Thursday, November 15, 2007

To CT or Not to CT? Another Salvo

Common things being common, anyone who has spent a little time perusing medical blogs has read a few posts about the value, or lack thereof, of CT scans in the evaluation of suspected acute appendicitis. I'll outline my opinions below (Opinions? Moi?), but there has been another salvo fired in this skirmish, this time aimed against the "CT everyone" crowd.

A study published in this month's Journal of Gastrointestinal Surgery from the University of Wisconsin asks the question Computed Tomography in the Diagnosis of Acute Appendicitis: Definitive or Detrimental? This was a retrospective study of all adult patients treated for acute appendicitis at their institution over a three year period. Any imaging results were correlated with operative findings, including the presence or absence of perforation of the appendix.

Results During a 3-year period, 411 patients underwent appendectomy for presumed acute appendicitis at our institution. Of these patients, 256 (62%) underwent preoperative CT, and the remaining 155 (38%) patients did not have imaging before the surgery. The time interval between arrival in the emergency room to time in the operating room was longer for patients who had preoperative imaging (8.2 ± 0.3 h) compared to those who did not (5.1 ± 0.2 h, p < 0.001). Moreover, this possible delay in intervention was associated with a higher rate of appendiceal perforation in the CT group (17 versus 8%, p = 0.017).
Although retrospective, this study gives a bit more ammunition to the "CT very selectively" crowd. It appears that CT scanning delayed operative intervention in most patients, and that was the supposed reason for a higher rate of perforation in the patients who underwent CT. Ergo, they say, use CT scanning less in cases of suspected appendicitis. Sounds logical, no?

Hold your horses, Kemo Sabe. There's a whole lotta supposition going on there, so let's look a little deeper into the data, shall we? In the article, a few interesting things become apparent:
  • While the majority of patients were male, a higher percentage of those undergoing CT were female. That's just plain reasonable, because women have those little things called tubes and ovaries that can be troubled and cause symptoms like appendicitis.
  • Those patients who had an "indeterminate" scan were lumped in with the "negative" scan patients. This is because the scan in those cases did not enhance the ability for the clinician to make a diagnosis.
  • 8% of those diagnosed with appendicitis on CT had a normal appendix removed at surgery. That's plain interesting, because CT has been touted as nearly perfect at diagnosing acute appendicitis when it's called "positive" by the radiologist.
  • 14% of those taken to the OR for presumed appendicitis without preop CT had a normal appendix. I'd say that's within historical norms, and actually a bit lower than I would have anticipated --- plus, it's not statistically different than those that had CT scans.
  • 7 of 14 patients with negative CT scans were ultimately found to have appendicitis; as a result, when evaluating both the negative and indeterminate CT scan results together, the negative appendectomy rate was 37% (leaving us, for those with statistical interest, an overall sensitivity of 92%, specificity of 68%, accuracy of 88%, and a negative predictive value of less than 40%). Hmmm. What we don't know is the true denominator of this number -- this is a small sample of patients who had a negative CT, as presumably the majority were sent on their merry way and never had any difficulties. It is interesting, however, that 14 patients with negative CTs made their way to the OR for presumed appendicitis, and half of them had it despite the CT findings.
  • The majority of perforations were not identified on CT. That's reasonable, as most of the time a small perforation is found at surgery. What is not spelled out is how many patients had a CT because of generalized peritonitis, which could have a variety of possible causes and for which a CT is often a good idea.
  • Interestingly, the study did not identify patients thought to have appendicitis on CT, who were found to have some other pathology. That is presumably because they only looked retrospectively at those patients identified by procedure codes as undergoing appendectomy.
Well, let's think a bit about this. At least at the University of Wisconsin, a CT scan is reasonably accurate for diagnosing appendicitis, but it sure ain't perfect. Well, what's an ED physician to do? IMHO, it's time to put a little common sense back into play --- the immediate availability of an abdominal CT scan does not justify its (over)use, so here are the Aggravated DocSurg guidelines for diagnosing appendicitis, with and without CT:
  • Young men with right lower quadrant pain, tenderness, and an elevated white blood cell count need to be poked and prodded by a surgeon, not sent through an irradiating donut.
  • Young women with right lower quadrant (not pelvic) pain, tenderness, and an elevated white blood cell count need to be poked and prodded by a surgeon, and then possibly sent through an irradiating donut.
  • Older men and women with right lower quadrant pain, tenderness, and an elevated white blood cell count need to be poked and prodded by a surgeon, not sent through an irradiating donut.
  • If there is any other combination of symptoms --- pain not in the "classic" location, a normal white blood cell count, a suspicion of diverticulitis/nephrolithiasis/PID --- by all means get a CT.
  • Never, ever (ever!) get a CT of the abdomen without oral contrast when there is even the slightest possibility that the patient may have GI tract pathology, including appendicitis (for some reason, that's en vogue in my hospital) --- it's worthless, and may require your patient to undergo a second round of radiation.
  • Last but not least, when in doubt, get a CT.
Wait a minute. Didn't someone who sounds a bit like me just say, "the immediate availability of an abdominal CT scan does not justify its (over)use?" Er, yes. And I also just said, "when in doubt, get a CT." I'm sorry, I know that makes me sound a little like Zaphod Beeblebrox, but one has to keep in mind that not every patient has read the textbook and presents like "classic" appendicitis. And I would prefer that ED physicians feel that the CT is a readily available part of the armamentarium they have at their disposal in evaluating abdominal pain --- but they should also should stick to their guns and ask surgeons to come evaluate patients who have likely appendicitis, and not be cowed into obtaining a CT every time just because the surgeon insists on it.

All I ask is for the ED physician to let "surgeon versus CT evaluation" cross his or her mind a little more frequently before asking for a CT. At least according to this study, it will save your patients time and possibly avoid an increased risk for perforation if the surgeon is involved early ---- plus, you can always punt the question of CT or no CT to him after he evaluates the patient.

Tuesday, November 13, 2007

The Speech

Every physician and every nurse in the country knows they type. Young, brash, frequently stoned, covered with gang tattoos and enough piercings to set off a metal detector at 20 paces. They show up in the ED with the same stories, the same injuries, the same attitudes. They have been stabbed, beaten, shot, or run over, and expect nothing short of an effort worthy of a Congressional medal to save their lives. Of course, we've all heard the same comments: "I got jumped by two dudes;" "I wasn't doing anything;" or, my personal favorite comment, "......" --- as in, "I ain't sayin' nothin', because I'm such a bad ass."

Of course, every physician and every nurse in the country knows otherwise --- the real bad asses are the cops tough enough to bring these jerks in, as well as the soldiers we are fortunate to have serve our country. My problem is that these frequent hospital clients get under my skin like botfly larvae and cause me heartburn worse than my teenagers. For years, I would just shut my mouth, take care of them, and send them on their way. But it always bothered me that while I could help with their physical problems, these young men were on a path to a place that no one ever dreams of ending up.

So, even though I'm sure I am rarely heard, I came up with The Speech™. This allows me to at least tell myself that I have given all of the medical warnings relevant to the situation. It goes something like this:

So, have you been in prison yet? No? Well, that's just great. Except that, given your present situation, with police officers in the emergency department than nurses on the night you decided to get my sorry butt out of bed at 2:57 AM, I would say that prison just might happen to be in your future. And, since I get the delightful opportunity to see young men just like you who are or have been in prison, let me introduce you to a few facts of your future life.

Let's start with anal warts. What? Never heard of them? That's right, they sound pretty disgusting, and they are. And, no, they don't result from sitting on the john in a dirty cell. They are sexually transmitted ---- yeah, that's right, some other man is going to give them to you. Sort of a little gift, courtesy of yourself, that often results from prison rape. Let me tell you, when you do get out of prison, nothing says "Hey ladies, I'm back and I'm ready for a little action" like a few warts on your butt and your Johnson. And don't forget about the potential for a colostomy should you resist a little too hard and it gets rough.

How about Hepatitis C --- know anything about that? Well, the prison mambo is one way you'll get the opportunity to experience this little treasure. Cure? Uh-uh, sorry. And if you are planning on adding a few "prison tats" to that collection of ink on your skin, there's another little chance to roll the dice with your liver.

Oh, yeah, one more thing. I know how much you have enjoyed this little hospital visit for your stab wounds. Just remember, you are one wrong look, one mistaken word, one friendship with the wrong guy from being stabbed again...and again....and again.

I don't like having these little chats any more than you do. So, do me a favor. Cut the crap, get a job, and get a life, because right now, everything I have laid out for you is all you have to look forward to. And I don't want to see you here ever again.

Have a nice day.
Am I being judgmental? You bet your ass, and I'd say it's high time we all got a little judgmental with these guys. I know it falls on deaf ears. But, if it sinks in, then maybe I will have done something better than just patch them up and send them out the door.

Sunday, November 11, 2007

SurgeXperiences #108 -- Snow White and the Seven Surgeons

When I accepted the invitation from the Monash Medical Student to host this edition of SurgeXperiences, I initially thought "No problemo, dude! Only one night of call during the week leading up to it; I should be able to knock it out with time to spare." Life as a surgeon has taught me that first thoughts are often wrong, especially when it comes to my free time! Anyways, after a hectic week, here are a few categories of surgical submissions offered for your approval --- with a little Disney flare.

First up is Grumpy -- we all have a little Grumpy in us, and surgeons have a well-deserved reputation for belly-aching. It must be all of the stale coffee we drink between cases. Dr. Alice lets her grumpy side shine in How to Not Run an OR. She shares her experience in a hospital that seems to lack the understanding that the absolutely most important person in the operating room is .... the patient. Not having the proper equipment available to take care of said patient is, well, a major no-no. From Surgeonsblog comes a well-written critique of the problem we face as surgeons in terms of training new physicians, gaining appropriate experience, and obtaining credentials -- Are You Experienced? Of course, for a surgeon, nothing makes us quite so grumpy as a case gone sour -- especially one that starts off difficult and heads downhill from there, as described by Bright Lights, Cold Steel.

Next in the door is Sneezy -- quite frankly, a dwarf with a bit of a handicap when it comes to wearing a mask in the OR. Well, these posts are really nothing to sneeze about. Bongi at Other things Amanzi describes the difficulty in dealing with patients who present with advanced problems because they initially sought care from a traditional healer in an undeveloped area. And the Evil Resident has learned that sometimes people do the strangest things.....and end up with some unintended consequences. Should one sneeze about asking just who is operating on you at the local training hospital? It's all discussed at the MedFriendly Blog.

And then there's Doc, who somehow carries that moniker without ever having taken an MCAT or passed a board exam! This week, there are a few unquestionably "Doc" posts. Dr. Schwab at Surgeonsblog offers a great description of an old-fashioned open cholecystectomy in Mini-Steps. Bongi, up for reading a second time, describes a rather different experience with the same operation.

All of us who practice in the realm of medicine outside of academia are well-versed with the sometimes strained relationships we may have with the closest Miracle Center. We have mixed feelings about them, and quite certainly they feel the same. A few "Doc"-like posts in this vein come from the Buckeye Surgeon, who delves into the problem of bed shortages, and again from Dr. Schwab, whose own name for the local academic facility is The BFH --- you can draw your own conclusions from that acronym.

Where would surgeons be without our anesthesia colleagues? Sleepy, you are being paged! Dr. Keamy from a great collaborative anesthesia blog gives us some insight into the significant role a good anesthesiologist -- and a good anesthetic -- plays in the delivery of good surgical care. Not to be outdone, at Counting Sheep we hear what it's like to spend one's days always behind a mask, as an almost unseen partner in surgery. And the Anesthesioboist gives a great introduction into pain, and how to make it go away during surgery.

Bashful?? Hell, not in the OR, if you want to learn anything or get anything done. From Flatus and Stool we learn that bashfulness needs to be thrown out the window in training --- never let a little thing like social propriety get in the way of asking a patient about their bowel habits! And a healthy lack of bashfulness, and appropriate confidence, is sometimes rewarded -- just ask the Buckeye Surgeon.

There's a little bit of Dopey in all physicians as well --- if you don't get a little dopey during training, you just aren't human; some of that needs to stay with you to stay sane during practice. Dr. Campbell, an academic ENT physician who spends a considerable amount of time dealing with malignancy, had his Dopey sensors up when he spotted T-shirt on a recent patient --- this one you need to read to get a great sense of the irony we deal with frequently. And what is more "dopey" than superstitions? All surgeons --- myself included --- must admit to our own little superstitions ("appendicitis cases come in threes"), a little secret that Make Mine Trauma lets everyone in on.

Just as we are all a little Grumpy and a little Dopey, surgeons all have (hopefully) a whole lot of Happy in us as well -- after all, people actually let us operate on them, and sometimes they even ask us to!! At Suture for a Living, we learn about the little things that make us happy during a work day --- just the simple conversations that happen in the operating room. And although he was more than a bit bored by the end of the day, learning about brain surgery was quite a treat for this medical student.

What about Snow White? Well, unless somebody wants to talk about sexual reassignment surgery, I think I'll leave her for another day. Next up for SurgeXperiences is the Monash Medical Student, who will host on November 25th; get your posts lined up by the 23rd!