microsoft powerpoint - rsna 2002_u_take_call [read-only]

You take the call!

Louis K. Wagner, Ph.D.

Medical Radiation

You take the call!

Louis K. Wagner, Ph.D.

Disclaimer ---

The following thoughts on the communication of benefits/risks in medical radiology are those of the speaker and have not been screened or approved by any professional society. They are open to criticism and criticism is welcome!

Handouts at: www.uth.tmc.edu/radiology/wagner_pub.html

You take the call!You take the call!Ground Rules Ground Rules ------

Know the caller Know the caller ------ Parent, Patient, Physician, Parent, Patient, Physician, Lawyer, Reporter etc.Lawyer, Reporter etc.

Get the facts Get the facts ------ Define the problemDefine the problem

Identify your skills and ability to helpIdentify your skills and ability to help

Discuss billing informationDiscuss billing information

Construct a focused answerConstruct a focused answer

You take the call!You take the call!

Know your callerKnow your caller--------How knowledgeable is the caller about radiation?How knowledgeable is the caller about radiation?

••No knowledge or experienceNo knowledge or experience•• Popular knowledge, public advocatePopular knowledge, public advocate•• Regulatory knowledge (NRC, EPA, State)Regulatory knowledge (NRC, EPA, State)•• Health physicistHealth physicist•• Medical physicistMedical physicist•• RadiologistRadiologist•• Epidemiologist or radiobiologistEpidemiologist or radiobiologist


Know your callerKnow your caller--------See the problem from the caller’s perspective and See the problem from the caller’s perspective and put yourself in their position.put yourself in their position.

ParentParent –– radiation is a mystery and it’s your childradiation is a mystery and it’s your childPatientPatient–– your worried and don’t know what to doyour worried and don’t know what to doPhysicianPhysician–– how important is this to health carehow important is this to health careLawyerLawyer–– did radiation cause the plaintiff’s did radiation cause the plaintiff’s problem problem OtherOther–– friend, relative, health physicist, friend, relative, health physicist, regulatory personregulatory person


Details on the number of xDetails on the number of x--rays and length of studyrays and length of studyPregnancy involved? Get gestation dataPregnancy involved? Get gestation dataWhere was study done?Where was study done?When was study done?When was study done?Was a problem observed Was a problem observed –– skin, pregnancy, other?skin, pregnancy, other?What is the concern?What is the concern?Is the question the correct question?Is the question the correct question?

Get the factsGet the facts--------

You take the call!You take the call!Identify your professional ability to helpIdentify your professional ability to help--------Example:Example:••I am a medical physicist, not a medical doctor. I am a medical physicist, not a medical doctor. ••I am a father of two healthy children. I am a father of two healthy children. ••I have 25 years of experience. I have 25 years of experience. ••My professional focus is to relate the practical My professional focus is to relate the practical benefits of medical imaging to the radiation risks.benefits of medical imaging to the radiation risks.••I offer opinions based on my understanding of the I offer opinions based on my understanding of the biological effects associated with radiations.biological effects associated with radiations.•• For medical advice, please consult a knowledgeable For medical advice, please consult a knowledgeable physician.physician.


Discuss billing informationDiscuss billing information--------

Let the caller know that there will be a chargeLet the caller know that there will be a charge

Some consultations involving dose workups can be Some consultations involving dose workups can be billed to insurance (Needs physician referral and billed to insurance (Needs physician referral and report in patient’s record)report in patient’s record)

Pro bono work should be identified as suchPro bono work should be identified as such


Construct a focused answerConstruct a focused answer

Don’tsDon’ts------Don’t use complicated analysesDon’t use complicated analysesDon’t be condescendingDon’t be condescendingDon’t assume your caller understands Don’t assume your caller understands technical languagetechnical language

Do’sDo’sDo pause and think before replyingDo pause and think before replyingDo place risks in perspective with benefitsDo place risks in perspective with benefits

You take the call! Case #1You take the call! You take the call! Case #1Case #1

Know the caller--Parent from another city concerned about 12-year-old daughter

Get the facts– Semi-monthly appointments with private physician about chronic urological problem, has urographic study at each visit, has had 4 visits and is scheduled for another.

Concern– what are the radiation risks?

Frequent urological examinationsFrequent urological examinations


Think before responding ---

I am not qualified to assess benefit/risk in this case

Radiation risks are not a concern if studies are necessary

Are studies necessary?

Better concern: Is daughter receiving proper medical care?



Advice—

I cannot answer your question because I cannot assess the medical need for these studies

Radiation effects are not the principle concern, most important concern is: is your daughter receiving proper medical care?

Seek a second opinion from another urologist.

Assistance: Obtained name of a recommended urologist is their area.


You take the call! Case #2You take the call! You take the call! Case #2Case #2Pituitary cyst following IVP examinationPituitary cyst following IVP examination

Know the caller – lawyer for woman exposed while pregnant to IVP exam (12 films)

Get the facts – 135 lbs and 5’6” (age not available); pregnancy test prior to study was reported as negative, after study completed mistake discovered and tests indicated she was actually about 16 days postconception. Patient very upset. Dose evaluation was 17 mGy and advised not to seek abortion. Child born with macrocephaly and pituitary cyst.

Enquiry - wanted expert witness to testify that radiation caused effect

You take the call! Case #2You take the call! You take the call! Case #2Case #2Pituitary cyst following IVP examinationPituitary cyst following IVP examinationThink before responding –

Patient was in sensitive window of organogenesis at time

Dose was below threshold of 50 mGy for changes that are observeable under microscope

Dose was below level of 100 mGy which is accepted threshold for these types of gross effects

Natural incidence of “severe” malformation on order of several percent

You take the call! Case #2You take the call! You take the call! Case #2Case #2Pituitary cyst following IVP examinationPituitary cyst following IVP examination

Advice – Radiation unlikely cause of problem.

Reply (paraphrased) – ‘That’s the problem. I can’t seem to find an expert who will testify that the x rays did this.’

Result – Acquired testimony from foreign expert and settled out of court day before trial.

Assessment - The physician did all the correct things. The person who took the call initially appears to have provided all the appropriate advice in the best interest of patient. Given the same circumstances, I would have given the same advice.


Know the caller—Husband from Korea e-mailed me about pregnant wife. Husband was teacher at a university but lacked knowledge about radiation.

Get the facts– daughter had broken thigh, mother held daughter while x-rays were acquired. Mother was early in pregnancy. No lead apron was used. Several films acquired. Hysteria over incident was evident in concern about radiation disfigurement.

Concern– what are the radiation risks? Should they seek an abortion?

Inadvertent exposure of pregnant patientInadvertent exposure of pregnant patient


Think before responding ---

Can only provide indirect information on dose since specific details are not acquirable

Radiation risks are negligible under normal conditions and this is probably the case here

Lack of lead apron use indicates poor technique

Need to disarm hysteria about radiation but must be cautious about possibility of abnormality due to other factors

Must provide caveats on normal risks and remote advice

Inadvertent exposure of pregnant patientInadvertent exposure of pregnant patient


Based on my experience in the U.S., dose to early conceptus would be very small even if field not collimated. Lack of lead apron not a serious concern. Remote advice can be uncertain and local assistance should be consulted.

Do not worry about radiation risk, just be sure to provide wife with good prenatal care

Assistance: gave reassuring vignettes about how low radiation was likely to be; used Denver, Colorado housewife exposure as an example. {Did caution about normal incidence of birth defects.}

Inadvertent exposure of pregnant patientInadvertent exposure of pregnant patientAdvice—


Know the caller—Parent of nine-year-old girl.

Get the facts– daughter had three AP pelvic x-rays. Gonad shields fell off sometime during examination.

Concern– what are the radiation risks regarding reproduction in child-bearing years?

Pelvic xPelvic x--rays and heritable effects in childrays and heritable effects in child


Dose to gonads from 3 well performed AP pelvic x-rays in child on order of 1 – 5 mSv, background radiation is more

Reproductive risks in humans never definitively demonstrated

Gonad shields used to protect gene pool, not individual

Shields often not used because obstruct necessary anatomy

Gonad shields difficult to position in girls

Pelvic xPelvic x--rays and heritable effects in childrays and heritable effects in childThink before responding ---


X-rays should be of no concern

More radiation accumulated in 20 years from natural sources than from x-rays

No risk demonstrated in humans even at very high doses

Gonad shields not used to protect individual

Gonad shields often not used for medical reasons

Example: Man rendered temporarily infertile by x-rays later had daughter who was a medical student in my class

Pelvic xPelvic x--rays and heritable effects in childrays and heritable effects in childAdvice—


Know the caller—Forty-year-old woman who had miscarriage three months previously wants to have another child.

Get the facts– had dual pass CT of abdomen, including pelvis, on GE lightspeed.

Concern– “Is it wise to wait to let possibly damaged/mutated eggs ovulate out before trying to conceive?”

Pelvic CT in 40Pelvic CT in 40--yo patient desiring childyo patient desiring child


Reproductive risks in humans never definitively demonstrated

Animal data suggest waiting 2 – 6 mos will reduce risk

Age of individual is an important risk factor, regardless of radiation, must discuss normal risks of pregnancy

Delaying pregnancy may result in missed opportunities and will delay pregnancy in this aging parent

Pelvic CT in 40Pelvic CT in 40--yo patient desiring childyo patient desiring childThink before responding ---


Brief answer is that radiation received in diagnostic CT should not play role in decision to have children

No risk demonstrated in humans even at very high doses

Natural risks must be understood and age is a factor

Pros of delaying: may reduce heritable risk if wait 2 – 6 mos

Cons of delaying: age increases and may miss opportunities

Opinion: delaying has dubious benefit.

Pelvic CT in 40Pelvic CT in 40--yo patient desiring childyo patient desiring childAdvice—


Know the caller—Wife of 40-year-old man who had TIPS procedure about two years prior

Patient with severe injury after TIPS Patient with severe injury after TIPS

Get the facts– man developed severe injury on back at level of liver that progressed in manner characteristic of radiation injury. Injury down to level of spine. Had three TIPS procedures in a week. Cause of wound misdiagnosed by physicians for 10 months after symptoms; and wife, not physicians, diagnosed problem.

Concern– why did this occur and why can doctors not recognize it and do something about it?


Patient is very sensible and wants psychological resolution about the factors behind the events

Cause of problem was inexperienced radiologist

Patient was at crossroads of new procedures and lack of knowledge by physicians about radiation injury from fluoroscopy

Case is essential for teaching

Patient with severe in jury after TIPS Patient with severe in jury after TIPS Think before responding ---


Advice—

Discussed situation with patient for four hours.

To reimburse me for my time I asked them to send me all documents on the case to be used for educational purposes.

Patient with severe in jury after TIPS Patient with severe in jury after TIPS


Know the caller—Radiologist had inquiry from male construction worker about rash on abdomen.

Get the facts– about 1 year prior man had x-ray series for lumbar spine after construction accident. Study performed at clinic where many such studies are done. Problem with exam and study was repeated for a total of about 14 films. Rash developed soon after study then diminished. Now has rash on abdomen that he believes is caused by the x rays. Patient behaves normally.

Concern– is rash caused by x-rays?

Patient gets rash after lumbar spine seriesPatient gets rash after lumbar spine series


Doses from lumbar spine radiography too low to cause effects in skin, unless something is frightfully wrong

Timing for development of rashes and telangiectasia is correct. Had biopsy consistent with mild radiation changes but this is not pathognomonic for radiation.

Patient was very anxious about skin changes and demonstrated focussed concern about radiation. Patient did not appear to be out of control.

Patient wants issue resolved.

Patient gets rash after lumbar spine seriesPatient gets rash after lumbar spine seriesThink before responding ---


Advice—

Patient is rational and strongly believes x rays caused the lesions. Patient had pale complexion but no diagnosed diseases that might sensitize him to radiation. Patient listens to reason, so I advised physician to have him make an appointment so that the skin of the patient could be examined. The character of the rash will not likely match the ports of the x-ray beam and then the patient will understand that x rays were not the cause.



Resolution after examination :

Patient had mild rashes on abdomen in locations matching expected locations of oblique entrance beams for lumbar spine x-rays, but not well defined. Advised patient to call Department of Health in the State to investigate if there were other complaints about the facility and if there are records of machine malfunctions. There was no record of other events at the facility, state inspections demonstrated no problems with equipment at time of incident. No reason could be established to believe radiation was the etiology. Origin of rashes remain unknown.


You take the call! SummaryYou take the call! You take the call! SummarySummary

Responding to calls on effects of medical radiations requires:

•• PatiencePatience•• KnowledgeKnowledge•• InsightInsight•• EmpathyEmpathy

microsoft powerpoint - rsna 2002_u_take_call [read-only]

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