In the pediatric emergency setting, Poirier says it is more likely that the clinicians will utilize the available information to talk families out of getting an unnecessary test. "They may come with preconceived expectations," he says. "Maybe they were sent from the adult facility or from another provider because they 'need' this head CT or they 'need' that abdominal CT—and in fact, they don't. We very frequently explain to them that we don't want to expose the child to any unnecessary radiation, and therefore, we don't think this test is necessary."
How significant a role "defensive medicine" plays in the decision-making process is unclear, although studies have shown that the fear of litigation increases utilization of all imaging, not just CT. The fear of being sued for missing a diagnosis could someday be countered by the fear of being sued for exposing a child to radiation unnecessarily—a rock/hard place debate if ever there was one.
"All you can do is apply the best information you have with your best clinical judgment and try to do what's right for the patient," Graykoski says, "and hope that in 20 years some lawyer doesn't come knocking on your door, saying 'pay up.' But I think for all of us, our motivation and training is 'first, do no harm,' and we all take that very seriously."
Will CT one day be a diagnostic modality for which informed consent is universally required? Or will advances in technology continue to occur, producing safer scanners? Larson, for one, defends the judicious use of CT, saying, "It keeps getting better and better, and the manufacturers are continuing to decrease the radiation dose. So I expect it's going to continue to be important for a long time."
As technology improves, other modalities may emerge as more valuable diagnostic tools in certain situations, providing alternatives to CT. "I think in the next 10 to 15 years, we're probably going to be shifting to high-speed MRIs, which don't have the radiation exposure," Poirier says. "And we're going to look back at this time, in the '80s and '90s, when the use of CT scans basically just exploded, and we're going to be dealing with the consequences."
Graykoski also points out that ultrasound "is becoming a viable alternative to CT in the case of appendicitis. The key now is training the ultrasonographers and having the quality in place to ensure that the accuracy is at a point where it should be."
Clinicians should also remember that the radiologist is another partner and a valuable human asset in patient care. He or she should be reviewing the orders, particularly the indication for the request, and may follow up if the order doesn't make sense.
"Try to avoid becoming defensive and understand that the radiologist usually views himself/herself as a last stand in confirming that this is an appropriate examination," Larson advises. "Often, the radiologist can offer alternative imaging or talk the clinician through a case that is on the margin in terms of whether CT is indicated."
Deciding whether to order CT in a child is about striking an appropriate balance. "On the one hand, we might say, 'If you don't need the CT, don't get it,' or 'If there is a reasonable alternative, then go with that reasonable alternative,'" Larson says. "On the other hand, if there is a serious or life-threatening illness or injury, or a case where you really need that information, then the parent and the clinician should absolutely just get the CT and not give it a second thought."
Poirier thinks there is a place for observation and for ruling out life-threatening and dangerous diagnoses, "but there's also a place for having an unknown and letting time help you decide, with close follow-up and appropriate observation. And therefore, sometimes you are able to avoid performing one of these tests. You're going to get the same information; you're just going to get it a little later. That's the art of medicine—knowing when to order it and knowing when not to."
"The bottom line is that medical science is a human science, and there are no absolutes," Graykoski says. "You can do your best, but you cannot predict the future. We graduate and get a stethoscope; we don't get a crystal ball."