Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Using CT scans to diagnose chest pain in the ER

John Mandrola, MD
Physician
March 6, 2010
Share
Tweet
Share

During residency, there was always a case of misdiagnosed chest pain to discuss in conference.  Incorrectly sending a patient home and missing the diagnosis of cardiac chest pain was an infrequent, but repetitively observed, phenomenon.

So as to tread carefully with words, it is sufficient to say that even now, chest pain triage remains a vexing problem.

Chest pain diagnosis is like appendicitis; there are always small numbers of unusual cases in which an accurate diagnosis proves elusive.  In medicine, there is no such thing as perfection in diagnosis and no better example exists than chest pain.

Chest pain is ubiquitous — hundreds of patients per day from all walks of life with all manner of co-morbidities present daily to the ER.  The stories vary, ECG’s can be normal even in the face of a real heart attack, and blood enzymes are often normal in the early phases.  Given the catastrophe of missing the diagnosis, many are working hard at a technological solution — the search for the ultimate adjudicator which provides a “yes” or “no” answer.

A recent study describes taking chest pain patients for CT scans of the chest to look for coronary calcium.   Calcium scores of zero are reassuring and confirm a low risk, thereby providing another tool for triage.

This proposed solution is emblematic of modern day medicine.  The CT scan attempts to mitigate clinical judgment by obtaining more objective data.  Present with chest pain and a nurse at the triage desk will just order a run through the CT scanner.

There are a variety of problems with this strategy.

Cost. CT scans are super expensive.  Whether they should be is another topic in itself.

Radiation dose. CT scans emit much radiation -many times that of a CXR.  Cumulative radiation dose should not be understated and this risk is likely significant.

Embarrassment. Ordering a coronary calcium score CT for the exclusion of cardiac disease seems embarrassing.  The doctor who employs common sense, including a careful history, a physical exam, an ECG, cardiac enzymes and in the worst case 4 hours of time for another blood test will triage patients equally well and with less cost and no radiation.

An older doctor must fight the urge to not dismiss new technology and act like the aged doctor who refuses to learn the new. However, in the case of chest pain, a dose of common sense and trained observation is not yet replaceable by a big dose of radiation.

There are those who argue we doctors order too many tests and in cases like the CT scan replacing clinical skills, they are correct. It is clear that technology helps us much, but common sense and a mastery of the obvious still retains its value.

John Mandrola is a cardiologist who blogs at Dr John M.

ADVERTISEMENT

Submit a guest post and be heard.

Prev

Disabled is a word that needs to be redefined

March 6, 2010 Kevin 4
…
Next

Why rosiglitazone would not have been approved today

March 7, 2010 Kevin 1
…

Tagged as: Cardiology, Emergency Medicine, Hospital-Based Medicine, Radiology

Post navigation

< Previous Post
Disabled is a word that needs to be redefined
Next Post >
Why rosiglitazone would not have been approved today

ADVERTISEMENT

More by John Mandrola, MD

  • What we can learn about weight loss from Al Sharpton

    John Mandrola, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Don’t be foolish enough to think you control outcomes

    John Mandrola, MD
  • a desk with keyboard and ipad with the kevinmd logo

    The problem with Obamacare is that it doesn’t do enough

    John Mandrola, MD

More in Physician

  • The physician who turned burnout into a mission for change

    Jessie Mahoney, MD
  • Time theft: the unseen harm of abusive oversight

    Kayvan Haddadan, MD
  • Why more doctors are leaving clinical practice and how it helps health care

    Arlen Meyers, MD, MBA
  • Harassment and overreach are driving physicians to quit

    Olumuyiwa Bamgbade, MD
  • Why starting with why can transform your medical practice

    Neil Baum, MD
  • Life’s detours may be blessings in disguise

    Osmund Agbo, MD
  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
  • Recent Posts

    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
    • How declining MMR vaccination rates put future generations at risk

      Ambika Sharma, Onyi Oligbo, and Katrina Green, MD | Conditions
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician
    • Time theft: the unseen harm of abusive oversight

      Kayvan Haddadan, MD | Physician
    • How one unforgettable ER patient taught a nurse about resilience

      Kristen Cline, BSN, RN | Conditions
    • The future of clinical care: AI’s role in easing physician workload

      Michael Wakeman | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
  • Recent Posts

    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
    • How declining MMR vaccination rates put future generations at risk

      Ambika Sharma, Onyi Oligbo, and Katrina Green, MD | Conditions
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician
    • Time theft: the unseen harm of abusive oversight

      Kayvan Haddadan, MD | Physician
    • How one unforgettable ER patient taught a nurse about resilience

      Kristen Cline, BSN, RN | Conditions
    • The future of clinical care: AI’s role in easing physician workload

      Michael Wakeman | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Using CT scans to diagnose chest pain in the ER
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...