Lean Thinking ..plus the other side of life at Toyota

Over the last couple of years there has been a lot of interest in using "Lean" techniques in healthcare to improve efficiency and quality in service delivery. "Lean" was invented by Toyota, and began life as the Toyota Production System.

Much of this, I believe, is relevant to the delivery of Radiology services, and the Bristish National Health Service is now interested in it too. The NHS institute has a section on its website on Lean Thinking, which has links to a lot of useful and interesting stuff.

However, an article in the Economist (19 Dec 2007) shows another aspect of working at Toyota. The company may be hyper-efficient, but employees in Japan put in enormous amounts of unpaid overtime. In 2002, A 30 year old Toyota quality control manager collapsed and died at work at 4 am. He had been doing 80 hours of unpaid overtime work per month in the 6 months prior to his death much of which was "voluntary" and unpaid. Last month, a court accepted his wife's claim that his death was due to overwork.

How to build a website like this one

Fancy building your own site? It's easy, and it's free. If you know how to shop online, you already possess the IT skills you need.

Here are the slides from a presentation I gave recently at the Management in Radiology (MIR) Congress in Oxford:
http://www.imagingmanagement.org/downloads/mir2007/Th9.45webblog.pdf

A full list of presentations from this meeting can be found here.

CERT : Continuing Education for Radiologic Technologists

The American Roentgen Ray Society will be starting a new series of monthly CPD articles for Radiologic Technologists (i.e. Radiographers) in January 2008, called CERT (Continuing Education for Radiologic Technologists).

Topics will include:

• CT of Pancreatic Carcinoma: Two Original Research Studies
• CT in Trauma Radiography: The Acetabulus, Tibia, and Scaphoid
• CT: Radiation Dose Update
• Women’s Imaging: Two Original Mammography Research Studies
• Women’s Imaging: Viewing Monitors and Dose Reduction Research
• Women’s Imaging: Computer-Assisted Detection, Current Research
• CT Colonography: Current Research
  

More details here.

CERT lessons are approved ARRT Category A credit; I don't know whether or not they are recognised by the UK Society of Radiographers.

Free online teaching material

Free online teaching material from the Uniformed Services University Department of Radiology and Radiological Sciences, kindly provided by Dr James G. Smirniotopoulos:

Check them out:

Brain Lesion Locator
Chest Film Review
MedPix Teaching File and Database
Case of Week - Category 1 CME -

Interruptions at work

A common problem for all radiologists: being interrupted. It's time consuming and disruptive, and the distraction can lead to loss of concentration, and errors in reporting.

In a 2005 study, researchers at the University of California at Irvine found that information workers at an outsourcing company spent an average of 11 minutes on a project or task before they were interrupted. Once diverted, it took them 25 minutes to return to the original task. Sound familiar?
Article from CFO.com.

Nevertheless, being consulted is part of our job.

Some suggestions, from a letter in Radiology, :

1. Institute a radiology consultant of the day or specific times for consultation.
   
2. Close the door, at least until you have finished reviewing the complex examination on your monitor.
   
3. Finish what you are doing before engaging with the clinicians .

More suggestions are found in this post in Lifehack, How to Avoid Lengthy Interruptions a Work. The one I like best is

When someone arrives for a pop-bye, stand and greet her but don’t sit down. Standing tells your visitor that you have things to do so let’s get on with it.

Accessories for Owls

According to Carl Gray, Radiologists and Pathologists tend to be "Owls" (Need three alarm clocks - Hate getting out of bed - Cannot function before 10 am, revived by lunch - Fully functional by mid-afternoon, productive in evenings - Stay up till 1 or 2 am routinely - Cannot sleep because of ideas - On holiday, sleep in even later).

I'm definitely an Owl.

I've recently learnt about some useful accessories for the Owl.

The Sonic Boom Alarm Clock is extremely loud and has a thing that goes under your pillow or mattress to vibrate you out of bed.


The Flying Alarm Clock flies around your room and you have to get up and catch it to switch it off.

I already have three alarm clocks, in addition to my wife's and my mobile phones, which makes five alarms in total, and there's no more space on the bedside table...

Radiation exposure and pregnancy

According to a recent article in Radiographics,

Radiation doses from properly performed radiologic examinations in pregnant women are extremely unlikely to harm the embryo or fetus; thus, when such examinations are necessary for the patient's health care, they should not be withheld.

Cynthia H. McCollough, Beth A. Schueler, Thomas D. Atwell, Natalie N. Braun, Dawn M. Regner, Douglas L. Brown, and Andrew J. LeRoy
Radiation Exposure and Pregnancy: When Should We Be Concerned?
RadioGraphics 2007 27: 909-917 (DOI: 10.1148/rg.274065149)

New Guidelines: Urinary Tract Infection in Children

The National Institute for Clinical Excellence (NICE) have issued new guidelines for UTI in children (Ref CG54).
There is a handy quick reference guide (Imaging is covered in pages 12 - 13).
Other relevant NICE documents, including the full guidance, can be found here.

A few months ago my paediatrician colleague Dr Job Cyriac gave a nice lecture on this topic. You can view his slides here.

A significant change in radiological practice has been the reduction in the number of micturating cystourethrograms, which is great for everyone.

CAD for detecting bone metastases on CT

There was some discussion at work the other day about how detection of bone mets on CT could be quite tricky. The authors of this article, which describes a computer aided detection (CAD) system for detecting lytic lesions in the spine, put it rather diplomatically

"It has been postulated that bone metastases are missed at CT ... there is a perception that these [bone] windows are underused by radiologists and oncologists."

CAD has been developed for lung and breast lesions. This might be another useful application.

O'Connor SD, Yao J, Summers RM.
Lytic metastases in thoracolumbar spine: computer-aided detection at CT-preliminary study.
Radiology. 2007 Mar;242(3):811-6

Open source PACS solution for private clinics

I installed Osirix , a free (Open Source) imaging workstation program, on a stand-alone iMac at our local private hospital almost two years ago (described here), and it has been used very successfully for reading CT and MRI exams loaded from CDs.

The iMac cost about £2000. (You can check current prices at www.apple.com) . A proprietary workstation would have cost 10 times that amount, at least. Also, each time there is a software update, the upgrade is free, and there has been fantastic free support from the online community of users and developers. Much better than from some commercial products I have used.

At Chesapeake Medical Imaging, they used Macs and Open Source software, including Osirix, to view and archive images from at least half a dozen CT and MRI scanners (Siemens, Toshiba, and Philips), in four clinics, doing 80 multi-scan patient studies every day, (about 3GB of data per day and a terabyte per year), and solved a quarter-million-dollar problem for about $12,000.
http://www.apple.com/science/profiles/cmi/

What's missing from the the Open-Source Osirix PACS solution is integration with the Radiology Information System (RIS), so it's not quite ready for big public hospitals, but it does seem like an excellent idea for smaller private facilities.

I suspect that one of the stumbling blocks may be that in many organisations, IT departments lack the ability, skills or inclination to do anything not covered by the Microsoft service manuals, while corporate management do not know any better and do not challenge the IT guys. It's a pity, because there are enormous potential benefits in cost savings and quality of care.

By the way, there's an online tutorial on how to use Osirix. I've not had to use it but you can check it out here.

ACR Guidance Document for Safe MR Practices

A very long and comprehensive artcle was published recently in the AJR
ACR Guidance Document for Safe MR Practices: 2007
AJR 2007; 188:1447-1474

Meanwhile, here's a low-cost device that might be ueful for screening people visiting your MRI facility

FREE online software for designing your reporting room (or ward, or bedroom, or kitchen)

Floorplanner is an internet-based program that allows you to draw floor plans and lay out your room. There's a free version which should be adequate for small projects, and it's very easy to use. The illustration above shows a plan of our reporting room which I've done from memory, and is not exactly to scale. (I'll publish a more accurate version later).
I found this via Dumb Little Man.

PACS Display Quality Assurance Check : FREE!

Can you read the text in all three boxes?
If not, your monitor may not be suitable for interpreting x-rays.

The PACS Display Quality Assurance Check is a free tool designed to assist with a QA programme for PACS web display devices.
We're currently looking into implementing it.

Read more about it here.

CT of Lefort fractures

Here's an article I've referred to from time to time when someone comes into the CT scanner with an unpleasant facial injury.

Rhea JT, Novelline RA.
How to simplify the CT diagnosis of Le Fort fractures.
AJR Am J Roentgenol. 2005 May;184(5):1700-5.
Free full text

Digital dictation part 2...

Our old PACS, a low-cost affair based on web browsers, and with no RIS-PACS integration, has been replaced by an Agfa Impax PACS, and we now have one-way RIS-PACS integration, so that when an examination is opened on the RIS, the images automatically load up on PACS.

It still needs a bit of tweaking, but it has made a world of difference, and reporting is much easier. I have now stopped using casette tapes.

Some time ago I published a post expressing reservations about digital dictation systems, but, as one correspondent suggested, it was because our system was not properly set up. He was right and I was wrong. We do not have speech recognition at present, but I'm investigating this actively.

How dark should your PACS reporting room be?

Not pitch black, but about 40-25 lux, comparable to a dim hotel room at night, according to one study. (Image above from RSNA News May 2007)

RSNA News May 2007 (p 13-14).

Other references:

Viewing conditions for diagnostic images in three major Dublin hospitals: a comparison with WHO and CEC recommendations E Mccarthy, PC Brennan Br J Radiol, Vol. 76, No. 902. (1 February 2003), pp. 94-97. Link

Ambient Lighting: Effect of Illumination on Soft-Copy Viewing of Radiographs of the Wrist Patrick C Brennan, Mark Mcentee, Michael Evanoff, Peter Phillips, William T O'Connor, David J Manning Am. J. Roentgenol., Vol. 188, No. 2. (1 February 2007), pp. W177-180. Link

Cleaning your monitors

Grey scale monitors cost thousands of pounds each. Here's advice from Barco about how to clean them:

And by the way, please don't touch the screen with your finger when pointing to something interesting.

Free online software for calculating bone age

I came across this on Sumer Sethi's famous Radiology blog.
http://sumerdoc.blogspot.com/2007/04/bone-age-estimation.html.

I'm not sure if it's easier than flipping through the Greulich and Pyle Atlas, and I've never used the Tanner Whitehouse method. Nor do I know if this method has been validated (I've tried to look in PubMed). But it looks like it might be interesting for people who like this sort of thing.
http://vl.academicdirect.ro/medical_informatics/bone_age/v1.0/

More bone age software, for Mac only, and integrated with Osirix:
http://homepage.mac.com/d2p/radiology/boneage.html

Medslist: Store a list of your medications online

This is not really to do with radiology but I'm sure a lot of people would find it useful.

A third year medical student has developed a website where you can list your medications, store them online, and even print out a pdf.
http://www.medslist.org/

The author also has a rather attractive website:
http://www.grahamazon.com/

Workstation ergonomics and PACS reading room design

One of the risks of PACS is work-related injuries as a result of using workstations for prolonged periods.

This article was posted on Lifehack. It's an online video tutorial on workstation ergonomics, with a self assessment checklist. Highly recommeded for anyone who spends time with computers (of whom radiologists are only a tiny minority)

Here are some articles about PACS reading room ergonomics and design:

Harisinghani MG, et al Importance and effects of altered workplace ergonomics in modern radiology suites. Radiographics. 2004 Mar-Apr;24(2):615-27.

Prabhu SP, et al. Ergonomics of digital imaging. Br J Radiol. 2005 Jul;78(931):582-6.

Here's more:
A powerpoint presentation of Dr Eliot Siegel's resentation at the UK Radiological Congress 2006, a presentation from GE, and a video by Dr Siegel: Digital eye for the analog guy.

This is not a post-contrast CT

The patient had a haemoglobin of 23, which presumably accounts for the increased attenuation in the cerebral vessels.

Radiology Grand Rounds X

I am hosting this month's Radiology Grand Rounds on behalf of Dr Sumer Sethi. An explanation of the general idea can be found in his site: http://radiologygrandrounds.blogspot.com/

Here's my contribution, two cases which I saw recently, an unsuspected myocardial infarct, and a patient with superior mesenteric artery syndrome.

Here are some other submissions, one from GC George, and another from Chris Depelteau.

"Radiology journal watch" is a new feature at filmjacket.com. 'You can now view titles for all, and abstracts for most, articles in the current issues or AJR, Radiology and Radiographics at a glance. You can also view the titles for all articles in the current issues of each journal separately by expanding the panels on the main page's lower right (you may need to scroll down a bit). The listings automatically update themselves frequently, so the content is always fresh.'
Check it out here.

Last, but not least, three submissions from the man himself, Sumer:

Gadolinium in renal failure (please also see my entry on this site, three posts down from this one, dated 9 February 2007),

Sumers's attempt to compile all radiology related blogs at one place- The radiology Blogosphere,

and a review of literature on acrominion shape.

The Radiology Grand Rounds archives can be found at www.radiologygrandrounds.blogspot.com.

I wonder how much these cost

I saw these at the ECR, and as usual I could not get a straight answer about pricing, but they might be just the thing for someone wanting an extra MRI scanner in the casualty department.

Update: MEHT Policy for accidental overexposure

PROCEDURE k - PROCEDURE TO ENSURE THAT THE PROBABILITY AND MAGNITUDE OF ACCIDENTAL OVER EXPOSURES ARE REDUCED
Revised Feb 2007

PURPOSE
To provide a mechanism for recording and investigation incidents where an individual undergoing a medical exposure receives a radiation dose greater than intended.
To identify persons responsible for making and acting on those reports and to identify the actions to be taken, including reporting to external agencies as considered appropriate.

Posted here.

Safety warning: Nephrogenic Systemic Fibrosis (NSF)and gadolinium

Advice from the MHRA:

Nephrogenic Systemic Fibrosis (NSF) is a debilitating and sometimes fatal condition. It has been associated with some intravenous gadolinium-containing magnetic resonance imaging (MRI) contrast agents in patients with severe renal impairment. On the basis of the available evidence, the UK Commission on Human Medicines (CHM) together with the European Pharmacovigilance Working Party (PhVWP) of the Committee for Medicinal Products for Human Use (CHMP) recommended:

• Do not use Omniscan (gadodiamide) in patients with severe renal impairment (ie, GFR [glomerular filtration rate] <30ml/min/1·73m2)>
• Careful consideration should be given to the use of other gadolinium-containing MRI contrast agents in patients with severe renal impairment (ie, GFR <30ml/min/1·73m2).

MHRA Safety Warning

Online GFR calculator

More info
European Society of Urogenital Radiology
RSNA News Feb '07
The International Center for Nephrogenic Fibrosing Dermopathy Research (ICNFDR)

Recent articles in Radiology here and here.

New Radiology Educational Resource

Thereportingroom.com is a new, free educational site developed by Simon Morley of UCH. The team includes Gerald de Lacey and Lol Berman.

The aim of this website is to allow you to test yourself at interpreting radiology cases using software similar to normal day to day practice. We have developed viewing software which runs on your web browser allowing you to scroll through stacks of CT and MRI images and view plain film images with windowing zoom and pan functionality - just like a PACS workstation.

It looks very good, but note that you need a reasonable computer with a broadband connection and adobe flash player. Some computers in some UK hospitals may not be up to the job.

I've added a permanent link to this site, which I via Sumer's excellent Radiology site (where, ahem, MidEssexRay has recently had an honourable mention).

Investigation of suspected malignant pleural effusion

Good article in the latest BMJ:

Rahman NM, Davies RJ, Gleeson FV.
Investigating suspected malignant pleural effusion.
BMJ. 2007 Jan 27;334(7586):206-7.

These are the BTS guidelines referred to in the above article:

Maskell NA, Butland RJ; Pleural Diseases Group, Standards of Care Committee, British Thoracic Society.
BTS guidelines for the investigation of a unilateral pleural effusion in adults.
Thorax. 2003 May;58 Suppl 2:ii8-17.

I note that the BMJ appears to have started a series on "Rational Imaging". Good idea.

Extravasation of contrast in CT

It happens occassionally, despite all precautions. Here, the extravasation was about 10 cm proximal to the injection site in the antecubital fossa, which we had not come across before. An x-ray confirmed that it was contrast.

This is not an advert for Dell

Since my previous post on using consumer-grade monitors for diagnosis there have been more reports on this subject, all suggesting that an appropriate consumer-grade colour monitor might perform just as well as medical-grade grey scale monitors costing 10 times more.

Read them here, here and here.

I've spoken to some vendors about this and mentioned it in the RCR PACS group forum, and the objections to these monitors have been to do with quality control and longevity.

We'll see what happens in future.

The monitor in question is the 24" Dell 2405 , which has now been superseded by the 2407. It has comparable brightness and contrast to medical grade monitors (not the case with other consumer-grade products), is currently on the "A-list". of PC Pro. Here's the review.

I've never even seen one of these Dells so this post is not a personal endorsement or recommendation.

Radiology Search Engines added

Yottalook (beta) is a Radiology Search engine for images or references that is based on Google .
Goldminer is a radiological image search engine hosted by the American Roentgen Ray Society, and results are limited to "images from respected peer-reviewed images".

Here's more about them from Pacsweb.

Yottalook and Goldminer have been added to the 'Links' section of this site, on the right hand sidebar.

New addition: MRI lumbar spine nomenclature

I have posted a summary of the American Society of Neuroradiology nomenclature for lumbar disc pathology, and an MR-based grading system for lumbar root compromise due to disk herniation (Pfirrmann 2004) in the "Protocols and Guidelines" section.

You can go to the page directly from here.

Cancer staging manual added to this site

I've added a Cancer Staging Manual with a link to the RCR guidelines and, for a start, pages for lung, renal and prostate cancer, with details of TNM staging and other things I've found useful. These are things I've found difficult to remember, and I've posted them here to save myself the trouble of hunting around for books etc.
You can get to the manual from the 'Protocols and Guidelines' page, or by clicking here.

MRI safety questionnaire added to Protocols and Guidelines Section

For the benefit of our patients, and the convenience of our esteemed customers, the MRI saftey questionnaire can now be downloaded from the "guidelines and protocols" section of this site.
To go straight to the page, click here .

Build your own PACS using free open-source software

From Antoine Rosset, developer of Osirix.
This is based on Apple Mac components but the all software is open source, and can be downloaded from the internet.

Full step-by -step instructions here.

You can work out the cost of the hardware (in the UK) by visiting the Apple Store.

From today's CT list

Small bowel obstruction due to left inguinal hernia

Sonosite portable ultrasound machines on eBay

I look on eBay for medical equipment from time to time, out of idle curiosty. SonoSite portable ultrasound machines are frequently on sale, and there were more than ususal today: one SonoSite 180 plus, one SonoSite 180, one MicroMaxx, one Titan, one Sonoheart, as well as a linear SonoSite probe.


Our old SonoSite 180 could do with replacement, and that linear probe would come in handy. If I recall correctly, our SonoSite originally cost £18 000 with one probe only.