After I saw reports of the 5-fold increase in CT scans in children, I asked for “The Husband’s” take. I worry about a rise in the use of pediatric CT scans in the US because when a child gets scanned, they are being exposed to radiation. A CT scan is a series of x-rays taken in quick succession that form a more composite view of the body. Although x-rays and CT scans save lives and improve diagnosis, the radiation given to children when obtaining these studies must be minimized. Children are more sensitive to radiation than adults; their bodies are still developing. And as the Society for Pediatric Radiology reminds, “What we do now lasts their lifetimes.” Here’s a post about why it may matter where your child gets a CT scan by Dr. Jonathan Swanson:
Pardon the interruption…I’m chiming in again on a similar topic as my last guest post (I am kind of a one trick pony) – radiation exposure in children. SMD has asked me to talk about a recent radiology-based study and what it might mean for how we take care of our children. My take:
If it were my child, and F or O needed to go to an emergency room, I would go to the nearest children’s hospital…to spare my children unnecessarily high radiation exposure. Bias alert, I am a pediatric radiologist working at a children’s hospital. However, I think the literature supports my position.
Recently, David Larson and his colleagues published a paper in the journal Radiology that confirmed a trend that those of us in the pediatric world have long suspected – the use of computed tomography, or CT scans, in children who visit the ER has increased substantially over the last 10 to 15 years. According to their research, from 1995 to 2008, the number of pediatric ED visits that included CT examination increased from 330,000 to 1.65 million, a fivefold increase. In other words, if your child were to go to the ER today, he/she would be five times more likely to have a CT than if he/she were to be ill back in 1995. Amazing. The older generation of doctors are groaning somewhere, mumbling “whatever happened to the physical exam.”
What I find fascinating is that, according to this study, 90% of these emergent CT scans occur at adult-focused hospitals and only 10% occur in children’s hospitals. Really? Sure, children’s hospitals are not ubiquitous, but I would have thought that more than 10% of families have relatively easy access to a children’s hospital. Maybe I am wrong, but my guess is that some of those families that ended up at a community hospital had a choice of a children’s hospital, and, for whatever reason– proximity, ER wait time, advertisement – they chose the community hospital.
According to this study, both the adult-focused hospitals and the children’s hospitals showed a similar alarming rate in the increased use of CT scans. So choosing a children’s hospital may not avoid the CT scan. But this paper suggests, and I agree, that going to an adult-focused hospital when your child needs a CT scan may expose your children to a higher dose of radiation.
Dose of Pediatric CT Varies Between Hospitals:
- Dr Larson writes, “Adult-focused facilities may have many competing priorities; focus on pediatric CT may be hard to achieve because of the relatively small volume that pediatric CT represents at such institutions.”
- Larson cites a 2001 study (Paterson et al) of mostly community-based hospitals that found that CT radiation doses were not typically adjusted for children’s smaller body size. In other words, even though lower dose CT scans on children can provide equal quality images as full dose scans on adults, community hospitals did not tend to make the adjustment to the lower dose.
- On the flip side, another study found that CT protocols and scans supervised by pediatric radiologists are routinely adjusted to an appropriate dose for children.
- Even if a pediatric radiologist is in the radiology group at an adult-focused community hospital, it is unlikely, if not impossible for that individual to be involved in all of the pediatric scans.
Why children may get a higher dose at an adult-focused hospital:
- Pediatric hospitals are more comfortable with alternative, lower dose approaches to common diagnoses. Take appendicitis, for example. At a children’s hospital, the first line of imaging for appendicitis is abdominal ultrasound. Ionizing radiation in an ultrasound is zero. In an adult-focused hospital, CT is often the first imaging tool. The reasons is that it can be very difficult to visualize the appendix by ultrasound in young children. If an ultrasound technologist isn’t accustomed to working with children, CT may be a more reliable choice.
- When adult-focused facilities take care of children, there can be a level of discomfort. Kids are the exception in the ER department, not the rule. From my experience as a radiologist, when physicians are uncomfortable, they tend to order more tests or order a test that will give them the most information, some of which may be more than they need to make the diagnosis. In the world of radiology, this can translate into a higher-than-necessary-dose of CT because higher dose can translate into sharper images. We radiologists like our sharper images. The problem is that sharper images don’t always translate into improved diagnostic accuracy.
If you don’t have a children’s hospital nearby, then I recommend that you read my earlier post on how best to inform yourself, your doctor, and your local radiology department about reducing the radiation to which your child is exposed. The Image Gently site is mentioned in my prior post and remains an excellent toolkit for working with your community hospital to lower the pediatric CT dose.
We pediatric radiologists need to continue to work with community hospitals to help remove barriers to decreasing the dose for children. We also need to work with manufacturers of CT scanners to make it near impossible to scan a child with an adult-dose of radiation. So, back to work…
Chris Johnson says
I’d add a couple of points. First, the model of a children’s “hospital within a hospital” is becoming quite common, even in mid-sized community hospitals. These are institutions that have constituted special children’s services inside the physical space of a general hospital, including the emergency department. So the facility need not be a free-standing (and separate) children’s hospital. Many of these facilities show their commitment to children’s health by belonging to the National Association of Children’s Hospitals and Related Institutions (aka NACHRI) and by following the guidelines of the Image Gently initiative. It’s an easy thing for a parent to ask about.
Second, like many of my colleagues in pediatric critical care, I often provide sedation to children needing a CT scan. Not only is this the kindest thing for the child (CT scanners can look scary), but it also can cut radiation exposure significantly because the radiology technician gets a good image quickly and on the first try. This is particularly helpful if the scan is a more involved one than, for example, a simple uncontrasted head CT. So sedation is another thing a parent can ask about.
Wendy Sue Swanson, MD says
Thanks, Dr Johnson. I think you bring up two great points and ideas and talking points for parents if ever in the situation where it is recommended that their child get a CT.
1) Ask the technologist performing the CT scan in the radiology department, if they use or are familiar with Image Gently. Direct them to Google the website if they are unfamiliar and discuss reducing the radiation.
2) Ask how long the CT will take and if sedation is appropriate for their child.
Oh, how I wish this didn’t enter my mind as I read this blog post, but I don’t think we can realistically address this topic without also acknowledging that many, many families essentially insist upon imaging that is not clinically indicated (be it CT or non-radiating ultrasound or MRI). This leaves the ER doctor, with whom the family has no pre-existing rapport, always wondering if this will represent the case that leaves them vulnerable to a malpractice claim. Let’s face it – sometimes, it really is “easier” just to order the scan.
Now, all of that being said, I absolutely put my foot down – in that nice, West Coast pediatrician way – about NOT exposing kids to the radiation of a CT scan (even in more kid-appropriate doses) unless I feel the likelihood of finding something we would need to know about outweighs the risk of radiation exposure. Thankfully, more and more families seem to understand that when I am not willing to order a CT scan, it does not mean they are somehow receiving lower quality care. On the contrary.
Jonathan Swanson says
Dr. Johnson – Thanks for your insight. I completely agree that the children’s “hospital within a hospital” is a great place for parents to ask about Image Gently. Although there may be a dedicated pediatric wing and ER in such a hospital, the radiology department often serves both the adult and pediatric populations. Asking about Image Gently will help the CT technologists switch to the pediatric mindset.
And thank you for highlighting of the utility of sedation. The newer multislice CT technology allows most pediatric scans to be performed in less than 10 seconds, but sedation provides a controlled environment for the more complex cases where timing of the scan is essential. One of the pillars of a strong pediatric radiology department is its access to and working relationship with an experienced pediatric sedation team.
DS – Thanks for fighting the good fight! Hopefully on-line conversations like these will add to the number of families that understand your good intentions when you opt not to order the CT scan.
T Chapman says
Thank you, Dr. Swanson, for your outstanding comments here.
As another pediatric radiologist myself, and one who is also a mother, I would also want to simply emphasize that CT as a diagnostic tool is important, when indicated, and does save lives and decrease time spent in the hospital, to globally summarize its benefits (again, when indicated). It can be easy to forget this point in the discussion of radiation safety.
In response to DS’s comments, physicians in all fields are pressed by patients to DO something — either intervene or order a test — to help alleviate the anxiety that accompanies illness and pain. It is hard for anyone to hear that it’s best to just wait and see if the illness goes away on its own. Bravo, as Dr. Swanson says, for fighting the good fight and providing your patients with the benefits of your clinical skills and knowledge.
One of the reasons we love our house, is that it takes 72 seconds to reach our children’s hospital from our driveway. Here, if you bring your kids to the adult hospital down the street, they will send you over to Children’s. The ER will do an extremely limited triage to make sure your child is stable enough for the 5 minute transfer, but other than that, they refuse to see kids.
The one time my kid got an x-ray at Children’s, though, we were sent home by the ER doc at 2 a.m. only to be called by the radiologist at 7 a.m. and told to come back. Does that mean they don’t have a radiologist there at night?
We are an intervention-happy society when it comes to health care. We don’t prevent early, we TREAT (intervene) once there is a problem. This is a cultural issue that will take continued aggressive education from everyone involved in health care.
Wendy Sue Swanson, MD says
Hallelujah, Sista! I concur (clearly). Communicating, caring, and taking time to explain the WHY behind prevention efforts and preventative interventions aren’t often valued or funded. For example, I am reimbursed far more to remove a wart in my office than to counsel a teenager and answer questions about decision making for 25 or 40 minutes. YOU DO THE MATH.
When we do figure out how to prioritize helping health systems prevent injury and illness (nurses, doctors, social workers, nutritionists, community workers, physician assistants, and medical assistants, etc) not only will we be a more informed, calmer society, I suspect we’ll be a healthier one, too. It’s proving it (with research) and changing policy that will take so much time and energy.
Jonathan Swanson, MD says
At Seattle Children’s, the current practice is for the radiology resident or radiology fellow (a physician who has finished med school and resdiency and is training to specialize in pediatric radiology) to stay at the hospital throughout night. The attending radiologist is also often in the hospital for large portions of the night assisting on reading x-rays, ultrasounds, MRIs, and procedures.
In your case, the attending radiologist may have come in at 7am and altered the preliminary interpretation that the resident or fellow made on the x-ray in the middle of the night. Alternatively, the ED physician may have made a preliminary interpretation from the x-ray which was different than the radiologist’s interpretation. Regardless, I am sorry to hear that you had to make another trip to the ED!
Chris Johnson says
More and more places, generally those without residents who are there all night, are contracting out their nighttime radiology reads. One called Nighthawk is a big one. It sounds incredible to those not aware of it, but x-rays and scans taken at 2 am can be transmitted electronically half-way around the world, such as to Australia, where it is daytime. A radiologist there reads the film and faxes back the results. For a facility without around-the-clock radiology coverage I suppose it is better than waiting until the next morning for a reading, but I’d rather have the radiologist down the hall than on the other side of the globe.
I know of at least one smaller children’s hospital that uses Nighthawk for their 11 pm to 5 am radiologist interpretations.
I wonder what Dr. Swanson, as a radiologist, thinks about those rent-a-radiologist arrangements.
Jonathan Swanson says
Chris, like you mention, I think the Nighthawk model makes sense for the smaller hospitals and underserved communities. But I agree with you – something is missing when the radiology studies are interpreted in the remote setting. I think that clinicians and radiologists that work in the same hospital day after day form a valuable symbiotic relationship. For example, the ER doc or an ICU attending may learn a radiologist’s tendencies. Some more likely to call every little subtle opacity on a chest x-ray pneumonia compared to their colleagues – and the ordering physician can take this into consideration when reading an interpretation of a chest x-ray. On the flip side, I know that when certain surgeons are concerned about a patient, there is a high likelihood that there is going to be an abnormality on the CT scan or ultrasound that they ordered. I have come to trust their clinical acumen.
As a radiologist, I have never been interested in the Nighthawk model because the best parts of my job are the patient interactions and my face-to-face conversations with the ordering clinicians. I wouldn’t trade that for anything…not even a beach house in Australia.
The chair of the radiology department at our children’s hospital is actually one of my best friends (funny, I never thought to ask her about this incident but I asked on a blog!) and I am pretty sure they don’t outsource anything… BUT it is a teaching hospital and Dr. Swanson’s explanation about residents/fellows/attendings makes sense, and would be my guess about what happened that night. Also, unfortunately I was on bed rest at the time and sent my husband to the ER with my daughter, it was a busy night there, and my husband wasn’t as good about communicating with the resident in the ER as I would have been (okay, he wasn’t as aggressive as I would have been ha!) and I know the doctor kind of blew him off, so it also wouldn’t surprise me if the ER doctor did a quick read of the x-ray and said it was fine. In fact, he had told my husband “she’s fine but we’ll do an x-ray just to be sure” so I know he had already decided there wouldn’t be anything there. When I sent them off, my daughter had woken up wheezing and retracting and her mouth was blue… after three hours of sitting up right in the ER waiting room, her breathing had improved a lot, and the ER doctor thought she was just fine. Turned out she had pneumonia and based on her wheezing again the next morning also needed breathing treatments. It all turned out fine, I just hope it was a learning experience for someone. And it did make me wonder a little bit about what the radiology situation was there at night. Now that I am thinking about it, I would actually be surprised if they didn’t have a radiologist there, BECAUSE the adult hospital affiliated with Children’s (the medical center down the street) does – I went there at 1 a.m. with bleeding during my pregnancy, and I read the radiology report and my ultrasound was read by a radiology attending that night. Hmmm.
I don’t think the “virtual outsourcing” is inherently bad – I would rather have a remote radiologist (or other specialist) than none at all. Actually ,we have a program in our state that allows rural ERs to consult with our neurologists when they have a stroke patient, because they don’t have neurologists available where they are. We have a similar program for NICUs in the state, because none have the experienced neonatologists that we do, and so they actually put cameras on those preemies and our docs look at them and discuss their care with the team taking care of the babies. Of course if it were my preemie, I would much rather have the doctor there touching my baby, but if the choice is between a telemedicine consult or not having anyone with that kind of expertise weigh in on my baby’s progress and treatment, I’d pick the former.
JM, MD says
Great post. I’m also a mama and a doc, fledgling at both. I just found your blog and it’s fantastic.
When my infant son hit his head on the floor as I tried to set him down to change his diaper, my first thought was, “Oh my god, my poor baby!” My second thought was, “Oh no, if we take him to the ER, he’ll get a head CT!”
He was totally fine, but a MamaDoc101 on head injuries in all ages would be great. Particularly when you can safely observe at home and when you should bring the child in. There are obvious choices on either end of the spectrum; if it’s a minor bump and the child doesn’t even cry, of course you don’t need to seek medical attention, and if there is a significant mechanism or neurologic deficits then the child clearly needs immediate medical attention. But some guidance about that gray area in the middle would be helpful.