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BMJ. 2007 May 12; 334(7601): 1006.
PMCID: PMC1867909
Personal View

CT scanning: too much of a good thing

Steven Birnbaum, radiologist

On 30 August 2005, coming off a mostly sleepless night of on-call which mainly involved reading computed tomography (CT) scans in the emergency room, I received the phone call all parents dread. My ex-wife was on the phone, sobbing and telling me that our 23 year old daughter had been hit by a car while jogging and was in intensive care in a large, prestigious hospital with a head injury.

When I arrived at the intensive care unit, Molly was conscious but suffering from altered sensorium. Given the miracles of modern picture archiving and communication (PACS), I was able to review her radiological studies at her bedside with her nurse almost immediately. I realised that her injuries, although serious, would not be life threatening. She had had a basilar skull fracture, a severe concussion, pubic rami fractures, and a severe left knee injury. No immediate intervention would be required except for semi-elective knee surgery, and, given her age and excellent physical condition, a full recovery would be anticipated. CT scanning had been key in determining this prognosis. Molly had had a scan of the head and of the cervical spine, an arteriogram of her intracranial vessels, and a chest scan and abdominal scan that day; all were appropriate, to my mind.

I stayed at her bedside, and on the morning of the next day she had blood drawn from the arm where her intravenous line ran. Her packed cell volume went down about 10 points. Rather than repeating this simple test in her other arm, where blood was undiluted by intravenous fluid, another abdominal CT scan was ordered. I insisted on accompanying her to the scanner. Initially I was not allowed to go in the scanner control room, but the technologists finally relented when I told them again and again I was a radiologist. They were adamant that I could not be next to her during the examination in the scanner room and would have to sit in the control room. In fact, I would have to face toward Molly's scanner as this was a joint control room for a second scanner facing in the opposite direction and it would be a violation of the Health Insurance Portability and Accountability Act for me to look in that direction.

I didn't think things could get more bizarre, but they did. The study showed a small amount of blood in the cul-de-sac of the pelvis. The radiology resident insisted on doing a set of delayed images through the pelvis to assess the bladder and whether the blood was “changing.” The resident then went to her attending physician, who wanted a third set of images through the pelvis. At this point I uttered the immortal words of Roberto Duran in his epic rematch with Sugar Ray Leonard, when he could not answer the bell at the start of the eighth round: “No mas, no mas”—no more.

I had seen a few examples of radiation overexposure in the community hospital setting in which I work and was beginning to act on this. Now I saw it happen to my own daughter. I was horrified. I asked the surgical chief resident if any thought had been given to radiation exposure in patients when doctors ordered CT studies. When she said that there was at the adjacent children's hospital, but not here, I replied, “If Molly gives birth to a salamander, I know who I am coming after.” That generated stunned silence.

A spiral scan of the abdomen or pelvis exposes a patient to about 10 mSv of radiation. The risk of one or two studies is negligible. However, in young patients, five of these studies exposes a patient to the amount of radiation that produced carcinogenic effects in the atom bomb survivors of Hiroshima and Nagasaki. In the United States, an estimated 60 million CT studies were done in 2006. Many doctors—including radiologists—have limited knowledge of the doses and of the potential consequences of the massive increase in diagnostic medical radiation exposure. I have become a zealot in trying to stem this tide.

In my hospitals, I began to give talks on radiation safety issues to educate clinicians and radiologists. I formulated an essay on radiation safety for my referring providers. Insurers in New Hampshire embraced this as a true patient safety initiative, rather than merely a cost cutting manoeuvre. Anthem Blue Cross of New Hampshire is likely to make CT radiation safety an ingredient of their pay for performance programme for the state in 2007 and will use the precertification process to identify frequently exposed patients. The New Hampshire Radiologic Society has embraced plans for identifying and monitoring patients who may have been overexposed to radiation from CT scans. I have received invitations to speak at several university centers as well as radiological societies. Molly and I were featured in an article on this issue in the Wall Street Journal on 2 November 2006 (http://online.wsj.com/PA2JBNA4R/article). I have been appointed to the recently convened panel on radiation dose in medicine of the American College of Radiology. This panel will produce a white paper which will authoritatively outline steps that should be taken by the medical, insurance, and manufacturing communities as well as the government to help stop this epidemic.

Molly has virtually completely recovered. She had planned to attend the Culinary Institute of America with the hope of becoming a food writer, but her accident left her anosmic. Yet out of the ashes of her illness, she arose. She moved to New York city and got an entry level job writing for a magazine. She wants to write for a living, and I have no doubt that the strength she showed in her recovery will ensure she gets what she wants.

It certainly is strange how an almost extraordinarily tragic accident has turned around both of our careers, hers at the beginning, and mine after 22 years of radiology. We are both deeply committed and passionate. It is time that medicine in all specialties became aware of the epidemic of exposure to diagnostic radiation in patients and did something about it.

Notes

Competing interests: SB is a paid consultant of New Hampshire Anthem Blue Cross/Blue Shield .


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