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Session 2
Session 2 Session 2 was devoted to investigating the rational use of commonly ordered x-rays in emergency medicine practice. Several themes are found in all the papers. Each author expresses concern about the need for cost effectiveness in an era of diminishing resources, but with appropriate protection of the physician and hospital from potential liability. This latter concern reinforces the need for better understanding by physicians of those known associated symptoms, complaints, and risk indicators that would suggest the possibility of a positive finding before the study is undertaken. Dr Clinton in particular emphasizes the need for better education of physicians in the proper application of known data to justify the ordering of chest films. A recurrent theme is the questioning of why standard film studies are ordered and which studies are most applicable to emergency medicine. Radiologists have designed studies to assess definitively any potential pathology that might be discovered during an examination. Emergency physicians, on the other hand, are usually using the investigative technique to ascertain the presence or absence of a single or a limited number of findings. This puzzle of single purpose versus definitive assessment results in research suggestions by all the authors. Dr Clinton's presentation on chest radiography reviews the changing status of appropriate indications for chest films. He stresses the importance of the cost savings that could be achieved by reducing the number of routine admission and screening chest •ms. He indicates, however, that several areas of research are still incomplete, in particular screening for carcinoma of the lung and use of chest films in pneumothorax and pneumomediastinum. Questions raised by the Session 2 audience included issues surrounding the use of chest films in preoperative situations. Although the discussion did not fully clarify this issue, it is clear that there has been a significant decrease in routine preoperative chest radiography, particularly in asymptomatic patients under 40 years old. Dr Thompson's presentation on rib films concentrates on the fact that, from the emergency physician's point of view, almost all serious sequelae can be seen on a plain chest film. Only in special cases - - when fracture of ribs 1 through 3 and/or 9 through 12 is suspected - - does he recommend rib Views. He qualifies this by stating that in the case of medicolegal concerns, films could be obtained within one to four weeks of injury and documentation at that time would adequately protect the patient. This point raised many questions from the audience about delayed complications from rib fractures that are not seen on initial chest film. The suggestion was made that perhaps a chest film could be ordered initially. If this were normal and the 15:3 March 1986
clinical suspicions for rib fracture remained high, rib views should then be ordered. On the other hand, if a chest film were positive for rib fractures or associated complications, rib views might be eliminated, for the index of suspicion for severe sequelae would be appropriately elevated. Dr Greene proposes a controversial approach to the use of abdominal films to assist in diagnosis and decision making for the physician who is evaluating abdominal complaints. She recommends that a supine abdominal film and an upright chest film are the two initial films indicated for conditions that are likely to be associated with radiographic signs. After initial interpretation of these views, more specific views, such as columnated, left lateral decubitus, horizontal, or prone films, may be ordered based on the reasoning that this would result in the demonstration of known associated emergency conditions, reduction in radiation exposure, and considerable cost savings. The audience raised the issue of the process of selective ordering of tests and its influence on timely disposition of patients in the emergency department. Because in some departments patients are retumed to the ED from radiology after initial films are taken, it was thought to be impractical to order sequential films and thus to move the patient back and forth between the radiology suite and the ED. Dr Greene suggested that a minor change in policy - - in which the patient need not be transferred back to the department until the reading is accomplished - - would result in advantage to patients. Dr Greene also emphasized the importance of reducing the x-ray exposure of pregnant patients, and spoke strongly for the use of pregnancy tests in all patients who require radiation exposure and, if possible, the replacement of x-ray with ultrasound. She concluded that this rethinking about the use of abdominal films in the emergency department will result in a number of new areas for clinical research. Dr Uehara's presentation on intravenous pyelogram addresses its use in blunt and penetrating trauma. He stated that blunt trauma is an area requiring research in emergency medicine, for the literature does not clarify the correlation of hematuria, physical pain complaints, and physical findings in relation to IVP findings. Although he discussed the use of computed tomography and its potential for enhancing diagnosis in patients with renal traumatic injuries, he reemphasized the fact that the IVP is the best screening tool. Dr Uehara also discussed the indications for retrograde cystourethrography in trauma. His thorough review of the literature results in a number of recommendations, many of which are already widely in use. He does suggest, however, that there be increased use of this test when there is severe lower abdominal or perineal trauma without fracture, for a
Annals of Emergency Medicine
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SESSION 2 Jayne
number of urethral and bladder injuries will be discovered using this procedure. He, too, recommends this area for new prospective studies by emergency physicians. All the presenters found that key data necessary for emergency medicine standardized testing are not currently available. They all recommend that new studies should focus on the decision-making process in emergency medicine, and that such studies could result in significant reductions in cost and x-ray exposure to patients. In addition, a recurrent theme found throughout the discussions was that much in-
48/253
formation is available in the literature indicating that disease-associated complaints and conditions generally are not evaluated when studies are ordered. All the presenters thought that if these were evaluated, a significant percentage reduction in x-ray use would follow immediately.
Harold A Jayne, MD, FACEP Division of Emergency Medicine University of Illinois Chicago, Illinois
Annals of Emergency Medicine
1,~:3 March 1986
clinical suspicions for rib fracture remained high, rib views should then be ordered. On the other hand, if a chest film were positive for rib fractures or associated complications, rib views might be eliminated, for the index of suspicion for severe sequelae would be appropriately elevated. Dr Greene proposes a controversial approach to the use of abdominal films to assist in diagnosis and decision making for the physician who is evaluating abdominal complaints. She recommends that a supine abdominal film and an upright chest film are the two initial films indicated for conditions that are likely to be associated with radiographic signs. After initial interpretation of these views, more specific views, such as columnated, left lateral decubitus, horizontal, or prone films, may be ordered based on the reasoning that this would result in the demonstration of known associated emergency conditions, reduction in radiation exposure, and considerable cost savings. The audience raised the issue of the process of selective ordering of tests and its influence on timely disposition of patients in the emergency department. Because in some departments patients are retumed to the ED from radiology after initial films are taken, it was thought to be impractical to order sequential films and thus to move the patient back and forth between the radiology suite and the ED. Dr Greene suggested that a minor change in policy - - in which the patient need not be transferred back to the department until the reading is accomplished - - would result in advantage to patients. Dr Greene also emphasized the importance of reducing the x-ray exposure of pregnant patients, and spoke strongly for the use of pregnancy tests in all patients who require radiation exposure and, if possible, the replacement of x-ray with ultrasound. She concluded that this rethinking about the use of abdominal films in the emergency department will result in a number of new areas for clinical research. Dr Uehara's presentation on intravenous pyelogram addresses its use in blunt and penetrating trauma. He stated that blunt trauma is an area requiring research in emergency medicine, for the literature does not clarify the correlation of hematuria, physical pain complaints, and physical findings in relation to IVP findings. Although he discussed the use of computed tomography and its potential for enhancing diagnosis in patients with renal traumatic injuries, he reemphasized the fact that the IVP is the best screening tool. Dr Uehara also discussed the indications for retrograde cystourethrography in trauma. His thorough review of the literature results in a number of recommendations, many of which are already widely in use. He does suggest, however, that there be increased use of this test when there is severe lower abdominal or perineal trauma without fracture, for a
Annals of Emergency Medicine
252/47
SESSION 2 Jayne
number of urethral and bladder injuries will be discovered using this procedure. He, too, recommends this area for new prospective studies by emergency physicians. All the presenters found that key data necessary for emergency medicine standardized testing are not currently available. They all recommend that new studies should focus on the decision-making process in emergency medicine, and that such studies could result in significant reductions in cost and x-ray exposure to patients. In addition, a recurrent theme found throughout the discussions was that much in-
48/253
formation is available in the literature indicating that disease-associated complaints and conditions generally are not evaluated when studies are ordered. All the presenters thought that if these were evaluated, a significant percentage reduction in x-ray use would follow immediately.
Harold A Jayne, MD, FACEP Division of Emergency Medicine University of Illinois Chicago, Illinois
Annals of Emergency Medicine
1,~:3 March 1986