Friday, April 13, 2012

Phear Of Photons

I never pass up an opportunity to throw in a Star Trek reference...

I had the usual joy of taking call last night, and the discussion about a particular case prompts me to put pen to paper, or fingers to keyboard as it were.

The call came through from the ER at 10 PM or so. The rather agitated ER doc related this scenario to me, desperate for advice: "I've got an elderly man with history of lung cancer, now presenting with dyspnea and wheezing after probably aspirating a beet. You know, the little red vegetables? Yeah, those. Anyway, he also had some EKG and lab abnormalities, and some chest pain. I just don't know what to order. I suppose he needs a CT pulmonary arteriogram, but I'm so afraid to give him any more radiation...."

Ummm, excuse me? The ER doc is afraid to give more radiation? The same ER department that just ordered about 30 CT's in the last four hours? The same ER that has no hesitation in ordering a CTPA-gram on teenagers? You're afraid to order a scan on someone whose already had a malignancy and is already on up there in years? You're AFRAID??

Clearly, we radiologists have shot ourselves in the foot on the issue of radiation. Because of a small number of scary articles (the latest now definitively states that we'll get meningiomata from dental radiographs), our ordering docs are now terrified of using radiation on those whom it will affect the least.

I've had the honor and privilege to participate in the most amazing technical miracle ever to happen to mankind. The diagnostic tools which we use daily, sometimes with some degree of nonchalance, are nothing short of magical wonders of the sort that could only be dreamt of not very long ago. Between CT, PET, MRI, SPECT, and the other members of our alphabet soup of toys, we can literally look inside the body without benefit of knives or getting our hands bloody. We can filet you open without filleting you open, and isolate abnormalities down to the molecular level (at least that's coming to a hospital near you soon). I could go on, but I might get emotional, and we can't have that. But when you think about it, what we do in Radiology is nothing short of amazing.

I've often said radiation is a lot like electricity. Use it carefully, and it's your friend. Stick your finger in the socket, and you'll get shocked. Proper use of our diagnostic tools saves lives. Improper use can cause trouble. Sadly, we've again got a disconnect between the truth and perception. Somehow, we've allowed the belief to flourish (or fester) that the next scan might cause a malignancy, even in the face of a more immediate threat. We need to do a better job of educating our clinicians. Somehow.

Set phasers to dumb....

By the way, the patient had a large piece of beet in the right lower lobe bronchus.


Prometheus said...

Its a fair point. Maybe risk of litigation sits in there somewhere too.

But one observation:
LAZER: "Light Amplification by *S*timulated Emission of Radiation"

Just an Anglo-Americano thang.

Dr.Sardonicus said...

How many times have I had to explain that the fetus of a pregnant woman with a PE often does more poorly than a fetus exposed to scatter radiation at 38 weeks

Dr.Sardonicus said...

Here's a thought - Docs like a binary decision tree: Chest pain! get a CT.

therefore, develop a numerical index (photon Phear Phactor if you would like):

Number of previous CTs *
(1/likelihood of positive scan in this patient ) *
(1/Likelihood of that disease killing patient ^3) ) *
age of patent)^2

When this value is below a certain level, order like water, above that level - think.

shortcomings: subjectivity in terms 2 and three.

You may want to add in a factor for physician's fear of lawsuits. That may trump everything .