ED Registrar (Proactive, patient advocate): Hey, how are you? Thanks for coming down.
ICU Registrar (Calm, relaxed, ready to negotiate): No trouble. What’s cooking?
ED Registrar: Well, I’ve got this guy I was telling you about. The intern saw him about an hour ago when he came in with a fever and looking clammy. Apparently he was a bit off when his daughter spoke to him on the phone earlier today, so she called an ambulance to bring him here.
ICU Registrar: Smart daughter.
ED Registrar: Yeah. In here he’s febrile, a bit tachy around 110 and I’ve had to give him 2 litre of crystalloid to prop up his blood pressure. So he’s probably septic.
ICU Registrar: Mmmm.
ED Registrar: The source seems to be his belly. When I examined him, he’s really tender in his right upper quadrant and probably a bit guarded too. His LFTs are a little off, with a mixed pattern and his Bili is around 30. The sonographer was in the unit so I asked her to have a quick look at him and she thought there was some fluid around his gallbladder. All the rest of his bloods, including renal and a lipase are fine, except his WBC count is 16, as you’d expect.
ICU Registrar: OK, seems fair enough so far …
ED Registrar: Right, so we’re just taking him around for a CT, ’cause I spoke to the Surgical on-call registrat and told him all this and he wanted a CT just to be sure. But I don’t know if we really need to. What do you think?
ICU Registrar: $f*! ^#@
So, once you’ve calmed down, what DO you think? CT or no and what is your objective reasoning to back up your response?
OK, this time, rather than outline a possible response and then bore you all to tears with clever deductive reasoning laced heavily with references and articles, go and listen to David Newman’s excellent podcast on the truth about diagnostic testing. You can get it on his Smart EM website or go to iTunes and subscribe to the free Smart EM podcast.
Smart EM Smart testing: Back to basics podcast
Whether you work in ICU, ED, anaesthetics, medicine, surgery or even psychiatry, this is stuff you should think about. Like David says in the podcast, it is probably stuff you already know and do, even if you are not aware of it.
A couple of caveats though. The podcast caters essentially for a North American health system of emergency medicine, so if some of it seems a little obvious or blunt, remember that clinical practice can differ quite substantially in the U.S. where litigation rates are high, medical insurance policies dominate and the tendency to test first and question later is the norm. But the core of the message he presents is valid no matter where you work nad no matter what specialty you pursue.
Once you’ve had a listen to the podcast, have another think about what your response to the scenario above might be.