Notes From the List Server

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By AHRA Staff

January 2010 — The AHRA List Server is an online tool that allows you to network with other imaging professionals, in one common place.  Many AHRA members take advantage of this exclusive member benefit and use the List Server daily to share valuable information with their peers.

Below is a recent discussion:

“What are you all doing about the sudden scare of radiation exposure in CT head perfusion studies?  I have looked at our exposure reports from the physicist and they seem okay but then, what is okay?  What kind of settings are we all using and what kind of exposures are we seeing with what equipment?

 

Sounds like I’m taking a survey but I just would like to know how we stand compared with the radiology community at large?”

–Sam Mittman

Responses:

“Go to ACR . . . they list the expected doses for typical procedure . . . compare with your doses.

Also, if you want to look at the European standards, Web is European Guidelines on Quality Criteria for Computed Tomography.

We are using a 64 row VCT, GE. Heads are 850 DLP in mGy/cm.  We do a head and neck angio with perfusion, total 3100.  Head and neck is 1648. 

There are no angio or perfusion standards in the European Standards.

We are in the process of writing a specific policy with limits for perfusion.  To exceed these, the medical director must approve.  We will be tracking all doses in both CT and the cath/angio suites. Once we have reviewed and approved all protocols, maximum doses will be specified for which approvals above those will be required as well.  A matrix will be posted in the scanners for the techs to use as a guide.  They will check the prescan indication of dose, and compare with after scan.  Radiologists will review the doses, and include in the reports.

Once all of this has been worked through, will be glad to share.  There is much interest in all quarters.  ED docs and surgeons are suddenly interested in exposure.  Perhaps there is a silver lining?

“No perfusion studies here, but an equally troubling problem with pulmonary CTA.  The public needs to be less concerned about the dose from a scan and considerably more concerned with the appropriateness.  In reading the article from The Annals of Internal Medicine, you find that there is a huge percentage of them that were medically unnecessary.  That needs to be what the man in the street needs to take away from the whole thing, not the dose factors.  

I will say that the recent publicity is going to cause some uproar here. I have a list of frequent fliers thru the ER and frankly, some of them are outrageous examples of bad practices.  The radiologists are now ready to write letters to patients advising them of their exposure. There is one woman, 52 years old, who is closing in on 20 CTs (4 of them pulmonary CTA) in the last 24 months.  The ER physicians are flat-out lying when they say they are reviewing the CT orders placed by the triage nurses—and I now have definitive proof of that.  It’s going to be an interesting trauma committee meeting next month because the radiologists feel that they, not the ER doc, are going to be at the tip of the spear when the plaintiff attorneys come calling—and they are correct.  One of the radiologists has begun dictating in their report that the patient has received X number of CTs in X number of weeks, all of which were normal.  The ordering MDs are about to have a cat about it, but the radiologist is standing their ground.

“I agree that CT in general is much over utilized.  CTAs of the chest are in particular.  Most are ordered with no history or symptoms other than a positive D-Dimer.  While it’s true that all patients with PE have a positive D-Dimer, it is not true that all patients with a positive D-Dimer have a PE.  I don’t feel that a positive D-Dimer alone is reason enough to order a CTA chest.  My other pet peeve is CT stone searches.  Some of these patients get 2 or 3 stone searches in a week’s time.  If you have proven there is a stone on the original CT, why not do a one shot IVP (remember those?) if you want to see if the stone has passed or is stuck somewhere along the way?

I think we are all about to be in the middle of feces storm over something that we have been preaching to deaf ears about for years.

“When in a feces storm, it’s a pleasant change to be the one who’s raining the feces on the richly deserving and that’s where we’re headed.  The strategy here is going to be to use the American College of Emergency Physicians’ own guidelines to whack the ER docs over the head with, especially on neuro imaging.  They have abandoned any idea of getting plain films on spines or sinuses and are going straight to CT every time.”

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