Do we really need that test?

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“I think you’re hitting a small nail with an awfully big hammer.”

—Unidentified U.S. General’s response to Peter Braestrup, Washington Post reporter, during press conference at Marine headquarters on Khe Sanh.

Overwhelming force applied to a small tactical situation. I need to fix a small problem, I apply maximal effort and inappropriate resources. Has anyone experienced this kind of misdirected work effort in their own shop?

I’ll tell you what got me to thinking about this: nasal fractures. I’ve had at least one. Those who know me realize early on that my nose is at least a little askew. I’m OK with it. It works fine. Air moves in and out and only a little more on one side than the other. It was my fault at least once—the pool was a little shallow for that dive. The other time, well, they made us box at the Academy. I had my headgear on, it just wiggled a little, and again, it was my fault. I shouldn’t have allowed myself to get hit. A little (quite painful) wiggle by the coach to fix it, and it wasn’t perfect, but it was at least better.

The imaging study performed in this regard was a visual inspection. Nothing more. Well, we have a new tool now: “CT maxillofacial: r/o nasal bone fracture.”

Huh? CT? Now, that’s worth a call.

“Does the nose look deformed?”

“Not really, but it hurts.”

You think, hmm, probably because someone hit it?

“Anything else?”


“Really? And you want a CT?”

You go through your rehearsed radiation exposure speech, orbits and globes, cataracts and costs, to no avail. You do the CT. There may be a little fracture there. You are tempted to say “clinical correlation required,” but you hold back. You call it a likely fracture, but you feel bad, kind of dirty, like you should go home and take a shower. Patient goes home after being instructed in how to duck better.

We radiologists are at some level victims of our own success. We can depict anything and everything, and we do it well. We do 3D pictures of it, for God’s sake, and now we can even make 3D models of it. You can hold your own skull and look at your very own minimally angulated nonsurgical nasal bone fracture. Ohmygod,I shouldn’t have said that. They will be asking for 3D models of nasal bone fractures now. There are so many other examples, I shudder to even list them. If nothing else, medical costs could be driven down by a return to plain films when they work.

Keep doing that good work. Mahalo.

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CD Phillips.  Do we really need that test?.  Appl Radiol.  2016;45(9):48.

By C. Douglas Phillips, MD, FACR| September 05, 2016

About the Author

C. Douglas Phillips, MD, FACR

C. Douglas Phillips, MD, FACR

Dr. Phillips is a Professor of Radiology, Director of Head and Neck Imaging, at Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY. He is a member of the Applied Radiology Editorial Advisory Board.

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