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Controversies And Cutting Edge

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Controversies And Cutting Edge

Controversies And Cutting Edge

Is Emergency Physician Reading Of Head CTs Becoming A "Best Practice" In Emergency Care?

Head CT is rapid to obtain but delays in interpretation could result in adverse patient outcomes if clinical treatment decisions cannot be made in a timely fashion. Surveys of emergency medicine residency programs suggest that, in many cases, radiology interpretation is not rapidly available for clinical decisions and that emergency physicians often perform the initial interpretation of radiographic studies. A study simulating a teleradiology support system estimated the time to interpretation of a noncontrast head CT at 39 minutes, potentially wasting precious time in patients with intracranial hemorrhage or ischemic stroke.143 The ability of the on-scene emergency physician to interpret the CT could be extremely valuable.

Can Emergency Physicians Accurately Interpret Head CTs?

Multiple studies have examined the ability of emergency medicine residents and attending physicians to interpret head CTs. A 1995 study showed that, in an EM residency program, although up to 24% of potentially significant CT abnormalities were not identified by the EM residents, only 0.6% of patients appear to have been mismanaged as a result.144 Studies have shown that substantial and sustained improvements in interpretation ability can occur with brief training. Perron et al showed an improvement from 60% to 78% accuracy after a two hour training session based on a mnemonic, sustained at three months.12 In the setting of stroke, emergency medicine attendings perform relatively poorly in the recognition of both hemorrhage and early ischemic changes which may contraindicate TPA administration, with accuracy of approximately 60%, but neurologists and general radiologists achieve only about 80% accuracy compared with the gold standard interpretation by neuroradiologists.145,146 Undoubtedly, improvements in training are needel,but the pragmatic limitations on the availability of subspecialist radiologists, even with teleradiology,mean that emergency physicians must become proficient first-line readers of emergent CT.

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