When to scan, when to operate
CMAJ 1997;157:18
In the article "Findings of negligence followed communication lapses in BC aneurysm case" (CMAJ 1997;156:49-51), by Karen Capen, the problem of resource allocation is a recurring theme. The comment by the Supreme Court judge that Jason Law's death was in part due to a reluctance to use computed tomography (CT) scanning "appropriately" could worsen the problem of inadequate resources for emergency surgery, which also appears to have contributed to Law's death.
The judge's emphasis on the family physician's reluctance to use CT scanning is unfortunate for medical reasons as well. Whereas a CT scan is difficult to obtain, a lumbar puncture can be performed safely if there is no clinical evidence of a mass lesion or localizing neurologic signs. The test is immediately available at almost any location and at a fraction of the cost of a CT scan. The presence of xanthochromia confirms the diagnosis. Used in conjunction with spectrophotometry, lumbar puncture is more sensitive than CT scanning in diagnosing a subarachnoid hemorrhage.1 The unwelcome presence of the law at the bedside discourages lumbar punctures from being appropriately used, because of the belief that they should not be performed unless preceded by a CT scan to rule out a mass lesion, even if there is no clinical evidence of one.
In Law's case, surgery was arranged for 7 days after the diagnosis was made. Such a delay is unconscionable. Many sentinel bleeds precede a major hemorrhage by days or several weeks.1 Of course, every day the aneurysm is unclipped there is an increased chance of death or disability, but that was a chance that Law appears to have been required to take. Unless there was some medical reason to delay surgery, it should have been done immediately. Could fiscal restraint have played a role in this delay?
Resources expended in 1 area leave fewer resources for another. If physicians were not pressured to order tests (such as CT scanning) for legal purposes, there would be more resources available for emergency surgery.
Stephen Workman, MD
Master's student
University of Toronto Joint Centre
for Bioethics
Toronto, Ont.
Reference
- Schvienk WI. Intracranial aneurysms. N Engl J Med 1997;336:28-40.
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