Controlling Costs

Clinical Vignette: 62 yo F, smoker, presents to ED with sudden onset severe, stabbing lateral neck pain for four hours, non-radiating, with no trauma. Pain does not radiate (i.e., does not move from place to place). She has diaphoresis (spontaneous sweating). She has had muscle spasm before, but never like this. No recent yoga, chiropractic adjustment. No headache. No vision loss or weakness. Vital signs: temp 97.8 F, pulse 102, respiratory rate 20, blood pressure 194/96, pulse ox 91% on room air. Exam, normal except for diaphoreses, and tenderness over the insertion of the paraspinous muscles on the L. There is no ptosis, no dryness of half the face, and eye movements are normal; all pulses are equivalent.

What did you think of for a differential diagnosis?

Most likely, you thought of muscle spasm; if you've been reading recent case reports, the pertinent negatives of yoga and chiropractic adjustment raised the spectre of vertebral artery dissection, and the clue of a smoking history and hypertension with no history of this in the past might have made you a bit uneasy. On exam, diaphoresis may have made you uneasy, but there is no neurologic deficit to lean on, and the tenderness of the muscles of the neck can be used to support spasm.

So, now the rubber meets the road: what do you do? If this case is being presented to you as a case on oral boards, there is an answer, and the heart rate, blood pressure, pulse ox, and respiratory rate must all be addressed and treated, and you can bet that there is a diagnosis waiting to be found. If this is a teaching conference, then most likely it is in the conference because there is a great case to be found as well.

In those cases, 'what do you do' would probably be met with the knee-jerk treatment for a potentially sick patient in the ED--two large bore IVs (or at least one), cardiac monitor, EKG, oxygen for the pulse ox, a full spread of labs, and symptomatic treatment to start, followed by imaging or a procedure to find the answer; either advanced neuroimaging, or, given the neck stiffness, a lumbar puncture for hemorrhage or infection I would guess. However, 'what do you do' in a community ED setting is quite different. Usually, I would venture a guess that this patient would get a dose of strong narcotic pain medication, probably with an IV because it's a richer community hospital and she doesn't have a long history of visits; she's also polite, and white, and not asking for drugs by name. An EKG probably is done, and some labs. Often there's some spice to the narcotic based on experience and training--some valium, or some oral cyclobenzaprine (a muscle relaxant and sedative), or oral tramadol (a useless hypnotic pain medication), or droperidol (another sedative), or some other such medication.

There's a gap in these two approaches, isn't there? And yet, in the vast majority of cases, the community approach will work. You perform a focused exam and chase definite findings, then chart like crazy that you considered heart attacks, PEs, dissections, and such, and send the patient home with some hydrocodone to help with your Press-Ganey scores. Most of the time--probably 99 out of a hundred or more, in this case--you will get away with this, meaning there will not be a bad outcome at home. Most of the time, this will also represent good care, in that the patient will feel better and not be harmed in any significant way, either by a miss, or by a harm inadvertently committed by the medical community.

But, once in a blue moon, this will be the zebra. We call rare disorders 'zebras' based on a saying often heard in medical training--when you hear hoofbeats, think horses, not zebras. That is, common things are common and most of the time that's what the patient has. Something common. However, more and more of our conferences and training ask us to find the uncommon, especially in Emergency Medicine. The zebra here is a vascular dissection; with neck pain in the back, a vertebral artery dissection, or a tear in the wall of the blood vessel on the left that travels up both sides of the neck in the back. The downside of missing this diagnosis would be stroke or severe neurologic impairment. It is, however, very rare; so rare that it's hard to tell how often it happens. There is an association with recent chiropractic adjustment, minor neck trauma, and even yoga, but it's hard to tell if this is a true association or rather the result of a hard search for causes of something terrible, since these often happen in young people. Smoking is also associated.

I did look for the zebra in this patient. She got a CT of the chest with neck after a discussion with the radiologist. The case will not appear in any presentations or journals; the study was normal. She felt better, and went home, probably with cervical muscle spasm; I did actually give her a bit of hydrocodone/APAP.

I wrestled with the decision for a while (meaning, since I'm an ER doc, about thirty seconds of hard thought). I'm still new-ish, and coming out of residency we often say that it's good to be overly cautious, and if you think of doing a scan, the right thing to do is to get that scan, so you avoid misses. But it also had to do with our doctor-patient relationship; she was very uncomfortable, sweaty, and hypertensive compared to normal. Yes, I'm jaded, but 194/96 and sweaty is a bad combination occasionally. And this is why costs in our system will be hard to contain. I wasn't overly worried about being sued; our state is not bad as far as climates go for malpractice, and I was certain I could chart well in this case. I would say I considered vertebral artery dissection, but the patient had no neurologic signs or symptoms and responded well to medication. But all of those worrisome little signs added up to a CT scan that cost a ton of money and carried with it the risk of radiation and kidney injury, both rare in their own right, but probably about as prevalent as the bad outcome I was trying to avoid. The problem is, you and your patient will never know which rare bad outcome you might get. It's easy to make a decision if you say to a patient the following: 'you could go home now, but I know for certain that you happen to be in the 0.01% of people I will see in my career with neck pain who have a vertebral artery dissection, and in 18 hours, you will suddenly collapse, lose your vision, and be unable to walk, resulting in a long nursing home stay and a lifetime of disability--would you like a CT scan to catch that for you?' I can't say that. Never will be able to. And until I figure out how to deal with that risk, I'll continue to order CT scans based on gestalt, and probably order a lot of 'useless' scans, with a few scans that catch obscure diagnoses and thus reinforce the cycle. It's a lot more complicated than it seems when we say 'stop ordering useless CT scans'. You try it.