“It hurts” is not an indication for an X-ray (plain film imaging). In the correctional medicine environment, we hold ourselves to a higher standard. At CorrHealth, we practice evidence-based – and not defensive-driven medicine.
In other environments, using plain film imaging or X-ray to treat a patient is often the result of a patient’s complaint, “It hurts!” And in my professional colleague’s defense, it is a quick and painless way to produce excellent 2-dimensional images of the bones in the body. It can also provide a lesser view of the location of organs in the body, the size and shape of the heart, lungs, bronchi, aorta, etc.
There are other more useful methods to consider before taking a quick picture.
When to consider imaging
So, when do we image? When it’s clinically indicated. Remember, when it comes to orthopedic injuries, if there is an obvious distracting injury (dislocation/open fracture) a picture is needed. One of the advantages of correctional medicine is that the patient is on-site.
Once an injury occurs, there will be a significant amount of pain and swelling. In this case, you will be unable to perform a meaningful exam and your urge will be to take a picture. But wait! Provide support for the injury and let the affected area calm down. An exam the next day may be significantly different and your worries of a serious injury and need for imaging, may have resolved. The next appropriate thing to consider before completing any imaging is “How will this change my management?”. If the results of the x-ray will not change the course of treatment, then resist the urge.
Common Complaints and Imaging
A very common complaint is about back pain. Living in a country with an obesity epidemic, seemingly everyone has back pain. Our bipedal infrastructure was only built to handle a specific amount of weight and most of us have far surpassed our documented max capacity. This additional weight comes with a price, and that price amongst other debilitating issues is back pain. And where there is pain, there will forever be an impulse to take a picture. Don’t do it! X-rays show bones and are most beneficial for looking for fractures.
Do you think this obese person’s chronic back pain is from a fracture?
Certainly, considering significant trauma, like a car accident, with acute back pain, an X-ray could show the etiology, but outside of this example, the results will not help you. It will likely indicate Degenerative Disk Disease (DDD) if the inmate-patient is more than 30yrs old. Will that change your management? No. That’s a very nonspecific finding. However, the inmate patient could use a DDD finding as leverage to obtain medications for the rest of their stay. If the x-ray shows narrowing or Spinal Stenosis, are you going to send them to the neurosurgeon? No. The results of the x-ray do not drive neurosurgical decision making.
The Best Course of Action
The best course of action is to order a detailed, well-documented physical exam. There is no substitute for a high quality, exquisitely documented physical exam. This alone will tell you if you have a true neurological condition requiring appropriate imaging (such as an MRI) or neurosurgical referral versus your extremely common, run-of-the-mill, (likely obesity and/or arthritis) back pain. Our responsibility as correctional healthcare providers is to provide the highest standard of care possible. At CorrHealth, we’re raising that bar by adding compassionate patient care as our #1 priority. To find out more about us visit us at mycorrhealth.com