Author Question: X-ray Anomalies

Barry Asks:

I have a character who is getting X-rays for headaches and vision problems. The X- rays show some kind of anomaly on or near the brain which requires a CT scan for further investigation. The CT scan needs to show something. I said a shadow, but any anomaly would work which cannot be biopsied due to the location.

For the development of the plot I need the doctors not to be able to ascertain immediately if the object on the scan is malignant or benign. Could this scenario work and would doctors wait to see what develops, or is there another course of action they would suggest in the absence of a biopsy?

Jordyn Says:
Very interesting question, Barry.
First of all, you’re starting off with the wrong test. An x-ray (or plain film) is done merely to look at bones and is not the test indicated for your character’s condition. A skull series would merely show fracture or bony tumors. It doesn’t show brain tissue. Its primary indication is skull trauma– looking for certain types of fractures that might indicate the need for neurosurgical evaluation. 
What your character really needs, ultimately, is an MRI. This might solve both of your problems. The concern for a patient with headaches and vision problems is that they could have a brain tumor. An MRI has the ability, in some cases, to distinguish between malignant and benign tumors. So, if the tumor location is in an inoperable area, such as the pineal gland or corpus callosum, then you could build your scenario around this.
If, as the author, you want to have a wait and see period, then your option would be to have the tumor not be differentiated on MRI but small in size. Then, the doctors could do serial MRI’s every 3-6 months to see if the anomaly changes. 
However, the likely initial radiologic study of choice in the ER setting for your character’s symptoms would be a CT scan of the head. The reason for this is that CT scans are very quick (less than five minutes.) An MRI of the brain can take anywhere from 30-60 minutes and are more expensive. What will show on CT is something bright white. Tumors and blood show up bright white on CT scan. Then, follow-up for the patient would likely be neurosurgical evaluation with an MRI scan. 
The term “shadow” is more reserved for ultrasound studies according to the doctor I spoke with. So I would adjust your terminology in that aspect.
Best of luck with your novel! 

Principles of Radiation Exposure

Even as nurses, we’re exposed to radiation– particularly in critical care areas. X-rays can be taken by a portable machine in the ER and ICU for patients that are too sick to move. Taking critically ill patients to radiology for CT scans who need to be monitored closely during transport and during their procedure. Patients getting reductions of fractures and dislocations in the ER where they bring a different type of x-ray machine that can take successive pictures and the picture can stay on for several seconds. We call it a C-arm but I’m sure it has another technical name.

Let me just say one of the most challenging places to code a patient is in radiology. Particularly if you have to pull them out of scanner which I have had to do on occasion.

But I digress.

I-stock Photo

As nurses, we have to think about protecting ourselves and our patients from extra exposure to radiation. We can benefit our patients in a number of way by advocating for:

1. X-rays NOT to be done portably. Portable x-ray machines tend to expose the patient to a higher amount of radiation than taking them to the radiology department.

2. Advocating for lower level films or for no films. There are a couple of situations in pediatrics that are very specific to this. Let’s look at abdominal pain. The single biggest cause of abdominal pain in pediatrics is constipation– yes, I said it– poop. You can actually tell how constipated a patient is by doing a basic abdominal x-ray which is one of the lowest radiation exposures. I like it because it rules out something simple and likely first. If the patient is constipated– alleviate that and see if their pain improves. If not– further testing may be indicated. Versus sending them straight to the CT scanner for abdominal/pelvis films looking for appendicitis which is lower diagnostically on the list. Abdominal/pelvic CT’s also have one of the highest radiation exposures.

Another example of not using CT scans is in the case of minor head trauma and/or concussion. Lots of parents bring their children to the ER over concern for concussion expecting a CT to be done. A CT is not necessary to diagnose concussion– we can do that based on signs and symptoms.

A CT in this example is really used to diagnose a bleed that might require surgery. So we look for more specific clinical signs that might indicate a bleed. Persistent vomiting (three or more episodes), diminished level of consciousness, or a focal neuro deficit (like the patient can’t use their arm). Then CT scanning is more indicated.

We are becoming more concerned in pediatrics about lifetime radiation exposure. A baby/child who has multiple CT scans has a much longer life to live to worry about developing later cancer versus an adult who has the same amount of scanning.

3. Provide protection. In our department, this might be using lead aprons to cover reproductive organs while a pediatric patient is getting an arm fracture reduced. Screening for pregnancy if a girl is menstruating.

When we think of radiation exposure– four factors must be considered.

1. Time: The length of the exposure.
2. Dose: What was the level of radiation at the time?
3. Distance: How close was the patient to the exposure?
4. Shielding: Was the patient protected in any way?

Check this link for further information on the basics of radiation exposure.

Also a GREAT article: Everything You Ever Wanted to Know About Radiation and Cancer. 

What do you think about radiation exposure? Have you ever used it in a story line?