With Zivia Reischer
That’s the paradox of testing: If you look long enough, you’ll find something. And that’s the balance we’re looking for: Treat the emergency, but don’t create it
ome people say the ER is another universe, separated from the rest of the world by pain, fear, the heightened sense that you’re out of control and anything could happen. Or it could be that the choices we face in the ER are the same as we face on the outside — just magnified.
Terry was 17. I recognized her from around the neighborhood. Mom and Dad brought her to the ER in a state of controlled panic — she had been playing basketball, tripped, and hit her head with a sickening crack on the asphalt.
Those who come to the ER are in a state of emergency, but they’re not all in need of lifesaving care. It’s our job to assess and treat each patient at the level of care that the patient requires.
Not always easy.
I looked at Terry. At a glance, she seemed fine. She answered all my questions normally, was able to track my finger in all directions, and could count down from 100 by sevens (if that sounds easy, try it). Her grip was strong. Her balance was fine.
Her parents were anxious. They wanted a CT scan.
I tried to reassure them. I discussed the risks of testing (with a CT scan, radiation, which is associated with risk of malignancy) and explained that in this case, the risks associated with the CT outweigh the potential benefit. I explained why Terry didn’t meet any of the criteria that would indicate the need for imaging, and that a CT scan would not change her treatment.
They weren’t listening. “We need a CT scan,” Mom kept insisting. “My cousin is a nurse for a dermatologist, and she told me we need a CT scan.” She started scrolling through her phone, looking for patient advocate services.
I am a parent. I get it. Your kid fell, and it was horrifying to watch, and her head hit the ground before her body, and a well-known celebrity was just in the news because she fell and thought it was nothing and died of a brain bleed two days later.
But I am also an ER doctor. Our role is to examine patients and determine the best, evidence-based plan for treatment, and nothing in this case indicated any need for further steps.
I don’t like to argue with patients or their families. I try to explain the rules by which we make decisions and show them statistics, but I have lights and sirens descending on me from all sides, so if you really want a CT scan, fine.
As it happened, there were stroke victims and trauma patients of higher acuity who needed urgent scans, so Terry waited two hours while Mom talked on her cellphone, made patchwork childcare arrangements, and fielded calls from work. Dad paced the tiny cubicle and tapped away on his phone and went out and came back with water bottles and pretzels and muttered about why healthcare costs so much if the wait is so long and how no one seemed to understand that this was an emergency room.
Dr. Brad from radiology reviewed the scan. He reported all clear: no brain bleed, no concussion. However, he noted a spot on the brain, a “small hyperdensity, difficult to characterize.” Translation: not really sure what that spot might be.
Honestly, if it had been Dr. Alexa’s shift, she would have said it was nothing, but Brad was a hedge-his-bets, err-on-the-side-of-caution type of guy.
Kind of like Terry’s parents.
Who, obviously, panicked at the news that there was a “spot” on Terry’s brain.
At this point we needed to do another CT (more radiation) with contrast. That means a radial opaque dye is injected into the veins to light up the blood vessels and surrounding structures. Because of the risk of kidney damage from the dye, we first drew blood (more tests) to determine that Terry’s kidney function was normal (ER rule: Tests beget more tests). Finally, Terry had the IV secured, we injected the contrast and performed the scan.
Poor Terry. Her veins were kind of fragile, and the contrast infiltrated her skin. She was lucky that it was only a bit — severe cases need a plastic surgeon to come clean out the spill. In her case, she was just very uncomfortable. Unfortunately, this also meant the scan was non-diagnostic, and further testing was not feasible in the ER.
When Mom and Dad took Terry home after six hours in the ER, they knew that she did not have any concussion or bleeding in the brain, but they had greater worries by then: Her arm was painfully infiltrated with contrast, and there was that mysterious, terrifying “spot” on the brain scan.
Mom secured a neurology appointment for Terry two weeks later. For two weeks, Terry lived in terror that she had a brain tumor.
She did not have a brain tumor. What she had was unnecessary testing.
I don’t know what the neurologist told Terry and her parents. I assume he threw the scans down on the desk and told them she was fine. It’s possible that he offered them an MRI (more radiation and may require sedation with accompanying risks) or even a brain biopsy (all the risks of brain surgery and anesthesia).
In that event, her case summary would have read like this: Terry came in for a CT scan she didn’t need and ended up with brain surgery she didn’t need.
But this is the problem. If you had a spot on your brain, would you ignore it?
Of course not. Once you see that spot, you’re stuck. It’s at the point where you fell and the doctor tells you you’re fine and don’t need further testing — that’s where you should stop.
In emergency medicine, you rarely get to know the end of the story. However, since Terry lived in the neighborhood, I noticed her four weeks later playing basketball again. Her mom came over to thank me and let me know that everything was okay.
That’s the paradox of testing: If you look long enough, you’ll find something. And that’s the balance we’re looking for: Treat the emergency, but don’t create it.
Or maybe it’s just the paradox of life — nothing is risk-free. Even in the ER. Life hangs in the balance.
All names and identifying details have been changed. Patient profiles may be based on composite cases.
(Originally featured in Mishpacha, Issue 758)
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