If you are really thinking about a combined resus/ct room - what is the objection to the statscan (because cost just became a non-issue)

I like the statscan because a whole body statscan is LESS radiation dose than a simple c.spine, chest and pelvis. perhaps the images are undiagnostic?

Philip

-----Original Message-----
From: Accident and Emergency Academic List on behalf of Coats Tim - Professor of Emergency Medicine
Sent: Wed 2/6/2008 13:54
To: [log in to unmask]
Subject: Re: Resus gantries / DR
 
I think that Tom Treasure and the NCEPOD report was referring to some european centres where the CT scanner is located within a resuscitation room. This is a really interesting concept and is given rave reviews by the clinicians that work with the system.

Some of the figures quoted for rapid times between arrival and scanning (the 'pan-scan' within 5 minutes of arrival) need to be viewed in the context of the european system of sending a doctor out to the patient, and so Primary Survey / Critical Interventions have already been completed by hospital arrival - so straight to scan becomes practical in a way that might not be so easy in the UK.

For a couple of new EDs we should probably be considering the idea of a combined resuscitation and scanning room, as this seems to be an idea that should be tried out in the UK context.

Tim. Coats.

-----Original Message-----
From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Cosson, Philip
Sent: 06 February 2008 11:27
To: [log in to unmask]
Subject: Re: Resus gantries / DR

OK, here goes - assuming some minds are a little bit ajar...

1) You should have chest and pelvic plates in place before the spine board/scooped patient is even put on the trolley so that the films can be shot immediately on arrival.

I object to patients remaining on a spine board, but that is nothing to do with being a Radiographer or 'Physics'. Evidence from studies between 1998-2007 all recomend to remove spine boards ASAP to allow full examination. They can mask the pain of other injuries, mimic the pain of injuries, cause injuries in the kyphotic patient, and generate pressure injuries. in fact the ATLS 2004 guidelines state a max 2 hr time. A recent survey of UK hospitals showed that only 21% of hospitals keep patients on the spine board for trauma xrays - so you are expressing a minority view.

2) Incidentally, you will hear lots of spurious pseudo-physics from > puzzled radiographers about this practice. The first is that the spineboards are not radiolucent

Air is not 100% radiolucent! a spine board will have some attenuation. Two issues - a) there might be edges that can become artefacts on images b) the overall attenuation reduces the signal to noise ratio.

looking at b) in more detail... Low atomic number materials, such as plastics, attenuate x-ray photons by compton scattering them. As soon as a photon is scattered it is both removed from the signal AND possibly added to the noise. I have just run a simulation and this demonstrates that a standard pelvis examination will have 56 million photons incident per mm2 on the patient. Assuming a 30cm thick body part, approximately 30 thousand photons per mm2 will come out the other side (this is the useful primary photons i.e. the signal, there will be a lot of scatter as well). If I add 3cm of spine board that figure drops to 15 thousand photons per mm2 i.e. a spine board reduces the signal by half in this simulation. The radiographer will increase the incident photons to compensate, to 110 million per mm2, giving 30 thousand per mm2 coming out of the patient. (I don't know what a spine board is made of, so I have used PMMA in this simulation - i used a simulation similar to the IPEM78 report)

Because the incident photons have doubled, the scatter must have gone up in the patient, the volume of irradiated material has increased, so the scatter must have gone up again. I can't simulate scatter using the tools I have to hand - but whatever way you do the 'physics' a spine board will reduce image quality and increase patient dose.

You are unconcerned about patient dose - because there are much bigger risks to the patient, but the reduction in image quality will almost certainly reduce the sensitivity and specificity of the radiological examination - which you should be concerned about. This is the legitimate point of debate - is a cr$p x-ray adequate for your purposes, you obviously think so. My car radio is fine for listening to radio 4 - but I can't listen to radio 3 - the lack of quality annoys me too much, and I cant hear the quite bits, I have to be at home with a proper stereo.

so - in summary, you may be right, this might give you 'adequate' images - but the radiographers objections are not 'psuedo physics' they are right to - the image quality will be cr$p

2) The second is a claim that there is scatter between the films. Again, that's wrong and can easily be disproved.

Impossible to disprove, because it is a fact. The issue, is there enough to reduce the image quality. I don't know. It depends on the sensitivity of the receptor to scatter (CR plates are much more sensitive than the old film/screen systems were), the distance between the collimated area and the other film, the quality of the x-ray beam, the size of the patient, the collimated area and the order you do the images. The chest will take much less irradiation than the pelvis, so doing that first will be a much better bet.

3) I am in full agreement with Tom Treasure's recent view that we should be moving to whole-body CT for multiple trauma.

I have already commented on that - you can't protocol what you can't achieve. Can you achieve 24 hr access to 3D CT within 1 hour?

Philip

PS. Our radiography students are taught physics by my colleague, who is a HPC registered clinical scientist, holder of a first degree in physics, holder of an MSc in medical physics and has had over 20 years clinical experience working in a medical physics department prior to taking this post a senior lecturer.


-----Original Message-----
From: Accident and Emergency Academic List on behalf of Rowley Cottingham
Sent: Tue 2/5/2008 20:11
To: [log in to unmask]
Subject: Re: Resus gantries / DR
 
Goodness me, some people do have chips on their shoulders! I'd be most grateful if you could identify any factual errors in my statements.
Perhaps you could tell me who teaches the radiographers physics incorrectly? I'd also suggest that you read the report into the management of major trauma and understand what strictures there are on clinicians faced with rapidly deteriorating sick patients before being quite so sarcastic. CT is most certainly appropriate, but at an appropriate time in an appropriate patient, Just like every other intervention.


> *From:* "Cosson, Philip" <[log in to unmask]>
> *To:* [log in to unmask]
> *Date:* Tue, 5 Feb 2008 16:08:19 -0000
> 
> Of course, CT everything! Why didn't we all think of that!
> 
> 1) There won't be any delay at all getting resus patients full CT, it 
> sits there doing nothing all the time; and the staff (that can do 
> everything, not just a simple CT head protocol) are never asleep in 
> bed at home.
> 
> 2) The CT scanner is right there in the next cubicle, so no problems 
> with transferring the acutely ill patient
> 
> 3) Once a patient is nice and snug in the 70cm wide gantry opening, 
> they will just nod off, and you can relax. They couldn't possibly need 
> any intervention during the scan.
> 
> 4) CT scanners emit these really cool x-rays that go through the 
> patient, but are completely harmless. Your patient can have loads of 
> them with no ill effects at all. The really cool 3D ones are the best, 
> they do a scan every mm - not like those old CT head protocols where 
> you needed 1 every cm with a big gap in between.
> 
> 5) All the Resus staff can happily stand in the CT room while the scan 
> is going on, keeping an eye on the patient at all times, just pop your 
> sunglasses on and enjoy the rays.
> 
> 6) CT scanners don't have any problem with artefacts from ECG leads, 
> and other metal structures like normal x-rays do.
> 
> (Please note a slight hint of sarcasm)
> 
> Just to be serious for a moment - What is wrong with the diamond 
> miner's scanner? I thought this would really take off in resus, but no 
> advocates so far. What's the problem with it?
> http://www.umm.edu/news/releases/statscan.htm
> 
> I don_t really need to ask - it will be cost. But it is a low dose 
> option, and it is fast.
> 
> 
> 
> 
> Philip Cosson _ Senior Lecturer _ Medical Imaging University of 
> Teesside _ Borough Road _ Middlesbrough Tees Valley_ TS1 3BA
>  
> LEARNING TECHNOLOGIST OF THE YEAR 2007 
> http://www.alt.ac.uk/docs/learning_technologist_of_the_year_award_20
> 07.pdf
>  
> t: 01642 384175 _ f: 01642 384105 _ m: 07817 362823
> e: [log in to unmask] _ AIM: philipcosson
> web: http://radiography.tees.ac.uk/soh_research/
> short c.v:  http://myprofile.cos.com/philipcosson
> 
> -----Original Message-----
> From: Accident and Emergency Academic List 
> [mailto:[log in to unmask]] On Behalf Of Rowley Cottingham
> Sent: 05 February 2008 15:15
> To: [log in to unmask]
> Subject: Re: Resus gantries / DR
> 
> Don't waste money on gantries. When I built a resuscitation room 
> everyone assumed I would specify en suite radiography. It was £400,000 
> (8 years ago) for each two bays. And for what? Three low-quality 
> radiographs per patient max. The comments about electric delays are 
> entirely spurious when the radiographers and plates aren't in 
> position.  You should have chest and pelvic plates in place before the 
> spine board/scooped patient is even put on the trolley so that the 
> films can be shot immediately on arrival.
> Incidentally, you will hear lots of spurious pseudo-physics from 
> puzzled radiographers about this practice. The first is that the 
> spineboards are not radiolucent. That can be cured with one test shot. 
> The second is a claim that there is scatter between the films. Again, 
> that's wrong and can easily be disproved. However, my favourite excuse 
> of all time was that the radiologist would have more difficulty 
> interpreting the films! A touch of the Catherine Tates soon sorted 
> that.
> 
> I am in full agreement with Tom Treasure's recent view that we should 
> be moving to whole-body CT for multiple trauma.
> 
> Forget gantries, go with rapidly acquired portable CR images for the 
> holy trinity and CT the rest.
> 
> Best Wishes,
> 
> Rowley. 
> 
> -----Original Message-----
> From: Accident and Emergency Academic List 
> [mailto:[log in to unmask]] On Behalf Of Cosson, Philip
> Sent: 05 February 2008 14:48
> To: [log in to unmask]
> Subject: Re: Resus gantries / DR
> 
> 
> Paul,
> 
> Firstly - one of the biggest delays is often getting the image linked 
> to the patient details. Raising an examination on the various systems, 
> and then linking the image to this record depends on different local 
> situations. If you have Electronic requesting, this will be done in 
> your department, otherwise it will be done in radiology. If it is the 
> latter - the radiographer will still have a problem when trying to 
> examine a patient that does not exist on the system. With a dDR system 
> - this all has to be done before the button can be pressed; examining 
> them as "a.n.other" is a risk.
> 
> Secondly - The concept does look attractive, but the receptor is 
> larger than a cassette and one fixed size. The radiographers lose the 
> flexibility of different film sizes. Cassettes have been around for a 
> long time, and they work because they are so flexible.
> 
> The linkage adds another level of inflexibility - it can be 
> infuriating when drip stands and the like are in the way. You may have 
> to purchase special radiolucent trolleys etc because the receptor 
> won't fit in the cassette tray on your old trolleys. These things are 
> quite big - so you would need a large clear space in the room and high 
> ceilings to store it away most of the time.
> 
> I would guess a CR plate reader in resus and a PACS work station would 
> be cheaper - and provide you with a similar solution. This has the 
> advantage of many different cassette sizes available, and familiarity 
> for the radiographers (useful for agency staff/new starters). Image 
> review is likely to be sub 90 seconds with such a system (if you can 
> crack the patient registration time)
> 
> The half way alternative is a mobile machine that has a digital 
> detector connected via a cable. These are capable of sub 10 second 
> image display (but the cable can be a pain). In a year or two a 
> wireless detector will be available.
> 
> Regards
> 
> Philip
> 
> 
> Philip Cosson _ Senior Lecturer _ Medical Imaging University of 
> Teesside _ Borough Road _ Middlesbrough Tees Valley_ TS1 3BA
>  
> LEARNING TECHNOLOGIST OF THE YEAR 2007 
> http://www.alt.ac.uk/docs/learning_technologist_of_the_year_award_20
> 07.pdf
>  

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