Sooner or later, most parents end up in the ER with their offspring. And if you’re a frequent customer, chances are pretty good you’ve bumped up against the increasingly ubiquitous CT scan (aka “catscan”).
Our Tiger has racked up more than his share of visits, including one when he was three when he ran a fever over 104 F and complained of a terrible tummy ache. At our local hospital, the doctors ordered an abdominal x-ray, which indicated a dramatic case of … constipation. But since his fever was high and appendicitis couldn’t be ruled out, we were sent up to Children’s Hospital in Columbus. There, the resident on duty wanted to do a CT scan as soon as possible.
“Can you really diagnose appendicitis with a catscan?” my husband asked.
“Could we talk to your attending about this?”
The resident’s boss agreed that there wouldn’t be much point to a CT scan. They didn’t want to release us, though, because if we went home we’d be an hour and a half away. And so the attending took a truly radical step: she admitted us. We spent a short and restless night with the Tiger, his dad sharing the bed with him, me scrunched into a recliner. (The Bear stayed with friends who generously took him in at short notice.)
In the morning, the Tiger pooped. He felt better. His fever was dropping. We were sent home that afternoon. A few days later, bloodwork came back with signs of a bacterial infection in his blood (a strain of pneumococcus not covered by the vaccine). He got antibiotics and never had another unexplained high fever again. To this day, his appendix is just fine.
Most parents probably wouldn’t have resisted the resident’s suggestion. Heck, if I’d been alone, I wouldn’t have questioned it, even though I’m usually quick to ask. When you’re scared and alone with a sick child in the middle of the night, it’s hard to challenge authority. It was only my husband who had enough presence of mind to weigh the long-term danger of radiation. The resident’s only concern was not to miss something – anything – that modern medicine might ascertain. Long before young doctors learn all they need to be expert diagnosticians, they learn not to discharge a patient until everything possible has been done, no matter how pointless, expensive, and possibly hazardous. This is classic defensive medicine, driven more by fear of lawsuits than by the patient’s optimal treatment.
Don’t get me wrong. CTs are a great tool. They are just overused, whether out of technophilia or fear or liability, or both. And the New England Journal of Medicine notes in its July 1, 2010 edition that the use of CTs is underregulated. Rebecca Smith-Bindman’s article, “Is Computed Tomography Safe,” was initially available as a free full text, but it has disappeared (here’s a .pdf of the onscreen free version that I’m using as reference). Essentially, Smith-Bindman argues: 1) Hospitals somewhat rarely but regularly make devastating errors when CT equipment is improperly monitored, which sometimes results in severe accidents. 2) There are no clear guidelines stating when a conventional CT versus a more precise CT (with greater radiation exposure) would be appropriate. 3) There are no guidelines in place for minimizing radiation exposure, period. 4) The FDA approves technology and devices but it doesn’t oversee the actual usage of equipment. 5) Unnecessary radiation from the ostensibly “safe” CT can kill:
We [Smith-Bindman and colleagues] found that the risk of cancer from a single CT scan could be as high as 1 in 80 — unacceptably high, given the capacity to reduce these doses.
The NEJM article neglects any discussion of children, but the literature to date has raised even bigger red flags about pediatric uses of the CT scan. This is only logical. Kids’ bodies are smaller. They are still growing, so damaged DNA will have many more opportunities to go rogue. They have many years ahead of them – or so we hope – such that rogue cells have many decades to exact their revenge. A 2008 article in Time magazine puts the risk of a fatal cancer from a single pediatric CT scan at 1 in 500, and vividly illustrates why parents should be skeptical:
When doctors first ordered a CT scan for Jen Houck’s six-month-old daughter in 2003, the new mom was more worried about the risks of anesthesia (used to keep children from squirming in the machine) than of radiation exposure. In 2006 and 2007, her daughter, now 5, had two additional CT scans, 6 months apart, for what doctors initially thought was a growth abnormality. They’ve since determined the child was perfectly healthy. “All that, just to find out her head is bigger than normal,” says the 27-year-old mother of two in Boone, North Carolina. In hindsight, Houck wishes she had done things a bit differently. “I would have asked more questions about the necessity for a third scan so soon after the second.” She also says no one mentioned the option of a low-dose scan, and she has no idea how much radiation her daughter received. “I wish I’d known to ask the question.”
So today’s Caturday post is a bit of a PSA, or at least a cautionary tale (tail?): Don’t be afraid to question the risks versus benefits of a proposed CT scan. Even if it’s your kid’s health at stake. Especially if it’s your kid’s health.
Editorial note from the patron cat of Kittywampus: Grey Kitty would have approved of the simpler, lower-energy greyscale catscan. Nice tail, too – very similar to GK’s own.