Once again, Drs. Teresa Wu and Brady Pregerson do an excellent job in highlighting a case in EP Monthly (and a topic that I am so incredibly passionate about – not only because of the benefit to the patient, the minimizing of CT scans/radiation, and the time spent in its work up – but also in health care cost and expediting diagnosis and management.) What am I talking about? Well, RENAL ULTRASOUND for RENAL COLIC. Yeah, I know, it sounds obvious. But, I heard of a patient the other day (again!) who had a known history of kidney stones, who had the same pain as her prior kidney stone flank pain, who begged to not have yet another CT scan done since it would have been her 13th for this at the age of 40. I highlighted this topic and other studies on it in a prior post, and AIUM posted a sound judgment series written by Drs. Chris Moore and Leslie Scoutt on this topic too.
So, let’s talk about TWu and Brady’s addition to the mix. Of course, they always start off their case with humor, yet reality, by saying : “I have to do a cost-benefit analysis of the situation,” your eager intern replies. It’s the end of the academic year and you are forcing your soon-to-be R2s to become more autonomous and confident in their management plans. You are amazed at the various answers you now get when you ask the simple question, “What do you want to do?” You ask your intern to summarize the case for you. He just finished evaluating a 21-year-old male who presented to your ED with back pain. The patient states that his “back is killing him” and he thinks he strained his muscles working out too hard at the gym last week. He just started doing CrossFit and he’s worried that he overdid it. The patient notes that the pain is 10/10 and that he has had minimal relief with his friend’s Vicodin. He’s tried icing his back and even sat in the hot tub all weekend per his friend’s recommendation. Nothing is working so his friend told him to come into the ED to get a prescription for something “stronger.”……
“Your question about whether or not this young 21 year old needs any imaging is giving him pause. “I think the cost of the imaging and the risk of radiation are too high. I don’t think there’s much benefit to keeping the patient here any longer. Plus I don’t know what we’d be looking for,” he replies. You are happy with your intern’s logic and pop into the room to see the patient. Within seconds, you realize that Vicodin and a hot tub probably won’t fix this patient’s pain. The patient is sitting hunched over on the stretcher rocking back and forth in pain. He has no appreciable tenderness to palpation over any of his back muscles, and there is no asymmetry or tightness on your exam. You are unable to reproduce or worsen his symptoms with testing his range of motion, but he is definitely rubbing his right lower back to try to ease his pain. You walk out of the patient’s room and grab your intern and the ultrasound machine. As you head back towards the patient’s room, you pimp your intern on the other more serious causes of low back pain. Acknowledging that you have the ultrasound machine in tow, your clever intern starts rattling off the diagnoses that can be easily made with bedside ultrasound. AAA, atypical appendicitis, cholecystitis, nephrolithiasis, abscess, etc. Since the patient is sitting upright and hunched over in pain, your intern decides to start his scan with a view of the right flank….”
BAM! oh yeah – do you see it? Weren’t expecting that? Funny what happens when you look, right? You must read about their findings and the pearls and pitfalls of renal ultrasound – go here for the true meat of the article.