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Pan scans for ground level fall? Can we do anything about this?
Is there really anything we can do for the relentless minimal injury CTs through the ER. Definitely pays the bills, but its just kind of gross participating. I guess if we had better laws and less lawyers we could improve on this BS? Anything in the ER literature (do they have literature?) to give guidance?
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61 Replies
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A lose lose situation
Put up any resistance and you are obstructing care.
Dont put up any resistance and our reimbursements will continue to plummet
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For now, all of this shift to ER “providers” instead of real physicians has been good for our volumes. This year looks to be a very good year volume (and thus income) wise.
Quality of care is bad tho.
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Quote from acpce1
A lose lose situation
Put up any resistance and you are obstructing care.
Dont put up any resistance and our reimbursements will continue to plummet
This is one of the main reasons I’m working to exit medicine. These unnecessary scans aren’t in any patient’s best interest (physically or financially).
I feel half guilty when I read them knowing I’m making money on these unsuspecting patients. It’s abuse and waste and I’m an enabler by not telling the ED I won’t participate in their sh***y care.
I don’t believe the answer is to just let it continue unchecked. Hope there is a smart cookie radiology leader that can figure out and negotiate an end to this.-
I see it slightly differently vadoc . Not working to exit medicine but will work to exit the hospital where this BS is rampant. There is a huge market in ambulatory care and radiology is the place to participate IMO.
Leave the hospitals to purchase their mercenaries.-
ER doctors have been totally trampled on and abused by admin. Some of the over-ordering also has to do with how busy the ER is, skill level, litigious state/location etc..
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Be careful when reading studies on drunk people who fall to the ground. They dont brace themselves and can have significant C-spine injuries, often older people.
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Although I totally agree on overutilization, I can honestly say as a general rule, we see worse injuries from ground level falls than most other “trauma” cases. Smashed up faces/orbits. Bashed up shoulders and arms. Rib fxs, pelvis fxs. VS a ton of MVAs where the patient has zero findings on a panscan. The problem is we never know anything about the pt or how bad they look from whatever their trauma was.
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Quote from dysdiadochokinesia
I can honestly say as a general rule, we see worse injuries from ground level falls than most other “trauma” cases. Smashed up faces/orbits. Bashed up shoulders and arms. Rib fxs, pelvis fxs.
Perhaps, but the vast majority of those ‘incidental’ positive findings aren’t treated or even followed…things like nasal, rib or nondisplaced facial fractures (and are probably only of concern to ambulance chasers). Anything else would be found in a decent assessment done after triage, but that doesn’t happen anymore. I can’t recall a single case of solid organ injury that was a surprise to anyone on the clinical side.
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Quote from Adahn
Quote from dysdiadochokinesia
I can honestly say as a general rule, we see worse injuries from ground level falls than most other “trauma” cases. Smashed up faces/orbits. Bashed up shoulders and arms. Rib fxs, pelvis fxs.
Perhaps, but the vast majority of those ‘incidental’ positive findings aren’t treated or even followed…things like nasal, rib or nondisplaced facial fractures (and are probably only of concern to ambulance chasers). Anything else would be found in a decent assessment done after triage, but that doesn’t happen anymore. I can’t recall a single case of solid organ injury that was a surprise to anyone on the clinical side.
Same here. The worst injuries from ground level falls are going to be at the head and c-spine since those are highest up.
Anything else clinically significant can be detected by clinical examination & x-ray. Never seen a significant abdominal injury.-
There is something you can do on a case by case, provider by provider basis. Talk to them, go to ED clinical service and Trauma cmte mtgs. review the notes, and hold them accountable to the ER literature standards. This means you have to participate. When the notes read as though they are laying out the case for why advanced imaging is unnecessary, and yet they order it anyway, have the discussion in a frank respectful way (not always easy) in an open forum. I promise you there are surgeons and some admins that will be in full support if only because of the absurdity. Even reference local medmal statistics, as that is almost always a red herring argument, the likelihood being so low in most places.
Im the chairman of Peer Review at the moment. These cases get open discussions. Its a glacially slow and never ending process. One key aspect that does decidedly get admins attention is demonstrably false physical exam charting, which is the obverse of the knee jerk panscan, but its really all the same deal. And ED leadership gets rattled by it too.
At last months meeting there was a case of grade 4 splenic rupture with exam notes indicating abdomen soft, no distended, no tender. AND, a case with bilateral femur fractures not picked up on trauma screening exam, notes indicating no extremity tenderness. Im not making it up. Open forum discussions are what we can do. These providers now have new expectations imposed on them, and will undergo chart audits looking for inconsistencies.
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It also helps police your own ranks. For example, when the report for the splenic rupture describes a large perisplenic hematoma and active hilar extravasation, but says splenic laceration is not seen. Opportunities abound for collegial feedback.
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Quote from uncleduke
It also helps police your own ranks. For example, when the report for the splenic rupture describes a large perisplenic hematoma and active hilar extravasation, but says splenic laceration is not seen. Opportunities abound for collegial feedback.
The folly of templated reports.
Much of the ED charting absurdity with missed femur fractures and benign abdomen exams on spleen ruptures are also the result of templates combined with unreasonable throughput demands by the clipboard carriers.
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As I stated in another forum.
A bilateral arterial study elegantly describing bilateral normality in a patient with a unilateral amputation. -
I have certainly kept normal gallbladder in my templates with patients s/p chole. Also flow voids preserved in the brain section of a triple stroke mr while detailing the occluded ica in the MRA portion. It happens when youre expected read 130 studies a shift. Your brain calculates normal and signs the template. I would NEVER fault an ED doc for a benign physical exam note, they have to move just as much meat as we do.
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The context of the splenic laceration not seen report makes it clear that this was a specific deliberate notation, despite the large perisplenic, hematoma, and active extravasation. The case was forwarded to peer review committee from trauma committee. As a sidebar to review of ED missteps, it was an opportunity to ask the Rad in writing, 1) Is nonvisualization of splenic laceration congruent with large hematoma and active extravasation? 2) Is a splenic laceration present, and if so what grade? And 3) Is there an opportunity for improvement in reporting clarity? All cmte queries are prefaced with commentary about the nonpunitive and educational purpose of all peer review. Done properly, it is the best means of inducing a few minutes of self reflection and self critique in usually defensive practitioners.
As for missed femur fractures in a Code Trauma evaluation, I guess Im less sanguine about chalking it up to template gaffes, and more concerned that it reflects sloppy and dangerous practice.
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“As for missed femur fractures in a Code Trauma evaluation, I guess Im less sanguine about chalking it up to template gaffes, and more concerned that it reflects sloppy and dangerous practice.”
It most certainly is reflective of the trend toward sloppy practice. I suppose I’m being fatalistic. I’ve been very disheartened watching the ordering practices of our “traumas” and how rapidly it has worsened. Appears that at our shop the mantra has become “run them through the scanner and let radiology sort them out.” -
Copy and past crap
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This is a thoughtful and the only realistic way to deal with it.
Reading the EMR, calling providers, going to conferences are part of our job. It also makes things way more interesting and engaging. Unfortunately because there is no RVU assignment, these are not valued by most.
From a group perspective, recruit enough so that your rads can provide the scope of services needed; not just maximizing RVU. Tough sledding though.
There is a runaway train of utilization in the ED, and we are simply chasing it.
Quote from uncleduke
There is something you can do on a case by case, provider by provider basis. Talk to them, go to ED clinical service and Trauma cmte mtgs. review the notes, and hold them accountable to the ER literature standards. This means you have to participate. When the notes read as though they are laying out the case for why advanced imaging is unnecessary, and yet they order it anyway, have the discussion in a frank respectful way (not always easy) in an open forum. I promise you there are surgeons and some admins that will be in full support if only because of the absurdity. Even reference local medmal statistics, as that is almost always a red herring argument, the likelihood being so low in most places.
Im the chairman of Peer Review at the moment. These cases get open discussions. Its a glacially slow and never ending process. One key aspect that does decidedly get admins attention is demonstrably false physical exam charting, which is the obverse of the knee jerk panscan, but its really all the same deal. And ED leadership gets rattled by it too.
At last months meeting there was a case of grade 4 splenic rupture with exam notes indicating abdomen soft, no distended, no tender. AND, a case with bilateral femur fractures not picked up on trauma screening exam, notes indicating no extremity tenderness. Im not making it up. Open forum discussions are what we can do. These providers now have new expectations imposed on them, and will undergo chart audits looking for inconsistencies.
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I’ve never met anyone in rads, ED or admin side who is receptive to that.
I envy that you can do that duke, but it sounds like a unicorn.
One wonders the volume of actual, actionable pathology missed while providers waste time on copypasta and rads pointlessly count exposure and scan numbers to catch the scraps for meeting claw back ‘quality metrics’, AKA backdoor fee cuts. -
The Radiology Paradox:
The more studies ordered, the more likely they are all negative. -
The people who are receptive to it are the ones you by and large dont have to worry about. They get reviewed from time to time and participate and lend credence to the whole endeavor. The ones who arent receptive get reviewed and get some earnest feedback and guidance from a group of serious peers, and that has some value. Unicornishness I suppose is directly variable with desire and effort regarding maintaining our professional quality of care. Remember that medical peer review is specifically legally protected from discovery as an acknowledgment of our oath confirmed purported professional dedication to the highest standards. Given that rare legal privilege, I believe we are obligated to exercise it in good faith.
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Ya its funny there are screening businesses out there now, but people can really just go into any ER and say they hurt all over or just act “funny”/ALOC and get a pan scan for free.
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I am trying not to be baffled, but I am.
SOB & CP, Hx of CHF –> CXR, BNP, Trop
All positive. Pulmonary edema, 1600 up from 600, 50 Trop
You guessed it. Next step is is clearly a CTPA.
This is a board certified ER doc.
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All. Day. Long.
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Next study: CT-AP for history of rattlesnake bite to the thumb two weeks ago.
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I swear I cant tell if youre joking.
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Quote from uncleduke
I swear I cant tell if youre joking.
My residency director sat me down and told me that my sarcasm spread ‘like concentric ripples in a pond’ on every floor I rotated through and to tone it down .
I wish I was joking about the snake bite. There was nothing documented in the chart linking the two. On the way out I stopped by at the triage nurse and asked what the story was. Turns out he had an allergic reaction to the antivenom and dropped his platelets 2 weeks ago when he was at ‘big U’. So despite the fact that the platelets were near normal today and the patient had no symptoms, we apparently were trying to rule out retroperitoneal hematoma…….
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Quote from fw
I am trying not to be baffled, but I am.
SOB & CP, Hx of CHF –> CXR, BNP, Trop
All positive. Pulmonary edema, 1600 up from 600, 50 Trop
You guessed it. Next step is is clearly a CTPA.
This is a board certified ER doc.
I honestly think that ordering imaging buys the ED docs some time/breathing room given that most are slammed (+/- covering midlevels and/or residents) -
Quote from jd4540
Quote from fw
I am trying not to be baffled, but I am.
SOB & CP, Hx of CHF –> CXR, BNP, Trop
All positive. Pulmonary edema, 1600 up from 600, 50 Trop
You guessed it. Next step is is clearly a CTPA.
This is a board certified ER doc.
I honestly think that ordering imaging buys the ED docs some time/breathing room given that most are slammed (+/- covering midlevels and/or residents)
It does but irradiating patients like that is something they know can cause harm on a population level.
Most of them scramble around a corner when the portable X-ray goes off, and an average CT is like 30-60 of those concentrated. -
Quote from jd4540
I honestly think that ordering imaging buys the ED docs some time/breathing room given that most are slammed (+/- covering midlevels and/or residents)
Correct (at least part of the time).
But absolutely unacceptable (all of the time).
Any provider ordering scans to buy time is soaking patients, insurance companies, dumping a portion of their workload on radiology, and contributing to the ever upward spiral of health care costs. -
Quote from jd4540
I honestly think that ordering imaging buys the ED docs some time/breathing room given that most are slammed (+/- covering midlevels and/or residents)
It does the opposite. The more you order, the more your ER gets gummed up. This patient needed a call to the admitter and a metric sh¡t-ton of Lasix. What he didn’t need was a bolus of contrast and a delay in his care.
To some extent ordering more stuff allows the ER to claim higher complexity in their coding. But I don’t even think thats driving this madness as they are all on salary.
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Will never ever change. Our ER docs and midlevels go into full panic mode when the waiting room swells. Triage nurse then takes over and orders the panscans and whatever else before patients get seen by a provider, so that their results are waiting- AND so that they are tied into the system (they cannot leave to go elsewhere when there is a long wait). This is intentional, and supported by admin.
Have had occasions of needing to call a critical result- and there is no one to call it to because pt is still unassigned in waiting room. I hear this is not unique. -
Quote from bostonrad1
Have had occasions of needing to call a critical result- and there is no one to call it to because pt is still unassigned in waiting room. I hear this is not unique.
Oh, happens all the time. Outside of a ‘code’* type situation , it should be an automatic referral to risk management and the fraud&abuse hotline as studies are being done without proper orders.
* stroke, leveled trauma, CPR in progress transport
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Quote from bostonrad1
Will never ever change.
Never get better? Or never get worse? On the current path it will continue to change to our detriment.
I don’t know how to stop this. I do know my end user input and complaining – as the ED calls it – hasn’t made much of a dent in my ED.
We should try to figure this one out before we drown and the solution is decided for us. I’m guessing it will be midlevels. Lists will harden as midlevels take the easy cases and radiologists slug through only complex exams.
Gas also complained there was nothing they could do with the increasing volumes. Hospital admin and investors solved the shortage for them. Now Anesthesia MDs either manages 5+ nurses or grind through incredibly complex patients. -
I think its like that at a lot of places.
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I saw an 80 ground level fall pan scan today with significant adrenal and renal hemorrhages.
Hard to make sweeping judgments on CT utilization for the ED it has become just another very expensive screening test, a truth machine.
How many times have you called a significant finding to an ED provider who did not seem to even know they were caring for the patient?
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Just noticed, the nuttiness goes in waves. For a while every NSTEMI got a CTA, because you know dissection and stuff. That seems to have abated somewhat.
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Panscans for ground level falls are never going away because they are not infrequently positive, especially in the >75 yo population.
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They are nearly exclusively negative unless serious skilled people exercising judgement about real guidelines are ordering them. The cost is astronomical. They are among the least useful of medical expenditures. In my experience.
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Half the ED docs I talk to seem so utterly burnt to a crisp they could give a shit about whats happening to the patient. Interesting case/scan? Not interested. All they care about is dispo. Utterly miserable. I just try to remember that when Im reading all the non-indicated scans. Someone has to explain to the chronic abdominal pain Fibromyalgia/POTS/Ehlers-Danlos patient that nothing is wrong, and that no they wont prescribe opioids despite the lawsuit threats, multiple times a shift. Or deal with the homeless who just drank too much, or have to break news about pregnancy loss or new cancer, or deal with people demanding this or that for minor stuff. Exhausting. No thanks. I read the negative pan-scan in 15 minutes and be done.
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They have themselves to blame. And those terrible burdens you list are for the most part childs play, in a manner of speaking, for well trained disciplined professionals. I talk to patients regularly about lost pregnancies, new cancer diagnoses, unexpected recurrent or second primary cancer diagnoses, and talk to frequent flyer worried well or chronically ill patients and ED providers, about how to manage care and expectations without unnecessary and costly unhelpful studies. Ive never seen a good ER doc get burned out. Its the mediocre ones that cant cope.
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Quote from vonbraun
Be careful when reading studies on drunk people who fall to the ground. They dont brace themselves and can have significant C-spine injuries, often older people.
There are definitely times when a GLF requires a pan-scan. ‘found down’, intoxicated, unwitnessed fall in patients with dementia who can’t contribute a history etc.
The ones that grate me are the ones where ER triage and the provider document all the pertinent negatives for a simple mechanical fall (full memory, did not hit head, no pain except a wrist or ankle) and still order everything.-
Yes exactly. Just thrown through the CT because no one has time to think or care. Is there anyone that was around before CT was widely available to comment on how these things were handled in the day? Im guessing they may have just observed people in the ER or done and obs admission in the day or something, but that would hurt ER turn around times/the corporate money machine eh?
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Quote from radrocker
Yes exactly. Just thrown through the CT because no one has time to think or care. Is there anyone that was around before CT was widely available to comment on how these things were handled in the day? Im guessing they may have just observed people in the ER or done and obs admission in the day or something, but that would hurt ER turn around times/the corporate money machine eh?
30 years ago, if you had a mechanical fall and now suffered wrist pain, a competent ER physician (or disgraced ex-surgeon) would squeeze on your pelvis and chestwall, ask whether your neck hurts and ordered a wrist film and a splint for your busted wrist.
Occasionally I see old ER charts from.our hospital scanned into PACS. The entire visit including triage, physician assessment, orders and nursing chart fit on one carbon copy triplicate form.
EMR and electronic order entry are what drive some of this craziness. I call it ‘order spasm’.
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Quote from Thread Enhancer
I see it slightly differently vadoc . Not working to exit medicine but will work to exit the hospital where this BS is rampant. There is a huge market in ambulatory care and radiology is the place to participate IMO.
Leave the hospitals to purchase their mercenaries.
thanks for this perspective. provides some hope. hope i get lucky and can find the right opportunity soon.-
Its gotten worse in the last year. No matter the injury its a pan scan with a max/face cta neck. Weve gone from 6 to about 12 traumas consistently every night. Its disheartening to read the notes. 8 CTs for an arm bruise.
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There is so much bad medicine in the ER. It is purely about throughput.
I use to think the pan scans were abusive. This has been trumped by 2 things.
The number of CT’s of the spine for non trauma or minor trauma is appalling. They are trying to use CT like it is MRI when it doesn’t have near the soft tissue resolution. We spit about garbage about stenosis and disc disease that I have no idea what they do with. Are they calling neuro surgeons with these reports? I doubt it.
The second is the abuse of neuro CTA. If it is for true stroke symptoms I get it and am fine with it. It however, has degenerated into being done for any and every possible neuro symptom. Syncope. Parasthesias. Non acute dizziness.
Last night alone I had 2 that were complete garbage. CTA for syncope in a 45 yo with wait for it…. Normal CTA in October. The other was a women who was chocked. I am perfectly fine with the CTA neck but the ER doc also throws in CTA head for no reason other than that is the button they always click.
The latest is the ER has started doing CTA CAP and run off of the lower extremities because CTA CAP just isnt enough anymore. It took the techs almost 2 hours to process all the recons and they messed it up.
Each and every one of these weighs on a system that is already barely functioning-
Quote from frank the tank
There is so much bad medicine in the ER. It is purely about throughput.
Good discussion…think the above statement is a large part of the equation, particularly when ED docs are supervising a bunch of mid-levels, and possibly residents. People are operating on auto-pilot rather than putting real thought to the process, in part due to lack of band-width and exhaustion. Plus there is no disincentive from over ordering imaging aside from increasing turn-around time and potentially increasing miss-rate due to image overload for the rads. Hospitals clearly benefit from over utilization. At times I think studies are ordered simply to buy some time for the ED docs. Regardless the system is dysfunctional but unlikely to change anytime soon…On a side note, we now have 24/7 MR’s for ED/in-pts. Always nice to get hit with a “stat” MRI pancreas for staging during a busy ED shift -
And then they complain when a report isn’t in in 5 seconds. FWIW, nothing we do produces more wRVU’s then these stroke workup though- CTA head and neck =3. the noncon CT brain is 1. the MRI brain that they should have done in the first place is 1.5. all total 5.5. I stopped complaining about it, nothing anyone, anywhere, can do about it.
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Quote from bostonrad1
And then they complain when a report isn’t in in 5 seconds. FWIW, nothing we do produces more wRVU’s then these stroke workup though- CTA head and neck =3. the noncon CT brain is 1. the MRI brain that they should have done in the first place is 1.5. all total 5.5. I stopped complaining about it, nothing anyone, anywhere, can do about it.
Agree. Throw in CT perfusion. Not to justify their behavior but just received our bonus for 2nd-Q. Seems like this year may replace this past banner year.
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Quote from Thread Enhancer
Leave the hospitals to purchase their mercenaries.
You know this is exactly what they do.
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Ya there was a recent post about “moral injury” in medicine. This is the rads version for sure. Seeing the insane amount of negative unindicated or over worked up cases that just saddles the system with unnecessary cost all while making us burned out. Get so busy reading garbage its hard to have energy for the cases that do matter. Agree with other posters. Ill probably majority exit hospital radiology in the next couple years and maybe do it as a significant locums every once in a while just to keep the skill. This will only add to the problem of course for everyone.
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We’re at the cultural break point of indifference, which was set in motion long ago when we lost any leadership and bad behavior is encouraged, good behavior maligned or cancelled. It’s happened many times in history when the culture becomes so corrupt, debased and decayed … a classic proxy is letting outsiders storm your borders – everyone loses any idea of what it is to be a citizen since outsiders are treated better, and thus the “country” has nothing left to exist for
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Quote from radrocker
Is there really anything we can do for the relentless minimal injury CTs through the ER. Definitely pays the bills, but its just kind of gross participating. I guess if we had better laws and less lawyers we could improve on this BS? Anything in the ER literature (do they have literature?) to give guidance?
Feels icky to cash those checks. We know the patient doesn’t benefit from the $1500 we take off their insurance for a completely unnecessary workup. You read the ER note and it has all the pertinent negatives and still 6 orders for studies with nothing but ‘trauma’ as the indication.
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Yeah it is icky but not like anything we can do to stop it.
I predict use of imaging is only going to continue to increase.-
Also good for job security. We will remain in high demand for the foreseeable future unless major disruption from AI, which is seemly less and less likely. In fact, AI may increase our incomes also, lol.
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My only point here is that I see many trends which are favorable to the field of Radiology and being a Radiologist today is a good spot.
Of course, reimbursement cuts are a negative trend, but so far has been largely off set by increasing volumes.-
Problem is that crap like this drives up the bills to medicare. Then they end up cutting our reimbursement as a delayed indirect consequence. Maybe if imaging was utlized sparingly we wouldnt have our reimbursement sliced and diced six ways to sunday.
Wish I was part of the golden age of rads when you could spend half the day shooting the shit with other rads and techs
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Quote from sartoriusBIG
Problem is that crap like this drives up the bills to medicare. Then they end up cutting our reimbursement as a delayed indirect consequence. Maybe if imaging was utlized sparingly we wouldnt have our reimbursement sliced and diced six ways to sunday.
Wish I was part of the golden age of rads when you could spend half the day shooting the **** with other rads and techs
Was recently discussing this issue (along with burn-out) with a much older colleague. Given the way the ED uses mid-levels, hard to see a decrease in imaging. Just imagine how burnt-out ED docs are. When they finally see the pt and make decisions they want to have everything covered already (which necessitates excessive imaging)
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I wouldn’t worry. This is just a manifestation of a completely unsustainable system which will, before too much longer, grind to a halt or actually fall in a heap.
It’s not healthcare. It’s a miserable merry-go-round with bearings that are on fire. Everyone debates which seat they want to ride on while failing to see that there is no attendant.
