October 2023 Pick of the Month

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Toward Moving the Needle in the Haystack


The dogma that many emergency physicians learn about paralysis related to spinal epidural abscesses (SEA) goes something like “what the patient goes into the OR with is what they come out with.” Thus, over and over in M&M conference, we are taught time is of the essence.

Also applicable, owing to the rarity of the condition, is the notion of finding the needle in a haystack. For these reasons, this month’s Pick of the Month by Cai et al, Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess provides unique and valuable data. Combing through a giant haystack of over 19 million visits, and excluding patients without laboratory or imaging data, the authors located just over eight million visits made by 3.6 million unique patients. From this, they found approximately a 0.008% prevalence of SEA diagnosis and a 0.17% prevalence of SEA among patients with back pain, underscoring the need for the big data approach.

The authors compare features of patients with SEA pre- and post-implementation of a “red flag” based clinical management tool. The differences pre- and post- are not stunning in terms of indirect data about potentially missed diagnosis (rate of recent visits) nor time to diagnosis after a prior visit, but do show some behavior changes by the clinicians in terms of laboratory and radiological orders. The prevalence data alone provide quantitative data for chief residents to use in M&Ms (and maybe for experts in medicolegal allegations of negligence), and the pre- and post- data show how difficult it is to move the diagnostic needle (in the haystack) for rare conditions.

Jeffrey A. Kline, MD
Wayne State University School of Medicine


infographic shows gender-based diagnostic testing for pulmonary embolism


Source: Jasmine Thompson, MD, LSU Spirit of Charity | AEM Resident Editor and Kirsty Challen, BSc, MBChB, MRes, PhD, Lancashire Teaching Hospitals | AEM Editor of Infographics