Transcript Mobile Nuclear Cardiology

Mobile Nuclear
Cardiology
An Idea .. A Concept ..
Reality
The Kentucky Society Of Nuclear
Medicine Technology
July 25, 2005
A Look At The Mobile Business
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Purchasing the equipment
• Camera/computer = DigiRad
• Hot Lab
• Truck or Van
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License application
Clinical sites
Nuclear Personnel
Cardiologists and Nurse Practitioners
When are we going on the road?
• Adventures in fine driving, scanning, and
transcribing
Imaging Equipment
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DigiRad system
• Computer –
acquisition and
processing station
• Imaging Chair and
the digital head
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Three addition
processing/review
stations
Networking your
results
Anger Technology
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Basic Components
of an Anger
camera:
Collimator
NaI Crystal
Photomultiplier tubes
Positioning
electronics and
circuitry
• Lead shielding
SHIELDING
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COLLIMATOR
Anger Technology
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Photomultiplier Tubes (PMT’s)
Point Response
Digirad
Camera
Anger
Camera
•0.8
•0.6
•0.4
•24.5
•20.5
•0.2
•16.5
•23
•20.5
•18
•15.5
•4.5
•25.5
X mm
•13
•10.5
•8
•5.5
•12.5
•8.5
•3
•0
•0.5
Weighted average method
produces a probabilistic
response. Bell shaped
(Gaussian) curve.
Relative Response
•1
•0.5
Y mm
CsI/Si Detector Module
CsI (TI) Scintillation Crystal
Si Photodiode
Circuit Board
Readout Electronics
Module Operation
Gamma Ray
CsI Crystals Converts Gamma
Ray to Visible Light
Scintillation
Photons
Photodiode Converts Light
to Electric Charge
Printed Circuit Board
Mounts Various Components
Analog ASIC Amplifies Electric
Charge to Useful Signal Level
•
Pins Conduct
Signal
to Motherboard
Electromagnetic Shield Protects
Analog ASIC from Digital ASIC
Mounting Stud of Heat Sink
Conducts Heat Away from Module
Tiled Modular Construction
The camera head is
made up of 2” x 1”
modules tiled to
configure an 20 cm
x 20 cm camera
head. Each module
consists of 128
individual solid-state
detector elements or
a total of 4092
elements.
Gamma
Photon
Detector
Element
Solid-State detector module
CsI/Si Imager Head
Collimator
Array of Detectors
Lead Shielded Head
Digital Position SensingTM
The point at which a
gamma ray strikes
the detector element
determines the
spatial positioning of
the event, not a
probabilistic
estimation algorithm
as is used in Anger
camera technology.
Gamma
Photon
Detector
Element
Solid-State detector module
Solid-State Gamma
Camera
Direct Position
TM
Sensing
2020tc Imager™
Point Response Comparison
Digirad
Camera
Scintillation
Camera
•0.8
•0.6
•0.4
•24.5
•20.5
•0.2
•16.5
•23
•20.5
•18
•15.5
•4.5
•25.5
X mm
•13
•10.5
•8
•5.5
•12.5
•8.5
•3
•0
•0.5
Direct digital
positioning provides for
excellent spatial
response and
enhanced image
contrast and
resolution. Consider
analog an digital
response.
Relative Response
•1
•0.5
Y mm
Clinical Comparison of Contrast
PMT Scintillation Camera
Digirad Solid-State Camera
Digital Position SensingTM
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Excellent
spatial
response
Enhanced
image contrast
Better image
resolution
PMT Scintillation Solid-State
Camera
Camera
Planar views
Equivalent counts in each image
Spatial Response and Source
Energy
Digital Position SensingTM
Anger Technology
99mTc
201Tl
With Digital Position SensingTM, intrinsic spatial response is independent
of source energy, unlike Anger technology. This means fewer uniformity
calibrations and excellent clinical image quality.
Solid-State Gamma Camera
Simultaneous Event Processing
Patient
E1
Detector
E2
In original Anger cameras, all events (E1+E2+…) that fall in the energy
window are positioned using a probabilistic algorithm.
In modified Anger cameras, positioning logic is revised to imitate
digital positioning, however, it is still an approximation. Pending the
amount of light received by the surrounding PMTs.
In the 2020tc Imager™, all events (E1, E2, …) are treated separately
with individual energies leading to true digital position addressing and
excellent clinical performance.
Solid-State Gamma Camera
Overall System Improvements
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No image distortions. Spatial linearity
is fixed.
Edge effects do not exist.
Non-hygroscopic detector. No
hydration or yellowing occurs.
Routine quality control comparable
the PMT system.
Solid-state reliability.
Buying A Van
• Make it economical - Diesel
• Issues on servicing
•Fire damage at Cardinal Dodge
•Lexington during Christmas
• Ya need a Lift that works
• Don’t forget the tie downs
Tie Downs and Lifts
Tie downs
Maxon Lift
• This is the Norton way
• There is a better design
- The DigiRad Way
• The flapper problem
• Three repairs later
• Look out for your fingers
• Refrib was free if you B .. Enough
Hot Lab With A Little Extra
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Hot Lab – Office Storage
Dose Calibrator
L-Block
In/Out box area
Radioactive storage
Documentation
• Notices
• Analog system
Other Odds and Ends
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Fax machine
File cabinet
Cardinal Health connection
Lawson – ordering the day to day
stuff
Treadmill at every clinical site
Cell phone and pagers
Personnel
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Two nuclear technologists and backup
• They do it all: Secretary, EKG tech, billing,
and bungling.
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Involving the cardiology groups
• Blue Grass Cardiology
• Cardiovascular Associates
• Commonwealth Cardiology
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Transcription connection
Nurse Practitioner at every clinic
Billing – getting all the coding
The Reporting Process
Does the Disk
Have the Pt Data?
Completed Exam
Uploading The Scan
The Exams
Aren’t Here!
Cardiologist Dictation
Advanced Medical Transcription, LLC
I Didn’t Get the
Prelim
You’ll Sign
It When?
Faxing the Report Back – The Prelim
One to Department other to Clinic
Returning the Report
Cardiologist Signoff
Delivering the signed
Report Back to the Clinic
48 Hour
Time Line
What About The License?
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State license
• Understanding the mobile perspective
• They liked the idea so much the State went
mobile
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Form 421 and the NRC
• Reciprocity agreement
• A missing link
• Defining the days your in Indiana
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Indiana – What about 57Co?
Treat every clinic as a separate
department
• Daily wipes and surveys
When Do we get started?
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Hiring Date 8/01/2004
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Procedures to write
Protocols to define
In service on the equipment to be completed
Clinic educations
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The new kid on the block – Mobile mania
Docs and office staff
Logistics and the equipment
First patient scanned 10/07/2004
Clinical Sites
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Concepts
• Going to the Norton clinics and providing a
service within our system – is this self
defeating?
• Rural nuclear medicine
• Patients enjoy visiting their clinic instead of
driving into Louisville
• Economics – ETT to Cath – keeping the health
care $$ in our system
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Carroll County Hospital
NMA Suburban and Dupont
CMA Clarksville
NMA Mount Washington
Should we be looking beyond the NMAs?
Preparing The Clinics
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Developing a PPT and hard copy for
physicians and staff
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What is mobile nuclear cardiology
Radiation safety
Scheduling
Pt prep
Exam information
Contacts – phone and pager numbers
Billing
Visiting each clinical site with equipment in
hand
Involving your Cardiolite Rep
A Day In The Life Of Mobile
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Headquarters
Audubon – but
they’re not our
boss
Loading the van
Utilization of the
lift
Tying the
equipment down
On the road
Arrival In Carollton
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One-Way = 1 hour
Entrance is in the
back of the
hospital
Issue is the ramp
into the hospital
Cardiac Rehab is
right inside
Setting Up the Mobile Unit
Perhaps the
hardest aspect
 Attaching the
Head
 Requires removal
From one unit and
attachment to
the other
 It does get easier
to do over time
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QC
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Daily Flood
There is no weekly
bar
Weekly COR check
All other aspects of
camera QC are
completed by the
Service Dude
Results of the Daily Flood
And We’re Ready To Image
Patient Setup
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Unique to the
traditional
approach
Setting reduces
certain artifacts
When asked most
patients prefer this
to laying down
Motion is still a
problem whether
upright or supine
Procedures
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Nuclear Cardiology Stress Test
• Treadmill in every clinic
• Routine protocol for stress
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Adenosine (pump)
• The six minute protocol
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Dobutamine (Grasbey pump)
• 10mL, 20mL, etc.
Imaging Process and Results
Patient with bowel and liver activity
Separation between activity and heart
Heart is always acquired in the center of axis or rotation
Images can be viewed on Mirage or QPS
Large patient with enlarged heart
Filters
Multiple filters available
Easy change of filters
Normal-1 GSPECT patient
First Row – Stress
Second Row – Rest
Third Row – Gated
PC based workstation with
easy ability to capture
JPEG and BMP images
Flexible workflow with
forward and backward
processing capability
Mirage Quantification or QGS option
Matching EF’s on this abnormal patient
- Mirage Quantification package comes with the camera
Patient Stats
Patient Statistics
Amount of Patients
25
20
15
10
5
0
1
4
7
10 13 16 19 22 25 28 31 34
Weeks
Road Hazards
Road Kill
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Winter AM hours
brings out the best
Hunting season is
another hazardous
time
• Counted 15 kills
within 15 miles
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They live in the
median where
have lots of food
and water
Look Out For the Smokies
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KY’s finest is out
there
Our speed is 69
mph and holding,
besides we’re on
the clock!
Let someone else
be the lucky one,
not you!
Turkey Buzzards
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Is this a prelude to a
bad day?
Always in the AM
On the way to Mount
Washington
If they are a circling
you can almost
guaranty there’s road
kill ahead
Our Evaluation on DigiRad
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In nine months we have never been
down = 100% uptime
Find yourself an applications
specialist and make her your best
friend
California is 3 hours behind us so
thank god for Alabama (Jim)
The wait time when calling is always
3.5 minutes
On The Downside
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If your system is
mobile you’re
going to have a lot
of wear with
certain results
Example 1 - pin
locking mechanism
to camera arm
Example 2 - Tray
that stores your
cable
Another Example
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Green tab down
brakes the wheel
Green tab jam
breaks the brake
End results wheels
have to be
replaced since
there’s no brake
Imaging Results
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We are very pleased with the data
we are getting. But there are still
questions
We are incountering high false
positive – positive ETT negative Cath
• Our cardiolite rep feels it’s the over read
of certain doctor(s)
• She has provided a Cardiolite vs. Cath
QA program via Excel that should define
our question
Patient With False Positive
Results Continued
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We know that we are finding disease
History – 27 yr old male complains of
CP when he carries his 30 pound
pack of tools around at the factory
he works at
The cardiolite was positive
So what the Cath
Let’s look at his Cardiolite scan
Cardiolite Scan
Cardiolite Prior To PET Scan
PET Scan
Last But Most Important
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Humor is the key to success and it is something than Mona and I interject
in the workplace All the time.
Think Patch Adams he’s our hero
Common saying to adopt (some of the sayings must be used with
discretion)
• Cool beans
• Understand rubber ban
• Smooth move Exlax
• Moo Foo
• I’m the boss applesauce
• It’s like a turd in a punchbowl
• Hears the story morning glory
• Son Beach
• And now for the next victim
• Babe In Total Control of Herself
• Oh my god, oh my god, oh my god
Sometimes we get in trouble and sometimes we don’t. but communication
and humor make the difference.
My Thanks ..
K.S.N.M.T.
The Graduates of U of L and JCC
Mona B. Good
And to my wife Dorsey for our son Jonathan