Academia and community ED settings are very different, and sometimes one community to the next is often times very different as well. This study– which included 35 pediatric ED’s and 52,000+ cases of appendicitis demonstrates this. Essentially, the authors took all their appendicitis data from 2010-2013, and looked at what imaging, if any, the patient received, negative appendectomy rates, length of stay, frequency of perforation, and 3 day bounceback rates from initial ED visit (ie, did ultrasound or CT “miss” an eventual appendicitis?)
Ultrasound use increased from 24% in 2010 to 35.3% in 2013 for the sole diagnostic modality in what eventually was diagnosed as appendicitis. CT rate decreased 21.4% in 2010 to 11.6% in 2013. Almost 50% of the patients (25,254 out of 52,153) had neither CT or US (!). The negative appendectomy rate in 2010 was 4.7%, while in 2013, it was 3.6%. There was no difference in length of stay, frequency of perforation, or 3 day bounce back rates from 2010 to 2013.
Ok. If you work in a community ED, raise your hand if 50% of your potential appendicitis cases get seen by surgery without any imaging. Only 11.6 % CT use? I think most community surgeons would be less than thrilled to be called at 2am for a “rule out” appendicitis evaluation without imaging.
While I think the authors live in an alternate universe, I think this paper makes a great argument to do the right thing. It would be great if non-academic settings could utilize US and surgical consultations for a “hot belly” without shipping them off to radiology. Or better yet, have surgery perform POCUS with you to confirm findings.