Introduction to Radiologic Technology - PowerPoint

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					Introduction to
Michael Solle, MD, PhD
Introduction to Radiology
   I: Radiology Basics and High Yield Topics
       Modalities in Radiology and Cases
       Contrast
       How to look at studies
       Catheters: tunneled vs non-tunneled
       Drains and Tubes
   II: How to Consult Radiology
   III: Plain Film Imaging of the Abdomen
   IV: Parting Thoughts

   Dr. Molina and Chest Radiology
Definition of Radiology
   Radiology is a medical
    specialty using
    medical imaging
    technologies to
    diagnose and treat
I: Basics/Hi-Yield:
Radiology Modalities
   Conventional radiographs (“x-rays”)
       Fluoroscopy
       Mammography
   Computed Tomography (CT)
   Nuclear Medicine (NM)
            PET-CT combines CT and NM

   Ultrasound (US)
   Magnetic resonance imaging (MRI)
Radiology Modalities
   Conventional
       Lingo:
            Density
            Opacity

   Observable Densities:
       Metal
       Bone
       Soft Tissue
       Gas
Radiology Modalities
   Fluoroscopy
       “Live” imaging
       Contrast agents often
Radiology Modalities
   Computed Tomography
       Lingo:
            Attenuation
            Density
            Enhancement
   Hounsfield Units
            -1000 air ***
            -100 fat
            0 water ***
            20-80 soft tissues
            100’s bone/Ca/contrast
            >1000’s metal

   Large radiation dose
Radiology Modalities
   Nuclear Medicine
       Lingo:
            Counts or Activity

   Physiologic imaging
       Radionuclides
            Technetium
       Radiopharmaceuticals
            “Choletec”
   Radioactivity stays with
    the patient until cleared or
Radiology Modalities
   Ultrasound
       Lingo
            Echogenicity
            Shadowing
            Doppler for flow

   No radiation
   Can be portable
   Relatively inexpensive
Radiology Modalities
   MRI
        Lingo:
             Signal intensity
             T1
             T2
             Enhancement
   No radiation
   Strong magnetic field
             No pacemakers
             No electronic implants
   Small, loud tube and patients
    must be able to hold still
   Relatively expensive
Radiology Modalities:
   Four different cases of Abdominal Pain
   Can you develop a differential diagnosis
    based location of the abdominal pain?
   Can you identify the modality used?
   Diagnosis?
Case 1: RUQ pain
Case 2: RUQ pain: Diagnosis?
Case 3: RLQ pain: Diagnosis?
Case 4: RLQ pain: Diagnosis?
I: Radiology Modalities Summary:

   Conventional radiographs (“x-rays”):
           Great place to start (cheap, fast, low radiation).
   Computed Tomography (CT):
           Diagnostic dilemmas (pricier, variable speed b/c of contrast).
           High radiation.
   Nuclear Medicine
           Physiological imaging, great for specific questions.
   Ultrasound (US)
           Relatively inexpensive, and no radiation.
           Highly dependent on patient’s body size and US operator.
   Magnetic resonance imaging (MRI)
           Relatively expensive, no radiation, not fast.
           Unmatched ability to contrast healthy tissue from disease.
I: Basics/Hi-Yield:
A few words on contrast
   CT contrast:
       IV- contains Iodine; which attenuates x-rays
            Contraindicated in renal failure (acute and chronic) b/c of risk of
             contrast induced nephropathy
            Allergy issues
            Power injected and causes vaso-vagal reactions (NPO)
       PO- contains dilute iodine or sometimes very dilute barium
        (flouro studies typically use barium)
   MRI contrast:
       IV- contains gadolinium chelated to a carrier molecule; acts as a
        paramagnetic molecule which increases signal on T1 images
            Contraindicated in renal failure (acute and particularly ESRD) b/c of
             risk of NSF
I: Basics/Hi-Yield:
A few words on contrast
    radiologist, because the creatinine may be

   In hyper-acute renal failure, the creatinine hasn’t
    risen yet. Decreased urine output or anuria is
    acute renal failure – regardless of the creatinine.

   Remember; first do no harm! Non-contrast
    studies can often be quite helpful.
I: Basics/Hi-Yield:
Looking at Imaging Studies:
   Adequate Study?
       Correctly labeled with patient’s name, MR#, and the date
        of the study?
       Technically adequate?
   Systematic versus Focused look at a study:
       Radiologist does both!
       As the requesting clinician, you should also look at your
        patient’s study (at least plain films), as well as follow up
        on the final report.
            PTX, PNA, pleural effusions, SBO, free air
            Evaluate lines and tubes (especially the ones you placed!)
I: Basics/Hi-Yield:
Looking at Imaging Studies:
   PACS workstations (diagnostic versus
          Picture Archiving and Communications System
          Radiology, ER, ICU’s, some surgery clinics
   Web based PACS (web 1000)
   WebCIS based PACS (java script)

          At UNC: “6-PACS” is PACS help desk
I: Basics/Hi-Yield:
tunneled versus non-tunneled catheters
   First, examine the patient!
       Inspect
       Palpate
       (Don’t auscultate or percuss)
   A tunnel is a short (several inches) segment of catheter that
    is within the superficial soft tissues (subcutaneous fat)
    between the venotomy site and the catheter access site.
       “Perm Caths”
       “PortaCaths”
       “Powerlines”
   A tunnel or port pocket infection usually means removal of
    the line.
   CVAD= central venous access device
I: Basics/Hi-Yield:
tunneled versus non-tunneled catheters
I: Basics/Hi-Yield:
tubes & drains (abscesses, G-, Neph-)
   Most VIR drains/tubes need to be flushed with sterile saline.
           The purpose of this is simply to keep the tubes from getting
            clogged. All tubes should be flushed after use.
           There’s usually a 3-way stopcock to accomplish this.
   Nephrostomy and Gastrostomy tubes need to be changed
    every 3 months or so.
   Abscess drains usually need a sinogram (tube injection) to
    evaluate the cavity size and for any fistulous connections,
    about 2 weeks after placement.
           If cavity small and output of drain is low, then drain may be pulled.
            If it’s pulled too early, then the abscess will fester/return.
   Surgical drains are managed by the surgical teams, and often
    do not need to be flushed (no 3-way stopcock).
II: Obtaining a Radiology Consult
   A Radiology consult is obtained every time
    a study is requested!

   Who handles these requests and reads
    these studies and/or performs these
II: Obtaining a Radiology Consult
   The Department of Radiology at the University of North
    Carolina at Chapel Hill has eight clinical sections:
       Abdominal Imaging (Body CT, US, MRI, Flouro studies such as
        UGI and SBFT, Biopsies)
       Breast Imaging
       Cardiopulmonary Imaging (Chest, Cardiac)
       Musculoskeletal Imaging (Bone, ER RR, MSK MRI’s)
       Neuroradiology (brain/spine CT & MRI; lumbar punctures)
       Nuclear Medicine (wide variety, PET-CT, bone scans, Cards)
       Pediatric Imaging (wide variety)
       Vascular-Interventional (wide variety)
II: Obtaining a Radiology Consult
   6-1461- The Radiology “Front Desk”
   Reading rooms (RR’s):
       Body CT 3-2938
       Chest 3-2939
       GI/Adult Flouroscopy 3-2961
       Neuroradiology 3-2978
       Pediatrics 6-7554
       MSK/bone 6-8850
       US 6-0038
       MRI 6-8112
       Mammography 6-6392
       Nuclear medicine 3-2937
       VIR 6-4645
The Face of Radiology
II: Obtaining a Radiology Consult (at
UNC Hospitals)
   Try to call the right reading room (RR).
        When you call, identify yourself, and expect whoever answers to identify themselves.
              Improves accountability
              Good policy to know who you talked to (always)

   When paging, it’s nice to put your name/pager number immediately after
    the call back number

   After hours:
              6-8850 Lower Level/ER RR
              216-2826 Upper Level (VIR, Doppler US, MRI)

   DON’T call 6-8850 during the day
              unless it’s an MSK radiology issue
II: Obtaining a Radiology Consult:
   VIR or any other invasive procedures:
       Who gives consent? Pleae get phone number of HC POA or
        spouse or relative
       Basics for any invasive procedure
            See the patient!
            Coags (PT, PTT, INR)
            Platelets
            NPO for sedation or GA
       Don’t promise the Bx/Line/procedure, but please tell the patient
        before we get there…..
       Don’t promise sedation (but we almost always use it)
   Think about risks/benefits prior to considering invasive or
    expensive procedures. Ask yourself if the results will change
Please page us if our report is confusing!
III: Plain film imaging of the abdomen
   Stones
          Gallstones
          Renal stones
   Bones
          Lumbar spine, pelvis, hips
   Masses
          Organomegaly, ascites
   Gasses
          3 cm small bowel
          6 cm large bowel
          9 cm cecum
III: Plain film imaging of the abdomen
   KUB (kidneys, ureters, bladder)
   2 View---AP supine and erect abdomen
   Acute abdomen series: 2 view with upright
   Lateral decubitus (Left or Right)
   Cross table lateral---prone or supine
III: Plain film imaging of the
abdomen: normal supine KUB
III: Plain film imaging of the
abdomen: Gallstones supine and erect
III: Plain film imaging of the
abdomen: Gallstones
III: Plain film imaging of the
Abdomen: Nephrolithiasis
III: Plain film imaging of the
Abdomen: Nephrolithiasis
III: Plain film imaging of the
Abdomen: Bones
III: Plain film imaging of the
abdomen: ascites
III: Plain film imaging of the
abdomen: gasses?
III: Plain film imaging of the
abdomen: gasses? This is SBO
III: Plain film imaging of the
abdomen: more gas & SBO easy to Dx
III: Plain film imaging of the
abdomen: more gas & SBO easy to Dx
III: Plain film imaging of the
abdomen: Pneumoperitoneum
III: Plain film imaging of the
abdomen: Pneumoperitoneum
IV: A Few Random Parting thoughts

   Patients want a doctor who cares about them. When admitting a
    patient, get their (family’s) phone numbers yourself, as part of the
    History and Physical.
        Patients will forgive you for a host of small things if you show them that you
         care, will be honest with them, you will work hard for them over the long
        Getting their phone numbers show you care about them and their family.

   Learn to take ownership of your patient’s and their medical
        Follow up on test/imaging results.
        Follow up on clinical outcomes.

   Longitudinal data is often the most valuable information there is.
        “Old is gold.”- in reference to getting prior imaging studies.
        Serial KUB’s and serial exams is often more clinically relevant than getting
         a CT scan.
Thanks for listening!

        Hx: Please
        New Line.

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