When techs ask for 'time out,' the end may be near

April 7, 2010

I recently had an extraordinary experience: Both an x-ray technologist and a nurse called me wanting to stop studies that other doctors had ordered.

“OK. Let's scan him.”

“Doctor, I think we need a time out.”

“A what? A time out?”

“Yes, to consider whether yet another CT of this young man is really indicated.”

“He has a skull fracture.”

“I understand, but he has been scanned so many times. Is it really necessary?”

“Yes, and who are you to question me?”

“Dr. Hawass, I just think this is too much.”

“It's King Tut. It doesn't matter.”

“Radiation is radiation and he has reached his maximum dosage.”

I recently had an extraordinary experience: Both an x-ray technologist and a nurse called me wanting to stop studies that other doctors had ordered. The nurse actually used the term malpractice. I was amazed. I am conflicted over whether this is good or bad. Now, if we could train paralegals to do it with lawyers, then I would know it's fantastic, especially since I see a scary trend coming.

We've all argued with clinicians about the appropriateness of studies, but two recent occurrences have led to staff and nurses asking for time outs. Dr. Jeffrey Shuren, director of the FDA's Center for Devices and Radiological Health, announced the FDA would institute new requirements for monitoring and recording patient radiation exposure and stringent policies to decrease exposure, and there's been a lot of negative press about all those patients harmed by excessive radiation. I didn't even know what a time out was until it showed up on a hospital privileges reapplication. It asked if I cooperated with mandated time outs. I was tempted to answer, “Only when my mommy makes me.”

Dr. Peter Pronovost, author of “Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out,” is changing the practice of medicine. He is director of the Quality and Safety Research Group at Johns Hopkins Hospital and in his book he talks about how patients routinely die due to a rigid medical hierarchy that dictates nurses and staff cannot challenge doctors. Yikes! I am not disagreeing with him, or with the FDA, and I am not saying these are bad ideas. But the law of unintended consequences may be about to come into play here.

Check out The New York Times story on Feb. 7 concerning Anne Mitchell, an administrative nurse at Winkler County Memorial Hospital. She wrote a letter to the Texas Department of State Health Services concerning what she felt was a pattern of improper care by Dr. Rolando Arafiles Jr. The hospital fired her and she is being prosecuted for a third-degree felony for misuse of official information, even though she would appear to be protected for reporting him by Texas whistleblower laws and by her responsibility to protect patients. The twist is that Dr. Arafiles complained to his friend and patient, Winkler County Sheriff Robert Roberts, who arrested Mrs. Mitchell. She faces 10 years in prison-which might be an improvement over Winkler County Memorial Hospital.

Stan Wiley, the hospital administrator, admits in the article that Dr. Arafiles “has been reprimanded on several occasions for improprieties in writing prescriptions and surgery,” (Dr. Pronovost, avert your eyes) and even had his license restricted because of previous problems.

But, Mr. Wiley said, “it was difficult to recruit physicians to remote West Texas.” (Has he tried Dr. Kevorkian?)

I don't know if Mrs. Mitchell is a vindictive nurse or Dr. Arafiles Jr. is a poor doctor. But I do know that as more doctors and nurses come into conflict, a take no prisoners policy like this one may become more common in our increasingly polarized society. Rather than people cooperating in the best interests of the patient, it will become like the Congress, where winning is more important than working together for solutions.

Another example: According to Wikipedia, “since 1950, the International Labour Office has periodically published guidelines on how to classify chest x-rays for pneumoconiosis. The purpose of the classification was to describe and codify radiographic abnormalities of the pneumoconioses in a simple, systematic, and reproducible manner, aiding international comparisons of data, epidemiology, screening and surveillance, clinical purposes, and medical research.”

In 1974 the National Institute for Occupational Safety and Health began the “B” reader program to further codify this process and to reduce interreader variability. Good idea? Sure sounds like it. Instead, lawyers turned a research tool into a weapon for legal extortion costing hundreds of billions of dollars to benefit people who had been merely exposed to asbestos, most without any demonstrable harm. The parallels with radiation exposure are chilling-or, if you're a lawyer, intoxicating.

Rest assured lawyers are going to look to the FDA guidelines as justification to sue doctors for needless radiation exposure. Nurses and techs will be questioning whether Mrs. Smith really needs that fourth CTA perfusion study this week for dizziness. Right or wrong, when that happens, will you be prepared?

Now might be a good time to start reviewing your policies, procedures, and protocols. Does a stone patient really need prone and supine scans? Or even a CT, if they have a classic presentation with hematuria? Do you really need a CT with noncontrast images, arterial and venous phases, and delayed bladder for abdominal pain? What justifies a CTA head and neck in someone with headache? And if someone challenges, who is going to be the arbiter? Will it always be you? Do you really want a bull's eye on your forehead?

Soon patients will have hard copies of their cumulative radiation dose. Better to get out in front of the curve and start addressing best practices with scientific evidence now. There is a good financial incentive too, since more insurance companies are refusing to pay for studies they consider are not indicated.

As for the boy king, Tut? Recently deciphered hieroglyphics suggest his demise may have had something to do with the announcement just prior to his death that he was going to take the LSATs.