CT and radiation exposure

My colleagues in the ER so often amaze me.  I have immense respect and admiration for how they manage such a challenging task.  Every day can bring catastrophe–or several–that can be heartbreaking or terrifying, and they face this while addressing a veritable flood of minor or chronic problems which, by training, are more outside their domain.  Yet there they are, juggling those diverse situations with such grace, compassion, and skill.

Not to sound critical, but as a primary caregiver there are circumstances when a cautious and deliberate approach may be preferable, but that can be immensely difficult in the ER where by necessity the focus must be on NOW.  That fraught difference may best be illustrated in the approach to CT imaging.  All good docs in and out of the ER nowadays try to keep in mind the risks of exposure to ionizing radiation.  People are subject to small amounts of radiation normally every day. A typical chest xray exposes one to 10 days and a CT scan to a whopping 8 months worth(that, itself, represents improvement in technology–it used to be 5x that amount)

Now, in many instances–and especially in the ER–the information obtained from CT scan is absolutely essential to make an accurate diagnosis and protect the patient.  But the reality is that we know that radiation exposure increases the risk of cancer.  We know the effect is cumulative and therefore greater for children. But we really don’t know HOW MUCH is a risk–where is the threshold?

So there is reason for caution but certainly not for panic.  For example, in one specific instance–head trauma–CT scans are indicated if there was loss of consciousness, amnesia, severe or worsening headache, vomiting, of if the person was drinking when they were injured.  Outside of those situations, CT is unlikely to add useful information.

Generally speaking, when confronted with these choices in the ER (or anywhere) keep these principles in mind:

• As a parent or caregiver you always have a choice.  It is important that you have all the information
• Is there a clear medical benefit for conducting a CT scan
• Are there other tests (such as an MRI or ultrasound) or actions (such as observation) that could safely take the place of the CT
• If a CT is indicated, ask to make sure that the scan settings are adjusted to the size and weight of your child
• Explain to your child that the scanner looks like a donut, they should lay flat and still, and that the test will be quick and will not hurt.  Sedation may be necessary for that purpose.
• Avoid multiple scans.  Note the number of scans.  Keep my office informed so that we can track the total over time.

Remember that in the large majority of these situations the ER doctor is an experienced expert who is focused on what is best for your child and usually his advise is your best bet.  But also remember that the ER doc should listen to you, too.   In the unlikely event that you are unclear on that side of it, call–let me help to clarify the situation for you and to advocate on your behalf there.  That’s my job.

Thanks for following.

 

Teens and Tats

I don’t at all get the piercings and tattoos.  But why would I?  I’m 61 and a grandfather: this is not from my era.  However, that does not make it “bad” or “wrong.” For my generation it was love beads, long hair and sideburns, and bell bottoms.  As children advance to adolescence and young adulthood, its normal to endeavor to express one’s unique identity.  Often that entails some breaking of those conventions that these young people associate with established, parental authority.  By itself, this is not at all unhealthy and I counsel parents to maintain a light touch and give your emerging young adult significant freedom to chose here.

Please allow me to add that, given the above, I also think it fair for you to inform your teen seeking body modification that they are free to make their decisions about their bodies and they are also free to pay for those choices themselves–you parents who are disinclined are under no financial obligation in these areas.  Freedom cuts both ways–right?

A recent article in the New England Journal of Medicine reviewed current data on this fashion phenomenon.  Among its findings:

• Current data no longer supports the concept that body modification occurs primarily among high risk youth and it should not be confused with non-suicidal self injury.
• Body piercing jewelry generally consists of hoops, rings, studs, or barbell shapes and are made of stainless steel, gold, niobium, titanium, or alloys.  Most piercing guns are not sterilized.
• Scarification creates words and images in the skin through cutting, burning, branding.  Artist experience in this field is quite variable, so caution is advised
• Carefully monitor the establishment for essential hygiene: sterile gloves, use only equipment from freshly opened packages, sterile needles, use only fresh, unused ink poured into sterile containers
• Adolescents should understand that visible body modification may negatively effect employment prospects
• Serious complications are uncommon but include inflammation, bacterial or viral infections at the site, infected blood vessels at the site(rare)– typically 4-22 days after placement
• “Q switched” laser is the preferred method
• Cleanse new oral piercings with nonprescription oral cleansers (mouthwash).  Tongue piercings have a high rate of tooth chipping
• Healing times are –clitoris, urethral meatus, tongue 2-6 wks; nipples 2-4 months; 9 months for navel or head of penis
• Up to 35% of ear piercings develop mild complications including pain, bleeding, bruising, cysts, allergic reactions, hypertrophic scars (keloids). Scarification techniques carries similar risks
• Children with diabetes, HIV, cystic fibrosis, or taking immunosuppressive agents are at increased risk for complications.

So let’s be safe.  But remember: you nurtured that little child so that (s)he can grow up to be a free thinking, independent, and autonomous person in their own right.  This is very much of that process, so it is to be managed but cherished as an important part of their growth, development, and self actualization.  As the French say–c’est la vie!!

Send along questions or comments and thanks for following