The leaf blower/CT scan quandary

To critics who admonish emergency physicians like myself for our excessive use of CT scans, I’ll ask them to consider the leaf blower. I’m sipping my morning coffee on our front porch, a bright, idyllic autumn day in New England, the tranquility ripped apart by the landscapers across the street. For many jobs, a powerful leaf blower might prove superior to a rake or broom. But in my neighborhood known for smaller yards, the humble rake and broom would work as well, if not better.

I’m not a leaf blower person. Raking my yard takes hours. It leaves my muscles knotted and hands calloused. Not so the speedy landscapers, nonchalant with technology strapped to their backs. Laughing and screaming over noise that assaults my eardrums, they bully grass clippings and leaves into a dancing cloud that swirls onto the street, often finding refuge on my lawn.

Why should the status of lawn detritus, or my serene coffee moment, concern them? They’re responsible for my neighbor’s lawn, not the yards nearby. And if leaf blowers improve the speed and perhaps the quality of their work, why wouldn’t they take advantage of the opportunity? Imagine the following argument from a landscaper-philosopher: “What is a leaf blower anyway but a push of air, like a strong wind? You have a problem with the wind?”

The accusations leveled against emergency physicians for over-utilization of advanced imaging often paint us as nearsighted as these landscapers, unconcerned for the consequences of technology that has eased the care for many patients. The data is alarming. The number of ED patients who received a computed tomography (CT ) scan jumped from 3% in 1996 to 14% n 2007.

That said, emergency physicians welcome efforts that reduce utilization and the accompanying costs and radiation exposure to our patients. The American College of Emergency Physicians advocated, as part of the Choosing Wisely Campaign, to “avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are low risk based on validated decision rules.”

But consider recent ED shifts, and the the range of circumstances that triggered a decision to order a CT scan. Intoxicants “found down” on the sidewalk, which could mean trauma worthy of evaluation or a nap that shouldn’t have been disrupted. The surgery resident who wouldn’t evaluate a patient with abdominal pain until the CT scan of the abdomen was done. A woman screaming in pain and grabbing at her belly, but who frequently visits the ED for abdominal pain and suffers from social and mental health issues. A patient with a headache following minor trauma, sent by her primary care doctor for a CT scan of the brain, though the Choosing Wisely criteria recommended otherwise. The patient and her husband didn’t want to hear about the medical literature and guidelines. They’d waited for hours, faced a nasty bill, and weren’t going home without the test being done.

Patients are prone to have confidence in their ED evaluation when it includes a CT scan, while demonstrating poor understanding of the associated radiation risk. Hospital administrators and The Centers for Medicare & Medicaid Services take patient satisfaction very seriously, tying these metrics to physician reimbursement. But higher patient satisfaction scores have also been associated with higher costs and mortality. This paradox is one example of the many crossing tensions that wire this unwieldy healthcare beast.

What’s absent from the medical literature, and perhaps more difficult to quantify, are the patients who I decide don’t need a CT scan. Instead, I take advantage of talk, symptom control, repeated physical exams and time. To be an emergency physician is to be in constant battle with time. Strategies that prolong occupation of precious ER beds distribute risk to the people in the waiting room by delaying their evaluation and treatment. It’s hard to ignore the heavy shadows of those patients who I’m responsible for and haven’t met yet.

CT scans speed the diagnostic process and promote ED efficiency. A CT scan now might cost less than a repeat ED visit tomorrow when patients have no doctor, or can’t get a timely appointment. My hospitalist colleagues, faced with unwieldy patient loads, often expect patients to be worked up, and a diagnosis identified, before being admitted to their service. Do these reasons offset the potential cancer risks to my patients, or the crushing healthcare costs?

Medical decision-making is loaded with shifting freight. Diagnostic uncertainty, logistical factors, emotional pressures and medical-legal worries can make my brain feel like a pile of wet leaves. And yes, sometimes the easiest way to clear the diagnostic process for me and my consultant colleagues involves a CT scan.

Noise pollution has driven some towns in parts of the United States to regulate leaf blower use. The exhaust gas particulates generated by gas-powered leaf blowers, along with carbon monoxide and other chemicals, pose appreciable risks to environmental and human health. However, these potential short and long term risks haven’t trumped convenience and efficiency, nor have they instigated a movement back to the less expensive rake and broom.

The leaf blower didn’t improve upon the rake or broom, only made gathering, piling and collected leaves and grass clippings a faster, less strenuous exercise. The CT scan on the other hand substantially altered previous imaging modalities, effectively slicing through the body and turning it inside out to reveal astonishing details. We have a CT over-utilization problem because it has great value when used responsibly. I couldn’t fault the surgeon in my recent shift. Studies looking at abdomen pelvis CT scans show how they increase the diagnostic certainty, reduced the need for emergency surgery, and staved off up to 24% of possible hospital admissions.

How can I responsibly draw an analogy between a CT scan and a leaf blower? It doesn’t save lives, though it might save more than a few stiff backs. It’s a technology of convenience. We have alternative ‘technologies’ that are far less expensive and just as effective. So why aren’t rakes and brooms pushing all the leaf blowers into a trash heap?

Walking my dogs around my neighborhood, I find leaf blowers are ubiquitous and used for many purposes. Even a hardy- appearing man ‘cleaning’ a small, concrete yard by blowing leaves and debris (i.e., garbage) into the street. My first instinct is to cast judgment, before acknowledging reasons–perhaps physical impairments–that might negate the use of a broom, and the effort it requires. Or maybe, like many people, he doesn’t like raking or sweeping.

Whether it’s leaf blowers or CT scans, the dialogue seems to ignore our emotional connection to technology, and how a favorable opinion impacts how we interpret risks and benefits.

As the debate on CT over-utilization in the ED picks up heat, I’ll ask the critics and policy wonks to answer this question: Does a leaf blower justify itself–does the cost, noise and assault on the environment outweigh the benefits of efficiency and effort? Patients are more complicated and mysterious than our yards. When confronted with yard work, what tool do you reach for?

by Jay Baruch

Jay Baruch (@JBaruchMD) is Associate Professor, Department of Emergency Medicine at Alpert Medical School of Brown University, as well as a fiction writer, essayist, baffled participant in healthcare, and unabashed advocate for more creativity in medicine.

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