Presenters: Dr JS Lapointe with the assistance of Dr BD Sarkodie, Dr J Oblitey, Dr S Mensah and Dr F Ofei

Size: px

Start display at page:

Download "Presenters: Dr JS Lapointe with the assistance of Dr BD Sarkodie, Dr J Oblitey, Dr S Mensah and Dr F Ofei"

Myra Thornton
5 years ago
Views:

1 Presenters: Dr JS Lapointe with the assistance of Dr BD Sarkodie, Dr J Oblitey, Dr S Mensah and Dr F Ofei

2 Debate common problems between clinicians and Radiology and possible solutions (for ex. how to get a timely examination and the most helpful radiological report about a patient). Discuss the need for and availability of radiological interventional procedures (Find out what the radiologist can do for your patient). Review the rationale for frequently ordered examinations and safe practices related to them Improve communication between clinicians and radiologists (sometimes by educating the radiologist).

3 1. List three expectations you have about Radiology/radiologist(s): a) b) c)

4 Expertise (i.e. better able to correctly interpret imaging studies than clinician) Well run department (availability of examinations, accuracy and speed of reports) Availability for consultation (Emergency and routine hours) Acquisition of new knowledge for use with other patients

5 2. Do you recommend a particular imaging facility to your patients? Yes/No What are your reasons if yes?

6 Proximity Speed of service/reporting Cost to patient Quality/expertise Patient centered care Safety Financial incentive Other?

7 3. List common Radiology problems you have encountered: a) b) c)

8 Availability of examinations and radiologists Cost of examination (and consumables such as contrast) Timeliness of report Other?

9 4. What knowledge would you want to be taught by the radiologist, to enhance your patient care? a) b) c)

10 The most appropriate and cost effective exam (USG, CT, MRI, etc) for this patient? Required information before ordering a test (ex: renal function if iodinated contrast to be used, absolute contraindications to MRI) Other

11 5. What interventional procedures would you want to request from radiologists? a) b) c)

12 Reduction of intussusceptions USG/CT guided biopsy Abscess/cyst drainage Other?

13 6.Do you use evidence based guidelines to order radiological exams? (Rationale for frequently requested examinations and safety practices) Have you heard about (for example): Chest x-ray criteria re pneumonia (2005) Ankle imaging rules (Ottawa) Obstetrical Ultrasound Guidelines (2009), etc

Focal Neurologic Deficit Present? Yes/No Midline Spinal Tenderness Present? Yes/No Altered Level of Consciousness Present? Yes/No Intoxication Present?

14 Focal Neurologic Deficit Present? Yes/No Midline Spinal Tenderness Present? Yes/No Altered Level of Consciousness Present? Yes/No Intoxication Present? Yes/No Distracting Injury Present? (i.e. non neck) Yes/No Patient has none of these Yes answer to any of the first five requires imaging to clear the cervical spine/remove the collar

15 7. How do you choose the type of exam to answer a particular question or when new type is available? Examples: MRI of lumbar spine: Is CT just as informative? When? Abdominal and/or pelvic ultrasound: When are both needed? Renal colic: USG, IVU or CT Ectopic pregnancy (and rare abdominal pregnancy) and pregnancy test Other?

16 Habit Knowledge of what the surgeon will need Least costly for the patient Likely the most informative Other?

17 Understanding contrast and radiation risks and radiation protection or Knowing about safe imaging practice and how to advocate for it (require it)

18 8a.Who is in charge of the examination? Who determines the views? 8b.Do the images produced meet your needs? Would another projection be routinely beneficial? How specific must you be on the request? 8c.Are there any cost implications to the patient for your specific requests?

19 Routine imaging protocols for each exam? Need for specific instructions from clinician (ex: without/with contrast; imaging planes, standard and bone windows, MPR images on CT)? Are CT/MRI exams monitored by the radiologist prior to reporting? Will all relevant anatomy be included in the routine protocol (ex.: Lumbar spine CT/MRI does not include sacral nerves and pelvis, in a case of urinary and fecal incontinence)?

20 In charge: radiologist or radiographer vs. clinician Giving detailed instructions on request: helpful to the radiographer Added cost: usually only if IV contrast optional, or if added plain films not part of existing protocol at that imaging location (ex: chest PA and lateral instead of PA only)

21 Ghana Atomic Energy Commission (GAEC) is responsible for monitoring x-ray equipment; testing done every 5 years. The schedules of the Radiation Protection Institute (RPI) of the GAEC include evaluating every radiographic unit/machine twice a year. 9.Have you heard of RPI reports for the centre where you send your patients or of any safety related publicity on your centre (good or bad)?

22 10. What type of exam uses ionizing radiation? (N.B. number of exposures performed may exceed number of printed images available to clinicians): Barium enema: Yes/No HSG (hysterosalpingography): Yes/No Obstetrical ultrasound: Yes/No Pelvis MRI: Yes/No CT of head Yes/No

23 Barium enema: Yes HSG (hysterosalpingography): Yes Obstetrical ultrasound: No Pelvis MRI: No CT of head Yes

24 11. Who is more at risk from radiation? Elderly 4 y. o. child Adolescent Fetus Pregnant woman Cancer patient

25 Elderly 4 y. o. child (no 2) Adolescent Fetus (No 1) Pregnant woman Cancer patient

26 What radiation precautions are routine in the centre (s) doing x-rays on your patients? a) b) c) (No accrediting body for Imaging Centres in Ghana currently, only accreditation of teaching institutions and programs)

27 Screening for possible current pregnancy in females (date of last menstruation) by radiographer Use of lead shields (to protect gonads) Radiation monitoring of personnel (radiation badge/tld) Use of qualified radiographers or sonographers Posted results of evaluations by Radiation Protection Institute of GAEC/ Accredited facility Other

28 13. The use of intravenous contrast agents (iodine or gadolinium based) poses a risk to your patient. Apart from well known anaphylactic reactions, bronchospasm and urticaria, please list other concerns about the use of contrast: a) b) c)

29 14. Do you check the renal function in the individuals before sending them for IV enhanced studies? 15. Is your diabetic patient having a contrast injection taking metformin (glucophage)?

30 egfr is best measure of renal function, rather than creatinine. Renal function/dysfunction and contrast induced nephropathy (CIN). At risk are hypertensives, diabetics, elderly, dehydrated people mostly. Diabetic patient on metformin (glucophage) at risk of lactic acidosis if in renal failure; do not give contrast if egfr <30).

31 16. Is gadolinium (used for MRI) safer than iodine based contrast (used for IVU, CT)? 17. Is gadolinium safe to use in everyone?

32 Answer: Yes, gadolinium is safer than iodine (i.e. less reactions; death can occur with both). Answer: No, very poor renal function can lead to nephrogenic sclerosing fibrosis (NSF), a condition of skin and organs documented since about 2000.

33 18. Have you had a patient with a contrast reaction? 19. Was the imaging centre equipped to deal with the reaction?

34 Most reactions occur within first hour with some up to 8 hrs after IV iodine Delayed contrast reactions can occur up to one week after IV injection of iodine Delayed reactions include cutaneous rash and in patients with poor renal function, polyarthropathy and iodine mumps (salivary gland swelling).

35 20. What information is appropriate on an imaging request? a) As little as possible, not to upset the patient and family b) Clinical impression only c) Detailed physical findings

36 INPUT: Request for Radiological Consultation Brief clinical history and major clinical exam findings, (incl. right or left) in addition to provisional diagnosis (least important) Ensure complete doctor s name is on request Encourage best practice by: a) Being knowledgeable about exam standards & imaging options b) Reviewing images with the radiologist

37 The clinical history/reason for exam (so other physicians can understand why it was requested) Pertinent abnormalities and negatives List of the normal structures in a sentence(to show that they have been reviewed and labeled normal ) Differential diagnosis Recommendation (when appropriate)

To avoid the problem of patients getting your mobile number or email address consider obtaining a

38 To avoid the problem of patients getting your mobile number or address consider obtaining a current copy & using the: Printed Published Doctors Directory (Full name required on request and report)

39 The radiologist is a specialist well placed to help clinicians reach the correct diagnosis and better manage the health of their patients. But good two way communication is essential to reach this goal.

40 Medical Expert Communicator Collaborator Manager Health Advocate Scholar Professional (from CanMEDs)

Contrast media Purpose of using contrast Contrast reaction Nephrotoxicity from contrast Nephrogenic systemic fibrosis When should contrast be used

Contrast vs Non-Contrast When to Order Stephen McManus, M.D. Contrast media Purpose of using contrast Contrast reaction Nephrotoxicity from contrast Nephrogenic systemic fibrosis When should contrast be