Microsoft PowerPoint - RSNA 2002_U_TAKE_CALL [Read-Only]

Download Microsoft PowerPoint - RSNA 2002_U_TAKE_CALL [Read-Only]

Post on 05-Dec-2014




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  • 1. You take the call!Medical RadiationLouis K. Wagner, Ph.D.
  • 2. You take the call! 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! Louis K. Wagner, Ph.D.Handouts at:
  • 3. You take the call!Ground Rules --- Know the caller --- Parent, Patient, Physician,Lawyer, Reporter etc. Get the facts --- Define the problem Identify your skills and ability to help Discuss billing information Construct a focused answer
  • 4. You take the call!Know your caller----How knowledgeable is the caller about radiation? No knowledge or experience Popular knowledge, public advocate Regulatory knowledge (NRC, EPA, State) Health physicist Medical physicist Radiologist Epidemiologist or radiobiologist
  • 5. You take the call!Know your caller----See the problem from the callers perspective andput yourself in their position. Parent radiation is a mystery and its your child Patient your worried and dont know what to do Physician how important is this to health care Lawyer did radiation cause the plaintiffs problem Other friend, relative, health physicist, regulatory person
  • 6. You take the call!Get the facts----Details on the number of x-rays and length of studyPregnancy involved? Get gestation dataWhere was study done?When was study done?Was a problem observed skin, pregnancy, other?What is the concern?Is the question the correct question?
  • 7. You take the call!Identify your professional ability to help----Example:I am a medical physicist, not a medical doctor.I am a father of two healthy children.I have 25 years of experience.My professional focus is to relate the practicalbenefits of medical imaging to the radiation risks.I offer opinions based on my understanding of thebiological effects associated with radiations. For medical advice, please consult a knowledgeablephysician.
  • 8. You take the call!Discuss billing information----Let the caller know that there will be a chargeSome consultations involving dose workups can bebilled to insurance (Needs physician referral andreport in patients record)Pro bono work should be identified as such
  • 9. You take the call!Construct a focused answerDonts--- Dont use complicated analyses Dont be condescending Dont assume your caller understands technical languageDos Do pause and think before replying Do place risks in perspective with benefits
  • 10. You take the call! Case #1 Frequent urological examinations Know the caller--Parent from another city concernedabout 12-year-old daughter Get the facts Semi-monthly appointments withprivate physician about chronic urological problem, hasurographic study at each visit, has had 4 visits and isscheduled for another. Concern what are the radiation risks?
  • 11. You take the call! Case #1 Frequent urological examinationsThink 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 medicalcare?
  • 12. You take the call! Case #1 Frequent urological examinationsAdvice I cannot answer your question because I cannot assessthe medical need for these studies Radiation effects are not the principle concern, mostimportant concern is: is your daughter receiving propermedical care? Seek a second opinion from another urologist. Assistance: Obtained name of a recommendedurologist is their area.
  • 13. You take the call! Case #2Pituitary cyst following IVP examination Know the caller lawyer for woman exposed whilepregnant to IVP exam (12 films) Get the facts 135 lbs and 56 (age not available);pregnancy test prior to study was reported as negative, afterstudy completed mistake discovered and tests indicated shewas actually about 16 days postconception. Patient very upset.Dose evaluation was 17 mGy and advised not to seekabortion. Child born with macrocephaly and pituitary cyst. Enquiry - wanted expert witness to testify that radiationcaused effect
  • 14. You take the call! Case #2Pituitary cyst following IVP examinationThink before responding Patient was in sensitive window of organogenesis at time Dose was below threshold of 50 mGy for changes thatare observeable under microscope Dose was below level of 100 mGy which is acceptedthreshold for these types of gross effects Natural incidence of severe malformation on order ofseveral percent
  • 15. You take the call! Case #2 Pituitary cyst following IVP examinationAdvice Radiation unlikely cause of problem.Reply (paraphrased) Thats the problem. I cant seemto find an expert who will testify that the x rays did this.Result Acquired testimony from foreign expert andsettled out of court day before trial.Assessment - The physician did all the correct things. Theperson who took the call initially appears to have providedall the appropriate advice in the best interest of patient.Given the same circumstances, I would have given thesame advice.
  • 16. You take the call! Case #3Inadvertent exposure of pregnant patient Know the callerHusband from Korea e-mailed meabout pregnant wife. Husband was teacher at auniversity but lacked knowledge about radiation. Get the facts daughter had broken thigh, motherheld daughter while x-rays were acquired. Mother wasearly in pregnancy. No lead apron was used. Severalfilms acquired. Hysteria over incident was evident inconcern about radiation disfigurement. Concern what are the radiation risks? Should theyseek an abortion?
  • 17. You take the call! Case #3Inadvertent exposure of pregnant patientThink before responding --- Can only provide indirect information on dose sincespecific details are not acquirable Radiation risks are negligible under normal conditions andthis is probably the case here Lack of lead apron use indicates poor technique Need to disarm hysteria about radiation but must becautious about possibility of abnormality due to other factors Must provide caveats on normal risks and remote advice
  • 18. You take the call! Case #3Inadvertent exposure of pregnant patientAdvice Based on my experience in the U.S., dose to earlyconceptus would be very small even if field not collimated.Lack of lead apron not a serious concern. Remote advicecan be uncertain and local assistance should be consulted. Do not worry about radiation risk, just be sure to providewife with good prenatal care Assistance: gave reassuring vignettes about how lowradiation was likely to be; used Denver, Colorado housewifeexposure as an example. {Did caution about normalincidence of birth defects.}
  • 19. You take the call! Case #4Pelvic x-rays and heritable effects in child Know the callerParent 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 regardingreproduction in child-bearing years?
  • 20. You take the call! Case #4Pelvic x-rays and heritable effects in childThink before responding --- Dose to gonads from 3 well performed AP pelvic x-rays inchild on order of 1 5 mSv, background radiation is more Reproductive risks in humans never definitivelydemonstrated Gonad shields used to protect gene pool, not individual Shields often not used because obstruct necessary anatomy Gonad shields difficult to position in girls
  • 21. You take the call! Case #4Pelvic x-rays and heritable effects in childAdvice X-rays should be of no concern More radiation accumulated in 20 years from naturalsources 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-rayslater had daughter who was a medical student in my class
  • 22. You take the call! Case #5Pelvic CT in 40-yo patient desiring child Know the callerForty-year-old woman who hadmiscarriage three months previously wants to haveanother child. Get the facts had dual pass CT of abdomen,including pelvis, on GE lightspeed. Concern Is it wise to wait to let possiblydamaged/mutated eggs ovulate out before trying toconceive?
  • 23. You take the call! Case #5Pelvic CT in 40-yo patient desiring childThink before responding --- Reproductive risks in humans never definitivelydemonstrated Animal data suggest waiting 2 6 mos will reduce risk Age of individual is an important risk factor, regardless ofradiation, must discuss normal risks of pregnancy Delaying pregnancy may result in missed opportunitiesand will delay pregnancy in this aging parent
  • 24. You take the call! Case #5Pelvic CT in 40-yo patient desiring child Advice Brief answer is that radiation received in diagnostic CTshould 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 6mos Cons of delaying: age increases and may miss opportunities Opinion: delaying has dubious benefit.
  • 25. You take the call! Case #6Patient with severe injury after TIPS Know the callerWife of 40-year-old man who hadTIPS procedure about two years prior Get the facts man developed severe injuryon back at level of liver that progressed inmanner characteristic of radiation injury.Injury down to level of spine. Had threeTIPS procedures in a week. Cause of woundmisdiagnosed by physicians for 10 monthsafter symptoms; and wife, not physicians,diagnosed problem. Concern why did this occur and why can doctors notrecognize it and do something about it?
  • 26. You take the call! Case #6Patient with severe in jury after TIPSThink before responding --- Patient is very sensible and wants psychological resolutionabout the factors behind the events Cause of problem was inexperienced radiologist Patient was at crossroads of new procedures and lack ofknowledge by physicians about radiation injury fromfluoroscopy Case is essential for teaching
  • 27. You take the call! Case #6Patient with severe in jury after TIPSAdvice Discussed situation with patient for four hours. To reimburse me for my time I asked them to send me alldocuments on the case to be used for educational purposes.
  • 28. You take the call! Case #7Patient gets rash after lumbar spine series Know the callerRadiologist had inquiry from maleconstruction worker about rash on abdomen. Get the facts about 1 year prior man had x-ray seriesfor lumbar spine after construction accident. Studyperformed at clinic where many such studies are done.Problem with exam and study was repeated for a total ofabout 14 films. Rash developed soon after study thendiminished. Now has rash on abdomen that he believes iscaused by the x rays. Patient behaves normally. Concern is rash caused by x-rays?
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