Worries about the lack of list-serve debate and doubts about
the worth or even the reality of evidence-based medical
practice are most disheartening.
In an attempt to fuel list discussion as requested by one of
you, is the following abstract a legitimate example of
EBM?
Dealing with the clinico-radiologic diagnosis of minor
chest trauma, the full manuscript was rejected by a free-
subscription journal because it showed "no methodology".
This may be so, but is it evidence-based by your lights?
While it is not clear in the abst ract, every claim, observ-
ation and technique mentioned in the MS is referenced.
With best regards....Karl Dockray
On Finding More Rib Fractures
I have never seen rib x-rays confirming that
bone has been taken by the Almighty to make his
first Adam a mate (Ref 1, Genesis,2:22). But,
I always have trouble in diagnosing simple
fractures with conventionally-made rib surveys.
Exposures following old teachings and hoary
custom are hard to interpret(2,3). Such studies
are limited to "the side of the chest that
hurts" and use filming techniques that black out
upper ribs and leave lower ones underexposed.
Examination times rise along with radiation
dose as exasperated doctors order repeat film
after repeat study to find out what is wrong.
Expenses climb even more as those same doctors
add regularly-exposed postero-anterior chest films to
each rib study. They do this because they are
taught that only a standard PA view with its
lighter exposure can show catastrophic lung
collapse.
Methods
To improve diagnostic accuracy, reduce patient
irradiation, save examination time and cut labor
costs, try the following: ask for three-film rib
series that guarantee coverage of all the ribs in
both sides of the chest. Insure that the upper-
most ribs are always in view as well as the
lowest ones. Demand exposure techniques that do
not black out those upper ribs made lucent by
the air of the lungs or leave lower ones hidden
by the thicknesses of the upper abdominal viscera.
Discussion/Results
A consecutive series of 121,055 patients film-
ed in several rural and semi-urban hospitals over
ten years held 1853 rib examinations. Seven-hundred
seventy of these were expressly ordered for one side
of the chest (i.e. the symptomatic hemithorax).
Reviews of 100 of these single-sided examin-
ations showed only thirty-nine fractures.
One thousand and eighty-three rib examintions
covered all of the chest from top to bottom and
side to side with three-film techniques. Sixty-
eight breaks were demonstrated in a one-hundred
case sample for a 57% improvement in fracture
detection.
Lastly, the 120,000 patient data-base was
checked for the raw totals of pneumothoraces(4).
One hundred and eighty-six cases of lung collapse
were listed only three of these occurred in the
1800 requested rib series. This paucity of cases
suggests that doctors bypass time-consuming rib
studies for profoundly-injured patients. Only
clients with minor chest complaints get full
rib examinations. It appears then, that these
people do not need supplemental PA views to
find lung punctures that are seldom present.
Conclusions
Routine three-film rib studies displaying
all the bone arcs in both sides of the thorax
with tailored exposure techniques reveal 57%
more fractures then do single-sided surveys.
Supplemental PA chests are not necessary to
find seldomly-occuring pneumothorax.
The new strategies reduce filming expense,
production times, radiation dose and the costs
of repeated examinations.
References
1. Genesis 2:22, p.9 in The Holy Bible, New
International Version, 1973 by the International
Bible Society published by the Zondervan Corpor-
ation, Grand Rapids, MI. pp 1950.
2. Bontrager KL and Anthony BT: Textbook of
Radiographic Positioning and Related Anatomy,
2nd ed, St. Louis, MO. C.V. Mosby Company, 1987.
3. Ballinger PW and Frank ED (eds): Merrill's
Atlas of Radiographic Positions and Radiologic
Procedures,St. Louis, MO, C.V. Mosby Company,1999.
4. Dockray, KT: Solo practice management:value
of a computerized reporting system. AJR 162:1439-
1441, 1994....and 15 others.
For those interested, the original draft and its
details are available at 1808 19th Street,
Lubbock TX USA 79401.
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