Patient 0- A Mystery Wrapped In An Engima
Today I am going to try something completely new- a case study as a blog. Typically, I have not attempted to make the focus of this blog individual case studies. But, this case touched upon so many interesting medical, ethical, political, and professional issues that I felt that it was worthy of its own post. So, let me give you some background on patient 0 and allow me to explain.
The Background On Patient 0
A fairly young patient arrives at our emergency department after entering the country by plane, 3 days prior to admission. She claims to have worsening right upper quadrant pain exacerbated by eating. In addition, she states that she never had any imaging studies either here in this country or from her home country. After “examining” patient 0, the emergency physician decides to order a hepatobiliary scan to exclude cholecystitis. So, the patient comes to our nuclear medicine department for the study. Initially, we take a prelim scout image prior to injecting the radiopharmaceutical and this is what we see:
A technologist looks at the study and determines that maybe there was some contamination and repeats the image again after cleaning the table. Here is the image again!!!
No change… Uh oh, where is this activity coming from? She just flew in from a foreign country and claims to have had no tests after entering the United States. The physicist is subsequently called down to interview the patient. Here are some of the questions and answers:
Physicist: “Are you sure you did not receive any medical tests since arriving in the United States?”
Physicist: “Did you receive any medical tests when you were in your home country?”
Patient: “Yes, I got an injection of something in my arm to relieve my pain.”
Physicist: “What was that injection?”
Patient: “I don’t know. Pain medication?”
Physicist: “Did you eat anything unusual?”
Patient: “I ate a regular light breakfast and lunch.”
So, the physicist calls over the radiology manager of the department and myself, the nuclear medicine physician of the day. Given the absence of a clear history of radiopharmaceutical administration, he becomes concerned that either patient may have ingested radioactivity from a contaminated source or the patient may have had an exposure something that is highly radioactive. Exposure to a dirty bomb??? We all begin to sweat profusely.
What would you do next?
Calmer Heads Prevail
So, the physicist takes at the Geiger counter and notes that the radioactivity coming from the patient is less than 0.1 mR/hr at 1 meter. Whew, at least we know that the patient is not a danger to the personnel in our department.
Now, how would you deal with this situation???
Well, we decided to change the primary photopeaks of the camera to determine the most likely Kev of the gamma rays emanating from the patient. Theoretically, if the radioactivity was from a nuclear plant or other unusual sources, the patient would not have a photopeak coming from the typical photopeaks for medical imaging. So, we tried imaging with photopeaks at I-131 and thallium. Neither of these photopeaks matched the images coming from the camera. (counts were lower and images were blurred) The best photopeak with the most resolution and counts was from the Tc-99m photopeak, shown in the images above. At least, we were now fairly sure that the radioactivity was from a medical source.
Given a large amount of uptake in the belly and the discovery that patient 0 was not a medical hazard to staff and patients, we decided to send the patient back to the emergency department. Since there was too much uptake in the abdomen, we could not run a hepatobiliary scan and recommended the patient receive a different test. (Patient ended up getting an MRCP showing numerous stones in a dilated CBD and had an ERCP to remove the stones).
Implications, Politics, And Ethics
Let’s go back a bit. I stated before that patient 0 reported to have recently traveled from a foreign country. How would it have been possible for patient 0 to get to this country with this amount of gamma rays coming from her abdomen? If the patient truly traveled from her home country several days ago, wouldn’t the radiation have been detected at the airport? Would she really be in this country at this point? Probably not.
But, no detectors are foolproof. Sometimes, a detector could not be functioning properly or can malfunction. But, does that still likely explain the patient’s radioactivity? Unlikely. Why? Since technetium 99m half life is 6 hours, and the patient states she traveled to this country 3 days ago, would she really have this amount radiotracer left in the large bowel? No.
So then, what is really is going on here? Personally, I think that she received a medical dosage of a radiopharmaceutical, possibly for a hepatobiliary scan, after arriving in the United States. And then, she likely left the other facility to come to our hospital, maybe against medical advice. That begs the question. Why?
Immigration Policy Issues
My first thoughts: Could she be here at our hospital because she feared deportation back to her home country? Was she a medical tourist who was hoping to get better treatment in our country? I’m not sure of the real answer to why she was here.
But, the real question in my mind. Are we going to see more of this type of situation in the future? With new and stricter immigration policies, more patients may decide that they cannot tell the truth about their prior imaging because of the real or imagined fears of deportation. I think this has the potential to be the proverbial “tip of the iceberg”. We may see more cases like this in the future.
Our Ethical Obligations
First and foremost, as physicians, we are obliged to serve our medical duty to the public and ensure that we do no harm to others. In this case, we accomplished that once we figured out that the radiation dose and exposures were not harmful to other people. However, in my mind, many questions still remain about this case, especially what are our ethical obligations if she was exposed to a non-medical radioactive source. How would we have handled that situation? Who would we have notified next? Do we follow the regular channels of just contacting the Radiation Safety Officer. Or do we also get in touch with the patient’s relatives, the police, the nuclear regulatory commission, or the FBI…
Fortunately for us, we averted a potentially scary situation. But, it really makes you think about all the potential outcomes of a radioactive patient 0 scenario. What about next time?
Comments From You
I would love to hear what you, the reader, think about this case since it makes for a great discussion. Would you have done anything differently? What are your thoughts about a patient such as this that could potentially arrive at your institution?