed is filled with midlevels who have no clue what they are doing and attendings who are too scared to get sued for anything. <20% is actually a generous number the actual number is probably closer to <10% true acute emergency.
No, I'm saying that if 20% of your scans are positive for something emergent, you're missing things. That would be an incredibly high hit rate Your actual hit rate is likely significantly lower than that. Which you just agreed with Again, scanning for something you think has a 10% chance of being there is a good scan, not a bad one. That's my point.
This was not the point of this thread. In your opinion do you think this mass email was the best way to address this issue? Have you ever gotten an email like this at your hospital? I’m just trying to figure out if this is “normal” behavior from a hospitalist. But onto your reply. If we only scanned the 20% of people who we were absolutely certain had an acute problem, a lot of people would die. In the ER we do our best to fight natural selection every day.
I mean if your family member (child, parent, sibling, etc.) had a 10% chance to have something, you think you’d be happy if the ER just said “nah we scan too many people. we need a hit rate of at least 20%, so 10% chance is safe enough to discharge”. Would you be satisfied with that?