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Postgraduate Institute of Medical Education and Research Chandigarh 160012, India
The fact that pediatric patients are inadvertently exposed to a high dose of radiation during CT because of the use of adult protocols has been established. One aspect of this problem has, however, been overlooked: In case of litigation, who would bear the responsibility for this? Is it the responsibility of the CT technician, the radiologist signing the report, the head of the department, or the institution?
We believe that it should be the responsibility of the technician who has obtained the scans. In our experience, the attitude of some technicians borders on callousness. Making them legally responsible for their conduct would instill the necessary sense of urgency and help reduce the magnitude of the problem. A related issue is how to maintain records of who actually performs the examination. In a busy radiology department, technicians at times change duty without written instructions. On other occasions, radiologists (including residents and consultants) take control of the console and perform the examination. Thus, if an incident overexposure to radiation comes to light after a gap of few weeks to months, it may not be easy to determine who is responsible for performing the examination. Moreover, it may be next to impossible to do so if the litigation comes years after the CT scans were obtained. Also, the persons involved in obtaining the scans and reporting the findings may have left the institution by the time litigation is filed. Will the institution bear the responsibility in such scenario?
Unfortunately, we do not have answers to some of the questions raised and seek the opinions of AJR readers about these important issues.
Rush North Shore Medical Center Skokie, IL 60076
The concerns regarding the high radiation dose inadvertently delivered to pediatric patients during CT examinations in India expressed by Drs. Saxena and Kochhar are very much shared by American radiologists. In the United States, CT examinations are estimated to account for approximately 15% of all radiologic procedures, and approximately 2.7 million CT examinations are performed annually in children [1]. Radiation dose generated by CT is of particular concern in children because of the potential carcinogenic effects of exposure to low levels of ionizing radiation [2]. Tissues of children are up to 10 times more radiosensitive than those of adults, and the long life expectancy of children is believed to increase their susceptibility to cancer as a result of radiation exposure [3].
Saxena and Kochhar ask rhetorically who is responsible for the radiation dose delivered in CT examinations of pediatric patients and then suggest that it should be the CT technologist who performs the examination. I do not possess sufficient information regarding the standard of radiologic care in India, but in the United States authoritative sources such as the American College of Radiology (ACR), which publishes the ACR Practice Guidelines (formerly called the ACR Standards) [4, 5], and authors of key articles in the radiologic literature place the burden of that responsibility squarely on the supervising radiologist.
The current revision of the "ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT)" states the following [4]:
The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician (i.e., the radiologist).... The practitioner (radiologist) will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care.... CT facility personnel must adhere to radiation safety regulations.... Overall program responsibility should remain with the physician (radiologist).... The supervising physician (radiologist) should review all practices and policies at least annually.
The lowest possible radiation dose consistent with acceptable image quality should be used in CT examinations of children.
Regarding the radiologic technologist, the practice guideline states the following [4]:
The technologist should have the responsibility for patient comfort, preparing and positioning the patient for the CT examination, monitoring the patient during the examination, and obtaining the CT data in a manner prescribed by the supervising physician (radiologist). (italics added)
The current version of the "ACR Practice Guideline for the Performance of Pediatric and Adult Thoracic Computed Tomography (CT)" contains similar language but also adds the following [5]:
Optimization of the CT examination requires the supervising physician (radiologist) to develop appropriate CT protocols based on clinical indications.... For pediatric patients, efforts should be directed to limit radiation dose when diagnostically feasible.
Affirmation that the supervising radiologist is the party responsible for determining radiation dose in pediatric CT examinations can also be found in the radiologic literature. In a recent article, Donnelly [1], concerned about a 65% increase in just 1 year of CT utilization in a children's hospital, described how the hospital's pediatric radiology faculty (not others) recognized the dangers associated with this increased utilization and then developed and undertook an aggressive educational campaign among referring physicians that was successful in substantially reducing utilization. Other researchers [2, 3] have written how radiologists (with the assistance of radiation physicists) can decrease radiation dose in pediatric CT examinations by modifying the tube voltage and current, section thickness, number of sections, and pitch.
Saxena and Kochhar also raise questions about record keeping and vicarious liability. The two ACR Practice Guidelines referred to earlier [4, 5] quite clearly point out that accurate and detailed records that include the parameters used and names of key personnel involved in performing CT examinations are essential and the responsibility of the radiologist as well as the imaging facility.
Under U.S. law, the imaging facility or hospital is generally held legally responsible for negligent acts committed by any of its employees. If the supervising or interpreting radiologist is employed by the facility, then liability for any of his or her negligent acts falls on the facility. If the radiologist is an independent contractor, he or she is liable for personal acts of negligence, but is not usually liable for the negligence of nurses, attendants, or technologists who are not employed by the radiologist. However, under the so-called "borrowed servant" theory, a radiologist who "borrows" temporarily another's employee may be held liable for the borrowed employee's negligent acts if it can be shown that the radiologist exerted sufficient control over the assisting employee [6]. In other words, if radiologic technologists are negligent in the performance of CT examinations while under the supervision of a radiologist, it is entirely possible that the radiologist could be held vicariously liable for any patient injury resulting from those negligent acts.
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