Stojanovska and colleagues present a review of cases from an academic medical center in the Midwest, retrospectively reviewing 602 CT for PE.³ The overall yield was reported as almost 10 percent, which is sadly unexceptional in the United States. More concerning, almost 20 percent of patients scanned were PERC negative. If a major teaching institution is misusing CT for PE in low-yield and low-value presentations, how will our trainees perform in the future?

Appendicitis in Children

Children, as they say, are our future. If this truism holds, our future is full of solid tumor diagnoses.

The evaluation and treatment of children in the emergency department exhibits some of the widest possible variation. This is to be expected given the gulfs of experience and comfort with pediatric patients. Harms should be avoided when they can be. For example, ultrasound-first strategies for the diagnosis of acute appendicitis are reasonable and widespread. Not every presentation is appropriate to forgo CT, but many uncomplicated presentations can feasibly be addressed first by ultrasound.

This article demonstrates the use of ultrasound deteriorates rapidly with distance from pediatric specialty centers.⁴ Comparing a pediatric emergency service at an academic center to a community-based practice still with pediatric emergency coverage, the rate of CT imaging was roughly triple in the community. At the academic center, fewer children with abdominal pain received lab work, and of those receiving lab work, only 10 percent underwent CT. Comparatively, at the community facility, a greater percentage of abdominal pain presentations received blood work, and 28 percent of those underwent CT. The difference boiled down to avoidance of CT by use of ultrasound and by admissions for clinical observation.

Ultrasound or observation-first protocols are widespread and certainly defensible foundations for shared decision making.

Harms should be avoided when they can be. For example, ultrasound-first strategies for the diagnosis of acute appendicitis are reasonable and widespread. Not every presentation is appropriate to forgo CT, but many uncomplicated presentations can feasibly be addressed first by ultrasound

Upper Respiratory Infections

Finally, just to complete our comedy of errors, we’re also now seeing extensive use of CT for even benign upper respiratory infections (URI). It is reasonable to have a serious debate over the risks, benefits, and diagnostic certainty for illnesses of significant morbidity and mortality, but the common cold?

These authors reviewed the use of CT for emergency department visits coded as URI or lower respiratory tract infections (LRTI).⁵ In 2001, only 0.5 percent of patients visiting the emergency department for URI symptoms received a CT, and by 2010, that rate had climbed to 3.6 percent. In 2001, 3.1 percent of LRTI symptom presentations received a CT, and in 2010, this rate had climbed to 12.1 percent. In keeping with classic features of overuse, there was no change in rate of antibiotic prescribing or the rate of hospital admission. Four times as many CT scans with zero benefit.

Undifferentiated Chest Pain

Flipping the channel a bit, this last article concerns not just CT overuse but suggests irresponsible overuse.