You're in an emergency room. You're worried. OK, maybe that's an understatement. Maybe you're terrified. This may not be the setting in which you always make your best decisions. But you won't get to take back any of the decisions you make in an ER, so you have to make the best decision you can the first time.
Assuming that you don't have an immediately apparent catastrophic illness, here are four questions you can ask your doctor that may save you time and money — and perhaps even spare you or your child one of the complications that are sometimes associated with medical care.
•Is this antibiotic really necessary? Antibiotics can be lifesaving in severe bacterial infections. But the Centers of Disease Control and Prevention has identified antibiotic overuse as a major public health problem leading to the development of resistant "superbugs" that kill many of the "helpful" bacteria that normally live in our bodies and causing complications including diarrhea and yeast infections. Some researchers believe that antibiotic overuse may even be related to asthma, obesity, inflammatory bowel disease, and diabetes in children.
A great majority of upper respiratory illnesses, such as the common cold, flu, sinusitis, ear infections, sore throats and bronchitis, are caused by viruses. Antibiotics kill only bacteria, so they are not helpful in most of these common illnesses.
•Is this CT scan really necessary? Computerized tomography is one of the true marvels of modern medicine. These imaging studies are so fast, and so good, that CT use has exploded to more than 70 million scans in the U.S. annually. But CTs have two little drawbacks: They carry a lot of radiation, and they're expensive.
How much radiation? One CT of the abdomen and pelvis exposes a patient to roughly the same radiation as 400 to 500 chest X-rays. This is important because radiation increases the lifetime risks of developing cancer, particularly in patients under 30. And the more CTs incurred, the greater the risk. Research published in the Archives of Internal Medicine has estimated that about 2 percent of future cancers will result from CT radiation. Children face the highest risks, both because they are much more sensitive to radiation and because they have more time to develop cancer.
Some researchers have estimated that as many as one-third of CT scans performed in the U.S. may not be medically necessary. Some could have been replaced by studies carrying less risk. Indeed, in some conditions, like minor head trauma or mild abdominal pain, your doctor's clinical judgment supplemented by close observation may be sufficient without a CT scan. Have a frank discussion with your doctor.
•Will this test really change how you would treat my illness? If a test will not alter the treatment prescribed for a given illness or condition, then the value of that test is called into question.
A common example would be performance of an imaging study, such as an MRI, for new onset of musculoskeletal low back pain. Even if you ultimately proved to have a herniated disc that required surgery, you would still likely be treated conservatively, initially with anti-inflammatory drugs and pain medication. That's because more than 90 percent of patients presenting with acute low back pain get better with no additional intervention. Only the 10 percent who do not improve will ultimately need to incur the expense of an imaging study, so it's low-risk to wait and see how it goes.
This same principle can apply to many other conditions.
•What is the probability that this illness or injury will have a bad outcome? Ultimately, the approach to diagnosing and treating an illness is often based upon statistical probability, and the risk tolerance of you and your doctor.
If your child falls off the jungle gym at school and hits his head, ultimately you and your doctor will decide whether or not to get a CT based on the probability that there has been dangerous bleeding into his brain. You will try to balance the risks of radiation from a CT against the risk of missing a bleed. At what odds will you be comfortable with not doing a CT and, instead, simply watching him carefully for signs of evolving head injury? At 1 chance in 10? One in a hundred? One in a thousand?
Obviously, these are often difficult and intensely personal decisions for which there is no clear right or wrong answer. You can arrive at a decision with which you are comfortable only through open discussion with your doctor. She should welcome that opportunity.
Remembering these four questions will help guide you through the labyrinth of decision-making that often characterizes an ER visit, and hopefully provide you with a little more peace of mind.
Dr. Bruce Foster, a native of Baltimore County, has served for 25 years as chief of emergency medicine at a Pennsylvania hospital. He is the author of the new book "Kiss Tomorrow Goodbye." He may be contacted through his website, www.dbrucefoster.com/.