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CT Scans For Kids: Is The Radiation Exposure Dangerous?

There was an interesting study published this week in the journal Radiology:

Rising Use of CT in Child Visits to the Emergency Department in the United States, 1995–2008 (Abstract)

The results are not surprising to anyone who has been working in medicine in the US over the last fifteen years. Basically, in 1995, a kid visiting the ER had a 1.2% likelihood of getting a CT scan, and by 2008, that number was 5.9%.

I had written about this general phenomon not too long ago, in defense of the general increase of CT utilization in the ER, largely on the basis that CT is a better tool: it provides diagnoses in a rapid and timely manner, and excludes many potential life threats, saving lives and mitigating malpractice risk. That was largely relevant to the adult population, though, and kids are not, as they say, just little adults. The increase in scanning children is more dramatic, especially given the generally lower incidence of disease in kids compared to adults and the chonrically ill.

The experience I have had in the ER was comparable to the study findings. When I started training in the mid ’90s, CT scans were time-consuming, offered less than excellent images and were relatively uncommon to get in general, let alone in pediatric populations. By the time I started practice in 2000, things had changed dramatically. The image quality and diagnostic information a scan provided was way better. The development of high-speed helical scans made it much easier to get them on kids without sedation, which greatly lowered the operational barrier to getting them. The overall accessibility and use of scans were rising and the pediatric use rose in lockstep. There was little concern about the risks of radiation or the downside of getting a scan on a kid if there seemed to be a clinical indication. This was largely (but not entirely) driven by percieved malpractice risk, especially in the hot-button liability scenarios of head injuries and potential appendicitis. The feeling was that the consequences, both human and financial, in missing an epidural hematoma in a child were so gargantuan, and the risk inferent in the radiation so trivial, that why not do it? We ordered scans willy-nilly, it seems in retrospect.

Appendicitis is a little different. There is the fact that you had other options, including ultrasound, observation, and surgical consultation. So CT was not used quite as profligately for potential appendicitis. But for some cases (and some docs) it did become the test of choice. Ultrasound is frustratingly insensitive, time-consuming and operator dependent. Surgeons are difficult to get to come to the ER for a consult. And, especially in the malpractice insurance crisis in the early part of the decade, many docs were uncomfortable with the risk inherent in watchful waiting. This is not to excuse, but to explain why CT rates shot up, at least in my experience.

But a very welcome countervailing trend has definitely arisen over the past four years or so, especially in but not limited to the pediatric population, as the risks of radiation with regard to lifetime cancer incidence have become better understood and better publicized. This has spurred a change in practice in our ER, driven by the clinical leadership in concert with our radiologists and pediatricians. I don’t have numbers, but it seems like the use of scans for kids has slowly dropped and dropped over this time frame.

We have been assisted in this by the development and validation of some good decision-making rules for selecting the kids with head trauma who are likely to benefit from a CT scan. There’s also increased awareness and acceptance amoung patients and their families. It used to be that parents had an expectation of and even advocated for CT imaging. I’ve always been more of a diagnostic minimalist, and back in the day I would have to really go out of my way to convince some parents that a CT scan was not necessary. Now it seems all I have to say is that “We have learned that this is a lot of radiation to focus on a growing brain/set of genitals,” and the parents are nodding and very accepting of my explanation that their child is not likely to benefit from a scan. We have also developed algorithms for the evaluation of abdominal pain which make it pretty clear that CT scans are discouraged unless there is a darn good reason. So things are changing, and for the better.

I recall a couple of years ago I blogged about a difficult diagnosis of appendicitis and the need to scan a young boy. It was complicated by the fact that the parents, from the Ukraine, has a remarkable fear of radiation, due to the Chernobyl incident. I had reassured the parents that “I had a five-year-old son, and if it were my son with the same pains, I would not hesitate to put my son in the scanner.” At the time, that was true. I’m not so sure that I would make that assurance today. Now, I am much more likely to treat kids with observation (either in house or at home).

The pendulum swings, but ever so slowly.

*This blog post was originally published at Movin' Meat*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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