Search for tag: "imaging"

Interviewer: You think you may have broken a bone but you're not sure. Is there a way you can tell? We'll find out next on The Scope.

Announcer: This is From the Front Lines with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health. And I know it seems like a silly question because one would think if I broke a bone I would know for sure that I broke a bone. But personal experience, when I was a kid, I broke a bone in my leg, I didn't know, my dad didn't know. He told me to walk it off, you know, as fathers back in that day did, and it turned out the next day I went to the ER and sure enough it was broken. So how can you tell if you broke a bone if you're not sure?

Dr. Madsen: Well, you know, it's really not a stupid question at all because there have been lots of studies done to answer that question for us. How can I know as a physician if someone possibly broke a bone, in their knee, their ankle, their foot?

Interviewer: And you're talking without doing imaging?

Dr. Madsen: Yeah, exactly.

Interviewer: Okay.

Dr. Madsen: To say, okay, are there cases where I can avoid getting an X-ray, or every time someone comes in and says it hurts here on this bone do I need to get an X-ray? So it's actually a great question. And in terms of ankles, knees, and feet, if you can't walk on it, you need an X-ray. That's kind of what these studies showed. But then they also show there are certain parts where if you push on a part of the knee or the ankle or the foot that are more prone to fractures, then those are people who need X-rays as well. So it's a little bit tough to kind of go through and say, "Well, if it hurts on this spot, you need an X-ray, or this spot you don't, this spot you do, this spot you don't."

That's what it comes down to for me as a physician, I know there are certain areas that are more prone to fractures but, you know, typically with fractures you're going to see a lot of swelling, you're going to have trouble moving that joint around or you push on the bone, it hurts there. Again, it's going to be kind of a judgment call. I would say if you're able to walk on it or you're able to use that joint okay, you might be able to get by. But if after a couple of days you're still having a lot of pain there, I think in my mind that increases the likelihood of a fracture in that bone.

Interviewer: And when you say fracture, that's used interchangeably with broken?

Dr. Madsen: Exactly. And that's a great question because sometimes, you know, if you say to someone, "Oh, you've got a fracture in the bone." They'll say, "Well, is it broken?" But, yeah, that's a great question because those are terms that are used interchangeably. You know, the other things we always think about are sprains, strains, you know, where you're pulling on muscles, you're bruising the bone, these are all possibilities as well, things that can look like fractures or like broken bones but, you know, the biggest thing in my mind in the ER is, is it broken, and do we need to do something about that fracture?

Interviewer: Yeah, on that next question sometimes if it is fractured there is nothing that really needs to be done?

Dr. Madsen: That's right. Yeah. Sometimes if something is broken its maybe in a place where there's really not a concern there. Maybe you need a splint on it, but it's all aligned, you don't need to push things back in place. There may be some fractures that are just little chip fractures, little chips off the bone where there's really nothing at all you're going to do for it. So there are certainly cases where, you know, you may have broken something but it's not a big deal. But in my experience, most cases of broken bones, they at least need a splint or a sling or something to keep that from moving around a lot and making it a lot worse.

Interviewer: So with this information that you have, the studies that have been done and knowing where to press and what to expect, how often do you not have to use imaging now? Can you just tell through a physical examination if the bone is broken?

Dr. Madsen: In terms of what I do in the ER, one of the challenges I face is that I think most people come there and if they're ankle hurts they came there to get an X-ray. So sometimes I do spend time trying to talk them out of getting an X-ray, I would say with the knowledge I have of where it hurts and where it hurts and where it doesn't hurt, and maybe 20% of the time people don't need an X-ray. The other 80% of the time people sort of self-triage, they say, "Hey, I can't walk on my foot. I need an X-ray." And I say, "You're exactly right, you need one."

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign me up" for updates of our latest episodes. The Scope Radio is a production of the University of Utah Health Sciences.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: All right. Here's a question. How can you reduce the use of imaging tests for patients that you are evaluating for appendicitis? That's what Dr. Eric Glissmeyer's research focused on. Thank you for coming to help answer that question. First of all, why did you want to answer that question?

Dr. Glissmeyer: Well, particularly when we're evaluating children that are being seen for abdominal pain and they may have appendicitis, we like to not do dangerous things or harmful things to children. It's not uncommon that a CT scan, a test with ionizing radiation that exposes the child to potential risk of harm, is done, especially in uncertain cases. So we wanted to try to set forth the protocol with the support of our surgeons and our radiologists that helps us one, standardize our approach and two, reduce CT use and that was our primary objective.

Interviewer: How have people tackled this problem before?

Dr. Glissmeyer: Well, there are a number of places around the country that have done great work in establishing protocols that many times have been just developed iteratively in a quality improvement kind of way, that have had the focus of reducing CT use.

I think that one unique approach that we took here is we didn't want to just know when is CT scan used in patients who are ultimately proven to have appendicitis, but when is it used in that larger demographic, that larger denominator of patients who are evaluated for suspected appendicitis? The doctor goes and feels their belly and says, "They may have appendicitis. I better rule them out for appendicitis."

What do you do next? We have a lot of tools at our disposal and there's a lot of variability in what people do. We wanted to standardize that with that objective of reducing advanced imaging tests like CT scans.

Interviewer: All right. Here's the moment of truth. What do you do?

Dr. Glissmeyer: What we believe the best thing to do is to take a standardized approach driven by physical exam and utilizing a scoring scale. We use something called the Pediatric Appendicitis Score and there are a number of other scores being used. We don't really think it matters exactly what the score is. We don't think there's any magic in one particular lab value or one particular physical exam finding.

Appendicitis is sneaky and it likes to present many different ways. What we've found though is with the support of our surgeons and our radiologists all working together to determine an algorithm, that as we go down and we do a blood count and we do an exam and we see what some of those initial results come back as, we can either put the patient into a category of low risk and, "Gosh we're done." We really don't need to have much worry about appendicitis unless things get worse, intermediate risk, where perhaps an ultrasound test and certainly you have to have an organization that does ultrasound well.

Pediatric ultrasound for appendicitis is not an easy test. Our ultrasonographers have been doing this a long time at primaries and are very good at it. We actually know based on what they see on the ultrasound there are four different grades for the ultrasound result. We know what the likelihood of appendicitis is for those different grades.

So we've got some great data to drive our decision making out of the results we get. You know what? There are some patients who don't even need an imaging test to diagnose their appendicitis. If it's a classic case, straightforward, the labs support it, you're done, call the surgeon, take the appendix out. This was done 20 to 25 years ago with no imaging tests regularly because they didn't have any. So we kind of need to go back to that in some ways.

Interviewer: And in your research, how accurate was this method?

Dr. Glissmeyer: For patients who come in and we see for having appendicitis, I want to first say how do we know when we were looking at this retrospectively that the patient was actually being evaluated for appendicitis? How did you crawl into that doctor's mind and determine, "Well, did they actually suspect appendicitis or were they just coming in for gastroenteritis?"

We developed a surrogate definition, whether they had an ultrasound done, whether they were coming in for a chief complaint or abdominal pain and the word appendicitis was used in the note and a CVC was obtained that 95% of those patients were evaluated for appendicitis.

It had a sensitivity and a specificity of 95%. We're confident that we could evaluate the patients or rather identify the patients that were being evaluated for appendicitis. So in that group, I think the real question people would want to know is what were you doing before you did this protocol and what did you achieve after in terms of the CT use?

Interviewer: Yeah, did it reduce it?

Dr. Glissmeyer: We were one of the lower utilizers in the country in CT. Our baseline data showed we were doing CT scan only 15% of the time in this cohort of patients being evaluated for appendicitis. If you look nationally, it's more around 30%. So we were already a low utilizer of CT.

But what I was so pleased to find was that as we instituted this protocol that has not just the standardization but this follow up option that we'll talk about too, we were able to drop that low rate in half again, from 13% to 6%, from 13% to 6%. So we were really pleased to see we were even able to cut that in half further.

Interviewer: Is there an ability to even cut that more, do you think?

Dr. Glissmeyer: I think potentially. But I think you achieve a certain baseline minimal rate where you get your unclear cases, you get your cases where your patient has been having pain for a week or so and you really suspect that this is a ruptured appendicitis and CT scan is really the optimal test to use. I think around 5% or so is probably about the minimum you want to achieve.

Interviewer: All right. Explain the follow up option you were talking about.

Dr. Glissmeyer: Probably somewhere around a third of patients who have abdominal pain are being evaluated for appendicitis. It's not totally clean, a third, a third, a third, but let's talk about it in those terms because it makes it easy.

If a third of patients come in and it's pretty obvious after your exam and some labs they don't have appendicitis, you're done. You don't need imaging tests. About maybe less than a third, somewhere around 15-20% and they come in and they have pretty clear evidence of appendicitis, labs support it, you call surgery, they get their appendix taken out, no imaging tests needed there.

Then there's this larger middle where the fall into an intermediate range of a Pediatric Appendicitis Score that we have called between 4 and 7. If they have that score, you do an ultrasound scan first. Boy, when it shows the appendix and it shows it's normal or it shows the appendix and it shows it's not normal, that's really helpful. Then you can make your decision based off of that, but if it doesn't see the appendix, what do you do then.

The patient still has some tenderness, you're still a little uncertain. Do you just go stick them in the CT scanner to get your answer? That's what I think historically has been done, when the ultrasound fails to give you the answer you want, we go and scan them. We work with our surgeons to say, "You know what? We've observed this patient for a couple of hours here in the ER. Their pain is not really getting worse. It's not a clear cut appendicitis. Why don't we have them come see you tomorrow morning in clinic?"

So if it's Sunday night between Sunday night or Thursday night where they could go the next morning, that being between Monday and Friday, they can show up at about 7:30, 8:00 a.m., come into surgery clinic, get their belly pushed on, be examined, get lab tests repeated if they need to, perhaps do another ultrasound if necessary and find themselves in the hands of another expert the next morning also with not a second ER charge, which is nice, but being able to come into the clinic.

We thought, "Are we going to go and be doing surgery clinic follow up now? Are people going to just be like all the time overrunning the surgery clinic the next morning?" Actually it's only about one patient every ten clinic days that utilizes this resource. But the fact that you can offer it to them in the emergency department the families love and the docs love because in the faces of uncertainty, it gives them a plan. That's been the magic of the approach.

Interviewer: What's the next iteration then of this research? Where do we go from here?

Dr. Glissmeyer: We've been pleased with what we've been able to achieve at Primary Children's Hospital. It's to take it to other hospitals within Intermountain Healthcare, University Healthcare, having the support of surgeons at those other hospitals is key and radiologists as well, we're working on that. But only half of the appendix case present to the tertiary children's hospital here, Primary Children's Hospital. We want to address that other important half and that's where we're going next.

Interviewer: Getting that feedback from the surgeon afterwards for the patients that didn't get the imaging but had the operation and you find out how successful you've been or haven't been. Have these tools proven to be pretty successful?

Dr. Glissmeyer: That's a great question. You wouldn't want to be going and admitting to the surgery service a lot of patients who you as the ER doc are convinced have appendicitis and then they go in there to take it out and then, "Uh-oh, it looks normal." That happens on a rare occasion. Nationally about 5% is the rate of negative appendectomy. You go in and, "Oh, we thought it was appendicitis and it's not."

Our rate here is about 2-3% and it's not increased since the use of the protocol. So going in and taking out patients' appendix without ultrasound test or any imaging test, it still is successful and doesn't increase that negative appendectomy rate.

Announcer: Discover how the research of today will affect you tomorrow. The Science and Research Show is on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope

Dr. Stehlik: How does advance imaging help improve the treatment of patients with heart failure? I am Dr. Josef Stehlik along with Dr. Stavros Drakos, and today we're talking with Dr. Jeroen Bax, a cardiologist from Holland and the president of the European Society of Cardiology, who is speaking at the Utah Cardiac Recovery Symposium, U-CARS, at the University of Utah.

Professor Bax, I would like to ask you how your field of cardiovascular imaging relates to a patient who presents to a doctor with a heart condition.

Dr. Bax: If we speak about imaging and how does it relate to the specific patient, I think one needs to realize the information one needs to have, so if we speak about such a patient, the first thing is that we need to diagnose specifically what's going on with this patient. Why is his heart not functioning? What is the problem underlying that? And based on the information that we get from our modern technologies such as modern CT scanners, MRI scanners, echocardiography, but also nuclear imaging, this information will help us then to select the therapies.

What are the therapies? Well, we could go for medical therapy, could go to surgery, we could have device therapies such as cardiac stenting, pacemakers, supporting hearts and transplantation. Once we have selected the therapy based on this imaging that we have acquired, then we could actually look into determining the prognosis for the individual patient. What is the prognosis after we have decided exactly what we are going to do? And that's the cornerstone, I think, the prognosis eventually for the patient.

Dr. Drakos: So Dr. Bax, my name is Stavros Drakos, as my colleague Josef Stehlik said. We are cardiologists here at the University of Utah, and we see all the time patients coming with more than one heart attack and their heart is weak. They don't feel well. They're tired. They're short of breath. So how would you approach a patient like this? How is advanced imaging going to help you?

Dr. Bax: Yeah, that's exactly sort of giving an example of what we just spoke about. In this case we actually need to know for this patient what do we need to do, what are the therapeutic options, and to understand the therapeutic options we actually need to image his heart. So we look in this specific heart, where are the infractions? We have all these modern technologies that I just indicated and the focus is where are the infarctions and how big are these infarctions? How much scar tissue is there in this heart, and if there is a lot of scar tissue then the likelihood that he will improve based on medical therapy or something is not that high. But if there is very little scar tissue we can just focus on giving medication. So the imaging is going to help us to choose the strategy for the patient.

A lot of scar tissue means that we have to look for different things than just medication. Then we need to think about devices such as pacemakers that can help improve the function of the heart, or maybe bypass surgery is needed, that we need better blood flow to this heart, or maybe in a worst case scenario, we need to think about transplantation. These decisions can be made by the modern imaging technologies that we have.

Dr. Stehlik: Let me now ask you about a different patient, actually not a patient, just a person who's at home and hears about her best friend about the same age, same lifestyle, having a big cardiac event, and now this person comes and says, "Well, wait a minute. Am I at risk? Should I have my heart imaged? Will that change my future?"

Dr. Bax: Yeah, that's a very important question. We're now shifting actually towards the topic of prevention and that is important. Actually we have techniques for that. We have, for example, the technique of CT scan that most of us know nowadays. With CT scan we can look, just with the scan, not from inside but from outside, at the patient's coronary arteries and we see if there is obstructive coronary artery disease. This is already affecting the coronary arteries. Is there already atherosclerosis? Do we need to think about something? If we see little bits of atherosclerosis we can actually then help this individual and improve his lifestyle.

What could we think about, then? Healthy lifestyles. That means exercise more, reduce taking too much food, control the blood pressure, quit smoking, and actually this can be done in collaboration with general practitioners. So this sort of screening imaging can really help to prevent. I think now we're talking about adults looking at these things, but eventually the future might be that we are going to look at the early youth when we need to intervene. More healthy lifestyles. Imaging can also play a role there, but then we don't talk about CT scanners. Then we speak about certain echocardiography techniques where we can look at the heart, how is the heart functioning, and based on that we can actually decide upon helping these individuals for a better lifestyle.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.