mortals

All Will Be Revealed

The CT scan came as a panacea for us doctors. You had your patient slide through a donut-shaped machine, and in ten minutes, all was revealed, your hard-learned clinical exam prowess supplanted by an image that showed you the anatomy like the textbooks. And if there was something distorting that anatomy, you knew that, too. CT scanning made the art of diagnosis superfluous. There was no guessing, no wondering, no arcane probing needed to discern the mysteries of the deepest regions of the corpus.

Past generations of physicians would hold court and blather on about how to percuss, how to shift the dullness of the abdominal fluids, and how to listen with a cocked ear and then with the magical stethoscope that they caressed like a fine violin. Oh, the affectations were rampant, the effect often quite mesmerizing on medical students, much like the Catholic Latin Mass in the days of incense and Gregorian chant, a time of mystery and awe. And then the CT scan arrived, like a light bulb amidst candelabra; the old was swept away, unable to compete. Indeed, the CT scan has become as pervasive as kids wearing iPods or the Yankees winning baseball games. But I don’t use it, ever, any more. I don’t use it because it scares me.

You see, the most common abdominal emergency in a child is appendicitis. The pain is always the first sign, and then the kid feels nauseous and quits eating over the next few hours. And when do kids tell their moms they have belly pain? Usually after school, and then there is a delay for dinner time for the rest of the family, and the kid doesn’t get to the doctor or the ER until somewhere around nine p.m. By the time the kid is registered, seen by a physician, and had blood work done, the night is approaching eleven.

Then the call goes out to the surgeon, who is home asleep. The surgeon, who lives some distance from the medical center, will order his interns or residents to evaluate the child “for teaching purposes.” Uh-huh. And whether or not he has residents, he (and it is usually a he) will invariably whisper into the phone, “Get a CT scan.” The scan is definitive, nearly perfect, he thinks, and it allows for “purposeful procrastination,” since all surgeons know, if the public and plaintiffs’ lawyers do not, that a few hours’ delay will not cause the appendix to burst. By the time all is done, it is three or four a.m., by which time it’s so easy to say, “OK, book him for first case at seven thirty.”

So the surgeon gets excellent data from the CT, doesn’t hurt the kid, who is given a tad of morphine sulphate for the pain—and buys a few more hours of sleep. Thus, all is right with the world. But wait a minute, you need to know a few other things, like why I won't order a CT scan on a kid with belly pain.

Well, CT scans are not at all accurate in skinny kids, of which there are still quite a few. It’s a photographic imaging axiom that you need fat as a foil to see inflamed tissue. Adults store lots of fat inside the belly, making CT scanning the gold standard for diagnosing acute inflammation of any organ, including the appendix. By the late nineties, CT scanning was so good for diagnosing appendicitis in adults that everyone figured you could extrapolate it to kids. Wrong, pure and simple. If there is no fat inside the body, the CT scan misses appendicitis, and that is what happens with lots of kids.

And so why else don’t I use CT scans to evaluate the most common abdominal emergency in kids? Because it has now been shown that, for children, CT scans are like mini-Hiroshima bombs: four such scans on a kid are equivalent to the radiation exposure that the survivors were subjected to in 1945. Now that pediatric surgery has documented the potential ravages of this very costly imaging modality, I no longer allow it to be performed on kids with belly pain, and neither should you. I, a purebred Democrat, actually save the health-care system dollars, even while saving kids from future cancers. I come in and evaluate the kids instead of dialing them through a scanner. I put my hands on them instead of irradiating them.

The avoidance of CT scanning for common surgical emergencies has significantly improved care for many children, and when we are all disappeared, mere atoms of the universe, our names unremembered, they will be free of cancers that are triggered in their cells by the harsh radiating ions of a CT scanner, too often used for our convenience, the financial benefit of a hospital, and the sake of some physicians’ inability to make the diagnosis with their own God-given talents. All is revealed, but not necessarily by a CT scanner. Tell your doctor: “No CT scans—lay your hands on my child!”

BRIAN GILCHRIST, A77, M84, is chief of pediatric surgery and vice president of Elliot Hospital in Manchester, New Hampshire. He was formerly surgeon-in-chief at the Floating Hospital for Children at Tufts Medical Center.