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The “Unnecessary” Test

Head Child Porcelain

Here’s a real case submitted by a reader.

A two year old child is brought into the department by her father, her mother, her grandmother, and her greatgrandmother. All were very concerned.

The child was walking on a curb using her dad’s hand for support when she lost her balance and fell. Her dad didn’t catch her quickly enough and the child struck the side of her head. The mother said she saw the child’s head “bounce off the concrete”. Both mother and child cried immediately after the accident.

After about 10 minutes, they put the child into the car. She went to sleep immediately. The mother tried shaking her leg, but she wouldn’t wake up. The father then stopped the car and they took her from the car seat and shook her. She still didn’t wake up. They called grandmother who called great grandmother. All agreed to meet at the emergency department.

When she got to the emergency department, she was alert. In fact, she was running around the room opening drawers and pressing buttons. Both parents had to restrain her just so she could be examined. Even then, she wouldn’t sit still. A thorough exam of her head showed absolutely no signs of injury. She did say “ouch” when the back of her head was palpated, though. Normal pupils. Normal TMs. Normal neck. No Battle Sign. No other evidence of inury. No vomiting. In other words, she met all of the criteria for a “low-risk” head injury (.pdf) except for the parents’ history of this prolonged unresponsive state.

Three generations of family members want a CT scan of the brain.
The explanation of injury doesn’t match the physical findings and you believe in your heart that the parent’s story of a 15 minute episode of unresponsiveness is inaccurate. You also know that there’s no way that the child will sit still for a CT scan. That means that you’ll have to do conscious sedation (including all the extra paperwork required by the Joint Commission) and observe the child for a couple of hours after the CT has been performed.

If you do the test and it’s normal, then you will be accused of performing defensive medicine, the nurses will be pissed at you for the rest of the shift, your productivity will tank, you’ll get an e-mail from your department chair about all the complaints from patients for the long waits, you’ll get bad Press Ganey scores from the upset patients, and you may get a letter from hospital administration for “overutilization” of resources.
If you don’t do the test, the family will be upset with you, will accuse you of providing poor medical care, and will give you bad Press Ganey scores (and you’re on the CEOs hit list for the two bad scores you had last quarter). Oh, and if you don’t do the test and the kid has a bleed, you’ll be sued, the chart will show that everyone in the family thought the CT should be done and you were just too dumb to perform it, and the State Medical Board will likely bring a licensure action against you … which could result in you not being able to practice medicine any longer.

What do you do?

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me.

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One comment

  1. You do what is best for the patient and reinforce the correct treatment plan – no CT scan, do the best you can to educate the parents, discharge the patient and tell them that you (or someone that you designate) will call them in a couple of hours to check up on the child. Then call them the next day and receive congratulatory thanks from the parents for being such a brilliant and concerned physician. I’ve done this dozens of times and have not had a negative experience. Screw Press-Ganey.

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