Steven Gould, DC, DACBR, wrote this article on behalf of NCMIC. NCMIC was founded in 1946 for the express purpose of providing the chiropractic profession with malpractice coverage. Today, NCMIC covers more than 38,000 DCs, and its strength is summarized by the motto, “We Take Care of Our Own.” Gould is a board certified chiropractic radiologist who became a diplomate of the American Chiropractic Board of Radiology (DACBR) in 1993. He has a full-time radiology and clinical/patient practice where he performs interpretations of plain film radiographs and MRIs for referring chiropractors. Gould holds memberships in the American Chiropractic College of Radiology and the American Chiropractic Association (ACA). He was president of the ACA’s Council of Diagnostic Imaging and is currently their secretary/treasurer.
As a chiropractic radiologist, I often talk to doctors of chiropractic who have questions about their exam findings. Recently, I heard from a doctor who was concerned about a two-view lumbar X-ray that revealed a fetus.
The 16-year-old patient had been experiencing low back pain and had denied pregnancy on several occasions: on the X-ray consent form, during the history and upon being questioned by the chiropractic radiologic technologist. The patient’s mother also was unaware of the teenager’s condition.
The doctor was concerned about the radiation exposure to the fetus, as well as his malpractice liability. Though the question of the doctor’s liability would be best be answered by his malpractice carrier, the effects of radiation on the fetus would depend on:
• The settings of the X-ray machine compared to the patient’s size, and
• The type of X-ray unit and film-screen (or digital detector) combination used.
What the research says: In general, it appears that the risk to a fetus during X-ray is fairly low. The National Commission on Radiation Protection (NCRP) states the risks to pregnancy from 5,000 mRad of exposure are negligible. Therefore, a two-view lumbar X-ray, which would expose a patient’s body to about 200-400 mRad, would not likely injure the fetus. Even so, it is not advisable to radiograph pregnant patients, unless there are life-threatening injuries or emergent conditions.
In “real-world” terms, an article in the Journal of the American Chiropractic Association by Dr. Joseph Howe and Dr. Terry Yochum stated that it would take nearly 45 X-rays done in a short period of time to cause irreparable damage to the fetus.
The Department of Health and Human Services and Center for Disease Control and Prevention has a fact sheet (www.bt.cdc.gov/radiation/pdf/prenatal.pdf) that addresses fetal exposure to radiation. This fact sheet indicates that even a rough equivalent of 500 chest radiographs at one time would increase the lifetime cancer risk by about 2 percent over the natural incidence rate of 40 percent to 50 percent.
Avoiding X-ray exposure during pregnancy: Many people find it hard to believe that a woman wouldn’t know she was pregnant. However, there are instances of repeated pregnancy tests showing negative results, despite the woman being pregnant. In addition, there are multiple cases of women who were unaware they were pregnant until going into labor.
One simple procedure to protect patients and their unborn babies is the “10-Day Rule.” This means only X-raying females who are within the first 10 days of their menstrual cycles. Days one through 10 of the menstrual period are the least likely time for pregnancy in the female cycle, with ovulation taking place on approximately day 14 of the cycle. It is important to include a notation of the last menstrual period date on the intake and X-ray consent forms of any female of childbearing age and/or with an active menstrual cycle.
Most chiropractic patients are not emergent cases and radiographic evaluation can be postponed until the next menstrual period begins. Putting the 10-day rule into place in your practice can reduce the potential for exposing a pregnant patient to radiography and can aid in evaluation of patients with unknown, underlying gynecologic conditions.
If the patient does not have a menstrual cycle in the normal time frame, it could be that a pregnancy exists. Or, there may be an undiagnosed pathology, such as ovarian or uterine disease, endometriosis, amenorrhea, or other hormonal abnormalities from multiple causes. In any event, the patient may require a referral to a gynecologic/obstetric specialist, and you will have provided them with a valuable healthcare service.
This research was provided by NCMIC.
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