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Patient Exposure

There are three problems that are associated with increases in patient exposure which are lack of physician knowledge, lack of patient awareness and physician’s practice of defensive medicine. These issues have led to an increase in patient radiation dose every year. From 1996 to 2010 overexposure due to radiation has doubled. (Bardi, p. 2) This is an alarming stat and shows that we need to really focus on this issue in the future. Another alarming stat is that Americans received seven times more radiation exposure from medical tests in 2006 than in the 1980’s.

Biomedical Instrumentation & Technology, p. 359) I believe that some of the reason for that is because the machinery has advanced so much over time that an exam can be done at a fraction of the time it would take them to do so in the past. Another reason is that computed tomography also known as CT has become more popular. Many exams that would have required x-rays have now been done in CT instead. A problem with this is that CT exposed the patient to more radiation than an x-ray would. To fully understand these issues you need to know the risks of radiation and the effects on a person who is exposed.

X-rays are electromagnetic rays that pass through the patient allowing the radiographer to see inside the patient due to the different types of attenuation of the body. These x-rays can cause harm to a person if used improperly or overexposed. The way they do that is through ionizing radiation. Ionizing radiation is when the x-ray particle goes into the body and they carry enough energy to remove an electron from an atom, thereby causing biological harm to the recipient. This damage can go as far as death or sterilization, which is why these issues need to be addressed.

The problem with ionizing radiation inside a human being is that there are three things that can happen. The cell dies, the cell can repair itself, or the cell mutates and becomes cancerous. Not all cells go through the same effects of ionization. Cells that reproduce the most and aren’t specialized are the most vulnerable. The human fetus is an excellent example of both of these characteristics, which is why x-rays and pregnancy are not a good combination. Radiation can be used to kill cancer cells in radiation therapy by narrowing down to a pin point where the ionizing radiation will take place.

Even then they run the chance of damaging or killing cells around the cancer site. The amount of radiation you are exposed to depends on the part of the body that needs to be radiographed. The part of the body may also have different densities inside such as organs and bones. Most often in x-ray it is the bones that we are concerned about or that is the reason for the examination. If the part of the body contains more dense structures the exam will require a higher dose of radiation. The reason that this is so important is because these physicians are the ones that are ordering these exams on patients.

Some of the time the physician wants to see the progress of the patient so they order reoccurring exams. The same patient can be exposed up to three times a day. Some will say that is overexposure. Basically what it comes down to is does the benefit of the exam outweigh the risks involved. X-rays are carcinogens and should only be used when absolutely necessary. Some physicians don’t see it that way. They want the exam they ordered to be done when they say for it to be done. Sometimes this can lead to an issue internally because the exam is not done in time or the radiographer does not think that the exam is necessary.

Guidelines need to be set in order for everyone as a whole to say that an exam should be done and when the exam is not called for. It is bad when insurance companies say that 20% to 50% of all high tech imaging provide no useful information and may be unnecessary. (Rao, p. 574) Like everyone else, physicians are only human. Nobody is perfect, and people are bound to make mistakes. There are times when patients come in and the physician may order the incorrect exam. The radiographer should catch on to this, but if he or she does not, the patient has just been unnecessarily exposed.

The main point is that x-rays are ionizing radiation and can cause biological harm to the human body. If we can avoid exposing the patient then we should by all means do so. The next step is to figure out how to correct this problem. There have been a number of suggestions like tutorials and workshops that can deliver valuable knowledge to the physician regarding radiation. These classes should not be limited to just physicians. I believe that anybody with interest in radiology and radiation should attend. Each hospital should make attendance mandatory for all employees to at least one of these classes.

There also should be informational packets readily available within the department. The class can be run just like a CPR course. You would have to get radiation certified every year or two. Patient awareness is another problem that is causing the radiation rate for the general public to increase yearly. In a survey done in Canada, the majority of the patients being tested were not informed of the radiation risks associated with the exams they were scheduled to have. I find this somewhat hard to believe. Part of the radiographer’s job is to thoroughly explain the procedure.

Is the radiation risk involved with the exam a conversation that you would like to have with a patient before an exam? I believe that the necessary information should be given to the patient by the ordering physician. This comes back again to the first problem we observed, which was lack of physician knowledge. In order for the physician to be able to break down the radiation risks involved with the exams, they must first familiarize themselves with the risks involved in diagnostic imaging. We all can’t point our fingers at the physicians and pretend that we are not responsible.

Good patient care does involve making sure the patient is fully aware of what’s happening during the exam. Radiographers should also let the patient know that they have the right to refuse the exam, if they don’t want it to be done for whatever reason. If a female patient within childbearing age has an exam ordered, she must first take a pregnancy test. If no test is given she must sign a pregnancy waiver in order for the radiographer to begin the exam. The fetus contains cells that are rapidly reproducing. The cells in the fetus are also not specialized.

According to the law of Bergonie and Tribondeau the radiosensitivity of a tissue is increased the greater the number of undifferentiated cells in the tissue. The greater the mitotic activity, and the greater the length of time that they are actively multiplying also increases the sensitivity. This means that the tissues found in the fetus are highly radiosensitive. Therefore it is highly recommended that you avoid the radiology department if you are pregnant. Now a days, when you receive the news that you are in need of a diagnostic imaging exam, the first thing you do is google the exam.

We all do it, for the little added comfort of knowing what is going to happen to us. If we can go as far as googling the exam, what is stopping us from checking the risks associated with the radiation we receive during these exams? We would find that, “according to a March 2009 report by the National Council on Radiation Protection & Measurements, the total exposure of the U. S. population to ionizing radiation over the past 2 decades has nearly doubled. ” (Moore, p. 250) They go on to say the rise is due to the increased exposure from higher-dose procedures such as CT, nuclear medicine, and interventional fluoroscopy.

Another thing is sometimes we are talking about minors who cannot make their own decisions. These decisions are made by a parent or guardian. Sometimes these guardians are the ones who can prevent their child from going through with an unnecessary exam. They think that if the doctor deems it necessary than that is the case. We have seen that sometimes the physicians are lacking of knowledge in radiation and risks to the patient. How can we increase patient awareness of ionizing radiation? I believe the radiographer should be able to inform the patient of the risks of ionizing radiation before going ahead with the procedure.

The issue for the patient is that it would be difficult to find out the amount or dose that they were exposed to. I think that in the future there should be some sort of dose registry. This dose registry would give the hospital staff and the patient the chance to monitor their radiation dose. This would hopefully lead to a decrease in overexposure and limit the amount exams performed on a single patient. The third and final issue I will be discussing is physicians’ practice of defensive medicine. I know we have all seen it before when a patient comes in complaining of wrist pain.

The doctor orders a hand, wrist, forearm, and elbow. The reason for this is that the doctor wants to cover himself in the rare case that he manages to miss the diagnosis. The sad part is we live in a world where everybody is looking for a quick easy way of making money. A lawsuit against a doctor is one way of doing so. “Radiology is one of the specialties most liable to claims of medical negligence. ” (Pinto, p. 275) Another case is if the patient is complaining of chest pain or shortness of breath the physician orders a portable chest x-ray in the ER.

If the patient comes in complaining of pain in any extremity and doesn’t really display any signs of a fracture the physician will order an x-ray anyway just in case. What happens is that all these x-rays add up. If they are not necessary then we have exposed these patients to radiation when they did not need to be. The institute of Medicine defines error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” and estimates that between 44,000 and 98,000 Americans die each year because of medical errors. Pinto, p. 275)

The point is that it has become way too common for doctors to order x-rays to patients in the Emergency Room. While I was at a clinical site during one of my rotations through the hospitals, there was a doctor in the ER who became infamous for ordering portable chest x-rays. Every day that he was there we would receive almost double the portable chest x-rays. I asked the tech that I was working with one day what is the reasoning for this? She told me that he just likes to order chest x-rays for most of the patients to come in.

That is how he does things. I found that was rather odd. In writing this paper I even felt that the doctor was in the wrong in how he was doing things. This doctor can’t be the only one in the medical field doing this. He is just the one that I came across during my clinical rotations. What makes it even worse is that some doctors are like this except their preferred modality is CT. During a CT scan the patient can receive a very powerful dose of radiation. It is known that a single CT scan can emit as much or even more radiation than 200 chest x-rays.

Economic incentive is also a powerful influence. ” (Richardson, p. 182) Some healthcare institutions pay a lot of money for these newer CT machines. At the same time these CT scan generate these institutions a lot of money. A CT scan makes more money than an x-ray. Overall, clinicians should have an increased awareness of the problem, realize there are uncertainties, and prevent unnecessary health risks when possible. We should all remember to “First do no harm. ” (Richardson, p. 184) What can we do to resolve this issue?

In order to effectively combat this issue we must address it at three different levels. These levels are at the systems level, at the institutional level, and at the clinician level. We must come up with an effective plan that can incorporate all three levels working for the combined goal, which is patient safety. Newer technologies such as dual source CT are also being implemented. This newer form of CT is said to produce better images at a faster speed while using half the radiation needed for traditional CT. Another way is to promote other modalities such as MRI.

The necessity of the scan should also be carefully evaluated. For example, a “wait and see” approach can also be considered in stable or minor situations or for those patients wishing to avoid a high-tech approach initially. (Richardson, p. 182) There also should be a radiation dose registry, that can monitor the amount of radiation a patient is receiving and send an alert if their exposure rate gets too high. This will involve the sharing of data between institutions and insurance companies, but whatever will make this work should be in discussion.

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