Hello Flow-ers, got a problem.  A revisionist movement at this facility
is wanting to go back to the good ole days of venography.  Memo sent regarding
the inaccuracy of our studies. (They quote ONE case, we called limited - though
no thrombosis seen, with a subsequent venogram that was called "suspicious" but
not positive for a partial thromb - as being a false negative study.)  Couple
of quotes from memo; "It is not clear that the standard of care for DVT
is a screening US and venogram if the non-invasive exam is equivocal."  "...if
the patient is asymptomatic, the predicitve value of an ultrasound is limited
(see attached meta analysis)."  "True, adding Doppler to the published US
studies may improve accuracy..."  "It is interesting to note recent published
studies in major journals still use contrast venography."  The meta analysis
referred to is "Accuracy of Ultrasound for the Diagnosis of Deep Venous
Thrombosis in Asymptomatic Patients after Orthopedic Surgery", PS Wells, AW
Lensing, BL Davidson, et al, Ann Intern Med 1995:122:47-53.
	The conclusion of that analysis; "Venous ultrasound imaging has only
moderate sensitivity and a moderate positive predictive value when used to
screen for deep venous thrombosis in patients after orthopedic surgery; thus,
ultrasound imaging may have limitations as a screening test."  It appears the
analysis considered 17 of 30 published studies to meet their eligibility test. 
The protocol was based on compressibility, and no seperate color or Doppler
criteria was used.
	Another article attached to the memo "Accuracy of clinical assessment
of deep-vein thrombosis" PS Wells, J Hirsh, DR Anderson, Lancet 1995; 345;
1326-30, is by the same group of authors and discusses the roll of clinical
diagnosis in determining when to appropriately use venography based on
ultrasound results.  I can buy into this argument, although in our institution
this would probably still result in many unnecessary venograms.  The flaw here
is the ultrasound protocol; "We examined two areas of the leg: the common
femoral vein at the inguinal ligament and the popliteal vein at the knee-joint
line traced down to the point of the trifurcation... Veins were scanned in the
transverse plane only. Lack of full compressibility was the sole criteria..."
	Hey, I MUST be doing this wrong!  When did I miss the 10 minute venous
study and why am I squandering my resources like this?  OR, could this at all
influence the outcome of the meta analysis???
	OK, I would like your ideas, references, whatever you think might help
me maintain the "standards" of patient care we have established here.  I should
mention the issue here is NOT a turf battle with Radiology.  In fact they
support the Vascular Lab quite strongly on this issue.  It is the trauma docs
that want to return to the contrast days when life was so much better.  One of
their main gripes is that we are on limited call, and duplex studies are not
available after 10pm on weekdays or 5pm weekends and holidays.
	So, finally, I would like to know how many of your facilities provide
24 hour call, and if there is any oversight process to avoid abuse of call (ie;
a venous reflux study at 2am).  
	Thanks, 
	Bill Johnson