Choosing Wisely Takes Courage

In a recent issue ofJAMA Internal Medicine, Schuur and colleagues listed five low value services in the emergency department (ED). Although compilation was not solicited by the American College of Emergency Physicians as part of the Choose Wisely program, it has the ethos of Choose Wisely.

The list was developed by a technical expert panel after multiple iterations. The list is not only wise, but derived from sound methodology. Most importantly, the recommendations are implementable. There is no nebulous advice such as “head CT shouldn’t be performed for uncomplicated headache,” or “always weigh risk and benefits of ionizing radiation.”

The selected low value services cut through the heart of emergency services. A notable example is CT in neck trauma, which is deemed unnecessary when the NEXUS or Canadian cervical spine criteria are not met. These rigorous decision rules guiding imaging in neck injury boast a near 100 percent sensitivity.

Per NEXUS, imaging of the C-spine can be foregone if there is no posterior midline tenderness, the patient is alert and has no distracting injuries.

How easy is it to follow these rules?

First, it’s tempting to obtain plain radiographs instead of CT when these rules are not met. This happens because some physicians feel comfortable neither in dismissing the decision rule nor in dismissing imaging.

This is a problem now. Over the years not only have radiologists been accustomed to not reading radiographs of the C-spine as CT has dominated, but there is a wealth of literature that CT is more sensitive for cervical spine fractures. Few radiologists would stick their neck out (no pun intended) for exclusion of C-spine fracture on radiograph. Disclaimers and questionable fractures will abound. One can argue about the appropriateness of this reality, but reality it is nonetheless.

A diagnostic cervical spine examination involves visualization of the junction of C7 and T1. I recall patients who were shuttled repeatedly between the bed and X-ray suite as progressive attempts to get C7/ T1 junction led to incremental success. This is disruptive for the patient.

My advice: if NEXUS criteria are not met and C-spine fracture is not suspected, get nothing; if criteria are met, get a CT. Don’t get a radiograph for the sake of getting something.

The criteria require posterior midline tenderness. Whilst distinction between posterior midline and lateral neck tenderness is not difficult for a clinician, it takes courage to not pursue imaging in someone with lateral neck tenderness, particularly after a rear impact auto-accident that classically leads to “whiplash.”

Then there is the caveat of distracting injury, injuries which cause so much pain that physical examination of the neck is unreliable. Sometimes the distractor is self-evident, e.g. fracture-dislocation of the ankle or a mid-shaft femoral fracture. Mostly it is subjective.

This caveat may nullify the entire decision rule, as neck injury is often part of a constellation of injuries, each of which may arguably “distract.” It will take a disciplined physician to not use the caveat when there is visible injury such as a broken nose.

The alert state is usually unequivocal. One group of patients who are not alert is those who have over consumed alcohol and sustained injuries in the course or as a result. These patients often get CT of the head and C-spine in tandem, as one cannot safely impute their non-alertness to alcohol (understandably) and if there is any possibility of injury, and often there is, their C-spine can no longer be cleared by physical examination.

It takes particular restraint to not follow a head CT for an isolated head injury, such as a direct blow to the pterion, with a C-spine CT. Head CT often reaches C2. It's so easy to continue the helical CT to T1.

Assuming decision rule has a sensitivity of 99.5 percent, one fracture will be missed in 10, 000 patients if prevalence of C-spine fractures are 2 percent. This doesn’t seem high unless you are the patient with the miss, the physician who missed or the ED taken to task by risk management for missing.

Will faithfully following the rules shield a physician from liability if a missed fracture resulted in quadriplegia? One can only speculate but there are no guarantees. “I followed the rules” is not something Greg House would say.

Choosing wisely is an important first step in reducing waste. The second step is more challenging: implementation of the wise choice. The devil is in the detail. That aside, implementation needs physician courage and self-restraint. It needs a cultural change; of the physician, the legal system and society at large.