A 31-year-old man presented to the emergency
department (ED) complaining of abdominal pain and vomiting. The
patient was well known to the ED staff (a "frequent flyer") as he
had presented multiple times in the previous 2 years with similar
complaints, always requesting intravenous hydromorphone (Dilaudid)
for the pain. In fact, he had been seen in the ED 2 days earlier by
the same physician who was on duty. At that time, the patient's
examination was benign, and a computed tomography (CT) scan of his
abdomen and pelvis was normal. He was discharged home with a
prescription for hydrocodone/acetaminophen (Vicodin).
On this visit, the patient stated that his
abdominal pain and vomiting had not significantly improved over the
prior 2 days. His vital signs were normal, and his abdominal exam
was unremarkable, with no tenderness, guarding, or masses. The ED
physician ordered laboratory tests and a CT scan of the abdomen and
pelvis, all of which were normal. Because of his persistent
symptoms, the patient was admitted to the hospital. An evaluation
by a gastroenterologist failed to reveal a clear cause for the
symptoms, and the patient was discharged to home after 2 days in
the hospital feeling somewhat better.
As part of a targeted review of intravenous
hydromorphone use in the ED, the Medical Director came across this
case. When she looked back over the prior 2 years, the patient had
been seen in the ED 12 times for abdominal complaints and had
received 12 CT scans of the abdomen and pelvis. All of them were
completely normal. When she reviewed the clinical details for each
of the 12 presentations to the ED, she felt strongly that most, if
not all, of the CT scans were not clinically indicated. When she
discussed the patient with the providers involved, many of the
physicians expressed that the CT scans (and many other tests) were
ordered out of "fear of getting sued"—as a safeguard against
possible malpractice liability. The Medical Director was frustrated
and wondered about the costs—to the health care system and to
patients—of practicing this "defensive medicine."
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