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.

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.

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).

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

Turned out he had endocarditis that disintigrated his valves.

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

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.