Patient Presentation
A 6-month-old male came to clinic for runny nose and coughing for several days. The night before he had post-tussive emesis twice, but continued to breast feed and have good wet diapers.
He had a fever to 102° Fahrenheit.
The past medical history revealed a term infant who had been seen for one ear infection and health maintenance visits.
The social history revealed that another child in his daycare room had been admitted to the hospital for pneumonia.
The review of systems was non-contributory.
The pertinent physical exam showed an alert male with growth parameters at ~90%. Respiratory rate was 30, pulse oximetry was 95% on room air. His capillary refill was brisk. Mucous membranes were moist.
Nose showed copious clear rhinorrhea. Tympanic membranes were dull, with a slightly splayed light reflex but normal mobility. Chest examination showed mild, intermittent intercostal retractions at the lower ribs. He had very mild end-expiratory wheezing at the bases.
The rest of his examination was negative.
The child was given an albuterol nebulizer treatment and monitored. Re-examination showed no intercostal retractions and resolution of the wheezing, but decreased breath sounds at the bases. No crackles were appreciated.
The physician discussed with the parents that although this could be a viral pneumonia, with the patient’s age, fever, pneumonia contact, and decreased breath sounds, that he was concerned about a possible bacterial lobar pneumonia. He wanted to obtain a chest radiograph but the father
vehemently refused stating that the radiation risk was too high and that he wanted to just have some antibiotics prescribed. The physician calmly asked him why the father felt this way. The father stated “the radiation will hurt him.”The physician tried to find out what other beliefs the father held about radiation, but the father could not give any other specific information as to why he held this belief.
The physician explained about why he wanted to do the test, what the benefits would be, and told the father that the radiation was about the same as if he flew in an airplane 500 miles.
The physician sensed that the parents wanted to talk alone so he left them. A few minutes later the physician returned and the mother said that the chest x-ray could be done.
The father did not speak to the physician for the rest of the visit despite attemps to engage him.
The radiologic evaluation of a chest radiograph showed a right lower lobe bacterial pneumonia.
The diagnosis of right lobar pneumonia was made and the patient was given azithromycin and albuterol. Before leaving the pulse oximeter read 98% on room air. The parents were instructed how to use the albuterol for increased work of breathing as well as signs and symptoms of respiratory distress.
Discussion
Life is inherently risky and everyday people make decisions that increase and decrease their risks.
But as Ropeik and Gray write, “Risk issues are often emotional. They are contentious. Disagreement is often deep and fierce. This is not surprising, given that how we perceive and respond to risk is, at its core, nothing less than survival. The perception of and response to danger is powerful and fundamental driver of human behavior, thought, and emotion.”
It can be very difficult for people to understand the real risks in their everyday life and also the benefits they can have from taking those risks.
People are more afraid of:
- New risks than those that have been around for a while, i.e. newly approved medication versus older medication
- Man-made risks than those of nature, i.e. medical radiation versus tornados
- Risks that are “imposed” upon them, than those they choose, i.e. required new vaccine versus motorcycle riding
- Risks that they feel they cannot control, i.e. flying in airplane that they cannot fly themselves versus driving a car that they can drive
- Risks that do not confer some benefits they want, i.e. would not live in Florida which is hurricane prone if it did not have warm weather and enjoyable water
- Risks that can kill or injure them in terrible ways, i.e. eaten by a shark verus heart attack
- Risks that come from sources that they feel they do not trust, i.e. information about drinking water contaminants from the local government, chemical company or non-profit conservation club
- Risks that they are more aware of then those they are less aware of, i.e. gun violence from school shootings versus daily gun violence
- Risks where the uncertainty is higher than where the uncertainty is lower, i.e. new cancer medication versus standard cancer medication
- Risks to children than to their own lives (for an adult), i.e. powerline radiation next to the child’s school than versus next to the workplace
- Risks that could directly affect themselves versus risks that threatens others, i.e. automobile accidents versus sky diving accidents for non-sky divers
Learning Point
Two common concerns parents raise are risks from medical radiation and vaccines.
Medical radiation does have risks but also benefits including improved diagnosis and treatment. The radiation risk depends on many factors including the size of the patient, body part being imaged, and imaging modality.
Some radiation doses are listed below:
- Natural background radiation (sea level) = 300 millirems/year
- Natural background radiation (Denver, Colorado) = 400 millirems/year
- Round trip airplane flight coast to coast = 12 millirem
- Chest radiograph = 2 millirem
- Computed tomography of head, or chest, or abdomen = ~ 300 millirem
Using the roundtrip airplane radiation of 12 millirems and an approximate distance from Los Angeles, CA to New York, NY of 2800 miles, the radiation from flying in a plane is .00428 millirems/mile. If a chest radiograph is 2 millirems, then the number of miles one would have to travel in an airplane to receive an equivalent radiation dose is ~ 500 miles.
A person would also need to have about 150 chest radiographs in a year to equal the background radiation they normally receive.
Vaccines also have risks and benefits. The Centers for Disease Control list the following as serious side effects for various vaccines. The date listed is the most current version of the information from the CDC:
- DTP (Tetanus, Diphtheria and Pertussis, 2001) – Allergic reaction > 1 in 1,000,000 doses, other reported problems include seizures, coma, lower consciousness, permanent brain damage1
- Tdap (Tetanus, Diphtheria and Pertussis, 2006) – Mild problems reported only, serious side effects being monitored for
- Td (Tetanus and Diphtheria, 1994) – Allergic reaction, pain and muscle wasting in upper arm
- Haemophilus influenza B (1998) – Not applicable, only mild problems reported
- Hepatitis A (2006) – Allergic reaction – Very rare
- Hepatitis B (2001) – Allergic reaction – Very rare
- Human Papilloma virus (2007) – Mild problems reported only, serious side effects being monitored for
- Inactivated influenza virus (2006) – Serious side effects being monitored for 2
- Live, attenuated influenza virus (2006) – Allergic reaction – very rare
- Measles, Mumps, Rubella (2003) – Allergic reaction > 1 in 1,000,000 doses, other reported problems deafness, seizures, coma, lower consciousness, permanent brain damage1
- Inactivated polio (2000) – Mild problems reported only, serious side effects being monitored for
- Pneumococcal conjugate (2002) – Mild problems reported only, serious side effects being monitored for
- Rotavirus (2006) – Mild problems reported, serious side effects being monitored for
- Varicella (2007) – Pneumonia – Very rare
1These happen so rarely experts cannot tell whether they are caused by the vaccine or not. If they are, it is extremely rare.
2Swine flu vaccine – Guillian-Barre syndrome is estimated at 1-2 cases/million people vaccinated.
As comparisons, the likelihood of death or harm for a U.S. citizen, per year and per lifetime (based on data from 1999-2003) are given below.
The numbers shown are odds ratios, and therefore are given as one event will occur in that number of people. For example, the one year odds ratio for a hurriane is that one person will die out of 17 million people, but the lifetime odds ratio is that one person will die out of 220,000.
These are statistical averages and are not the exact chances for an individual person which are influenced by many factors including activities and work participated in, where someone lives or drives, etc.
One Year Odds Lifetime Odds Nature Hurricaine 17,000,000 220,000 Flood 11,186,539 144,156 Lightening or Tornado 3,000,000 39,000 Dog bite 19,000,000 240,000 Bear attack (death) 94,000,000 1,200,000 Hornets, wasps and bees 4,406,818 56,789 Shark attack (death) 280,000,000 3,700,000 Crime and Suicide Homicide (all) 18,000 240 Homicide by gun 28,000 360 Suicide 9,200 120 Transportation Motor vehicles 6,700 88 Motorcycling 79,121 1,020 School bus 4,900,000 63,000 Bicycling 381,693 4,919 All-terrain vehicles 1,600,000 21,000 Snowmobile 7,200,000 94,000 Commercial aviation plane 3,100,000 40,000 Recreation Football 59,000,000 770,000 Soccer 840,000,000 11,000,000 Skydiving 9,100,000 120,000 Accidents Drowning (general) 79,121 1,020 Drowning in a bathtub 840,000 11,000 Electrocution from wiring /appliances 300,000 4,000 Fireworks 26,440,910 340,733 Fire and smoke exposure 86,331 1,113 Health Asthma 56,000 730 Cancer 510 7 Diabetes 4,100 53 Heart Disease 300 4 Pregnancy and Childbirth 760,000 99,00 Stroke 1,800 23 Infectious Diseases Hepatitis (all types) 59,000 770 Human papillomavirus 51 Not available Influenza 130,000 1,700 Measles 94,000,000 1,200,000 Meningitis 370,000 3,800 Mumps (cases) 800,000 10,000 Pneumonia 4,300 57 Pertussis 56,000,000 730,000 Varicella (cases) 4,400,000 57,000
Questions for Further Discussion
1. List various forms of natural radiation.
2. What is the risk of death from oral contraceptive pills?
Related Cases
- Disease
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Radiation Exposure
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Centers for Disease Control. Vaccine Information Statements. Available from the Internet at http://www.immunize.org/vis/ (rev. various- see specific vaccine above, website revised 4/20/07, cited 4/23/07).
(Note: most current statement date for each vaccine is given above)
Ropeik D, Gray G. Risk A Practical Guide for Decising What’s Really Safe and What’s Really Dangerous in the World Around You. Houghton Mifflin Co. Boston, MA. 2002.
National Safety Council. What are the odds of dying? Available from the Internet at http://www.nsc.org/lrs/statinfo/odds.htm (rev. 8/2/2006, cited 4/26/2007).
Huda W, Vance A. Patient Radiation Doses from Adult and Pediatric CT. AJR 2007;188:540-546.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
June 4, 2007
Pediatric Education 