Wednesday, November 18, 2009

Gerald O'Malley, DO: Embracing Ambiguity

Today my senior resident, I’ll call him Ricky, wanted to order an ultrasound to rule out testicular torsion. Ricky is a pretty sharp guy and he prefaced his request by saying, “I really don’t think he has a torsion, I think he probably has epididymitis, but I want to make sure he doesn’t have a torsion.”

We talked about the fact that the patient was 27-years-old, sexually promiscuous, and had been seen eight days ago for the exact same complaint (testicular pain) during which he had undergone a scrotal ultrasound. My colleagues that had seen him last week were concerned about testicular torsion, had ordered the ultrasound, ruled out testicular torsion and then sent the patient home with Percocet.

I asked my senior resident, “What does his physical exam show?” Ricky replied that his testicle wasn’t swollen and appeared normal, but was tender to palpation, particularly around the epididymis.

“Come again?” I asked.

My resident sheepishly answered, “His epididymis is tender, the rest of his testicle isn’t, and it really looks like a straight forward case of epididymitis.”

“But you want to get the ultrasound anyway.”

“Well, yeah – how else am I supposed to be sure that it’s not a torsion?”

Variations of this conversation happen every day in my ED (my ED is not so unique that this doesn’t happen everywhere).
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Perfectly neurologically intact kids that fall down get CT scans “just in case” there’s a head bleed; 18-year-old soccer players are admitted to chest pain units “just in case” their two weeks of chest pain might represent an acute cardiac syndrome; otherwise healthy renal colic patients have numerous CT scans “just in case” there is an obstructing stone.

Emergency medicine residents and recently graduated attending physicians have an absolute intolerance of ambiguity.

One time I accepted sign-out from one of my younger colleagues and as we made our way to the twelfth bed of the 18-bed unit (I still like to do bedside sign-out; it tears the residents away from the computer which drives them crazy), I realized that I was being tasked with following up on my fifth chest CT to rule out pulmonary embolus. I asked the assembled group of residents, “What are the odds that five out of the 18 patients in this room all have PEs at the same time? The odds are astronomical!”

My junior colleague pulled me aside and told me that she didn’t appreciate my being critical of her clinical judgment. I replied, “Show me some clinical judgment and I’ll decide if it needs criticism. So far, all I see is a lot of wasteful, time-consuming testing all in the hope of ruling out the worst possible diagnosis. Where is the clinical judgment?”

We are training a generation of residents to not use clinical judgment. We instruct and direct them to not use clinical judgment. We introduce algorithmically driven protocols that exclude the need for disciplined reason and thought. We teach residents to order every test and do everything necessary to exclude a life threat, no matter how irrational, rather than to direct patient management based on what is most likely.

The biggest area at issue in my ED surrounds the use of ultrasound in first trimester vaginal bleeding. At the conclusion of three years of residency (in 1995, thank you), I could count on the fingers of one hand the number of ultrasounds we obtained on first trimester bleeders – and we weren’t stepping over the bodies of young previously ectopically pregnant patients on our way out to the vending machines. Now, pregnant patients with vaginal bleeding routinely get ED ultrasounds “just in case” there is an ectopic pregnancy. The argument always seems to devolve into the “dinosaurs” like myself that trained in the era when the decision to chase the diagnosis was predicated on the ED physician’s suspicion that a ruptured ectopic pregnancy was the most likely scenario versus the “new generation” of ED attendings, all well versed in how to make an ultrasound machine sit up and roll over and that stick a probe on anything that’s not nailed down.

Any criticism of ultrasound application labels me a Luddite. I’ve got nothing against the technology – I think it’s kind of cool, although to me, most ultrasound images look like two polar bears humping in a snowstorm. It’s the overuse and misapplication of the technology that drives me nuts, not just because it wastes time and interferes with patient throughput, but more importantly, because it lets the physician off the hook for having to make the hard decision and it makes us invisible and erodes patient confidence in our competence.

When a patient insists on a CT scan or an ultrasound at the conclusion of my bedside evaluation, I take it personally.

Patient: “I came here to get a CT scan.”

Me: “No, you came here to get an opinion. My opinion is that you don’t need a CT scan.”

Patient: “Well, I’d feel better if you ordered one.”

Me: “Where’s the Maalox?”

When I tell the residents that the presence of an ectopic pregnancy is not a medical emergency, they look at me like I have gills and scales. “For crying out loud, OB/GYN sends them home with methotrexate!” Still disbelief. Ectopic pregnancy is not a medical emergency but ruptured ectopic pregnancy is darn sure a medical emergency and one diagnosis that you can’t afford to miss. Of the half dozen or so ruptured ectopic pregnancies that I have personally examined in my career, none of them were subtle.

“Do you think it’s OK to miss an ectopic pregnancy?” they ask. Of course it is. We do it every day. Even patients that have indeterminate early gestational ultrasounds in the ED go home with “early IUP versus possible ectopic pregnancy” as the diagnosis and “clinical correlation required.” Fat chance of that. The possibility of missing an ectopic pregnancy or a hot appendix or an early pneumonia always exists – that’s what discharge instructions are for.

I practice in Philadelphia – ground zero in the med-mal maelstrom. The medicolegal climate in this city is permanently at DEFCON 1 (expectation of actual imminent attack) but I don’t sweat appendicitis or ectopic pregnancy. I accept the fact that those diseases may be present, but are unlikely in a particular patient and explain to my patient and document the absolute need to return if signs or symptoms change or get worse. I think the vogue term these days is “risk stratification.” I call it “using your clinical judgment and common sense.” My Irish mom calls it “using the brains that God gave you.”

Despite Ricky’s objections, we never ordered the testicular ultrasound. We took a urethral culture, gave him ceftriaxone and azithromycin, advised him to have his sexual partners (all of them) treated, and discharged him. As we watched him walk bow-legged out of the ED, I said to my resident, “I wonder if he had torsion of his appendix testis?”

Ricky turned slowly towards me with his mouth open. “I thought you said he had epididymitis.”

“No, I said that he probably has epididymitis. He sure as heck doesn’t have a testicular torsion. Maybe he has a varicocele. Maybe he’s passing kidney stone. Who knows? Dude, relax. Embrace the ambiguous.”

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

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