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Feb 25
2010
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How does one set the protocol?Posted by: Prashant Bhatt on Feb 25, 2010  |
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Starting a MRI unit from scratch is an interesting and challenging exercise. Establishing one’s professional reputation is also a question of survival in different settings with referring consultants of different universities, training and temperament.
The layers of this were first set during early residency.
See blog: http://www.iradix.in/284-Pedagogy.html
There is a difference between the pressures faced in government hospitals and those that a private organizer puts on you when starting a new centre.
The commercially available protocols of most vendors will have to be tried in your setting. This involves planning as one sets out to test each and every protocol on test patients. Catching hold of staff who want to be scanned, (and finding unexpected things-one completely normal helper had a large syrinx in his entire cord but was roaming around absolutely normal, so we never told him...he is still normal). One cannot have a patient come in and then find that the particular sequence is not optimal.
Training the technicians to the different protocol requirements is another exercise. Technical review meetings and tailoring of one’s approach according to the local conditions, links with managers (informant-subversive services) are things which one has to keep in mind.
However, no modern imaging department can do without a well trained and disciplined team of technical persons.
See blog: http://www.iradix.in/277-Day-One.html
There is the larger question of how one set up the protocols for different disease processes.
There is something known as the MRI brain, but one has to tailor the MRI brain protocol based on the indication of the study, whether it be epilepsy, dementia, stroke, trauma, tumor, congenital (VINDICATE can serve as very useful grid)
A small list as an example to jog one’s memories and also give some alignment
V Vascular The threshold for watching the flow voids
(see blog: http://www.iradix.in/367-Minimize-Mistakes-Avoid-Blunders.html
I Inflammatory Cysticercosis, Meningoencephilitis
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Pediatric Brain: A 3 year girl with seizures and altered sensorium. Confluent areas of FLAIR hyperintensity in right basal ganglia and right parietal cortex. Abnormal meningeal enhancement is seen on post contrast images. Provisional diagnosis of Meningoencephalitis was given. Setting the protocol, coordinating the anesthesia and Pediatric ICU is an interesting multi-layered exercise.
http://www.iradix.in/432-Puppets-in-a-Puppet-Show.html
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N Neoplastic Contrast study. MR Spectroscopy
D Degenerative Dementia
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Successfully aging brain Axial FLAIR Images in three different patients. Normal-20 yr Normal 60 yr Normal 82 yr The “successfully aging brain” has thin periventricular high-signal rim.One cannot predict cognitive function from standard CT/MR. We will examine the evolution of the Non-specific hyperintensity in coming articles. However, one does encounter some “Neurophysicians” who after read some article on FLAIR or diffusion start asking about b values. Establishing one’s reputation while negotiating through some of these rims of hyperintensities (which they may find ‘abnormal’ and come back to point out your ‘mistake’) is a task which anyone who will start a new centre from naught will face. See blogs: http://www.iradix.in/309-Measuring-Referral-Slips.html
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I Iatrogenic The Post operative protocols
C Congenital The heterotopias and Chiaris
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Post operative CSF Turbulence, Hydrocephalus, Pseudomeningocele formation The way one looks at the posterior fossa and base of skull, is one of the distinguishing features between a person who knows how to read a MRI and the ones who just pass off a few changes in the normal template. The mid sagittal section of the brain has many messages and this is another thing which will distinguish you from a skilled reader and those who just pass off. See blog:http://www.iradix.in/406-Revisiting-Chiari.html
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A autoimmune Multiple Sclerosis protocol
T Trauma Fast sequences-Accidental trauma
E Endocrine Pituitary and suprasellar regions.
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Tailoring protocols: Suprasellar Mass: Coronal T1W,Coronal T2W, showing an large suprasellar lesion with the pituitary seen separately. Having a joint technical meeting with the Neurosurgeon can be rewarding as some people always like to say “In Germany we did it like this”
See blog: Conversations with Neurosurgeons http://www.iradix.in/365-Doc-What-is-T1-What-is-T2.html
Doc what is T1? What is T2? Conversations with a Neurosurgeon
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How does one set the protocol for low back ache?
One of the centres where I worked in at a junior level used to charge separately to see the Sacroiliac joints in a case for Lumbo-sacral MRI. I never agreed with this ‘approach’ but was not able to do anything due to the organizational position I was in. The protocol for any given region should be set to rule out the different causes of the Clinical problem. Sacroiliitis can lead to severe back pain. So the protocol should include that and if there is a lesion seen on the scan, thin sections should be taken (at no extra charge).
Putting the patient on the table and then saying that we have to do extra slices and hence we will charge more reflects poorly.
How does one scan for headache?
If one sees Subarachnoid hemorrhage and has to extend the study to include Angiography sequences does one start charging separately?
Does one extend the study?
If one does not find a lesion in the area of spine requested for scanning does one extend the study to see for other lesions or does the radiologist send the patient back saying-I scanned the area which the doctor told me to. Such an approach has led to erosion of our value as doctors.
Dilemmas and the Medical Refugee
These examples raised dilemmas which troubled me in my junior days and so, when I became incharge of a MRI unit, I saw to it that the protocols were set to see for the disease process and not just doing some sequences and sending the patient away.
The Medical refugee is something which one sees everyday. Internally displaced persons within the country or immigrant workers crossing borders in search of reliable diagnosis and medical care. For narratives relating to some “medical refugees” who became my friends see blogs
http://www.iradix.in/391-Preparing-for-Ramadan.html
http://www.iradix.in/385-In-the-Face-of-Adversity.html
http://www.iradix.in/389-Pals-Forever.html
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We will examine these and other related issues in greater detail in coming blogs, hopefully tailored by our commentators.
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Alok Varshney
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... Good one Prashant. Regarding setting up disease specific protocols, I think there are three approaches in general. 1)Scan till you find the problem, or till the level the problem is found. 2)Scan whatever is requested for, assuming the clinician has made a part specific decision based on his clinical findings/ other tests. 3)Screen the whole area (e.g. spine) and then focus on a relevant part. To charge or not to charge for something beyond the scope of routine examination is a tricky question. Much of it is decided by who is paying the bill for running the machines/ cost of exam. In an academic institution, entire examinations may be done for free as an extension of an on-going study (thereby leading perhaps to over-examination at times). In private set ups, every single scan/ procedure/ sequence outside the basic protocol may get charged. The answer probably lies somewhere in the middle. Reasonable extension of a study, criticalness and urgency of a situation probably should determine guidelines. I do recall an old fox’s comments regarding the same Ghoda ghaas se yaari karega to khaayega kya? |
Prashant Bhatt
said:
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... Thanks for the comments..and the "Ghoda-Ghaas" dictum made me (re)think on what is a Radiological Consultation? |
Dr. Sridhar V
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... Dr.Prashant said "no modern imaging department can do without a well trained and disciplined team of technical persons." It is true that Imaging dept however modern it may be...It is useless if it does not have Good Technical persons either in the form of a Professional Radiologist or intelligent Radiographers. It is also a fact that Present day Radiologists have to be extraordinarily smart and vigilant in their subject to cope up with the onslaught of Modern day Non Radiologist Radiologists, who no doubt unknowingly bring out their ignorance of Radiology by putting what they claim as intelligent questions and at the same time dreaming that they are in a commanding position to embarrass the Radiologist. Regarding setting up of protocols..There is no excuse, since it is part and parcel of Radiology profession and Radiologist is delivering the report to the best of his knowledge. Regarding extension of protocols or charging the patient additionally depends on which school of thought you belong.Whether you belong to 1. Philosophy of business or 2. Business philosophy. Philosophy of Business- If you belong to this category ,everybody knows that you a person of Principles,the one always giving importance to moral obligations and highly ethical.Hence Money matters are least of your concern and when the situation demands... you do not hesitate to extend the protocols,take additional sections, extend the area of study and finally without charging a single penny.And mind you you are boss of your own and do not care what your owner says or or your institution head barks.and even if you own the center it makes no difference to you. Business Philosophy- Here the Importance is given to the Person doing the business.So you decide in the begining itself whether you have to be money minded or not. If you are money minded, you are correct in every aspect when you charge extra money for the extended study,because you are principled in that way and in fact you are not hesitating to do that extra cut or extension of protocol which is beneficial to the patient. Here the personality trait of the individual decides the nature of Business he is going to do. It is unjustified If the Radiologist does not follow the Protocol of investigation If the Radiologist does not extend his study when the situation demands for proper diagnosis and at the same time Charging the patient |
Alok Varshney
said:
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... How far should one extend the exam ? 1) In a patient with neuro-cutaneous syndrome where abnormalities can be all over the body. 2) In a patient with malignancy with mets all over the body but requisition for examination of a single part (neck or chest or abdomen). There can be many situations in which extension of examination may become unreasonable or burdensome, if one stretches the things too far. In my opinion we should coordinate with the clinician and the patient if we are planning a major extension of the study. Just a few cuts or a few sequences, no big deal. But a whole area of study, I don't know. I would charge.. |
Prashant Bhatt
said:
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... In long-run reputation will be built by those extended studies which show Application rather than the routines which anyone could have done |
Anuj Mishra
said:
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... It basically depends on your place of work, whether private or public. And also if private, then whether self owned or as an employee. Extension of an examination to reasonable limits is logical as this exercises reinforces your own previous experiences and also quenches your thirst to know more. But if centre running expenses and overheads are a concern, then one may feel restricted at certain times in the modern world. In my personal experience in private practice, as a fresh pass-out I was quite eager (sometimes overboard !) to do full justice to my patients. A famous (but greedy !) surgeon of the city referred a patient for CT Chest to stage the lung cancer. Logically, I extended the examination to include the abdomen as well to exclude adrenal mets (as we had been taught in the medical institute), which incidentally were there. Next morning I received an angry call from the surgeon questioning my decision to scan the abdomen. On my asking him the reason for his unpleasant behavior, he advised me to suggest advice in my report if any further scanning is required and can help the patient as then he will resend the patient for another scan. Then I understood that the main reason was not my smart application ability but his greed for more commission from two scans! I also agree with Alok Varshney when he said "Ghoda ghaas se dosti karegaa to khaayegaa kyaa?". |
Blogs are a great way to share your experiences ideas with others.
Feedback from clinician is very importantn"Disease dont follow textboooks nowsda...
