X-Rays and Unshielded Infants

It was well after midnight when Dr. Salvatore J. A. Sclafani finally hit the “send” button.

Soon, colleagues would awake to his e-mail, expressing his anguish and shame over the discovery that the tiniest, most vulnerable of all patients — premature babies — had been over-radiated in the department he ran atState University of New YorkDownstate Medical Center in Brooklyn.

A day earlier, Dr. Sclafani noticed that a newborn had been irradiated from head to toe — with no gonadal shielding — even though only a simple chest X-rayhad been ordered.

“I was mortified,” he wrote on July 27, 2007. Worse, technologists had given the same baby about 10 of these whole-body X-rays. “Full, unabashed, total irradiation of a neonate,” Dr. Sclafani said, adding, “This poor, defenseless baby.”

And the problems did not end there. Dr. John Amodio, the hospital’s new pediatric radiologist, found that full-body X-rays of premature babies had occurred often, that radiation levels on powerful CT scanners had been set too high for infants, and that babies had been poorly positioned, making it hard for doctors to interpret the images.

The hospital had done the full-body X-rays, known as “babygrams,” even though they had been largely discredited because of concerns about the potential harm of radiation on the young. Dr. Sclafani and Dr. Amodio quickly stopped the babygrams and instituted tight controls on how and when radiation was used on babies, according to doctors who work there. But the hospital never reported the problems in the unit to state health officials as required.

A little over a week ago, after The New York Times asked about the situation at Downstate, the state health commissioner, Dr. Nirav R. Shah, ordered two offices of the department to investigate.

“Our investigators will pull films, they will examine the medical records and they will interview relevant staff,” said Claudia Hutton, the department’s director of public affairs. “Our authority to investigate goes basically as far as we need it to go.”

The errors at Downstate raise broader questions about the competence, training and oversight of technologists who operate radiological equipment that is becoming increasingly complex and powerful. If technologists could not properly take a simple chest X-ray, how can they be expected to safely operate CT scanners or linear accelerators?

This poor, defenseless baby..

With technologists in many states lightly regulated, or not at all, their own professional group is calling for greater oversight and standards. For 12 years, the American Society of Radiologic Technologists has lobbied Congress to pass a bill that would establish minimum educational and certification requirements, not only for technologists, but also for medical physicists and people in 10 other occupations in medical imaging and radiation therapy.

Yet even with broad bipartisan support, the association said, and the backing of 26 organizations representing more than 500,000 health professionals, Congress has yet to pass what has become known as the CARE bill because, supporters say, it lacks a powerful legislator to champion its cause.

In December 2006, the Senate passed the bill, but Congress adjourned before the House could vote. At the time, the House bill had 135 co-sponsors.

“I would think the public would be outraged that Congress was sitting on what could reduce their radiation exposure,” said Dr. Fred Mettler, a radiologist who has investigated and written extensively about radiation accidents.

Individual states decide what standards, if any, radiological workers must meet. Radiation therapists are unregulated in 15 states, imaging technologists in 11 states and medical physicists in 18 states, according to the technologists association. “There are individuals,” said Dr. Jerry Reid, executive director of a group that certifies technologists, “who are performing medical imaging and radiation therapy who are not qualified. It is happening right now.”

Two months ago, in Michigan — which sets no minimum standards for technologists — the Nuclear Regulatory Commission reported that a large hospital had irradiated the healthy tissue of four cancer patients, three of whom suffered burns, because a technologist repeatedly used the wrong radiological device. “It’s amazing to us, knowing the complexity of medical imaging, that there are states that require massage therapists and hairdressers to be licensed, but they have no standards in place for exposing patients to ionizing radiation,” said Christine Lung, the technologist association’s vice president of government relations.

In New York State, technologists must be licensed and prove that they have passed a professional examination. But there were no continuing education requirements — a provision of the CARE bill — until last year, and regulators usually let hospitals decide whether to discipline technologists. Over the last 10 years, New York health officials say they have not disciplined any of the 20,000 or so licensed technologists for work-related problems.



Copyright 2011 by The New York Times


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