Cache Cows! Who needs a (General) Conference?

[Flystripper]

Not sure if it was brought up in the thread or not. But I thought running option, and pitching the ball, right before the soon-to-be infamous final play was stupid, dangerous (from a fumble standpoint; not a injur your young star standpoint, that was the next play), and one more nail in the Doman coffin

It has been mentioned and yes it was ridiculously stupid. Like a first year Pop Warner coach wouldn't even do it stupid.

[Shaka]

As a veteran of many torn ligaments and several knee surgeries I can't remember a post-injury trip to my doc where they didn't take an x-ray. When I first Napoleon McCallum'ed my right knee as a teenager they found fractures and some detached bone fragments in addition to the multiple ligament tears and meniscus damage. The bone issues showed up in the x-ray and helped the doc figure out how to treat me.

[ERCougar]

Just seeing the injury occur I would want an X-ray. You can get combined ligament injury and fracture. There may be an avulsion fracture or an impaction fracture of the anterior plateau. It is a relatively cheap study and allows me to feel comfortable in allowing patients to put weight on the leg.

Hey, I said it could be a plateau fracture!

This threadjack started because doctorcoug implied we shouldn't have so many negative knee xrays. The reason is that we (like you) have a selection problem--either people have serious enough injuries to think they need an ER or ortho, or like coach pointed out, they're pansies and think they do, and they're not leaving without an Xray. The vast majority are the latter--hence, the high negative xray rate.

[San Juan Sun]

Hey, I said it could be a plateau fracture!

This threadjack started because doctorcoug implied we shouldn't have so many negative knee xrays. The reason is that we (like you) have a selection problem--either people have serious enough injuries to think they need an ER or ortho, or like coach pointed out, they're pansies and think they do, and they're not leaving without an Xray. The vast majority are the latter--hence, the high negative xray rate.

I am patting myself on the back for not challenging the idea that radiography is sufficient for neck imaging. And dc saying that you don't need imaging in neck trauma.

Crap... I just blew it.

[hostile]

Hey, I said it could be a plateau fracture!

This threadjack started because doctorcoug implied we shouldn't have so many negative knee xrays. The reason is that we (like you) have a selection problem--either people have serious enough injuries to think they need an ER or ortho, or like coach pointed out, they're pansies and think they do, and they're not leaving without an Xray. The vast majority are the latter--hence, the high negative xray rate.

I was agreeing with you. Sorry if that didn't come through.

[doctorcoug]

I was challenging the notion from drug that radiography, in his words, is overall useless.

SJS, what do you think about the canadian c spine rules?

via a galaxy s3 far far away

[San Juan Sun]

I was challenging the notion from drug that radiography, in his words, is overall useless.

Yes, I got that. I think my experience is totally different from his, although perhaps yours is a little closer.

SJS, what do you think about the canadian c spine rules?

I think they might be fine in an FP office, but they don't reflect the typical trauma patient I see. What do you think of NEXUS criteria?

I am willing to concede that we likely see very different patient populations (I see Level 1/2 traumas, or patients with seemingly lower acuity who have a positive workup).

I was just amused at your typical confident bombast ("I can clear almost any c-spine clinically" ). Family physician, emergency physician, trauma surgeon, sex therapist. Is there anything you don't do?

[doctorcoug]

Yes, I got that. I think my experience is totally different from his, although perhaps yours is a little closer.



I think they might be fine in an FP office, but they don't reflect the typical trauma patient I see. What do you think of NEXUS criteria?

I am willing to concede that we likely see very different patient populations (I see Level 1/2 traumas, or patients with seemingly lower acuity who have a positive workup).

I was just amused at your typical confident bombast ("I can clear almost any c-spine clinically" ). Family physician, emergency physician, trauma surgeon, sex therapist. Is there anything you don't do?

Don't out words in my mouth. I never said anything close to your pretended quotation.

I don't pretend to be a em physician, at all. I hate it. There is too much risk to reward ratio.

I have seen gobs of FM/IM docs working in an ED ordering pan CT of patients. It wasn't till later on that I learned about canadian (which has better evidence than nexus). Level 1 trauma patients have a distracting injury, so... your patients are not the ones I'm talking about. This is a huge issue in medicine. If we can radiate less, we should. Why order a test if the pretest probability is very low? I bet a dollar that these physicians have no idea what a fagan nomogram is nor do they understand likelihood ratio positive/negative. Its a mess out there now.

just don't put words in my mouth.

via a galaxy s3 far far away

[San Juan Sun]

Don't out words in my mouth. I never said anything close to your pretended quotation.

Here it is for all to see:

I was a second year resident before I learned I could clear a c-spine without imaging

So did I quote you exactly? No. I was just going off my recollection of what you said. It read that way to me. Maybe I got the wrong impression, or maybe you give off the wrong impression. If you feel like I've misrepresented you, then I apologize.

It seems like you're saying c-spines are usually cleared clinically. You said your practice is 20% sports med based, and maybe that's true in your patient population. It is certainly not amongst trauma patients.

I don't pretend to be a em physician, at all.

It seems to me that you criticize other people's practice. Again, maybe that's just my faulty perception. Your authorship of other threads seems to hint at this as well. When you say outright derogatory things (like telling Douger he needs to work on his H&P skills), what sort of impression do you expect people to get?

I have seen gobs of FM/IM docs working in an ED ordering pan CT of patients. It wasn't till later on that I learned about canadian (which has better evidence than nexus). Level 1 trauma patients have a distracting injury, so... your patients are not the ones I'm talking about.

Your clumsy descriptions of trauma related topics reveals you to be a novice in these subjects. I'm sure you know a lot about various subjects, but this isn't one of them. That's okay, I would probably make rookie mistakes on problems you work up on auto-pilot.

[doctorcoug]

Here it is for all to see:



So did I quote you exactly? No. I was just going off my recollection of what you said. It read that way to me. Maybe I got the wrong impression, or maybe you give off the wrong impression. If you feel like I've misrepresented you, then I apologize.

It seems like you're saying c-spines are usually cleared clinically. You said your practice is 20% sports med based, and maybe that's true in your patient population. It is certainly not amongst trauma patients.



It seems to me that you criticize other people's practice. Again, maybe that's just my faulty perception. Your authorship of other threads seems to hint at this as well. When you say outright derogatory things (like telling Douger he needs to work on his H&P skills), what sort of impression do you expect people to get?



Your clumsy descriptions of trauma related topics reveals you to be a novice in these subjects. I'm sure you know a lot about various subjects, but this isn't one of them. That's okay, I would probably make rookie mistakes on problems you work up on auto-pilot.

No doubt there is a misunderstanding via forum.

Ya, my comment to douger was mean. I shouldn't be like that. For those that know me they know that I almost always take the side of the physician during peer review. One should ask the question, if this test is useless because of all the negative results, maybe better pretest selection will result in results more in line with other physicians.

I am a novice in regards to trauma, thankfully. I have a great respect for the EM physicians and surgeons that take care of these patients that hardly ever pay.

via a galaxy s3 far far away

[San Juan Sun]

No doubt there is a misunderstanding via forum.

Ya, my comment to douger was mean. I shouldn't be like that. For those that know me they know that I almost always take the side of the physician during peer review. One should ask the question, if this test is useless because of all the negative results, maybe better pretest selection will result in results more in line with other physicians.

I am a novice in regards to trauma, thankfully. I have a great respect for the EM physicians and surgeons that take care of these patients that hardly ever pay.

via a galaxy s3 far far away

Something we totally agree on!

[The_Douger]

I just think that in an urgent care setting, lots of things like antibiotics and xrays are overused.

Keeping in mind the very socioeconomically disadvantaged population I work with, going through evidence based guidelines are often met with the feeling of "the doctor not wanting to do anything for me because I'm poor/Mexican/have medicaid, etc"

Surely you can easily clear a knee after an injury in most cases in an urgent care setting. These aren't big trauma cases. Usually they're meniscal injuries, or contusions. There's occasionally some ligamentous injuries, but in the end most of the stuff is fine. That's why most of the time the Xrays are normal.

I just don't get why you'd toss stones from your high horse when I, like most other medical providers, want to do right by the patients I see and treat them well and make them feel happy with the care they received.

[San Juan Sun]

Does it need to be pointed out that Hill's injury, despite not looking too bad and having probably negative x-rays, turned out to be serious. Ironic considering all of the arguments over the last few pages.

[doctorcoug]

I just think that in an urgent care setting, lots of things like antibiotics and xrays are overused.

Keeping in mind the very socioeconomically disadvantaged population I work with, going through evidence based guidelines are often met with the feeling of "the doctor not wanting to do anything for me because I'm poor/Mexican/have medicaid, etc"

Surely you can easily clear a knee after an injury in most cases in an urgent care setting. These aren't big trauma cases. Usually they're meniscal injuries, or contusions. There's occasionally some ligamentous injuries, but in the end most of the stuff is fine. That's why most of the time the Xrays are normal.

I just don't get why you'd toss stones from your high horse when I, like most other medical providers, want to do right by the patients I see and treat them well and make them feel happy with the care they received.

I'm sorry for being a jerk

via a galaxy s3 far far away

[ERCougar]

I'm sorry for being a jerk

via a galaxy s3 far far away

Everyone in medicine does it. We just take the brunt of it.