In a previous blog, How heartburn caused a patient to lose her left leg, I discussed the problems that might occur if you have an advanced imaging test (CT or ultrasound) without first being examined by a physician. This principle also lends itself to plain x-rays, which also should be performed after a physical exam.

Here’s a prime example: 6 year-old Caitlyn comes in to the ER with right wrist pain after a fall. Caitlyn and her parents first see a nurse who takes down the history; Caitlyn fell yesterday in gym class while playing kickball. She has been hurting in her forearm and it is swollen this morning. The nurse puts in an order for a forearm x-ray.

The exam is performed and read by the radiologist as negative, but the radiologist notes if there are symptoms referable to the wrist or elbow, a dedicated x-ray of the wrist or elbow is recommended. On physical exam by the Emergency Department physician, the patient is found to be point tender over the distal radius (at the wrist). X-rays of the wrist are ordered which are positive for a buckle fracture of the distal radius. Even in retrospect, the forearm x-rays do not show the fracture—the larger field of view limited the exam and precluded the detail needed to see the fracture.

Because of the rapid triage to imaging, the child was exposed to unnecessary radiation.

Another example—a 26 year-old man comes in with a two day history of nausea, anorexia (unwillingness to consume food) and abdominal pain. The triage nurse orders x-rays of the abdomen. On exam, the patient is point tender at McBurney’s point in the right lower quadrant and likely has acute appendicitis. A CT is ordered which confirms the diagnosis.   The x-rays, then, were of little utility.

Both of these example resulted in exposure to unnecessary radiation. A few x-rays alone will not lead to any appreciable risk of cancer, but every little bit counts, particularly in children. Not to mention the added cost. So the next time you’re in the ER, make sure you or your loved ones are examined before imaging is performed.

Rourke Stay is a radiologist and the Founder of Lightbulb Radiology.

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