Thread by @jeremyfaust

There was a non-covid twitter debate recently (I didn't see it) re: a tension pneumothorax.

The apparent crux was that diagnosising tension ptx should never happen via imaging because by then it's too late.

Leaving the debate aside, there's an interesting concept to discuss 1/

There are a great many conditions that are *supposed* to be made NOT by imaging/testing, but by the HISTORY and physical EXAM.

We call these "clinical diagnoses."

Teaching is that we docs must diagnose these dangerous time-sensitive problems using our brains, not our tests...

Because if we don't, we squandered precious time.

***Here's the thing***

All of those maxims, sayings, and phrases made up by old dead physicians...

They didn't have what we have.

They didn't have point-of-care ultrasound.
They didn't have STAT CT Scans.

We do!
This matters:

Why?

Because unlike back when these maxims were coined, we CAN get HELPFUL answers in MINUTES.

In most cases (if the patient is stable with regard to their vital signs), the choice on whether to put a needle in someone, or take them to the Operating Room can wait 10 minutes.

It can't wait very long. But it CAN wait a few minutes.

I'll give you an example.

I've seen a few cases of necrotizing fasciitis and ovarian torsion in the last year.

I was 85% certain of the diagnosis on sight.

I call the surgeons.

They want imaging before going to the OR.

Now I can sit there, judge and say:

"HEY! Nec fasc and torsion are clinical diagnoses that should NEVER be made on imaging! GET THEM TO THE OR! NOW!"

But I don't say that.

Why?

Because I understand the basic risk assessment that they are doing demonstrates wisdom and care.

If the relevant imaging study can be done in five, ten, heck, even 15 or 20 minutes--while they're probably prepping the OR anyway--then why not get that study?

In the case where the imaging is slam dunk negative, you've bought time to reassess things, and maybe avoid the knife.

In the case where the imaging is slam dunk positive, the teams hurry that much more than they otherwise would. (That OR was being prepped anyway, remember?)

And if the imaging is equivocal? Well...then you are back were you started and you've lost a few minutes.

Personally, I think (and I have not run the numbers; someone should) that this strategy does NOT cost lives or organs.

In the cases where "time is organ" or "less time=greater chance of life saved," I think we pick those up and we get them to the OR in a hot millisecond.

But...

For the rest of these cases, the lost few minutes is highly unlikely to change the outcome of the case for the worse and IS very likely to change the outcome for the better if the imaging is totally normal, and by the time that's clear, the clinical situation is more reassuring.

So it is my belief that my surgeon colleagues are NOT lazy or dumb. They're very careful and thoughtful and they are assessing risk in real time using the tools we have at our disposal today, in the year 2020.

I'm sure that in 1935 (or heck 1975) the calculation was different.

But today, with the speed and availability of immediate advanced imaging while an OR is scrambled?

I'm cool with it.

Avoiding unnecessary surgeries and not removing organs that didn't need to be removed are MAJORLY important.

In sum, clinical diagnoses remain clinical diagnoses.

But not in the same way that they were 20, 40, 60, 100 years ago.

Let's all work together to find that balance

In real life, I believe we almost always get it right.

We can be proud of that.

Go team modern medicine! Fin.