Case 1: Headache [To Irradiate or Not]

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[Triage Note: Twenty-two year old girl, home from university, headache for two weeks. Constant headache, nauseated. No vomiting. Alert, looks well, no distress.]

A young woman sits on the examining table. Texting. As  I approach the room, she dangles her legs, and checks her watch. She notices my approach and turns to the anxious woman standing beside her. The woman is starched – not a single joint flexed. She snaps back at her daughter, who once again turns her attention to her phone.

“Hi,” I say to the young woman. “What brings you in today?”

Her mother speaks: “She’s home from university – half-way across the country. She’s only here for the weekend, so I need this taken care of.”

The young lady sighs.

“I’m going to do the talking, okay?” The older woman says. “You’ve called me twice this week.” She turns to me. “Crying. She called me crying.”

I turn to the daughter. “Jennifer.”  She nods. “What brings you in today?”

“Headaches,” she says, turning off the phone. Her eyes bright, her movements animated, she frowns: “Like someone’s churning a knife inside my head. More than two weeks.”

“Do they come and go?”

“There always there. Sometimes worse.”

I search for clues. She has no past medical history. She’s never had surgery,  doesn’t smoke, and drinks as expected – heavily on weekends. “Were you able to go out this past weekend?”

“Only on Saturday,” she says. “I couldn’t on Sunday. The headaches were too bad.”

I know better than to make a connection between Jagermeister and the throb behind her temples. I won’t have a chance, anyway. Her mother is about to take control: “She needs a CAT scan before I can send her back to school.”

I smile, and reassure her: “Hold that thought.” I ask Jennifer several more questions, then move on to the physical exam. She is physiologically and neurologically perfect – excellent vital signs, normal blood pressure, heart rate, and temperature. But moreover, she simply looks well. She’s in no distress. Ten feet away, a baby wails. The lights are bright and the department is buzzing. None of this bothers her. After I finish my exam, she reaches into her pocket, silences her ringing phone, and smirks at the display.

I explain all of this to Jennifer and her mother. I also suggested that she try discontinuing her contraceptive pill, which she had started shortly before the onset of her headaches. If things haven’t settled down in a week or two, she could be re-examined at school.

Her mother is irate. “Why are you being so difficult?” she asks. “All I’m asking for is a CAT scan.”

“A CT scan is just a test,” I say. “It’s a useful tool in conjunction with the history, physical exam, and other tests, if needed. But on it’s own, it’s just a foggy look at the brain. It also means exposure to radiation, which isn’t really justifiable at this point.”

She raises her voice, looking for an audience among the patients waiting in chairs. “This is ridiculous,” she says. “How can you guarantee that there is nothing wrong inside her head without a CT scan.”

“There’s no reason to believe that there is anything wrong inside her head,” I say.

“Is there anyone I can speak to?” she says, stepping out of the examining bay and looking around. “I didn’t have any trouble getting my other three kids their CAT scans.”

I know then, that there will be no resolution until the young woman and her mother receive the test that’s been requested. She’ll simply be back tomorrow, or the next day, until the young woman’s head is under the ring, and a grey-and-white picture tells her everything is alright. And if she can’t get her scan at this hospital, she’ll get it somewhere else.

I turn to the patient: “Jennifer, you haven’t said anything, but you’re here and you’re letting your mother talk for you.”

“Another doctor said I should have the scan too,” she says.

“Why didn’t he order it?”

She shrugs and turns back to her phone.

I give in, and order the scan. This is bad medicine. Tests don’t often give binary answers  – yes, your brain is fine or no, your brain isn’t fine. Most tests, like CT scans are useful adjuncts to the big picture – the history, the physical exam, other tests if indicated. And Jennifer’s history, and physical exam suggest a very low pre-test probability of a positive finding on scan. And what if there is something on the scan – what if there’s a benign cyst that needs no management? What more testing will they want? What if there’s artifact – something that seems abnormal, that really isn’t. What then.

Two hours later, the results are back, and there’s a shadow on the scan.  This girl, who is active, alert, and jumps on and off the exam table has an abnormality on her scan. She’s able to party on weekends, play sports after class, and has an excellent academic record. But, because of a fuzzy shadow, more expensive testing – an MRI – is suggested. Her mother is in tears as I explain this to her, and try to reassure her. I know she will worry daily in the next weeks, as she waits for her daughter to have another test.

The New Yorker recently published an article, that I wish I’d had when I’d seen Jennifer and her mother. We Are Giving Ourselves Cancer, by cardiologist Rita F. Redberg, and radiologist Rebecca-Smith Bindman, is timely, well-written, and puts into mainstream print what medical professionals have been hearing for years. In short, the radiation doses for CT scans are 100-1000 times higher than x-rays, and that radiation, from medical sources, is the leading environmental cause of breast cancer.  I followed Jennifer’s course as she had further, more precise imaging. At the end, after great expense, and I’m certain – great anxiety to both patient and mother – everything was normal. Through it all, I wonder if Jennifer, or her mother, even remembered the suggestion of stopping her birth control. And, I wonder, if her headaches ever resolved.

13 comments

  1. It is often hard to resist the demand for further clinically unwarented tests at the risk of the wrath, confrontation, and ever valuable time. Unfortunately, some times it is just easier to provide the test in spite of the risk.

    1. Penny – you’re so right. Some battles aren’t worth fighting. I often tell people this – it’s easier for me to order the scan you want, than to explain why you don’t need it.

  2. Don’t get me started on birth control pills… Great writing Raj! As a mother I always wish for a definitive diagnosis, but prefer it to be reached in the most conservative way possible.

  3. I find this really interesting. I couldn’t read a book of events like these but getting well written doses in this blog are just right.

  4. Dr Raj, l thank you for your time in doing this blog (in your spare time….lol). l just came across your blog and have been sitting here just glued to the screen like a good book you can not put down. The medical field is blessed to have you and your staff. Nurses…..one of my bf has just retired last year and she has every degree going but a Dr’s and if there was no Dr’s it is her that l would want to care for me.
    She did 10 yrs in Norman Wells plus other areas…..so yes hats off to all the dedicated nurses and Dr’s. Looking forward to your future blogs.
    Nancy Robert

  5. Dr Raj, l thank you for your time in doing this blog (in your spare time….lol). l just came across your blog and have been sitting here just glued to the screen like a good book you can not put down. The medical field is blessed to have you and your staff. Nurses…..one of my bf has just retired last year and she has every degree going but a Dr’s and if there was no Dr’s it is her that l would want to care for me.
    She did 10 yrs in Norman Wells plus other areas…..so yes hats off to all the dedicated nurses and Dr’s. Looking forward to your future blogs.

  6. Dr. Raj,

    Thanks so much for these! It’s like Christmas morning for me when I get an email telling me
    You’ve uploaded a new story!! 😁 Can’t wait for more to come!!
    -Ashley

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