Browsing the Internet, I came across Jessica Caldwell’s essay Fractured: A First Date, in which she tells her story of breaking her arm in a drunken flirtatious arm-wrestling session. What struck me about it was that, when the doctor saw her in the emergency room, he told her that he would need to do a pregnancy test to confirm she wasn’t pregnant before he could X-ray her arm.
Wait, what? I get that, if a woman is pregnant, it’s worth thinking about whether a particular X-ray/CT can be postponed a few months until she no longer has a passenger to share in the radiation dose; doses from X-rays are trivial, but can add up over a lifetime and it makes sense to limit them. But Caldwell had a broken arm. Her X-ray was essential and couldn’t wait.
I’m wondering – what on earth would that doctor have done if Caldwell’s pregnancy test had been positive? Left her with a second elbow in her arm for the next nine months? Put a cast on it sans X-ray and kept fingers crossed that it didn’t heal too crooked? You know, I formulated those questions as flippant ones… thinking about some of the scary things I’ve heard about the dominance of pro-life thinking in the USA, I’m actually not too sure. If Caldwell had been pregnant, would she actually have found her doctors putting that embryo’s priorities before hers and denying her the X-ray she needed for her medical care?
A. Noyd says
What kind of utterly incompetent radiography are they doing there? It’s a simple limb x-ray, FFS. That’s like the same amount of radiation exposure to the patient as, at worst, simply existing for a week.
I don’t know for sure, but my guess is the follows: 1. Say “Well, crap, what’s the protocol anyway? Hey, anyone ever seen one of these be unexpectedly positive before?” 2. Inform the patient of the (really very low) risk of the x-ray and document that they did just in case something goes wrong with the pregnancy. 3. Put some lead over her lower abdomen before the x-ray. Again, not sure it’d help, but just in case. 4. Take the x-ray unless she refused. Because, as you said, it’s not like it can be deferred.
Aren’t they supposed to do that anyway…? Any time I’ve gotten an x-ray, they lay a lead thingy over my torso and legs regardless of where the x-ray is. Including dental x-rays.
Probably depends on the local tradition. For whatever reason, the only time I’ve gotten a lead apron is for dental x-rays. Also, apparently, I either look remarkably trustworthy or remarkably infertile, because I’ve never had anyone do more than ask if I were pregnant before doing the x-ray. I’ve never had a test demanded, that I can remember. In any case, a single arm x-ray is probably going to be about as much radiation exposure as a moderate length flight, so I wouldn’t worry that much about it.
From the provider point of view, the problem is that if someone is pregnant and something goes wrong with the pregnancy, they’ll be looking for a reason. If they had an x-ray at any point during the pregnancy, that can be the explanation, whether it had anything to do with the problem or not. There have been drugs taken off the market because women who took them while pregnant had babies with birth defects. Mind you, women who did not take the drug had babies with birth defects at almost exactly the same incidence, but that didn’t matter because people like explanations, whether they are correct or not.
For mammograms and other X-rays I was only ever asked to sign on a form that I’m not pregnant.
This has been standard practice at every hospital at which I’ve worked in the last thirty years.
Ian Rennie says
Many years ago, my wife (girlfriend at the time) went to urgent care with kidney stones (she’d had them before and knew the symptoms).
At urgent care, a nurse told her it was more likely she was pregnant and pretty much sent her packing.
48 hours later when she was rushed to hospital in severe pain, the first thing she was asked in the ER was whether she was pregnant. I should point out that at this point I lived 4000 miles away, making it anatomically unlikely.
Finally after a long and painful multi-day hospital stay including X-Rays, CT scans, etc, she was released, with a bill that contained…
Twelve pregnancy tests.
In 3 days.
I don’t know what they thought she’d been getting up to in her hospital bed. My only assumption is that they toutinely do a pregnancy test before each scan, partly to cover their asses in case a scan harms a baby, partly because as they’re a quick and easy thing to charge for and make a profit on, which may well be the case for Jessica Caldwell as well.
Dr Sarah says
Wait… what??? Your wife was in pain, a nurse thought she was pregnant, and thought that was a reason to send her packing? Did that nurse sleep through the lecture on ectopic pregnancy at nursing school??? Apart from anything else, that’s appallingly dangerous neglect. If the nurse actually thought she might be pregnant, that really is a solid reason to do an on-the-spot pregnancy test (and proceed to urgent ultrasound if positive).
That, however, does make excellent medical sense. That is indeed one of the questions that needs to be asked of any woman or girl of potentially reproductive age presenting with acute abdo pain. See ‘ectopic pregnancy’ above.
(Yes, even if her partner is 4000 miles away. With no disrespect meant towards your wife, it’s hardly an unknown thing for people to cheat on their partners (or engage in consensual polyamoric sex with other partners while their main partner is away, for that matter).)
And that certainly doesn’t make excellent medical sense, or any medical sense at all. You’re probably right about one or both of those reasons, but I sure as hell hope the insurance company (if you had one) queried that sort of ghastly inefficiency. Other people should not be getting stuck with the bill for the hospital’s failure to check the records as to what tests have been done.
Anyway, hope your wife was all right after it all.
Dr Sarah says
@starskeptic: What, doing pregnancy tests before X-rays? So what would a doctor do if a test was positive and the patient needed the X-ray?
Dr Sarah says
@Siobhan: That’s what I thought. That’s certainly what was done when I trained, although, having said that, I’ve been out of hospital medicine for so long I have no idea what the protocol is now.
I know that when I’m ordering an X-ray or CT for a woman of reproductive age, the computer form will ask when her last period was; if I don’t know or if she isn’t within 10 days of the start of her last period, I’ll be asked to confirm that I want to override the 10-day rule. That seems reasonable, as it reminds me to check each time but also gives me the option of making the decision that an X-ray is medically appropriate even where there might be a possible risk of the woman being pregnant (or, alternatively, making the decision that worrying about pregnancy is not necessary in this particular case for whatever reason regardless of when the last period was).
Dr Sarah says
@dianne: I think you’ve got a good point. It probably does come down to a CYA thing – if the test does come back positive, they can explain the risks of doing an X-ray while pregnant (such as they are, since I think you’re right about the amount of radiation exposure), document that they’ve done so/get the woman to sign something, and then they’re indemnified against getting sued later. There’s also the risk that someone might get pregnant immediately afterwards, have a baby with some sort of problem, and come back to the hospital to sue them, in which case it would be useful to be able to point to a documented test result showing that that person wasn’t pregnant at the time of the X-ray.
Ultimately, for the patient to decide; other imaging might be useful if a pregnant patient is leery of exposure. The bottom line is to avoid a situation where the patient ends up with a child with developmental problems that could (lawyer-wise) be traced to an exposure that the patient wasn’t warned about.
Nowadays, you couldn’t get away with charging for 12 preg tests. Insurance companies dictate what gets paid for – anything they don’t approve or isn’t justified, the hospital eats the cost of…
Dr Sarah says
@starskeptic: OK, that does actually make sense (at least within the context of the current legal situation around malpractice law in the US, which sounds pretty problematic anyway).
And glad to hear that insurance companies would clamp down on the whole ‘twelve pregnancy tests’ ridiculousness.
WMDKitty -- Survivor says
I’ve been on Depo for a good 16-17 years now, and still, every time I’m in hospital — whether it’s a 3AM emergency visit, or a scheduled surgery — EVERY SINGLE TIME, they make me pee on a stick. I haven’t ovulated or had a period in nearly two decades, people…
Dr Sarah says
That… again, actually does make sense. If you were in hospital in situations in which excluding pregnancy is important for whatever reason, then, yes, that’s appropriate even if you’re using regular contraception, since no contraceptive method is 100% perfect. If I need to exclude pregnancy, then if the woman has been sexually active with a man within the past few months I’m going to test.