Why I ‘Ration’ Care

Your son just got a concussion playing soccer. You want a CT scan to make sure he's OK—or do you?

As an emergency physician and a parent, I can see it both ways. Following the recent death of Natasha Richardson, we saw more patients coming to the ER for a head injury who might have previously just taken some Tylenol. Richardson bumped her head skiing, thought she was OK, and ended up dead. It's a scary scenario.

Several weeks ago, I saw a 15-year-old who was hit in the back of the head playing soccer. He wasn't knocked out, but initially wasn't sure where he was and seemed slow to answer questions. When I saw him, he had a slight headache, but his confusion was gone. He wasn't nauseated, his pupils were reactive, his neurologic exam was normal, and there was no external trauma. He'd suffered a concussion, but his parents wondered if something more serious had occurred. Wouldn't a CT scan show skull fractures and internal bleeding?

It's a question I hear often from parents, and I take it seriously. In a case like this, evidence shows the chance of a life-threatening injury is vanishingly small. Since we're dealing with radiation, a CT scan isn't harmless: some estimates put the long-term risk of cancer death from a single CT as high as one in 1,000—a risk that's greater in younger patients who have longer to live. (In an era when we are now doing more than 60 million CTs annually—up from 3 million in 1980—nearly one in six Americans may have one in any year.) And though there's concern with the ballooning expense of imaging, cost was not necessarily an issue. It's not going to stop a physician who feels a CT is needed. Don't want to get sued? Order the CT.

I guess that many emergency doctors in my situation would have done just that. But I didn't. I involved the patient and his parents in a discussion; they listened, and we decided together not to get one. I spoke with the boy's pediatrician and recommended that the patient follow up in the morning with "impact testing" to see if there were any postconcussive issues.

These kinds of conversations between doctors and patients need to happen more frequently. This wasn't "rationing"; in this case, not doing the test simply represented sound medical advice: in my opinion, the potential long-term harm to the patient outweighed the benefit. And he's doing fine now—back in school, but taking a break from contact sports.