Wednesday, April 03, 2013

idiot test ordering

Can I just say that it has gotten to the point of ridiculousness with test ordering in the ER?  I mean seriously,  MRIs have become the norm.  When did that happen? It used to be MRIs were considered an exotic test that was never ordered in the ER.  Now there are at least a few a day.

Yesterday I had a patient who had not one, but two, MRIs ordered.  And you are not going to believe this, but they were both NEGATIVE.  Wow what a shock.

I have an idea: Lets just have a standard order set for EVERYBODY that comes into the ER.  Everybody gets CBC, Panel 8, belly panel, troponin, UA, a complete body MRI. Damn it, if there is anything off in your body we will be able to diagnose it, whether you like it or not.  Just think, if we find something a little off, we can order even more tests and charge your insurance company even more money!  What fun!

This way, the hospital gets to use those expensive MRI machines, the doctors can jack up their acuity level and everybody will be happy.....


jimbo26 said...

If they are not used , they don't need servicing , so the contracted servicing people won't be needed . They will complain to the hospital which will then have to use them so they can be serviced . Vicious circle . ;-)

Ivan Ilyich said...

My MRIs weren't ordered in the ER, but a CT scan was. To rule out a pulmonary embolism, I suppose. It was negative. It seems to me that's useful information. If it were known what result would come from a test, no tests would ever need to be done. Could that work?

My MRIs (three) were also negative, but I was glad to have them. Information is good. That's the patient's point of view.

Anonymous said...

It's so we don't miss anything. I had a deposition over a case that may or may not have been diagnosed with an MRI. Defensive medicine at it's best.

Aesop said...

I'm wondering what condition would be diagnosed that would be simultaneously
> acute
> emergent
> treatable
> unobtainable by less exotic means
in order to justify an MRI in the ER, ever.

I got nothing.

Ivan Ilyich said...

Aesop, here's a link to an article addressing the point you raised:

I'm not claiming it's right (or not) — it's just something to consider.

Aesop said...

Thanks. That's the sort of thing I was hoping someone might have handy.

"Other limitations of MR imaging include poorer spatial resolution compared with that of CT, increased sensitivity to motion-related artifacts, and limited compatibility with equipment used in intensive care and monitoring of patients (4). CT is many times faster than MR imaging, even when the latter is performed with fast gradient-echo sequences, and therefore CT is more suitable for diagnostic imaging of an acutely ill patient who may be unable to cooperate and lie still for the duration of MR image acquisition. Finally, most radiologists are more familiar with the appearance of acute abdominal and pelvic conditions on CT scans than they are with the MR imaging features, and their lack of familiarity with the latter is a hindrance to the use of MR imaging in an emergency setting."

That and the 5-fold cost increase over U/S, and double that of CT, seems to pretty well rule it out until further notice, except in a very limited subset of cases.

Pretty much exactly as it is, now.