Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/web/20090706002318im_/http://www.bmj.com/icons/misc/sectionDOWN.gif)
An inefficient and costly way of managing an acute abdomen.
- Richard G Fiddian-Green (30 June 2009)
|
|
|||
|
Richard G Fiddian-Green, FRCS, FACS None
Send response to journal:
|
In this study, "Surgical residents evaluated 74% (n=757) of patients, and emergency medicine residents evaluated the other 26% (264). The mean clinical experience of the residents was 25 months (range 2 months to 8.7 years). The ultrasonography was done by a radiological resident in 57% (582) of patients and by a staff radiologist in 43% (439). Fifty two per cent (300/582) of the ultrasonography examinations by residents were done during office hours under the supervision of a staff radiologist, and 48% (282) were done after office hours without supervision. The experience of the ultrasonography and CT readers ranged from one year’s residency to more than 30 years’ experience as a radiologist" (1). No mention was made of the time passed between admission to the ER and definitive intervention. In my experience in academic medical centers in the US this could be many hours and even longer than 24 hours. That all patients had blood work done prior to imaging it but one factor contributing to the delay. When my young daughter developed appendicitis whilst we were out watching the Wolverines plat a football game I made the diagnosis within minutes of returing, having been informed by my eldest daughter that she was not well, and took her to the ER having called the consultant surgeon/attending of my choice in informing him that my daughter had an acute abdomen. I then called the consultant anaesthetist of my choice telling her of my diagnosis so she could prepare the OR. The surgeon, who was waiting for me when I arrived at the ER, confirmed my diagnosis within 30 minutes without blood tests or imaging and took her to the OR. All was done in hours and she came home in under 24 hours, and that was prior to the advent of laparoscopic surgery. Running the gauntlet of inexperienced clinicians in training and being subjected to unnecessary investigations is, sadly, the rule in many medical centers today including those in this Dutch study. How much more efficient and cost-effective it could be if patients with an acute abdomen had were first seen by a consultant surgeon/attending. This is not difficult to do. In the medical center in US in which I worked consltant surgeons/attendings would be on call for emergencies for 24 hours about once a month but the patients were still evaluated by residents before they were called. It would not take much more to have them evaluate all patients presenting with acute abdominal pain. Furthermore residents could learn much by assisting in the process. Ultrasound might be a helpful addition to a consultant surgeon especially if he/she were to perform it him/herself. By the time imaging reveals anything the pathology is, however, usually fairly far advanced. More helpful might be the support of a computer progran such as that poineered decades ago by de Dombel (2). 1. Wytze Laméris, Adrienne van Randen, H Wouter van Es, Johannes P M van Heesewijk, Bert van Ramshorst, Wim H Bouma, Wim ten Hove, Maarten S van Leeuwen, Esteban M van Keulen, Marcel G W Dijkgraaf, Patrick M M Bossuyt, Marja A Boermeester, Jaap Stoker on behalf of the OPTIMA study group Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study BMJ 2009; 338: b2431 2. de Dombel, F. T., Dallos, V., & McAdam, W. A. (1991). Can computer aided teaching packages improve clinical care in patients with acute abdominal pain. BMJ (Clinical Research Ed.), 302(6791), 1495-1497. Competing interests: None declared |
|||