The Nonindicated Study

A study is not indicated if in a given clinical setting no information can be expected from it that could in any way alter further management. That may sound trivial. The execution of any nonindicated procedure, however, may lead to the delay or prevention of necessary, indicated diagnostic or interventional measures. As a matter of fact, it may sometime prove fatal for the patient:

Patient Paelie: Brazil Paellé (56) fell out of the bus that carried him and his friends back home from an out-of-town victory of "his" soccer team. He is not exactly sober and has suffered a bleeding skull laceration. Like all his friends who have brought him to the emergency department, he is in a splendid mood and fully oriented as to the latest league results. A radiograph of the skull is performed to exclude a fracture and turns out to be normal. After his wound has been sutured and dressed by the young doctor on call, Paelle's friends bring him to his luxurious bachelor apartment to rest. That night he becomes disoriented and helpless, and finally becomes unconscious to meet his ultimate "referee" and creator early in the morning. His body is examined by the forensic medicine department. The colleague there discovers a lethal intracranial epidural/extradural hematoma (see p. 236). The public prosecutor confiscates the patient documents. Just what went wrong?

For starters, nobody with a significant head injury should be permitted to remain without close supervision for the next 24 hours—friends or spouses can also monitor the level of consciousness in less severe cases. Secondly, the unremarkable skull radiograph lulled the on-call doctor into falsely believing that no significant injury had occurred. This was a fatal misconception since it is not the potential skull fracture that determines the course of events but the intracranial, space-occupying, and poten-

I Primum Nihil Nocere

I Primum Nihil Nocere

Hippocrates First Harm
Fig. 5.1 "Primum nihil nocere" ("First do no harm") Hippocrates and/or Galen used to say. In Greek, however. It was then as it is today: Patients undergoing treatment of any kind need to trust us with their lives and they should have every reason to do so.

tially lethal hemorrhage that may develop slowly. A radiograph cannot exclude intracranial hematoma or other significant abnormality and is therefore irrelevant. If any disturbances of consciousness develop after head injury, if a skull fracture is likely, or if the presence of a laceration or the mechanism of an accident suggest the possibility of significant intracranial injury, a head CT is indicated. Much more frequently, however, studies are performed that burden the patient and cost time and money without improving the patient's health or quality of life at all. It is the same here as everywhere in life: an experienced professional may know very well when further investigation may not be warranted. Patients entrust themselves to us and those who cannot or do not want to question our actions must not be disappointed by too cavalier an approach of their physicians (Fig. 5.1). Now, how can you quickly scrutinize the indication of a scheduled study or find the right procedure for your patient if you are not really experienced? The indication list of the British Royal College of Radiologists "Making the best use of a Department of Clinical Radiology" provides some orientation and has been integrated into this book. An adapted specific excerpt precedes each of the clinical chapters.

f Diagnostic imaging, however expensive and impressive it i may be, does not replace a careful physical examination or well-thought-out therapy. In emergencies, clear indications help expedite the diagnostic process; the appropriate choice of modality depends on its power to comprehensively examine the clinical problem at hand.

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