Perspective: Must physicians do a lumbar puncture on every suspected subarachnoid hemorrhage?
Charles A. Pilcher MD FACEP
Classic medical training has been to do a lumbar puncture (LP) on every patient with a new, sudden onset headache if a CT scan does not show a suspected subarachnoid hemorrhage (SAH), usually from a ruptured cerebral aneurysm. That wisdom has been challenged by a presentation at the 2012 ACEP Scientific Assembly, by Dr. Ashley Shreves and Dr. David Newman. They found that for every SAH one might find on LP, one would have to do 700 such procedures, with the risks accompanying those procedures. Continued ->
Whiplash: To treat or not to treat, that is the question.
What interventions help patients with acute cervical strain? The condition, commonly referred to as “whiplash,” is most often the result of a rear end motor vehicle crash The question has been debated for years. Chiropractors and physical therapists insist that frequent, and often prolonged, treatment is helpful. Others are more skeptical. In a recent review of 3851 patients published online in Lancet, Dr. Sarah Lamb and colleagues found that “active management” was no different than “usual care” in shortening the course or reducing the disability from such injuries. “Active management” included multiple sessions with a physical therapist. “Usual care” included one session of advice from a PT, then simple home care with NSAIDS, rest and time. The outcomes were not significantly different between the two groups. This is in line with an earlier study by Kongstad et al. “The extra and more costly treatments do not speed recovery” says Dr. Lamb. “What is more, although additional physiotherapy, beyond a single advice session, did offer a modest short-term benefit, it was not cost-effective.” A summary of Dr. Lamb’s recent study is available on Health Day.
The cost of defensive medicine
Jackson Health Care recently published a paper on the costs of defensive medicine. The authors goals for the study were: 1) To voice physicians’ growing concerns over the negative impacts of defensive medicine, and the way it is affecting their relationships with their patients, and 2) to encourage physicians, patients, attorneys and state and federal representatives to work together to find a solution that eliminates defensive medicine practices, protects physicians from frivolous lawsuits, penalizes true malpractice and compensates patients for negligent care. In 2011 ACEP surveyed over 20,000 emergency physicians. Nearly 10% responded and of those, 53% believed that “defensive medicine” was the main reason emergency physicians order the number of tests that they do. [Editor’s Note: My personal experience over 35+ years of practice is consistent with most studies that place the average cost of defensive medicine at somewhere in excess of 25% of our health care costs. However, if a doctor **truly** ordered an unnecessary test, such practice would fall below the standard of care, be unethical, and lead to a valid claim of medical malpractice.]