Fast Scanning by Poorly Trained ER Physicians Can Slow Diagnosis

August 18, 2008

Critically injured patients could be diagnosed and treated far more quickly if trauma protocols took account of 21st-century radiology services. Victims of severe injury are referred for unnecessary x-rays, vital CT scans are delayed, and potentially life-saving imaging-led interventions are not requested, according to Dr. Anthony Nicholson, consultant radiologist and clinical director for intervention and ultrasound at the Leeds Teaching Hospitals NHS Trust in the U.K.

Critically injured patients could be diagnosed and treated far more quickly if trauma protocols took account of 21st-century radiology services. Victims of severe injury are referred for unnecessary x-rays, vital CT scans are delayed, and potentially life-saving imaging-led interventions are not requested, according to Dr. Anthony Nicholson, consultant radiologist and clinical director for intervention and ultrasound at the Leeds Teaching Hospitals NHS Trust in the U.K.

"We are not learning the lessons that the military are learning right now," he said. "On the battlefield, people are being saved because of speed. Here in the U.K., once you get trauma patients into hospital, that speed is just not happening."

Trauma is the leading cause of death in young people in the Western world. Studies suggest, however, that one in three deaths of severely injured patients is preventable.

The Advanced Trauma Life Support (ATLS) manual, the bible of emergency room physicians, is rigidly adhered to, Nicholson said. But even the most up-to-date version makes little mention of CT. If a patient has injured his or her spine, has suspected internal damage, or is bleeding from an unknown location, then CT is essential. None of these conditions can be evaluated properly on plain-film x-ray.

Many endovascular procedures, such as embolization and stent-grafting, are not mentioned at all in the ATLS manual. This ignores the potential of imaging-led interventions to shore up patients with life-threatening injuries quickly and safely. Early and late deaths after trauma are almost always the result of hemorrhage.

"We produce less damage and less shock, and are quicker than most surgeons, if we treat patients endovascularly when they are bleeding," Nicholson told delegates at an ECR 2008 teaching session. "Any visceral injury you care to mention-whether it affects the spleen, liver, or kidneys-can be sorted endovascularly. Pelvic fractures should be sorted endovascularly, but sadly the mortality is still hugely high because they are not."

He called for CT scanners to be placed much closer to accident and emergency departments than they are at present. Once patients have been stabilized, they can then be examined on CT without a long transfer to another department.

When CT is indicated, physicians should go ahead with an examination straight away rather than performing a FAST (focused assessment with sonography for trauma) scan first, Nicholson said. He suggested that less time would be wasted if FAST scanning was performed by trained ambulance staff, who could relay results to the trauma team.

"For me, FAST scanning is the worst thing that has ever happened to trauma management," he said. "We have handed ultrasound machines to a load of ER doctors who, by and large, have no training in ultrasound, who use it inappropriately, and who delay matters horrifically."

Nicholson would also like to see catheter labs situated close to the emergency room. Trained and skilled endovascular specialists should be included as full members of trauma teams, rather than simply providing on-call cover.

"There is no point receiving a telephone call at home and saying, 'Yes, I'll be there in an hour,' when the patient is dying," he said.

-By Paula Gould