How Escalating Tests Can Lead to a Sad Outcome

The medical community increasingly accepts that care in the U.S. often involves unnecessary and inappropriate diagnostic testing, a subject we’ve written about for years. But sometimes showing in detail how overtesting can be dangerous is far better than just talking about it.

A recent post on KevinMD.com by Dr. Rourke Stay, a radiologist (physician who reads and interprets diagnostic images), is a clear, although fictional, illustration of the harm of inappropriate imaging. Here’s his scenario: A 37-year-old woman showed up at the emergency room one day complaining of heartburn and abdominal pain she’d had for several hours. The nurse ordered a variety of blood tests, which were normal except for mildly elevated liver and heart enzymes.

The nurse contacted a physician, and he ordered a noncontrast abdominal/pelvic CT. CT, or computed tomography, is a fancy X-ray that can be given with or without the use of contrast agents to show detailed images of internal organs. The patient underwent the scan, then was taken to an exam room.

The nurse gave the patient some TUMS for her heartburn, and she quickly felt better. The radiologist who read the CT scan deemed it negative for acute pathology; that is, it showed no cause for the patient’s acute abdominal pain. But it did pick up a small mass of about an inch in her liver. A mass protocol CT was recommended to determine what it was.

That’s a more complicated screen that also relies on radiation and involves the injection of contrast substance to view the specific organ more clearly.

In the meantime, the patient was seen by the emergency doctor, who took a full medical history and performed a physical examination. The patient was discharged from the emergency room with a diagnosis of gastroesophageal reflux (stomach acid or stomach content flows back into the esophagus, irritating the lining), a prescription for Prevacid and a prescription for a contrast-enhanced CT scan.

She had that procedure, but the results offered no additional information about her liver lesion. The doctor recommended that she have an MRI. That imaging technique uses a magnetic field and radio waves to create detailed images of organs and internal tissues body.

The patient had the MRI, whose results seemed to indicate the presence of a benign mass. The radiologist, who reviewed her history, noted that it included her use of birth control pills, which would support the diagnosis. The radiologist also mentioned that she might have a mass in her esophagus, but it wasn’t clear on the MRI or on the earlier, noncontrast CT scan. The radiologist recommended an upper GI.

That procedure is an X-ray to view the upper digestive system (esophagus, stomach and duodenum). The patient drinks a barium solution for contrast on the image.

A radiologist performed the scan, which was negative. But because the patient’s recent knee surgery had limited her mobility, she wasn’t able to move into all the positions advised.

So, based on the imaging results and the history of heartburn, an upper endoscopy was performed. That test involves inserting a flexible tube with a tiny camera on the end down the patient’s throat to view more clearly the esophagus, stomach and part of the duodenum. They looked normal. But during the procedure, the patient had a massive aspiration event. That means she vomited food or fluid into her lungs while under sedation.

That caused her to be admitted to the hospital, where she had a chest radiograph, another kind of image using radiation. It showed damage to her lungs consistent with a history of aspiration.

The patient ended up with a long hospital stay with lots of serious complications – several hospital-acquired infections, including pneumonia, sepsis, endocarditis (lining of the heart) and septic emboli, a blood clot that’s infected, in her left leg. The leg developed gangrene, which required an amputation below the knee. After that, she developed a post-operative infection, and had to have another amputation above her knee.

Although this is a mock case study, it’s utterly plausible.

“The point of this case is simple,” Stay wrote; “inappropriate imaging can have far greater consequences than the time and expense of the one test. Yes, this patient has gotten caught in an imaging loop, but how did she get there in the first place? Improper imaging often begets additional diagnostic tests that have their own inherent risks. Every medical decision was handled correctly with one exception – the CT should not have been performed for an indication of heartburn, particularly before the patient had a history and physical from the physician.”

Stay was very clear that ordering a CT did not cause the patient to lose her left; that the emergency department wasn’t responsible for that drastic surgery. “But did the ordering of an advanced imaging test without a proper indication set off a chain reaction that ultimately resulted in the patient being subjected to an invasive test (upper endoscopy) with a complication that begot another complication?” he asked. Yes.

For all the problems associated with this patient, and the horrific outcome, we haven’t even mentioned the cost. Charges for care start the minute you get to the ER, and continue for each exam, test, lab workup and scan review. Somebody pays, usually several somebodies (patient, insurance company, health system in general), and there’s no accounting for the amount of time spent overtreating.

Stay concluded with wise words for anyone in a similar situation, reminding people that emergency departments are always under tremendous pressure to triage, treat and place patients in a rapid fashion: “…[I]t is crazy the juggling they must do between their own ideas of best practices, the expectations of their patients and the metrics imposed by administrators. But that doesn’t lessen my central point; it is not a good practice to have patients triaged to imaging before they are seen and fully evaluated.”

If you or your loved one is advised to undergo an imaging procedure before you’ve been seen by a physician who has a complete medical history, make sure there’s a compelling reason to have it.

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