CAN DARK ROOM CHEST FLUOROSCOPY BE REVIVED IN INDIA ?
Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
In modem days, people all over the world are very conscious of radiation hazards. Therefore, doctors will agree that routine chest fluoroscopy as practised in the past has become obsolete. Yes, it is true.
However following points need consideration
In absence of National Health Scheme in India, for every investigation patients have to pay from their own pockets. The Indian doctor comes across hundreds of patients who cannot afford to pay for a single X'ray plate costing Rs. 501- to Rs. 80/-. 1 am therefore not very sure whether chest fluoroscopy should be given up in our country. In olden days, if a general practitioner diagnosed tuberculosis and thought that the patient cannot afford Rs. 20/- for an X-ray chest, he would refer him for fluoroscopy which then costed Rs. 2/-. This should now cost Rs. 10/- to Rs. 20/-. 1 see nothing wrong if a practitioner by doing chest fluoroscopy can confirm the diagnosis of a moderate or a massive pleural effusion or extensive Koch's.
The solution certainly does not lie in telling the general practitioner to spend 20 minutes on every patient and diagnose the above illnesses in poor patients (who cannot spend for X-ray) with the help of inspection, palpation, percussion and auscultation. The naked truth is that very often:
a) Either there are no physical signs at all.
b) The Indian lady patient often will not undress.
c) There is too much noise in the dispensary interfering with auscultation.
d) There is a long queue of ill patients waiting to be examined and the doctor cannot spend more than two to four minutes per patient.
Many Radiologists may also like to continue accepting such cases because :
1. Better methods from protection of radiation are available in modem days.
2. Presence of image intensifier (collimater) or similar systems in the X-ray units markedly reduce the radiation hazard.
3. Modem cosmic radiation theoretically is becoming as harmful! In this article, I am going to discuss the role of chest fluoroscopy as practised by old fashioned physicians, First of all, I must make it clear that if a patient can afford to spend, most of the times X-ray chest should be ordered and only occasionally fluoroscopy may be requested for certain indications. But, if a physician does a fluoroscopy for every patient (like recording the blood pressure) and does not charge extra fees for the procedure, then of course fluoroscopy has lot of advantages.
These are as follows:
1. All gross lesions of pulmonary tuberculosis can be seen and the treatment can be started immediately. The X-ray chest can be brought by the patient after two to three days; till then, time is not wasted for starting the treatment.
2. In a patient in whom clinically one suspects a massive pleural effusion or a pneumothorax, after fluoroscopy the patient can be sent straight to the hospital for emergency tapping.
3. In heavy smokers, so often the hilar vessels are enlarged because of pulmonary hypertension due to COPD. A malignant hilar mass is difficult to differentiate on an X-ray chest. On fluoroscopy, the presence or absence of pulsations can easily help in differentiating the two.
4. Often in patients who can afford Rs. 60/- to Rs. 100/-, for a single X-ray plate the radiologist refuses to comment on the shadow since he does not know whether the shadow is lying anteriorly or posteriorly. He then asks for a lateral view which will again cost Rs. 60/- to Rs. 100/-. Apart from the waste of time, not many patients may be able to afford the second X-ray plate. On fluoroscopy one can easily turn the patient and find out whether the shadow is anterior or posterior.
5. In heart conditions often fluoroscopy is more useful than an X-ray chest (PA view) e.g. :
a) Sometimes the radiologist diagnoses an enlarged heart on an X-ray chest. If he saw the same heart on fluoroscopy with the patient taking deep breath, the changes in the diaphragm level would immediately help him to avoid making a wrong diagnosis of an enlarged heart.
b) In patients with enlarged pulmonary conus, the hilar "dance" can easily differentiate patients of pulmonary stenosis with post stenotic: dilatation from shunts causing pulmonary hypertension.
c) Tuberculosis of the pericardiurn is a common condition in our country. Once the enlarged cardiac shadow shows very poor cardiac pulsations, the diagnosis is very much in favour of a pericardial effusion. Also if the left dome of the diaphragm is elevated, and moves less with respiration, the aetiology of pericardial effusion is amoebic abscess of the left lobe and not tuberculosis. The above discussion is specially true in all poor and middle class patients who cannot afford the investigation of 2-D echocardiography which costs about Rs. 600/- to Rs. 900/-.
6. Movements of the right dome of the diaphragm form an important diagnostic tool when a patient who has come for fever and/or pain in the right hypochondriurn is being investigated in our country. Diminished movements of the right dome will point to a pathology in the liver or the gall bladder. In fact sometimes fluoroscopy has an advantage over an X-ray where the right dome of the diaphragm is described as normal because it is not elevated. It is very important to note that an amoebic abscess of an inferior surface of the liver or infection of the gall bladder may not elevate the diaphragm but could still result in diminished movements. Many posterior surface liver abscesses produce a slight flattening or blurring of the right dome with diminished movements. Once a localised, immobile (or less mobile) elevation of the right dome of the diaphragm is se i, amoebic abscess of the superior surface is the most likely cause. In such a patient if he cannot afford Rs. 300/- to Rs. 600/- for sonography or an isotope liver scan, treatment of amoebic abscess can be started on the strength of this finding only.
In a patient complaining of fever, pain in the epigastrium and/or left hypochondrium, an elevation and/or diminished movements of the left dome of the diaphragm are very suggestive of a left lobe liver abscess. Very often the air shadow under the diaphragm is displaced by the liver swelling.
7. Doubtful apical shadows reported on an X-ray chest are always a problem. The radiologist will ask for lordotic view and the patient has to spend extra money. It takes only two to three seconds under fluoroscopy to see the apex in lordotic view.
8. Most of the doctors look after patients of COPD who live for as long as five to ten years or longer. Whenever, such patients come for an exacerbation of symptoms, patches of pneumonia or a pneurnothorax must be excluded. In a known case of COPD, fluoroscopy examination is enough to do this.
9. So often we have a problem that a poor patient diagnosed as pulmonary tuberculosis has started drugs but comes back after a few weeks for loss of appetite and inability to eat. 'Me differential diagnosis then is between tuberculosis resistant to the drugs and early iatrogenic toxic hepatitis. If fluoroscopy examination shows that the shadow has reduced in size then, this is an additional point in favour of iatrogenic hepatitis. In this situation an X-ray chest is not required and the patient's money can be well spent in ordering a blood test of SGPT.
10. In Indian female patients, large nipples and buckles of undergarments, which are often misreported in X-ray chest, are easily identifiable on fluoroscopic examination.
11. External swellings of musculoskeletal origin are easily identified on fluoroscopy.
I have not tried to include many theoretical indications which may not be useful to a private practitioner or even a private consultant physician.
Before I complete, I would like to mention some conditions in which the diagnosis is never to be made by fluoroscopy. These are:
i) Miliary tuberculosis
ii) Early minimal tuberculosis
iii) A small tuberculous cavity
iv) Single or multiple secondary deposits
v) Diseases like interstitial fibrosis of lungs
vi) A small pneumothorax
vii) And many more other theoretical conditions
On the other hand, there are rare medical conditions like peripheral pulmonary lesions, local obstructive emphysema and encysted pleural effusion etc., where a chest fluoroscopy will help in the diagnosis more even when the X-ray chest is available.
In India can chest fluoroscopy be revived? Will it mean that we are going backwards instead of progressing towards Digital X-ray? In my opinion, no .
Many of my radiologist colleagues and students have disclosed to me that when they do an X-ray plate on a slightly concessional rate of Rs. 40/-, Rs. 30/- being the cost of the film and its developing, there is little margin of profit.
Secondly, India is a poor country. Even in cities like Bombay, as the rich population is increasing; simultaneously very poor slum and pavement dweller population is also increasing. The latter cannot afford to spend for an X-ray plate. Many inexperienced writers and doctors will suggest, that why can they not go to the free government or municipal hospitals? After having worked in such hospitals for over thirty years, my advise is never to send these patients to these hospitals, because it will be too costly for your poor patient to get one free X-ray plate. In Bombay and elsewhere, commuting has become costly. The patient has to make three to four or more visits before getting one -ray plate. Often on the day of the procedure (after two to three visits), the X-ray plates are reported to be 'out of stock'. Often the final report comes with the comments - "please repeat".
Therefore, if the radiologists can be coaxed to start doing chest 'fluoroscopy' procedures at the nominal cost of Rs. 10/- to Rs. 20/- the practitioner and the patient will also get extra bonus! This will be in the form of a 'personal touch'. It often happens that the technician takes the X-ray pictures, which are reported in the evening when the radiologist comes. The patient does not see the face of the specialist. Next day he has to commute again to collect his report.
a) the Radiologist, personally attends to the patient,
b) the Radiologist can tilt the patient or turn him depending on the decision made on the spot,
c) the patient will get a report at the same time thus saving the commuting expenses,
d) the family doctor will not mind getting the report like 'NAD' on a small piece of paper scribbled and signed by the radiologist. In return, the radiologist will save money on the letter heads and the services of a typist.
Grateful thanks are due to Dr. Anirudh Kohli and Dr. Vipul Parilch for their helpful criticism.
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