I just had a most disturbing chat about the excessive use of CT scans with a MSK patient I am going to call “Athena“.
“I wanted u to know I’ve been diagnosed with leiomyosarcoma …
Which they think could have been caused the high doses of repeated radiation from CT scans.“
(I learned from my friend Google) is a fast spreading cancer and with a 63% survival rate for stage 1. Athena will be having part of her uterus removed to try and stop it’s spread. There is also a “dark spot” on her liver that doctors are concerned about.
The dangers of CT scans are not well understood by most people and MSK patients need to be extra aware of the dangers because of the prevalence of over use in the detection of kidney stones… and so, the chat quickly turned into more of an interview:
La Velle: How old are you?
La Velle: “Could you estimate how many CT scans and x rays you have had in your lifetime?
Athena: “I’ve had about 200 X-rays n about 150 cat scans or more.”
La Velle: “What was usually the reason they would do a CT scan?”
Athena: “To check for stones n the size. Anytime I go to the hospital they don’t want to help me in anyway unless I get a cat-scan because that’s their best way to determine stones.”
This is not the first time I have heard about CT scans, in the States, being performed over and over with little regard for the damage being done. This is interesting to me, because I live in Canada, where doctors don’t typically subject patients to that much radiation by the time they’re 27 years old… and our medical standards are on par with the USA. So, why the frightening over use in the USA?
La Velle: “After they would confirm a stone and the size, how did it change the treatment they would give you?”
Athena: “They usually will ship me by ambulance 4 hours away saying they ‘don’t have the technology’. Or ‘the doctors there will be better for me’. Or they’d give me a dose of Dilaudid n send me home with Tramadol.”
La Velle: “Is your understanding that they were using the CT scans and X-rays to make sure that you actually needed pain meds? Or do you think that they were really necessary to be sure of what treatment would be best?”
Athena: “To make sure I needed pain meds. . The evidence from ultrasounds let them know I had stones, hydronephrosis, or enlarged kidney plus bloody urine; But they’d still insist on cat-scans.”
According to my nephrologist, Athena is not wrong about that – Ultrasounds along with the patient’s symptoms and urine tests will give a doctor a pretty good idea of what is going on with a patient’s urinary tract without subjecting them to the radiation of CT (the radiation of a CT is much higher than normal X-rays).
La Velle: “This is infuriating.”
Athena: “I know, but if I didn’t do what they wanted I wouldn’t get treatment. Last time I refused they waited 5 weeks with a 3 stone blockage in my kidney before they would even put a stent in and that’s because I refused a ct. They just gave me meds n a strainer n told me to wait til I pass it.”
Athena, you see, had been subjected to so many CT scans and X-rays in the past that radiologists had told her doctors “absolutely no more cat scans unless it’s life or death.”
Athena: “But they still ordered them n every time I refused I got treated like a druggie.”
Feeling the need to ‘defend’ herself from further CT scans, she refused to have another one done after an Ultrasound and KUB revealed the 3 stones blocking. She felt that was sufficient information to warrant a stent with no further testing and that is what she asked the doctors to do for her. The doctors claimed however, that they first needed a CT scan ‘to determine if the stones were small enough for her to pass them on her own’ or whether she might need surgery. After Athena refused the CT scan, the same doctors sent her home claiming they were confident that she would pass them fine on her own with Flomax and increased fluids. The stent was refused.
Some might argue that the CT scan Athena refused was one she actually needed given that she had a blockage. Maybe. Maybe not. None the less, her sense that she needed to avoid the CT should have been understood given her circumstances. She has the right to self determination. She has the right to accept or refuse any medical treatment and exercising that right should in no way change the doctor’s objective and obligation to provide the best possible medical care.
After being sent home that day, Athena sat on that blockage for 5 weeks. The situation reached critical mass when she found herself in so much pain, and her blood pressure so high, she suffered a mini stroke. She was admitted to hospital, and a CT scan was done at that point because, as she put it “it was either that or die.”
So what difference did the CT scan make in her treatment? In the end, they did exactly what she had asked for in the first place. They put in a stent in order to help the stones pass. After another month, surgery was performed to remove the blocking stones. Clearly, the stent could have been put in place from the beginning, even without a CT scan and, if after a month they had not passed, surgery could have been scheduled. So the CT scan that the hospital insisted on really appears to have been unnecessary.
If Athena were a patient with no history of stones or someone who didn’t have MSK, it might make sense for doctors to insist on a CT scan before treating her, but her painful history is well documented. There is a long history of frequent stones as well as CT scans and surely, a sense of how big the stones likely were could have been extrapolated from that.
In a manner of speaking, Athena’s medical treatment was held for ransom. The question is, why?
For lack of any reasonable excuses, it appears hospital staff took her refusal of a CT scan as license to deny her treatment for what they knew was a blockage, placing her at increased risk of more serious medical issues.
My outrage over this girls’ treatment is partly due to the difference between the treatment we each receive (me in Canada and her in the States) because it appears to makes no sense unless you look at the non-medical aspects of the problem.
Here in Canada doctors make limited use of CT scans and X-rays in their treatment of kidney stones. The reason is that ultimately, the damage caused by radiation does not justify what they actually learn from the scans and while Ultrasound is not as clear cut- between the patient’s symptoms an Ultrasound and urinalysis, doctors can get a very good idea of what is happening with a patient without exposing them to harmful radiation. Certainly it is a good enough picture to make decisions about how to move forward with treatment in the case of a blockage. Further, little known is the fact that CT scans routinely miss kidney stones all together and in those cases, treatment waits until the situation becomes more critical anyway.
Why is this approach so different from doctors in the US? Athena and many other MSK patients in the USA have indicated to me that they are often given CT scans as soon as they complain of abdominal or flank pain. (Which is how Athena wound up having had so many by the age of 27.)
There are several things that appear to be driving the differences in treatment.
First and foremost, on both sides of the border, is money.
In Canada, doctors are discouraged from using expensive tests and scans frivolously. The reason for that is that our healthcare system is universal. We pay a healthy tax premium for that privilege. But to maintain the sustainability of the system, doctors can’t be subjecting every case of abdominal or flank pain to CT scans and X-rays. So they think more carefully about when these tests are really necessary and use them accordingly. Canadian doctors offices and hospitals are also not run as for profit businesses, giving them incentive to order unnecessary scans.
In the USA, the medical system is set up as a for profit industry. Doctors are paid more and hospitals charge more for each test and scan they send you for. Costs are inflated such that the average bill for hospital stays, testing, etc. is 3-4 times higher in the States than if a US citizen were to come to Canada and pay out of pocket for the very same services. So doctors in the States have a vested interest in making sure they are giving you every test and scan they can in the treatment of your disease. There is an incentive to “up-sell” as it were.
The next culprit is the “war on drugs.” In Canada, we have drug addicted people just like in the States. And, we have people who are responsible to make sure doctors are not abusing their authority to prescribe narcotics however, they are not actively encouraging hysteria over the narcotics that are legitimately prescribed to patients who need it to treat chronic pain and there is no “war on drugs” propaganda being piped through the media.That whole thing is creating twisted misconceptions about the use of narcotic pain medication such that patients who are “dependent” on narcotic pain medication (meaning, their medical condition genuinely requires narcotic pain medication in order for them to function from day to day) are erroneously labeled “addicts” (which is actually what a person who doesn’t have a condition that requires narcotic pain medication is when they can’t get through a day without narcotics.)
In the USA, the DEA and its policies are pushing doctors to ignore their medical training in an effort to avoid losing their medical licenses which forces them to act in ways that are contrary to the best interest of their patients. DEA agents are not doctors and thus have no medical expertise to know if a patient genuinely needs narcotic medications- yet they are ultimately the ones who are driving these bad medical decisions in many cases. So some doctors are using CT scans as a tool to prove they are not giving drug seekers narcotic scripts instead of using CT scans to properly diagnose and treat disease.
Furthering what I think can be accurately called “narcotic hysteria” is that there truly are drug seekers who try to fake kidney stones (and other painful ailments) in their efforts to get doctors to feed their addictions. Doctors are in a position that compels them to do what is reasonable to avoid giving seekers narcotics. For their own peace of mind, CT scans are (unreasonably) being used as a tool to filter out the addicts- to the medical detriment of legitimate patients.
This approach is giving some patients the false impression that CT scans are an important part of the process whenever they have a sudden sharp pain. A doctor’s failure to send those patients for CT scans is perceived as a failure to provide proper treatment when nothing could be further from the truth.
In my opinion a doctor who refuses to give a patient a CT scan for the purpose of ‘finding out if their pain is being caused by a stone’ is probably a pretty good doctor- because he/she is choosing what is in the best interest of the patient over personal gain. When a doctor is willing to do that, even in the face of a patient who is pushing for the CT scan, it suggests he or she has some integrity and genuine concern for the patient’s health and well being.
If you have MSK and you have pain that feels like a stone, it probably is. There is no need to subject yourself to radiation to know for sure. Knowing will not make the stone less painful when it passes. In a lot of cases, the CT scan makes zero difference in how your treatment will be carried out.
Bottom line is this: The radiation from CT scans is dangerous. There is no “safe” radiation. The more you are exposed, the higher your risk for cancer in the future. So it is smart to reserve CT scans for the times when they are really necessary. Before agreeing to have one, ask lots of questions about the reasons for the scan, how it will change your treatment if you have the scan and if you don’t. Ask about what will happen if the scan misses the stone. Ask what the CT is going to provide over Ultrasound, urine tests and symptom analysis and ask the doctor to explain why that is sufficient reason to expose you to the high radiation levels of a CT scan. Avoid doctors that use them as a screening tool for addicts and try to surround yourself with doctors that won’t subject you to high levels of radiation needlessly.
I think it is wise to think of each CT scan, KUB and X-ray as steps toward a cancer diagnosis and to utilize them accordingly.