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Teachable Moment
Less Is More
July 27, 2020

Low-Value Diagnostic Imaging in the Intensive Care Unit: A Teachable Moment

Author Affiliations
  • 1Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
  • 3Beth Israel Deaconess Center for Healthcare Delivery Science, Boston, Massachusetts
JAMA Intern Med. Published online July 27, 2020. doi:10.1001/jamainternmed.2020.2681

A patient in their 40s with no significant medical history was admitted to the intensive care unit (ICU) with respiratory failure due to pneumonia. The patient required intubation and mechanical ventilation. On admission, routine daily chest radiographs (CXRs) were scheduled on a repeating basis in the electronic medical record for each upcoming morning. On day 6 of the patient’s ICU stay, their clinical condition had improved significantly, and extubation was anticipated the following day. On day 7, early in the morning, a routine CXR was performed. The ICU resident received a page from a radiologist shortly thereafter, expressing concern regarding a pneumothorax apparent on CXR. There was no change in the patient’s clinical status or measures of compliance on the ventilator. After a repeated CXR was performed with identical findings, an emergency surgical consult was called. The surgical resident on call arrived with a tube thoracostomy kit and began to prepare to insert a chest tube. While awaiting a supervising physician for the procedure, a lung ultrasound was performed that suggested no pneumothorax was present. The patient’s clinical status remained stable; therefore, they were sent for a chest computed tomography, which demonstrated resolving pneumonia and no pneumothorax. The procedure was aborted. After further discussions with a radiologist, it was determined that the prior CXRs appeared to show a skinfold mimicking pneumothorax.

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