Tuesday, August 10, 2010

Radiation: From Three Mile Island to Daily Family Medicine

"A massive uncontrolled release of radioactive material from a Nuclear Reactor at Three Mile Island occurred this morning."

I remember hearing that radio broadcast in March of 1979 in the Milton S. Hershey Medical Center where I was a third year resident in family practice (now family medicine).  I had a pregnant wife and two children who suddenly occupied my thoughts.  They were home in our apartment on the grounds of the Medical Center.  It was Friday morning.  Rounds just ended on Gyn Oncology and all our patients were discharged.  Word from the attending physician was to feel free to do whatever was necessary for ourselves, depending on responsibilities to other services and call schedules.

I had no call for the weekend, and the hospital was being evacuated, so I called my wife immediately with instructions to pack up the kids and all our photos and the lock box with important documents.  The nuclear problem could become deadly.  I got to our apartment and had an intense, strangely empty, familiar feeling.  I heard the popular hit song "Music Box Dancer" playing on our radio as we drove off and frequently for the next few days.  When I hear it now, I get the intense, strangely empty feeling, associated with a fear about harm coming to my wife and sons.  It was a feeling that I had a few times as an Army officer in Viet Nam, where I flew helicopters for the Army Engineers.  Those times were associated with very serious danger or death.  Like the day during Operation Lam Son 719 near Khe Sanh when the US had over 75 helicopters shot down, with significant casualties.  We left Hershey for a Washington, D. C. weekend and the feeling disappeared about 50 miles away.

Years later, when they opened the reactor at Three Mile Island, they found that it had experienced a partial melt-down.  The nuclear engineers involved with the Medical Center in 1979 assured us that there was absolutely no chance that such a thing would ever happen because it wasn't in the nuclear reactor literature.  Basically, it couldn't happen because it had never happened.  That is good "Evidence Based Thinking".  I've been skeptical about an over reliance on "the literature" ever since 1979. 

We Hershey Medical Center residents who were in the AMA Resident Physicians Section wrote a resolution about radiation safety for our AMA RPS Annual Meeting to warn of the dangers of radiation, but our colleagues laughed it off and defeated it.  It wasn't a problem.  We were disappointed that we couldn't communicate better about the unknown radioactive world beyond the limits of the medical literature.

Within four years, the wife of my co-author on the defeated AMA RPS nuclear safety resolution died of an unusual breast cancer (in her 20's) diagnosed shortly after the birth of their son.  Our baby was born with congenital spinal cord tumors, requiring multiple surgeries between ages 4 and 7.

Sometimes these events get one's attention.  Use of radiation in medical  imaging is now expanding dramatically.  I now cringe at patient stories of CT scans done for this or that abdominal or chest pain or neck pain (e.g., a palpable sternocleidomastoid spasm after a described minor trauma).  The serial CT scans to follow an incidental finding of pulmonary nodule, which happens in about  35 % of CT scans of the chest is worrisome.  One study noted that about 11/2% (one and one half percent) of the nodules might become something serious, but usually would show up some other way if left alone.  If a CT scan is done to evaluate a person with flank pain, enough lung base is uncovered to often identify a pulmonary nodule.  Then, they are recommended for "serial CT scans" of the chest every three to six months for three years.

The radiation of  a Computed Tomography scan, aka, CT scan is equivalent to 400 to 600 chest X-Rays.  Different techniques may reduce the radiation, but not a lot, if you ask for hard data (I know sometimes the literature is unreliable, but agreement on the subject is now convincing the FDA to pursue better radiation safety).  You might think that you would be informed about the exact risk of each CT scan if you're the patient, and give "informed consent" in writing (e.g., sign a form), but that usually isn't the case. They don't even have a consent form for CT scans at the two emergency departments that I relate to in a big system of six hospitals.  Don't you think we would be safer if people had an informed choice about the decision to do the CT Scan?  If the doctor ordering the test had to clarify risks and benefits for the patient or patient's parent or guardian, and get a signature, would we have more comfort in our decisions?  Would the decision be sometimes negotiated into a more mutually favorable outcome?

Our use (overuse?) of CT scans is now estimated to cause 27,000 (twenty-seven thousand) cancers per year in another 5 years.  How many of those patients needed the scans?  Physicians would say that most of them did.  How many were informed of the risks versus the benefits?  No one has the data because patients weren't informed in the way we have to inform them of even minor surgeries.  Risks versus benefits. 

If a test had a two percent chance of causing you to get cancer in twenty years would you get it?  What if the problem the doctor has at the top of her probabilities for you (her differential diagnosis) has a ten percent chance of death in two days without the CT scan?  If you had the recurrence of a kidney stone after ten years without one and the first stone passed on the same day with no residual effects, would you want a CT scan to be sure it was really  a kidney stone? Or a urinalysis and a quick history and physical instead of a two percent chance of cancer twenty years later?  These tests are ordered so quickly that the consent form must be insinuated into the process to basically call a timeout in knee-jerk decision making.  Isn't a short explanation of risks and benefits owed to the 27,000 who will get cancer?  When did our physicians opt for these expensive, dangerous shortcuts?  We have to rethink our commitment to "First, do no harm."

Three Mile Island jitters are coming back to me as I hear story after story from my patients about CT after CT after CT scan, none of them with informed consent.  I don't want to hear the "Music Box Dancer" playing in my head every time I'm near a hospital or emergency department.

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