Last Post for Clinicals

I hope everyone has had a great semester! I know that I am glad to get a little break for a couple of weeks!

I am attaching a CT head image after administration of 75 cc Omnipaque 350. We use a 3 minute delay for our heads. This patient, a 56 year old male, first came initially for a CT chest in March. He had been having some hemoptysis with little to no shortness of breath. The CT showed a left lung cavitary mass. We biopsied this mass in March and it came back positive for Stage IV adenocarcinoma. In April, we scanned him again and we found bone mets in his pelvis. In May, we repeated the scan and found bilateral metastatic adrenal lesions. Now, the patient presents back to us while undergoing radiation and we perform the CT head and find mets to his brain. The report reads that there is a 2.5 cm left cerebellar mass with moderate effacement of the fourth ventrile. No hydrocephalus.

This is the great thing about working in CT, and also the hardest. These patients once they keep coming over and over become like family. It's hard to see them deteriorate and then pass. But, we have such an ability to impact their last days in making more tests easier to bear. We have an opportunity to ask them about their family and fun things they would like to do. Once, one of our cancer patients brought back seashells from the beach. This trip to Florida was her last wish that her family fulfilled. It meant so much to the staff that she shared that with them. We, as healthcare workers, often don't realize how much we can impact a patient's outcome just in helping keep spirits up.

I hope everyone enjoys the rest of their classes, this is my last clinical class.

Susan Brumley

CT Radiation Dose

As everyone is aware, CT dose is a hot topic in the layperson media along the ACR and other Radiology journals. At Deaconess, we try very hard to keep up with current best practices. Recently, the CT Team Leader and myself listened in on a webinar regarding CT dose and how to reduce it. We actually realized during this national webinar, that we...in little Evansville, IN are doing what many larger institutions are doing. We've done alot surrounding radiation safety to ensure the public is safely receiving adequate CT studies.

We have done recently:

*Looked at all of our protocols-per scanner. One particular Radiologist has taken ownership and we run all of our protocols through him.

*Developed a CT Dose Audit tool. We actually take this audit tool and place it at the controls for the scanner and the technologist must record the dose from the CT Dose report that is attached to every CT exam and sent to PACS. This makes the technologist think about radiation dose as they audit.

*Radiologist helped determine "normal ranges" for the dose audits. In doing our audits, we found that our CT Sinus/Face protocol could be realistically tweaked down a bit on one particular scanner without sacrificing quality images.

*We've made a huge stride to shield as much as possible. Attached you will see an image using a breast shield. The breast shields are great and they cause very little artifact while saving the female breast tissue a huge dose.

*Radiologist is going to do a "Grand Rounds" at Deaconess for Medical Staff so that MD's are educated on CT Radiation dose and what exams are best for what diagnoses.

All of these things are actually reported out to our Radiation Safety Committee quarterly so that they know at what lengths our department is going to keep our patients safe!

Deaconess Update

We've had a very busy start to our work week...or at least it felt that way! Our scanner went down overnight and today was a bit chaotic to start. It turns out that we've had some air conditioning problems in our VCT room. This is our 64 slice scanner and it puts some heat out! We use it all the time and it just doesn't really get a break, even at night. So, we had to call engineering and maintenance and get it taken care of. Apparently, the ducts had not been cleaned out for quite some time causing the air conditioning to not work the best. But, by 1030 am we were all cooled down and running smoothly again!!!

Clinicals Update

We've been really busy the past few weeks in the CT department at Main and Gateway. Yesterday we were hopping from the ER all day! We had a gentleman with a history of a fall come over for a CT chest, abdomen and pelvis. Of course, we were looking for trauma related pathology, but unfortunately, the patient ended up with an abnormal lesion in his chest. The fall of course is bad, but it could have saved his life! He was asymptomatic and had no cancer history. The radiologist recommended a biopsy so I am sure that we will be seeing him back in a few weeks once he has healed up from his fall.

Clinical Update

Hello all! I hope everyone is having a great semester. Things are moving along for me. Our hospital is beginning to ramp up for our HFAP survey. HFAP is a hospital accreditation similar to JCAHO. Many hospitals are moving to this type of survey. Right now we are really working hard on our Stroke Indicators. With our Stroke Certification we must do alot of PI (performance indicators) to show what our turn around times are. I am given a list of patients that coded out as a stroke and then must audit their charts for their CT head or CTA head results and then also their CXR's. We are supposed to have results to the ordering physician in 45 minutes. For the most part, we are very good at what we do. CT is a well-oiled machine in most cases. Of course, there are always an outlier or two that needs a little research. It helps alot that I still go back and watch staff and scan. It is a huge help to get buy in from staff and also to develop policies that actually work.

Hello All

Happy Clinicals! My name is Susan Brumley for those who may not know me. I am the department manager for Deaconess Hospital, Gateway Hospital, and Deaconess Clinic. I have been a CT technologist for about 13 years now. I passed my boards finally last April...just decided I needed to do it! I can't expect my CT staff to take a board exam if I don't.

I am running a bit late this semester! We've had a busy past few weeks at Deaconess in managment and staffing. We had a routine unnannounced inspection from the Indiana State Board of Health. I am happy to say that the Radiology department passed with flying colors! The surveyors complimented our staff on how helpful and knowledgeable they were. Then, as that was drawing to a close, the NRC walked in! Boy, was I nervous. I had not gone through this type of rigorous inspection before and our previous RSO had taken a new job not two months previous. So, needless to say I was nervous about how things would play out. But, again, our staff did a tremendous job. The surveyor was extremely detailed and interviewed every technologist and team leader including myself. But, we did a wonderful job and there were no citations or recommendations. This was a real test in leadership for me, and I feel like if I can go through an NRC and State inpection on the same day...I can probably handle anything!

Update to Clinicals

Well...this has been a crazy week, to say the least! CT at both Main and Gateway have been extremely busy. Thursday we had a code called at the Main campus in CT. He was a 72 year-old gentleman from a regular medical telemetry bed. He was getting a CT Head without contrast due to altered mental status. We noticed he was very uneasy and unsettled while we were transferring him to the table. He then just wouldn't hold still, but after repeating the first axial group, we got what we needed after we shortened the scan time. As we entered the room, we noticed he had turned gray and was not breathing. We knew that the family down here were discussing his code status, but with no official changes in the chart, we called the code. Immediately, we had much help. Due to the fact we had an ICU patient down in another room, the ICU nurse jumped right and started compressions. I think everyone was glad that she happened to be there! After some work, the team got him back and transferred him to ICU. As we were completing this...the trauma pager went off. I guess when it rains, it pours. The trauma was a 20 year old who was cutting limbs and a limb came back and hit him in the face and then knocked him off the ladder...he did some major damage to his face and caused a SDH.

Friday, our scanner at Gateway went down again. So, I went over there to help with any issues with the ER and to make sure service was on it. It went down during a bone biopsy, but luckily the needle wasn't placed. We had to move him and then work on the 6 ER orders that we had before we could get the biopsy going again.

The biopsy patient was a 56 year old male with hepatocellular carcinoma with metatstatic disease. He now presented with terrible pain and CT showed that the disease had infiltrated his bone. The radiologist was asked to perform a right iliac wing bone biopsy. Believe it or not, it went very well. He made 3 passes in to the bone and the pathologist said that we had an excellent specimen. I've included an image that shows the needle location while we were passing through.

Update to Clinicals

Well, thankfully, the pregnancy season is closely coming to an end in the CT department. We have had 4 maternity leaves all spaced about 3 weeks apart. The second technologist returned this past week and I have one more returning on April 5th. While it is stressful for all involved, it is nice to stay closely in tune with the department. CT at Main and Gateway are two of the busiest departments in the Radiology department. We average about 4000-4500 scans per month, and to be honest, that is down a little bit from last year. I worked this past Friday evening to give some relief to my Team Leader. As we all know CT dose is a hot topic. I had an OP present to the department for a CT stone protocol. When I went in to look at his record I noticed that he'd had 3 separate scans in the past 5 weeks. I thought that was odd that a urologist would order yet another scan only a week later. So, I phoned the physician. It puts the technologist in a precarious position to actually ask the practioner..."Are you sure you really want this?", but this patient was only 35 so I figured it was better to err on the side of caution. It turned out that the patient was scheduled in error. He was supposed to get it in 30 days after his lithotripsy! So, I was glad that I put a little time into it and saved the guy $2,000 and unnecessary radiation.

Clinicals Update

Here at Deaconess Hospital we have a Level II trauma certification. We had a category II come in while I was working. Category I activations are the most severe activations that require alot of accurate QA documentation. Category II's are a little lower level of trauma activation. Above are some images from a recent category II. This patient was a 70 year-old female who was a restrained passenger. The car was T-boned. She was airlifted to Deaconess from Illinois on March 1st.

She had multiple displaced rib fractures, a large right pneumothorax, and a hematoma to her RLQ anteriorly. She also had a Grade I liver laceration. Luckily, she had no head injuries or spinal injuries. The patient had chest tubes placed in the ER and was transferred to Trauma ICU. Her liver laceration was monitored while in the ICU as it was not deemed surgical at the time of admission.

Update to Clinicals

Things are going fairly well so far for CT at Deaconess. We are very busy with Inpatient work these days and of course Outpatients. We have several technologists that are off due to maternity leaves so that leaves us a little short handed. I have to say, the group has risen to the occasion and things are going just fine.

I helped out Saturday due to our physician order entry portion of our EMR going live. So, I assisted where needed and scanned at Gateway. I scanned an older gentleman who had an abnormal bone scan the day prior. So, we were looking for metastatic disease. An unfortunately, there were mets everywhere. The report showed a spiculated LLL lung nodule and also metastatic disease to the thoracic vertebral bodies and rib fractures...all which are pathologic in nature. I have attached a sagittal reformatted image of the lytic lesions to the vertebral bodies.

Welcome back everyone!

Hello!
For those of you new this semester, my name is Susan Brumley. I am a supervisor at Deaconess Hospital and Gateway Hospital. I passed my boards in CT this year...a long time goal for me! My next goal was to then finish my bachelor's degree. I manage the CT, MRI, and Diagnostic modalities at both campuses.

I am married and have 6 kids. Yes, I did say 6...I didn't give birth to them all, but I claim them! The four older kids are off in college or on their own. We have two younger children at home, age 7 and 2. Between work, school, and kids I really don't have much time for anything else. But, I love to shop, read, and watch movies. We also love soccer and spend a good amount of time on the field.

Have a great semester!

Merry Christmas!

Well, I hope everyone had a great semester! I am ready for a little break before the Spring semester begins.

We've had a bit of a bad luck run on illness in CT. Several have been hit with the stomach flu. So, I figured it was my turn so I worked several hours tonight. I scanned several patients as the ER at Gateway was hopping! It's best to just think of that as job security. I scanned a elderly gentleman tonight that was s/p open heart surgery. He had a low hematocrit so there was some concern of hemorrhage. However, he also was having shortness of breath and some chest pain. The radiologist said that it was pleural effusions and had no mediastinal hemmorhage.

My other big time consuming patient was actually a 2 year-old. He had a cxr and it was normal. The other technologist wanted to call the radiologist and get the new CT chest order approved. I chose to take the other route and bring the patient/mom down and get a better history. I was able to use Epic, our new electronic medical record, to my advantage and checked the physician notes. There was no history that warranted scanning this child's chest. So, I called down and spoke with the nurse who then said that the order was entered incorrectly. As a technologist, we often feel unimportant..especially from nursing. Had I just performed the exam, I would have given the child unneccesary dose. Asking clarifying questions can save the technologist unneccesary work...but more importantly we must do what is right for the patient! The key here is treating the ER physician with some respect to make everyone's lives easier!

All in all, it was a nice change in pace. I worked last week at Main Campus, but was in charge so I didn't get to scan.

Merry Christmas to everyone!

CT Clinicals Update

I had no idea I would have something for everyone so soon! We had an interesting case that I got to follow through on beginning with the planning of the patient with the Radiologist's portion of the exam to the CT exam at the end. This patient was in the ICU and intubated and a request came down for a cervical myelogram. Most Radiologists perform their lumbar punctures with the patient prone so he wanted to have some senior tech involvement and the Team Leader for the area was off. So, I assisted. Below is a brief case study of the patient:


We received a 61 y/o male through the emergency room for a CT cervical spine among everything else ordered. He was alert and orientated and was responding to questions. However, he had tingling sensation to the nipple line, but was unable to feel anything from that point down. He suffered a 4 foot fall from a truck bed.

The exam was performed and it was noted that he had a significant C-3 fracture with significant offset. All other imaging studies were negative. After a short time in the emergency room, the patient's respiratory effort declined significantly and had to be intubated.

The following day a CT cervical myelogram was ordered. An attempt by the Radiologist was made, but due to equipment and patient condition a blind stick by the Neurosurgeon in the ICU was performed. The patient then returned to the CT suite to have post images performed.

I've attached the reformats performed and it shows a moderate to severe disc bulge. This certainly can be causing his paralysis.

Neurosurgeon re-evaluated patient and states he is ineligible for MRI due to pain stimulator implant. He will give the patient another day to recover and see him again to evaluate stability with flexion and extension movements. He also states that he has cord contusion that can resolve with some time.

Due to the numbness/tingling and inability to feel past that point the ED physician felt certain that there was a spine injury. These injuries can resolve on their own, with medications, or often require surgery to assist healing.

Update from Deaconess!

Well, things are very busy for me lately. Our new EMR has been implemented and like all new systems...there have been a few bumps in the road. I've had to spear-head collection of issues and assist in getting information out to staff. Lots of issues surrounding availability of reports in a timely manner.

Things are very busy in our CT and MRI departments after a brief lull. We are seeing flu symptoms of course, but have had a influx of trauma and broken bones as well. We have a new traumatologist at Deaconess and he is having us do lots of 3d images via our Tera Recon workstation now. So, we've been training everyone on those. Here is an example...

This was scanned at 2mm increments on our VCT 64 slice scanner. We then reformat an AP pelvis, and inlet and outlet views on every trauma for sure, but he'd like them for all ER pelvis exams. They are just a little time consuming so we haven't gotten that far yet. This particular patient had IV contrast for an abdomen as well and had a catheter in. It showed that really well! It's unbelievable the detail we get from our workstation.

I hope everyone has a great Thanksgiving!

Update from Clinicals at Deaconess

Hello all! We are speeding right along to a new Electronic Medical Record here at Deaconess and all Deaconess sites. We've gone through training and been able to log in to play with the system. But, to be honest, I am just very ready to do it. I have been rotating around trying to help refresh staff, but I am also replacing people so they can go to class or the open labs. This past weekend I went to Gateway.

I am attaching a couple of images from scans that I performed. One was a worsening small bowel obstruction. We scanned her routinely and the reformatted in coronal and sagittal images. Our main radiologist who works with our contrast and protocols just changed everything and we are back to giving 100 cc's of Omnipaque. So, we'll see how things look.

The next picture is an axial image of a probable hemangioma. It was scanned as a routine abdomen/pelvis from the ER. So, if this is something clinically needing follow up we will do a dedicated hemangioma protocol on her. This gives us a without and then arterial and venous phases of contrast enhancement.

Wish me luck this weekend! I will be living at Deaconess for the next two weeks!

Susan

Update 2 on CT clinical experiences

I hope everyone is doing well so far this semester! Deaconess is currently going through the process of implementing an electronic medical records system. So, there are lots of training activities going on throughout our department across all campuses. I am helping in the training, but I am also assisting in the CT and Diagnostic areas to make things a little easier while others are gone to class. I worked Friday at the Main Campus in CT. We had alot going on through the ER and also just general OP work. I worked on our 16 slice scanner and did most Emergency Room work. I had an elderly lady with a severe headache with a history of hypertension. The patient had no history of CVA, although looking at her images she definitely had a CVA in the past. The next patient was a patient who'd fallen from a ladder. We scanned her head and cervical spine with sagittal and coronal reformats. By the time I'd gotten back there, we'd finished our biopsy for the day. When our main interventionalist is gone our special procedure work tends to wane. We typically do a minimum of 2 procedures per day, but many days may do up to 5. Our latest addition that has become a little more routine for us is a CT guided liver ablation. I will try to get back there for the next one and scan for it so I can post a picture for you guys. They are extremely involved procedures that includes anesthesia and our cardiovascular short stay unit.

Susan Brumley

Update on Clinicals 1

Hello all!

I hope your clinical time has been going well. I actually have a bit of a different role in my department. I am a supervisor, so I don't scan all day anymore. So, I take opportunities to actually schedule myself back in CT at either Deaconess Main Campus or Deaconess Gateway. This past weekend I worked at Gateway. It was actually a pretty routine shift. Lots of abdominal pains and stone protocols. The only thing that was of any major difficulty was a PE study on a mid-50's gentleman with stage IV lung cancer. He was not in good shape and it was a modified exam, to say the least. I've included a couple of images that might be of interest to someone. I scanned a gentleman who had a history of DVT/PE. He had an IVC filter placed. This picture is at the top of the blog. You can see the "white" around the inferior vena cava. This is one image showing the filter. Since we retro back at such thin intervals, you can get a great idea what this filter looks like. The second picture denotes a renal stone in a young female that caused a mild to moderate obstruction.

Susan Brumley