Mobile Nuclear Cardiology An Idea.. A Concept.. Reality The
Kentucky Society Of Nuclear Medicine Technology July 25, 2005
Slide 2
A Look At The Mobile Business Purchasing the equipment
Purchasing the equipment Camera/computer = DigiRadCamera/computer =
DigiRad Hot LabHot Lab Truck or VanTruck or Van License application
License application Clinical sites Clinical sites Nuclear Personnel
Nuclear Personnel Cardiologists and Nurse Practitioners
Cardiologists and Nurse Practitioners When are we going on the
road? When are we going on the road? Adventures in fine driving,
scanning, and transcribingAdventures in fine driving, scanning, and
transcribing
Slide 3
Imaging Equipment DigiRad system DigiRad system Computer
acquisition and processing stationComputer acquisition and
processing station Imaging Chair and the digital headImaging Chair
and the digital head Three addition processing/review stations
Three addition processing/review stations Networking your results
Networking your results
Slide 4
Anger Technology Basic Components of an Anger camera: Basic
Components of an Anger camera: CollimatorCollimator NaI CrystalNaI
Crystal Photomultiplier tubesPhotomultiplier tubes Positioning
electronics and circuitryPositioning electronics and circuitry Lead
shieldingLead shielding COLLIMATOR SHIELDING
Point Response 0.5 3 5.5 8 10.5 13 15.5 18 20.5 23 25.5 0.5 4.5
8.5 12.5 16.5 20.5 24.5 0 0.2 0.4 0.6 0.8 1 Relative Response X mm
Y mm Digirad Camera Anger Camera Weighted average method produces a
probabilistic response. Bell shaped (Gaussian) curve.
Module Operation Gamma Ray CsI Crystals Converts Gamma Ray to
Visible Light Photodiode Converts Light to Electric Charge Printed
Circuit Board Mounts Various Components Scintillation Photons Pins
Conduct Signal to Motherboard Analog ASIC Amplifies Electric Charge
to Useful Signal Level Electromagnetic Shield Protects Analog ASIC
from Digital ASIC Mounting Stud of Heat Sink Conducts Heat Away
from Module
Slide 9
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. 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 Solid-State detector module
Detector Element
Slide 10
CsI/Si Imager Head Collimator Lead Shielded Head Array of
Detectors
Slide 11
Digital Position Sensing TM 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. 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 Solid-State detector module Detector
Element
Slide 12
Solid-State Gamma Camera Direct Position Sensing TM 2020tc
Imager
Slide 13
Point Response Comparison 0.5 3 5.5 8 10.5 13 15.5 18 20.5 23
25.5 0.5 4.5 8.5 12.5 16.5 20.5 24.5 0 0.2 0.4 0.6 0.8 1 Relative
Response X mm Y mm Digirad Camera Scintillation Camera Direct
digital positioning provides for excellent spatial response and
enhanced image contrast and resolution. Consider analog an digital
response.
Slide 14
Clinical Comparison of Contrast PMT Scintillation CameraDigirad
Solid-State Camera
Slide 15
Digital Position Sensing TM Excellent spatial response
Excellent spatial response Enhanced image contrast Enhanced image
contrast Better image resolution Better image resolution PMT
Scintillation Camera Solid-State Camera Planar views Equivalent
counts in each image
Slide 16
Spatial Response and Source Energy Digital Position Sensing TM
Anger Technology 99m Tc 201 Tl With Digital Position Sensing TM,
intrinsic spatial response is independent of source energy, unlike
Anger technology. This means fewer uniformity calibrations and
excellent clinical image quality.
Slide 17
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.
Slide 18
Solid-State Gamma Camera Overall System Improvements No image
distortions. Spatial linearity is fixed. No image distortions.
Spatial linearity is fixed. Edge effects do not exist. Edge effects
do not exist. Non-hygroscopic detector. No hydration or yellowing
occurs. Non-hygroscopic detector. No hydration or yellowing occurs.
Routine quality control comparable the PMT system. Routine quality
control comparable the PMT system. Solid-state reliability.
Solid-state reliability.
Slide 19
Buying A Van Make it economical - Diesel Issues on servicing
Fire damage at Cardinal Dodge Lexington during Christmas Ya need a
Lift that works Dont forget the tie downs
Slide 20
Tie Downs and Lifts Tie downs This is the Norton way There is a
better design - The DigiRad Way Maxon Lift The flapper problem
Three repairs later Look out for your fingers Refrib was free if
you B.. Enough
Slide 21
Hot Lab With A Little Extra Hot Lab Office - Storage Hot Lab
Office - Storage Dose Calibrator Dose Calibrator L-Block L-Block
In/Out box area In/Out box area Radioactive storage Radioactive
storage Documentation Documentation NoticesNotices Analog
systemAnalog system
Slide 22
Other Odds and Ends Fax machine Fax machine File cabinet File
cabinet Cardinal Health connection Cardinal Health connection
Lawson ordering the day to day stuff Lawson ordering the day to day
stuff Treadmill at every clinical site Treadmill at every clinical
site Cell phone and pagers Cell phone and pagers
Slide 23
Personnel Two nuclear technologists and backup Two nuclear
technologists and backup They do it all: Secretary, EKG tech,
billing, and bungling.They do it all: Secretary, EKG tech, billing,
and bungling. Involving the cardiology groups Involving the
cardiology groups Blue Grass CardiologyBlue Grass Cardiology
Cardiovascular AssociatesCardiovascular Associates Commonwealth
CardiologyCommonwealth Cardiology Transcription connection
Transcription connection Nurse Practitioner at every clinic Nurse
Practitioner at every clinic Billing getting all the coding Billing
getting all the coding
Slide 24
The Reporting Process Completed Exam Uploading The Scan
Cardiologist Dictation Advanced Medical Transcription, LLC 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 I Didnt Get the Prelim The Exams Arent
Here! Youll Sign It When? Does the Disk Have the Pt Data? 48 Hour
Time Line
Slide 25
What About The License? State license State license
Understanding the mobile perspectiveUnderstanding the mobile
perspective They liked the idea so much the State went mobileThey
liked the idea so much the State went mobile Form 421 and the NRC
Form 421 and the NRC Reciprocity agreementReciprocity agreement A
missing linkA missing link Defining the days your in
IndianaDefining the days your in Indiana Indiana What about 57 Co?
Indiana What about 57 Co? Treat every clinic as a separate
department Treat every clinic as a separate department Daily wipes
and surveysDaily wipes and surveys
Slide 26
When Do we get started? Hiring Date 8/01/2004 Hiring Date
8/01/2004 Procedures to writeProcedures to write Protocols to
defineProtocols to define In service on the equipment to be
completedIn service on the equipment to be completed Clinic
educationsClinic educations The new kid on the block Mobile mania
The new kid on the block Mobile mania Docs and office staff Docs
and office staff Logistics and the equipment Logistics and the
equipment First patient scanned 10/07/2004 First patient scanned
10/07/2004
Slide 27
Clinical Sites Concepts Concepts Going to the Norton clinics
and providing a service within our system is this self
defeating?Going to the Norton clinics and providing a service
within our system is this self defeating? Rural nuclear
medicineRural nuclear medicine Patients enjoy visiting their clinic
instead of driving into LouisvillePatients enjoy visiting their
clinic instead of driving into Louisville Economics ETT to Cath
keeping the health care $$ in our systemEconomics ETT to Cath
keeping the health care $$ in our system Carroll County Hospital
Carroll County Hospital NMA Suburban and Dupont NMA Suburban and
Dupont CMA Clarksville CMA Clarksville NMA Mount Washington NMA
Mount Washington Should we be looking beyond the NMAs? Should we be
looking beyond the NMAs?
Slide 28
Preparing The Clinics Developing a PPT and hard copy for
physicians and staff Developing a PPT and hard copy for physicians
and staff What is mobile nuclear cardiologyWhat is mobile nuclear
cardiology Radiation safetyRadiation safety SchedulingScheduling Pt
prepPt prep Exam informationExam information Contacts phone and
pager numbersContacts phone and pager numbers BillingBilling
Visiting each clinical site with equipment in hand Visiting each
clinical site with equipment in hand Involving your Cardiolite Rep
Involving your Cardiolite Rep
Slide 29
A Day In The Life Of Mobile Headquarters Headquarters Audubon
but theyre not our boss Audubon but theyre not our boss Loading the
van Loading the van Utilization of the lift Utilization of the lift
Tying the equipment down Tying the equipment down On the road On
the road
Slide 30
Arrival In Carollton One-Way = 1 hour One-Way = 1 hour Entrance
is in the back of the hospital Entrance is in the back of the
hospital Issue is the ramp into the hospital Issue is the ramp into
the hospital Cardiac Rehab is right inside Cardiac Rehab is right
inside
Slide 31
Setting Up the Mobile Unit Perhaps the hardest aspect Perhaps
the hardest aspect Attaching the Head Attaching the Head Requires
removal Requires removal From one unit and attachment to the other
From one unit and attachment to the other It does get easier to do
over time It does get easier to do over time
Slide 32
QC Daily Flood Daily Flood There is no weekly bar There is no
weekly bar Weekly COR check Weekly COR check All other aspects of
camera QC are completed by the Service Dude All other aspects of
camera QC are completed by the Service Dude
Slide 33
Results of the Daily Flood
Slide 34
And Were Ready To Image
Slide 35
Patient Setup Unique to the traditional approach Unique to the
traditional approach Setting reduces certain artifacts Setting
reduces certain artifacts When asked most patients prefer this to
laying down When asked most patients prefer this to laying down
Motion is still a problem whether upright or supine Motion is still
a problem whether upright or supine
Slide 36
Procedures Nuclear Cardiology Stress Test Nuclear Cardiology
Stress Test Treadmill in every clinicTreadmill in every clinic
Routine protocol for stressRoutine protocol for stress Adenosine
(pump) Adenosine (pump) The six minute protocolThe six minute
protocol Dobutamine (Grasbey pump) Dobutamine (Grasbey pump) 10mL,
20mL, etc.10mL, 20mL, etc.
Slide 37
Imaging Process and Results
Slide 38
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
Slide 39
Large patient with enlarged heart
Slide 40
Filters Multiple filters available Easy change of filters
Slide 41
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
Slide 42
Mirage Quantification or QGS option Matching EFs on this
abnormal patient - Mirage Quantification package comes with the
camera
Slide 43
Patient Stats
Slide 44
Road Hazards
Slide 45
Road Kill Winter AM hours brings out the best Winter AM hours
brings out the best Hunting season is another hazardous time
Hunting season is another hazardous time Counted 15 kills within 15
milesCounted 15 kills within 15 miles They live in the median where
have lots of food and water They live in the median where have lots
of food and water
Slide 46
Look Out For the Smokies KYs finest is out there KYs finest is
out there Our speed is 69 mph and holding, besides were on the
clock! Our speed is 69 mph and holding, besides were on the clock!
Let someone else be the lucky one, not you! Let someone else be the
lucky one, not you!
Slide 47
Turkey Buzzards Is this a prelude to a bad day? Is this a
prelude to a bad day? Always in the AM Always in the AM On the way
to Mount Washington On the way to Mount Washington If they are a
circling you can almost guaranty theres road kill ahead If they are
a circling you can almost guaranty theres road kill ahead
Slide 48
Our Evaluation on DigiRad In nine months we have never been
down = 100% uptime In nine months we have never been down = 100%
uptime Find yourself an applications specialist and make her your
best friend Find yourself an applications specialist and make her
your best friend California is 3 hours behind us so thank god for
Alabama (Jim) California is 3 hours behind us so thank god for
Alabama (Jim) The wait time when calling is always 3.5 minutes The
wait time when calling is always 3.5 minutes
Slide 49
On The Downside If your system is mobile youre going to have a
lot of wear with certain results If your system is mobile youre
going to have a lot of wear with certain results Example 1 - pin
locking mechanism to camera arm Example 1 - pin locking mechanism
to camera arm Example 2 - Tray that stores your cable Example 2 -
Tray that stores your cable
Slide 50
Another Example Green tab down brakes the wheel Green tab down
brakes the wheel Green tab jam breaks the brake Green tab jam
breaks the brake End results wheels have to be replaced since
theres no brake End results wheels have to be replaced since theres
no brake
Slide 51
Imaging Results We are very pleased with the data we are
getting. But there are still questions 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 We are
incountering high false positive positive ETT negative Cath Our
cardiolite rep feels its the over read of certain doctor(s)Our
cardiolite rep feels its the over read of certain doctor(s) She has
provided a Cardiolite vs. Cath QA program via Excel that should
define our questionShe has provided a Cardiolite vs. Cath QA
program via Excel that should define our question
Slide 52
Patient With False Positive
Slide 53
Results Continued We know that we are finding disease 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 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 The cardiolite was positive So what the
Cath So what the Cath Lets look at his Cardiolite scan Lets look at
his Cardiolite scan
Slide 54
Cardiolite Scan
Slide 55
Cardiolite Prior To PET Scan
Slide 56
PET Scan
Slide 57
Last But Most Important Humor is the key to success and it is
something than Mona and I interject in the workplace All the time.
Humor is the key to success and it is something than Mona and I
interject in the workplace All the time. Think Patch Adams hes our
hero Think Patch Adams hes our hero Common saying to adopt (some of
the sayings must be used with discretion) Common saying to adopt
(some of the sayings must be used with discretion) Cool beansCool
beans Understand rubber banUnderstand rubber ban Smooth move
ExlaxSmooth move Exlax Moo FooMoo Foo Im the boss applesauceIm the
boss applesauce Its like a turd in a punchbowlIts like a turd in a
punchbowl Hears the story morning gloryHears the story morning
glory Son BeachSon Beach And now for the next victimAnd now for the
next victim Babe In Total Control of HerselfBabe In Total Control
of Herself Oh my god, oh my god, oh my godOh my god, oh my god, oh
my god Sometimes we get in trouble and sometimes we dont. but
communication and humor make the difference. Sometimes we get in
trouble and sometimes we dont. but communication and humor make the
difference.
Slide 58
My Thanks.. K.S.N.M.T. The Graduates of U of L and JCC Mona B.
Good