CardioExchange Archive

Three weeks ago, Cedars-Sinai Medical Center in Los Angeles revealed that since February 2008, 206 patients undergoing CT brain perfusion scans at their hospital routinely received radiation doses 8 times what they should have been. The hospital only became aware of the problem after a patient complained of patchy hair loss. The good news is that the scans were performed in older patients, making it less likely that significant long-term complications, such as brain cancer, will result. While much of what happened remains unclear, the error appears to have resulted when the factory settings were reconfigured to perform this relatively distinct procedure. To its credit, Cedars-Sinai has been forthcoming with details both to patients and the media, even as it conducts its own internal investigation. 

I find this story troubling for several reasons. First, the rapid increase in imaging is something we are all familiar with, especially in cardiology. In fact, imaging use has become almost casual in contemporary medicine. Recently, my friend, cardiologist Reza Fazel at Emory University, demonstrated the potential implications of this phenomenon on radiation exposure in the general population. However, I’m also troubled because I’ve become highly sensitive to how dependent I am on others to ensure the safety of CT scanners and similar imaging equipment, especially since Reza’s study. I’ve always felt lucky to practice in an environment where highly trained experts in radiation physics free me from day-to-day worry about this issue — but should I be reassured? And are others so lucky?
 
Of course, this last issue is critical. When something like this can happen at Cedars-Sinai, it’s hard not to worry about the rest of us. One can only imagine what is going on at the approximately 8000 CT scanners currently in operation across this country, many associated with free-standing centers (including the 45% of cardiology practices that reportedly lease or own a CT scanner). Kimberly Applegate, a radiologist at Emory University and an expert in radiation safety, noted that quality assurance and control regulations for CT scanners vary substantially by state. While the American College of Radiology and the American Association for Physicists in Medicine have taken leadership roles in defining CT safety and quality standards for accredited facilities, these are optional. For example, the Cedars-Sinai CT scanners were not accredited.
 
So what does all this mean? Drs. Fazel and Applegate have an ongoing bet about whether (or when) U.S. patients will need to provide informed consent for CT scans. While such a debate would have seemed far-fetched a few years ago, it is hard to imagine this idea not gaining traction in light of recent events. I suspect this will be especially true for populations particularly susceptible to long-term complications of radiation exposure, like young children. And if you don’t agree, ask yourself, would it matter to me where my child went for a head CT? 

In your practice, do you routinely discuss radiation exposure risks with patients undergoing cardiac CTA?
Do you ever adjust imaging protocols to the weight of the patient?
Do you know if bismuth shields are used on the thyroid during CT scans?