WhiteCoat

Unnecessary Testing

Real patient encounter …

A 22 year old guy comes to the registration grabbing his chest. He’s having palpitations and chest pain.

He’s a pack a day smoker, has no family history of heart disease, and was out late the prior evening partying. So when he woke up, he was dragging a little. He had to be at his construction job in an hour, so he drank a “Monster” energy drink. When he got to work, he still felt tired, so he drank another “Monster” energy drink. That’s when the palpitations and chest pain started. He was anxious and felt a little short of breath, too.

The EKG from triage showed a mild sinus tachycardia of 106. No arrhythmia. No ischemia. His physical exam was completely normal except for his anxiety and his elevated pulse. He got an aspirin and some Ativan.

A half hour later, he wasn’t feeling any better even though his pulse was in the 80s.

Now everything points at this guy being acute “Monster” caffeine overdose. It was suggested that he be discharged with a prescription for Ativan and an order to lay off the caffeine. But because he was still symptomatic, he got an entirely unnecessary cardiac workup. His second EKG was normal sinus rhythm and still showed no ischemia. His CBC, chemistries, cardiac enzymes, and urine drug test were all normal.

Oh, and his chest x-ray showed a complete collapse of his left lung.

The problem with labeling testing “unnecessary” – even though the tests may be normal most of the time, they aren’t normal all of the time.

Where do we draw the line between what is and is not “unnecessary”?

———————–

This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

15 Responses to “Unnecessary Testing”

  1. Torgrim says:

    If his physical exam (including, I presume, percussion of the thorax and auscultation over the lungs with a stethoscope) was “completely normal” and the patient had a completely collapsed lung – surely some testing is called for, but I suggest that the examining doctor’s skills are tested first

    • Essay says:

      You beat me to that punchline! Unless, of course, the lung completely collapsed acutely at some point after the PE, but I think I’d have a hard time selling a jury on that one.

  2. Jlinde says:

    Had a proper H&P been done a collapsed lung would have been found earlier.
    What happened is the physician got caught up in the hysteria and custom of ‘chest pain’.
    The physician should have enough knowlege and objectiveness to risk stratify the overall pt. Look at his current symptoms and the possible things that could cause them in this male age group. Yes, spontaneous pneumothorax is one of them. Listen to his lungs, sound decreased? You most also have the clinical skills to do this.
    A CXR would have been a neccessary test.
    Shame on the physician who wrote this. I hope it’s not a real case?

  3. Simon says:

    Is this a real case???

  4. Anonymous says:

    2 Monster’s isn’t enough caffeine for an overdose unless the guy has a serious tolerance issue.

  5. SeaSpray says:

    Thank God it was caught!

    I give you physicians a lot of credit and appreciation for all that you do to help – diagnose and facilitate healing in patients.

    Thank you. :)

  6. Nurse K says:

    “His physical exam was completely normal.”

    Um, really? He had normal breath sounds with a collapsed lung?

  7. Hamhock says:

    I was thinking all during the first part of this story that the arguement better not be that a CXR is unnecessary.

    There is absolutely NO WAY this guy is getting out of the department without a CXR.

    It drives me a bit nuts when physicians hold on to the anachronistic belief in the physical exam, but it drives me insane when nurses or EMTs or such say that something like this should be caught on physical.

    Within the past two months I have pointed out to residents that a large pericardial effusion that required emergent pericardiocentesis 6h later and then an 80% PTX were not caught on physical exam but frightening after testing (bedside ECHO and CXR, respectively) identified the pathologies. (I’ll admit that the pericardial effusion did have a HR in the 100-115 range).

    Of course, the CBC, chem, and trop were definitely wasted in my opinion — but not the CXR!

    HH

    • Nurse K says:

      * Where do we draw the line between what is and is not “unnecessary”? *

      Anyone who is a relatively low user of the ER (ie. not coming in for anxiety weekly) who has any sort of chest or shortness of breath-y complaint, especially when the symptoms are new, tends to get a CXR where I’m from. 99% of them in a similar patient are negative. For this guy, it probably could have/would have been the only order or maybe a CXR and an EKG and perhaps a d-dimer due to the tachycardia. It’s pretty rare that anyone is given a new diagnosis of anxiety or caffeine whatever without any work-up.

      CXRs on short of breath people are not going to “collapse” the healthcare system. I always find drawing troponins on the very young and healthy to be bizarre, however. Have yet to see a positive one in 10 years of nursing.

      Worse case scenario, the guy is discharged home with instructions to lay off the caffeine and returns a few hours later when he’s caffeine-free and worse and then they do the CXR. It’s not overly common for 22-year-olds to be keeling over dead from a spontaneous pneumo (again, have never seen that).

      Overall, to answer your question, I feel that shortness of breath in an otherwise-healthy 22-year-old with normal sats/temp and HR 85-105 is a low-risk issue in my opinion when taken in the overall spectrum of all 22-year-olds that come to the ER with “shortness of breath”. Low-risk issues don’t need the zebra or mega work-up. (To me, a non-STEMI is a zebra).

    • WhiteCoat says:

      What I’m getting at is how to create prospective rules on what testing should and should not be performed.
      This is an issue that is going to be front and center in the near future with this goofy “Choosing Wisely” campaign.
      Governmental audits and demands for reimbursement for “unnecessary” testing won’t be too far in the distance.

  8. southerndoc says:

    30% of pneumothoraces are not caught by physical exam. We all can claim we’re better than that and would never miss one, but in a noisy emergenc department it’s easy to miss a ptx by clinical exam.

  9. Long Time E.D. Doc says:

    I do so enjoy the comments from all of those most superiorly skilled individuals who infer their own astute physical exam would have clearly picked up the dx, while Dr. White Coat’s exam was less than careful. Having known so many of these clinicians over the years, I always enjoy having them explain away the extraordinary circumstances when THEY missed this same clinical condition. Anyone who has been in this business for any length of time knows this “miss” has the potential to happen to them. But for the grace of god…

  10. WhiteCoat says:

    This is a real case with some facts changed.

    I agree with southerndoc and Long Time ED Doc. It is interesting to read how many people suggest that an appropriate physical exam was not performed on the patient.
    I wasn’t there to witness the exam, so I can’t comment on the quality of the exam performed. However, I was told that after the results of the x-ray were known, several people went back to listen to the patient’s chest and heard perhaps a small increase in the pitch of the breath sounds, but not a dimminution in breath sounds.
    I have also seen more than a few pneumothoracies – some of them large – where there are no changes in the breath sounds. In some cases, I go back and listen to the lungs after knowing the diagnosis and still don’t hear a change in the breath sounds. This Medscape article even states “Unilaterally decreased or absent lung sounds is a common finding, but decreased air entry may be absent even in an advanced state of the disease.”
    Regarding chest percussion, I work in two residency programs and in more than 10 years I can count on one hand the number of times I have seen anyone percuss a chest during a physical exam. I’ll do it sometimes if a patient is dyspneic without any other abnormality on physical exam, but otherwise it seems to be a low-yield maneuver.

    I was trying to illustrate the idea that sometimes lives are saved by doing “unnecessary” testing and that by decreasing the amount of “unnecessary” testing, there are going to be additional bad outcomes. Maybe not a lot of bad outcomes, but we as a society have to decide where to draw the line between exhaustive amounts of expense and testing to catch what is sometimes a needle in a haystack (or to diagnose something in which treatment will not be altered) versus saving money and increasing the amount of morbidity and mortality. I’m not going to draw that line, but it is a decision we are coming to in the near future.

    Should we look at the “unnecessary testing” angle from another viewpoint? Is a chest x-ray an unnecessary test for a possible pneumothorax because the physical exam alone is sufficient to diagnose and exclude pneumothorax? How many “normal” chest x-rays do we have to perform before we get the hint?
    Would be an interesting study to determine how often chest x-rays alter diagnosis or treatment.

    • Nurse K says:

      My old ER had some “hard” rules for unnecessary testing. A few of the doctors would, I sh*t you not, MRI everyone with knee pain in the ER. None of this was ever reimbursed and the medical director said “no MRIs on extremities”. He also indicated that back MRIs should only be done with significant neuro deficits consistent with cauda equina syndrome or similar serious neurological emergency. None of those “I’ve had back pain for a week and it hurts” MRIs got reimbursed as well they shouldn’t have.

      In my current ER, there is no such thing as limiting head CTs, for instance. Everyone who hits their head, ages 2-100 gets a head CT regardless of LOC, severity of illness, risk factors (eg. coumadin) or the fact that children can get cancer as a result of CTs. If the medical director had some balls to tell these guys not to order head CTs unless they meet an accepted trauma criteria for one, we’d be in business.

      My all-time favorite unnecessary head CT still is on the 8-year-old whose little brother hit him in the head with a Cadbury egg on Easter and caused a small bruise. That child is probably on his first round of chemo now.

      I don’t think chest XRs for short of breath people are going to be on the unnecessary list anytime soon.

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