As medical imaging becomes common, experts urge caution

A patient undergoes a CT Scan. There is little hope the average Kenyan can afford medical care. PHOTO | FILE | NATION MEDIA GROUP

Plying the busy Nairobi-Mombasa Highway can be a dangerous manoeuvre around trucks, motorcycles and other motorists. The more than 300-kilometre stretch between Salama (Makueni County) and Mariakani (Kilifi County), just before Mombasa Island, is accident-prone, not forgetting the more than 200-kilometre Nairobi-Mtito Andei stretch.

For victims of traffic accidents on these stretches, the health facility they are rushed to, and particularly whether it can offer advanced diagnostic services to determine what action a doctor should take next, can be a matter of life and death.

This was the case for Mary Shali, who was involved in an accident, while riding pillion on a motorcycle. She would have been forced to travel to Mombasa for a head scan, and been forced to dig deeper into her pockets to pay for accommodation, food and transport, since she has no relative to host her.

CT SCAN

But a computed tomography (CT) scan machine that was recently installed at the Voi Level Five Hospital in Taita Taveta County, saved her and other accident survivors, who would have been referred to hospitals in Mombasa and Moshi, Tanzania, for the scans, the trouble.

Having a CT scan machine close by can be a matter of life and death for trauma and assault patients, because it provides images of the finer details of internal body injuries that might require immediate surgery or admission to the intensive care unit. And it does so fast.

“A simple x-ray cannot tell us if a patient’s brain is bleeding, but a CT scan can. Having it close means the doctor is able to quickly tell the action or procedure that must come next to save the patient’s life,” explains Catherine Adema, the radiographer in-charge at the Thika Level Five Hospital in Kiambu County.

In August last year, the government signed a contract to acquire CT scanners for 37 counties from China at a cost of Sh8 billion, with 80 per cent funding from the Chinese government (through the China Development Bank).

The scanners were supposed to be rolled out with other equipment in the 2014 Managed Equipment Service project to provide advanced, but affordable medical technology in public hospitals, but was delayed due to funding constraints.

Although the quest to equip public county hospitals has been shrouded in some controversy, Dr Mercy Nyanchama, a radiologist in Kiambu and chair of the Radiology Department at the Jomo Kenyatta University of Agriculture and Technology, says the equipment has made services that were only available in big towns accessible to Kenyans in the rural areas.

With just 90 CT scanners (two for every million Kenyans) — 18 in public hospitals in 16 counties, and six not functional — an additional 37 are a welcome boost.

In Taita Taveta, where the CT scanner was installed at the Voi Level Five Hospital in September, it can serve up to 20 patients a day, cutting up to 60 per cent of patient referrals to other facilities.

The first of the 37 was unveiled at the Thika Level Five Hospital in June, with four others in the initial 10-scanner batch going to the Iten County Referral Hospital (Elgeyo Marakwet County), Kakamega County Referral Hospital, Narok County Referral Hospital, and Voi Level Five Hospital (Taita Taveta County).

Kenyatta National Hospital, Moi Teaching and Referral Hospital, Kerugoya Level Five Hospital (Kirinyaga County), JM Kariuki Referral Hospital (Nyandarua County), and Kericho Level Five Hospital are expected to get theirs installed soon. Close to 10 others are complete and ready for launch, while the rest have the infrastructure in place, pending the fitting of the machines.

CASH COW?

However, even as access to advanced medical imaging services is rolled out in counties, saving patients the hustle and cost of having to seek help in other facilities, there are concerns that these services, whose cost is met by the National Health Insurance Fund (NHIF), have become a cash cow for medics who are driven by greed for profit more than need for the images.

Last year, NHIF called out facilities that were making fraudulent claims for services such as magnetic resonance imaging (MRI) and CT scans, and introduced the requirement for a pre-authorisation request for such specialised services before conducting the tests on patients, as a way to curb fraud.

And, although, most of the fraud was from billing for diagnostic tests that had not been done, some radiologists worry that profit-driven medics have found a way around that by sending patients for CT scans and ultrasound tests they don’t need for the next medical decision to be made.

“The way radiology works, your primary health provider sees you (the patient), who then makes a decision that a medical imaging test would help him or her make a better diagnosis,” says Dr Nyanchama.

The patient then goes to a radiographer (the technologist who performs the test), then a radiologist (medical doctor who diagnoses and treats disease or injury using medical imaging techniques) interprets the results and sends a report to the doctor who ordered the test.

Medical imaging tests like x-rays, CT scans, MRI, ultrasounds and PET scans give a clear picture of things that are happening in the body, without having to use invasive procedures, to ease diagnosis and treatment.

They are also used to monitor response to treatment or to guide the process of another medical procedure by showing the inner parts where equipment is passing through. Some diseases don’t require medical imaging, while others like cancer and surgery might require multiple exams.

CAUTION

Because medical imaging procedures such as x-rays, CT scans and PET scans use ionising radiation to create clear images that can be used to make medical decisions, Dr Nyanchama, who is also the national secretary of the Kenya Association of Radiologists, says that doctors, clinical officers, nurses and other medical workers should practise the principle of “doing no harm” and avoid exposing patients unnecessarily to radiation.

This is because radiation causes changes in cells that have been linked to cancer, but when the test is needed, the benefit (being able to make the best medical decision using medical images) often outweighs the risk (slightly higher risk of getting cancer than normal).

However, the test must be absolutely justified to protect patients and the public from unnecessary exposure to radiation. So important is protecting people from unnecessary exposure to radiation, that radiology workers are required to take blood tests every year, to check if they have been exposed to too much, and if they have, they take a break and other precautions.

“Pregnant women, the foetuses growing in them and children are particularly more sensitive to radiation exposure, because their cells are dividing and transforming rapidly, so they face a higher cancer risk from being exposed to radiation,” explains Dr Nyanchama, adding that children exposed to radiation are more likely to get leukaemia (blood cancer) or lymphomas.

“Everyone in the process, including the patient, has to ask, is this test necessary? Are there other options (such as ultrasounds and MRIs which don’t expose patients to ionising radiation or even other tests)? Is a repeat procedure necessary?” says Dr Nyanchama, who adds that how the test is done, the equipment that is used and how the results are reported all determine safety for patients.

“It should be very clear that medical imaging is important. We can’t see an eye tumour, trauma, what is happening in the chest without it, but we need patients to be informed to avoid falling in the schemes of profit-driven medics, who will expose them to unjustified radiation. Ask questions and seek a second opinion.”

DECISION-MAKING

Dr Nyanchama recommends for patients to avoid falling in the schemes of profit-driven medics who will expose them to unjustified radiation.

Dr Nyanchama also calls for decision-makers to involve radiologists and radiographers in decision-making on things like the kind of equipment to buy, training needs and setting up of guidelines and protocols that health workers can use in weighing whether a test like a CT scan, which exposes people to higher doses of radiation, is justified.

“CT scans are good and we are happy that they are now available to patients in more public hospitals, but they are a double-edged sword. We need official guidelines and protocols and strict criteria on their usage.

“The other thing is that most hospitals don’t need 64-slice machines; most exams need a 16-slice CT scan; unless you have a cardiologist on board… the 64-slice machines take clearer pictures faster, but it is like buying a high-end phone just to send text messages, when a cheaper phone can do the same job,” says Dr Nyanchama, noting that guidelines are important because not every imaging centre is going to turn away patients who don’t need a test, because there is money to made from it.

NHIF covers MRIs up to a maximum of Sh15,000 per session while payments for CT-scans are capped at Sh8,000.

Besides installing and maintaining the scanners in county hospitals, the five-year deal with the Chinese includes training of staff radiographers. Already, there is a centre in Nairobi to train radiographers, radiologists and biomedical engineers to use and maintain the scanners effectively, while another group of radiologists is undergoing specialised training in China to boost operational capacity in far-flung areas.

At the Thika Level Five Hospital, which can handle more than 100 patients a day, because it takes less than a minute to scan one patient, the radiographer in-charge Catherine Adema says human resources to meet this demand, mostly from trauma/accident victims, are still a challenge.

“Patient numbers are high, but staff are inadequate. We have radiographers and one radiologist, who needs to report all the x-rays, CT scans, MRI and special ultrasounds and this is overwhelming,” said Adema.

 

Reporting by Lucy Mkanyika, Ruth Mbula, Mary Wambui and Felista Wangari

 

TYPES OF MEDICAL IMAGING

X-ray: An electromagnetic wave of high energy that passes through the body to give internal images of the body. Gives off mild dose radiation.

Mammogram: An x-ray of the breast taken on a compressed and flattened breast, used to screen for breast cancer. Gives off mild dose of radiation.

Computed Tomography (CT) scan uses a computer linked to an x-ray machine to make a series of detailed pictures of tissues, bones, blood vessels and organs from different angles. The patient is put on a table which slides into a tube to see the internal body. The scanner divides the body into "slices" and takes pictures of these slices which are then reconstructed using a computer. The scanner produces two-dimensional pictures which are put together by the computer into very detailed, three-dimensional images. The number of slices needed depend on what the doctor needs to see. CT scanners have more radiation than normal x-rays.

Positron Emission Tomography (PET scan) uses small amounts of radioactive materials which are injected and target the area of the body being pictured.

Nuclear medicine scan uses small amounts of radioactive materials which are either injected, swallowed or inhaled to help target the area of the body being viewed

Ultrasound scan – uses high-frequency sound waves to capture live images of the internal body (infant brains, eyes, gallbladder, kidneys, liver, ovaries, pancreas, spleen, thyroid, testicles, uterus, blood vessels). Because it doesn’t use ionising radiation, it is the preferred method for viewing the foetus during pregnancy. It is also used to guide a surgeon’s movements during procedures like biopsies.

Magnetic resonance imaging (MRI) scan uses a large magnet, radio waves, and a computer to create a detailed, cross-sectional image of internal organs and structures. Just like in a CT scanner, the patient is put on a table which slides into a tube to see the internal body. Like ultrasound scan, it doesn’t expose patients to ionising radiation.

HOW TO PROTECT YOURSELF AS A PATIENT

Be involved in ensuring that you only get the tests that are needed so that you can limit your exposure to radiation. Ask your healthcare team these questions, and seek a second opinion if you are not satisfied:

 

1. Ask if the test is really necessary to diagnose or treat your medical condition and whether it is the best one to use in your case. Will that particular test make a difference in how your condition is managed? Would an alternative test still achieve a diagnosis?

2. Ask if a lower-dose x-ray or a test that uses no radiation e.g. ultrasound rather than a CT scan, would still work. What does your healthcare team expect to learn from a CT scan and can it be learnt from another test?

3. For a repeat test, ask why you need a new one. What might have changed since the last test to warrant a new one?

4. If you need regular CT scans for a chronic condition, ask if it is possible to increase the time between scans and whether lower-dose imaging or observation without imaging would give the same result.

5. Be especially vigilant about tests for children: Ask if the test is necessary and whether that particular test’s results will affect the management of the child’s condition and the risks of not having that test (the benefit should outweigh the risk).

6. Don’t ask for a CT scan just because you want to feel assured that you have had a thorough check-up. The exposure to radiation is not worth looking for incidental findings when you don’t have symptoms that would justify the scan.

7. Get the tests done at credible facilities which have taken the necessary measures required to run a facility that offers radiology tests. If you do need to have a test that will expose you to radiation, ask if there are ways to shield the parts of your body that are not being imaged to limit their exposure to radiation e.g. by using a lead apron or collar. Breasts, genitals and the abdomen are the most sensitive to radiation.

 

Sources: Harvard Health Publishing (Harvard Medical School); American Cancer Association; other internet sources