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DEPARTMENT OF DIAGNOSTIC IMAGING
RHODE ISLAND HOSPITAL
BROWN MEDICAL SCHOOL
RESIDENCY MANUAL
Initial Formulation: 1984
M...
2
PHYSICIANS IN CHARGE OF SECTIONS
Chairman John J. Cronan, M.D.
Program Director Martha B. Mainiero, M.D.
Physician in Ch...
3
RESIDENCY MANUAL
TABLE OF CONTENTS
I. GENERAL INFORMATION Page 3-32
A. Selection Policy Page 4
B. Lines of Supervision P...
4
RESIDENT SELECTION POLICY
Resident applications are accepted through ERAS, and interviews are granted after review of me...
5
Upon completion of the program, the resident physician will be a competent, well-rounded diagnostic
imager and will be c...
6
communication skills, problem-based learning, and systems-based.
The resident is responsible for maintaining a procedure...
7
SUGGESTED CURRICULUM
4 WEEK BLOCKS (13/YEAR)
BREAKDOWN BY YEAR
TOTAL FIRST SECOND THIRD FOURTH
GI/GU 4 2 1 0 1
NUC MED* ...
Resident Evaluation Form
Resident’s Name Level of Training 1 2 3 4 Return To: Dr.
Evaluator’s Name Dr. Rotation Evaluation...
Actively opposes efforts to improve Needs attention: Avoids harmful diagnostic and
systems of care. Specify_______________...
ER Evaluation
10
Tech Evaluation
11
CONFERENCES
Departmental Noon Conference
The daily noon conference is an integral part of resident education, and therefor...
Pediatric Radiology
I. Cardiac:
1. Cyanotic congential heart disease
2. Acyanotic congenital heart disease
3. Vascular ano...
Tumors with fibrous matrix (benign and malignant)
Enchondromatosis
Osteocondromatosis
Mafffucci’s syndrome
Simple bone cys...
Miscellaneous
Oxalosis
VI. Metabolic
Osteoporosis
Osteomalacia and Ricket’s
Scurvey
Menke’s
Paget’s disease
Hyperphosphata...
Stippled epiphyses
Osteopetrosis
Pychnodysostosis
Sclerosing bone dysplasias (osteopoikilosis, striatum, mixed)
Wormian bo...
Fetal CNS (brain, spine)
Gestational trophoblastic disease
Normal fetal exam/measurements
Fetal abdomen/pelvis
Infertility...
Infectious disease
Uncommon malignant tumors of the lung
Congenital lung disease
Cardiovascular disease I
Cardiovascular d...
Vasoactive agents
Relevant hormones
Anti-coagulants
Thrombolytics
Anti-platelet agents
Sclerosing agents
Noninvasive testi...
Mesentery
Ischemia
Acute
Chronic
Bleeding
Diagnosis
Treatment
Infusion
Embolization
Hepatic-splenic
Portal dynamics
Varice...
AVM
Collecting system
Nephrostomy
Ureteral access
Stone
Varicocele
Impotence
Uterus
UAE
Post-partum bleeding
Musculoskelet...
Interdepartmental Conferences
Interdepartmental conferences within our institution will often require the participation of...
RESEARCH
During the four years of training in Diagnostic Radiology, there will be opportunities to
participate in both cli...
RESIDENT ON-CALL RESPONSIBILITIES
All radiology residents will share overnight call responsibilities. The resident assigne...
The on-call resident shall:
• Maintain a constant presence in the Emergency Room in order to assist the
Emergency Room phy...
INTERVIEWING FOR FELLOWSHIP:
If more than 5 days, including travel, are needed for fellowship interviews it will
be requir...
resident must have approval from the Program Director before engaging in any
moonlighting activities. The Program Director...
REPORT OF THE COMMITTEE ON THE IMPACT OF
MATERNITY ON RADIOLOGISTS
The large number of women entering medical schools has ...
HOSPITAL LEAVE POLICY
The state of Rhode Island has a Parental and Family Medical Leave Act, instituted in
1990, and the h...
RESPONSIBILITIES OF THE CHIEF RESIDENT(S)
It is an honor and privilege to be selected as the Chief Resident. The major
res...
BROWN MEDICAL SCHOOL
DEPARTMENT OF DIAGNOSTIC IMAGING
ACADEMIC TRACKS
(as of 7/1/04)
Full Time
Professor
John J. Cronan, M...
Clinical Educator
Professor (Clinical)
Barbara Schepps, M.D.
Associate Professor (Clinical)
Douglas F. DeOrchis, M.D.
Rich...
Hanan Khalil, M.D.
Eric Yun, M.D.
Clinical
Clinical Associate Professor
No Physician currently at this level
Clinical Assi...
Emeritus
Allan Deutsch, M.D. Clinical Assoc. Prof. Emeritus
Gary J. Dorfman, M.D. Professor Emeritus
Daniel Hanson, M.D. C...
ROTATIONS
A. CONCIOUS SEDATION POLICY Page 37-41
B. COMPUTED TOMOGRAPHY Page 42-63
C. EMERGENCY DEPARTMENT Page 64-71
D. F...
A. CONSCIOUS SEDATION POLICY
Department of Diagnostic Imaging
Lifespan Academic Campus Guidelines for Sedation
These polic...
Examinations may be scheduled by the referring physician or their designees.
Determination as to the need for sedation is ...
Medications other than insulin should be taken as routine. Half- normal dose of insulin
may be taken in consultation with ...
Equipment- The following constitute minimal accessory equipment for the performance
of sedation and during the recovery ph...
Sodium pentobarbital- Recommended agent for all children >2yrs of age and for children
>6mo of age when intravenous access...
B. COMPUTED TOMOGRAPHY
Table of Contents
I. General Description of CT Division at Rhode Island Hospital
II. Educational go...
I. General Description
There are currently four helical CT scanners at Rhode Island Hospital which perform in
excess of 50...
expected to help referring physicians interpret studies performed at Rhode Island
Hospital when they come to the CT sectio...
It is our routine to use "ionic" contrast agents unless there is a contraindication.
Technologists screen patient for the ...
is normal, the patient can resume medication. In the CT section, we will fill out a lab slip
for creatinine to be drawn wi...
pulses and presence of pain. The patient should be observed in the CT suite for 2-4 hours
after the extravasation with the...
ABDOMEN: The liver, gallbladder, pancreas, kidneys and adrenal glands
are normal. The spleen remains enlarged measuring 20...
which is kept near the interventional CT console. This information should then be
reviewed with the charge technologist (E...
surgery? If the patient is on any anticoagulants or drugs which could effect coagulation,
this should be noted. When blood...
Guidelines for Hematologic Values and Medication Usage Prior to Invasive Diagnostic Procedures
Procedure PT INR Rx Notes
T...
In general we do not perform biopsies in patients with <50,000 platelets. Avoid platelet transfusions prophylactically but...
An outline of specific procedures follows.
1. Abscess Drainage:
Abscess drainages should be performed with antibiotic cove...
In this circumstance we follow the same protocol that is used for a liver biopsy. This
includes the appropriate lab work (...
• For a patient who develops a pneumothorax post-procedure and becomes
symptomatic, a chest tube should be placed either i...
You will need a Lifelinks password. The login ID is the same as the six digit
number assigned to you for Radiology dictati...
attending does not get nasty letters from the medical records department about
suspension of admitting privileges. Dischar...
7. Observation of the Patient:
The patient should be observed in the radiology holding area or on the floor for
inpatients...
All MR and CT scans must be checked by a radiologist at the completion of the study,
prior to the patient being moved.
The...
EDUCATIONAL GOALS AND OBJECTIVES
First and Second Year Residents:
Patient Care:
1. Become familiar with CT protocols
2. Be...
Systems-based Practice:
1. Demonstrate knowledge of how radiologic information is integrated with the
other parts of the h...
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Transcript of "DEPARTMENT OF DIAGNOSTIC IMAGING"

  1. 1. 1 DEPARTMENT OF DIAGNOSTIC IMAGING RHODE ISLAND HOSPITAL BROWN MEDICAL SCHOOL RESIDENCY MANUAL Initial Formulation: 1984 Most Recent Review/Revision: June 2004
  2. 2. 2 PHYSICIANS IN CHARGE OF SECTIONS Chairman John J. Cronan, M.D. Program Director Martha B. Mainiero, M.D. Physician in Charge CT William Mayo-Smith, M.D. ER Thomas K. Egglin, M.D. Fluoro Brian L. Murphy, M.D. Nuclear Medicine Richard B. Noto, M.D. Musculoskeletal Robert E. Lambiase, M.D. Pediatrics Michael T. Wallach, M.D. Cardiopulmonary Gerald F. Abbott, M.D. Physics Douglas R. Shearer, Ph.D. Vascular & Interventional Gregory M. Soares, M.D. Ultrasound Damian E. Dupuy, M.D. Breast Imaging Barbara Schepps, M.D. Women & Infants' Patricia K. Spencer, M.D. Neuroradiology/MRI Jeffrey M. Rogg, M.D. Medical Office Complex Scott M. Levine, M.D. The Miriam Hospital/MRI Richard L. Gold, M.D. Research Glenn A. Tung, M.D.
  3. 3. 3 RESIDENCY MANUAL TABLE OF CONTENTS I. GENERAL INFORMATION Page 3-32 A. Selection Policy Page 4 B. Lines of Supervision Page 5 C. Evaluation Policy Page 5-11 D. Formal Grievance Procedures Page 6 E. Noon Conference Curriculum Page 12-22 F. Imaging Conference Page 22 G. New England Roentgen Ray Society Meeting Page 23 H. Self-Study Page 23 I. Research Page 24 J. Call Responsibilities Page 25 K. Duty Hour Policy Page 26 L. Vacation Policy Page 26 M. Leaves of Absence Page 27 N. Moonlighting Page 28 O. Report on Pregnancy Page 29 P. Hospital Leave Page 30 Q. ACLS Certification Page 30 R. Duties of the Chief Resident(s) Page 31 S. Faculty Appointments Page 32 II. ROTATIONS: HOURS, GOALS, OBJECTIVES AND READING LISTS A. Conscious Sedation Policy Page 37-41 B. Computed Tomography Page 42-63 C. Emergency Department Page 64-71 D. Fluoroscopy/Gastrointestinal/Genitourinary Page 72-78 E. Nuclear Medicine Page 79-86 F. Musculoskeletal Radiology Page 87-92 G. Pediatrics Page 93-97 H. CardiopulmonaryRadiology Page 98-104 I. Physics/Radiobiology Page 105-107 J. Vascular & Interventional Radiology Page 1108-119 K. Ultrasound Page 120-125 L. Breast Imaging Page 126-130 M. Women & Infants Page 131-137 N. AFIP Page 138 O. Elective Page 139 P. Neuroradiology/MRI Page 140-154 Q. Medical Office Complex Page 155-160 R. TMH/MRI Page 161
  4. 4. 4 RESIDENT SELECTION POLICY Resident applications are accepted through ERAS, and interviews are granted after review of medical school transcript, letters of recommendation, personal statement and USMLE scores. After receipt of the Dean’s letter, two members of the education committee interview each applicant, and all interviewed applicants are discussed among and ranked by the members of the education committee. The rank list is then submitted to the NRMP. Decisions regarding selection for interview and rank order are made without regard to the applicant’s race, sex, creed, ethnic background or national origin. DRESS At all times the residents should dress in a manner fitting the professional position he or she has attained. Weekend dress should be similar to weekday. TELEPHONE ETIQUETTE It is appropriate that you identify yourself and the section in which you are working. Remember at all times to be courteous, patient and helpful. REPORT SIGN-OFF On arriving to work in the morning, at noon, and finally prior to leaving, the resident should read, correct, and electronically sign all of his/her transcribed radiology reports. It is absolutely essential that this task be completed in an expeditious manner. THE FOUR-YEAR CURRICULUM The four-year training program in diagnostic imaging is a competency-based curriculum with the goal to proportion residency training to conform to the contemporary practice of diagnostic imaging (Table I). The clinical program has been designed so that the resident will spend time optimally distributed through the areas involved in medical imaging and interventional radiology. In the first year the resident's time is distributed in those areas in which s/he must become acquainted to become competent in basic radiology skills. These clinical rotations include GI/GU fluoroscopy, emergency radiology, bone radiology, chest radiology, nuclear medicine, ultrasound, computed tomography (CT), pediatric radiology, vascular and interventional radiology, and obstetrical sonography and MRI. In the second, third, and fourth years of training in radiology, the distribution is such that the resident will spend approximately one additional month in each area each year including mammography. An elective at the Armed Forces Institute of Pathology (AFIP) is possible in the third year. At least one additional elective month is available in the third and fourth years. Electives can be spent in a number of useful and innovative ways to refine the resident's skills and to explore new career possibilities. During the second and third years it is expected that the resident will progressively move closer to the goal of being able to run the clinical section, an ability expected of all the fourth year residents.
  5. 5. 5 Upon completion of the program, the resident physician will be a competent, well-rounded diagnostic imager and will be competent in basic angiographic and interventional techniques. It is felt that the four-year residency program is not a time for subspecialization; intensive subspecialty training is the purview of a fellowship program. POLICY ON LINES OF SUPERVISION Upper level residents and fellows may at times supervise residents, but faculty members are ultimately responsible for the clinical care given to patients. Residents will be given increasing responsibility during the four-year curriculum, with appropriate levels of faculty supervision at all times. At all levels of training, cases must be reviewed by an attending radiologist before report sign-off. Interventional procedures must be supervised by an attending radiologist. Toward the end of the first year of training, residents will take an examination to assess competency for taking independent overnight call. Only after successful completion of the examination will 2nd year residents begin to function as the in-house radiologist after 11pm. Fellows and attendings take call from home to assist the resident, including coming into the hospital to review cases and perform procedures when necessary. The weekly attending/fellow schedule lists who is on call for general radiology, pediatric radiology, VIR, and MRI. Residents are encouraged to contact the fellow or attending staff at anytime when assistance is needed. The appropriate person should be paged or called at home. Pager numbers are provided through the Lifespan intranet and home phone numbers are provided by the department. Home phone numbers should be kept confidential. If the responsible individual cannot be reached for any reason, the resident should call any other faculty member necessary for assistance. EVALUATION OF PERFORMANCE It is necessary that a residency-training program establish minimal standards of acceptable performance, which will be used to determine advancement as well as to commend above average achievement. The written evaluation is essential to the regular assessment of resident performance. Following the completion of each monthly rotation, the teaching faculty will complete an evaluation form (Table II). Evaluation is based upon the resident’s performance in achieving the stated goals and objectives in the six general competencies for each rotation at each level of training. These six general competencies are defined by the Accreditation Council for Graduate Medical Education (ACGME) as follows: medical knowledge, patient care, professionalism, interpersonal and communication skills, problem-based learning and systems-based practice. In addition, on services where there is interaction with the technical staff, the lead technologist will evaluate the residents on professionalism and interpersonal and communication skills (Table III). In addition, we are piloting a program to have the Emergency Department physicians evaluate the residents performance in the six general competencies while on the night float rotation (Table IV). The evaluation form will become a permanent part of the resident's record. All written evaluations are available for review by the resident at any time. It is expected that the resident will contact the attending responsible for formulation of the written evaluation if concerns are raised. This semi-annual review will be performed with the resident and competency in the six general competencies outlined by the Accreditation Council for Graduate Medical Education (ACGME) will be assessed. These six areas are medical knowledge, patient care, professionalism, interpersonal and
  6. 6. 6 communication skills, problem-based learning, and systems-based. The resident is responsible for maintaining a procedure log for all non-vascular procedures on an excel spreadsheet, which will be provided by the chief residents. The resident must bring this log to every semi-annual review. The log of procedures kept by the vascular and interventional computer system (HIQ) should also be printed and brought to the review. This review will become a part of the permanent record. The American College of Radiology (ACR) written "in-service" examination is required of all first, second and third year residents. This examination is given in February and the results are received and will be received approximately six weeks later. A mock oral board examination will be given to third and fourth year residents several weeks after the written board examination. For the fourth year residents, this practice run will help in preparation for the oral board examination given by the ABR in June. For the third year residents, this experience should further refine and coalesce the knowledge and organization of thought that the resident has acquired over the years. At six-month intervals, i.e., in December and June, the resident's overall performance will be assessed and reviewed by the Program Director. Advancement to the next level of training will be contingent upon demonstration of competency in the above areas. Unsatisfactory on clinical evaluations and/or failure to score above the 25th percentile on the ACR in-service exam may necessitate academic remediation. FORMAL GRIEVANCE PROCEDURES As defined in the Rhode Island Hospital (RIH) House Officer Agreement, the house officer agrees to participate in safe, effective, and compassionate patient care under supervision commensurate with his or her level of advancement. The resident also agrees to participate fully in the educational activities of the training program and to participate in other institutional programs and activities involving the medical staff. The residents are to involve themselves in a personal program of self-study and professional growth with guidance from the teaching staff. Formal disciplinary action may be taken for due cause. Except under circumstances requiring an immediate emergency disciplinary action to preserve acceptable standards of care, safety or ethics, probation, suspension or termination from the training program will be recommended by the Program Director only after a period of counseling and remediation. The resident has the right to a review of any probation decision with the Director of Medical Education.
  7. 7. 7 SUGGESTED CURRICULUM 4 WEEK BLOCKS (13/YEAR) BREAKDOWN BY YEAR TOTAL FIRST SECOND THIRD FOURTH GI/GU 4 2 1 0 1 NUC MED* 4 1 1 1 1 US 3 1 0 1 1 CT 3 1 1 0 1 TMH 3 1 1 0 1 MRI 3 0 1 1 1 ER 3 1 1 1 0 MOC 3 1 1 1 0 CHEST 4 2 0 1 1 PEDI 4 1 1 1 1 CVIR 4 1 1 1 1 W&I 4 1 1 1 1 AFIP 1 0 0 1 0 FLOAT 4 0 2 1 1 ELECT/RES. 2 0 0 1 1 MAMM 3 0 1 1 1 TOTALS 13 13 13 13 *Experience in Nuclear Medicine will total six months with the addition of lectures and float experience
  8. 8. Resident Evaluation Form Resident’s Name Level of Training 1 2 3 4 Return To: Dr. Evaluator’s Name Dr. Rotation Evaluation Period Please evaluate the resident’s performance for each component of clinical competence. Circle the rating which best describes the resident’s skills and abilities. Use as your standard the level of skill expected from the clearly satisfactory resident at this stage of training. Identify the strengths and weaknesses you have knowledge of by circling the relevant phrases and/or providing comment on the reverse side. A rating of 4 is defined as “marginal” and conveys the expectation that with remediation the resident will meet the standards for Board certification. Be as specific as possible, including reports of critical instances. Global adjectives or remarks, such as “good resident” do not provide as meaningful feedback to the resident as specific concerns. Unsatisfactory Satisfactory Superior 1. Medical Knowledge Limited knowledge of anatomy, Immediate recognition of abnormalities pathology and clinical medicine. 1 2 3 4 5 6 7 8 9 and development of unifying diagnoses. Cannot explain the basis of imaging Insufficient contact to judge Evidence-based approach to diagnosis and findings. Knowledge based on rote Needs attention: intervention tailored to each patient and with no understanding. Minimal Specify_________________________ setting. Highly resourceful development interest in reading. ________________________________ of knowledge. 2. Patient Care Fails to review history and prior studies. Always gathers available information Unable to synthesize data from different 1 2 3 4 5 6 7 8 9 to make diagnostic and therapeutic sources; poor clinical judgment. Insufficient contact to judge decisions based upon sound clinical Ignores evidence and patient preference Needs attention: judgment, best available evidence when making decisions. Specify_________________________ and patient preferences. Poor procedural skills. ________________________________ Stellar procedural skills. 3. Practice-Based Learning Lacks insight into strengths and weaknesses. Constantly evaluates own performance. Resists or ignores feedback. 1 2 3 4 5 6 7 8 9 Incorporates feedback into improved practice Lacks intellectual curiosity. Insufficient contact to judge Identifies, rectifies and learns from errors Fails to use information technology to Needs attention: Efficiently uses technology to access improve knowledge base and enhance Specify_________________________ information and enhance patient care. Patient care. ________________________________ Maintains exemplary procedure log. 4. Communication and Interpersonal Skills Reports incomplete or inaccurate. Reports clear and concise. Fails to communicate significant 1 2 3 4 5 6 7 8 9 Communicates efficiently with staff. Or unexpected findings. Insufficient contact to judge Excellent rapport with referring physicians. Ineffectual or antagonistic encounters Needs attention: Excellent “bedside manner” with patients. With colleagues, patients, staff. Specify_________________________ Well respected by peers. ________________________________ 5. Professionalism Lacks respect, compassion, integrity, Always demonstrates respect, compassion, honesty; insensitive to diversity. 1 2 3 4 5 6 7 8 9 integrity, honesty. Fulfills responsibilities in Shirks responsibility. Insufficient contact to judge an exemplary fashion. Always acts in the Places self-interest above patients. Needs attention: best interest of the patient. Specify_________________________ ________________________________ 6. System-Based Practice Fails to follow protocols. Follows established protocols. Unable to utilize outside resources. 1 2 3 4 5 6 7 8 9 Utilizes standards and appropriateness criteria. Uses algorithms indiscriminately. Insufficient contact to judge Implements system improvements. 8
  9. 9. Actively opposes efforts to improve Needs attention: Avoids harmful diagnostic and systems of care. Specify_________________________ interventional procedures. (OVER) Comments: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Overall Performance: Unsatisfactory Satisfactory Superior 1 2 3 4 5 6 7 8 9 9
  10. 10. ER Evaluation 10
  11. 11. Tech Evaluation 11
  12. 12. CONFERENCES Departmental Noon Conference The daily noon conference is an integral part of resident education, and therefore, attendance is essential. Residents are excused from the clinical service during this time so that they may attend. Most of the noon conferences will be part of a formal educational curriculum covering the subspecialty areas of radiology. The topics covered by each subspecialty area in the two-year curriculum are included in on the following pages. In addition, occasional noon conferences will focus on non-interpretive issues such as ethics, research, and business practice issues. Noon Conference Curriculum Topics will be covered in a 2 year cycle Nuclear Medicine Quality Control VQ Scans Bone Nuclear Cardiology Endocrine Renal Hepatobiliary GI Infection Neurology Oncology and PET Miscellaneous (shunt, flow, lymphoscintigraphy) Breast Imaging Overview BIRADS Breast Masses Breast Calcifications Breast US Needle Localization and Core Biopsy Breast MRI Surgically Altered Breast 12
  13. 13. Pediatric Radiology I. Cardiac: 1. Cyanotic congential heart disease 2. Acyanotic congenital heart disease 3. Vascular anomalies 4. Misc II. GI 1. Plain films 2. Pharynx/esophagus 3. Nonobstructed small bowel/colon pathology 4. UGI obstruction 5. Liver/Pancreas/ Spleen 6. Lower GI obstruction 7. Abdominal Masses and Congenital Lesions III. GU 1. Kidneys, congenital 2. Kidnys, tumor 3. UTI 4. Lower GU anomalies 5. Male testicle 6. Female genital track Musculoskeletal I. Trauma Basic description of fractures and basic orthopedic principles of reduction and fixation Pelvis Lower extremity Spine, thoracic and lumbar Upper extremity Neuropathic Osteonecrosis Stress and insufficiency injuries II. Tumors Introduction to bone tumors Tumors with osteoid matrix (benign and malignant) Tumors with chondroid matrix (benign and malignant) 13
  14. 14. Tumors with fibrous matrix (benign and malignant) Enchondromatosis Osteocondromatosis Mafffucci’s syndrome Simple bone cysts Giant cell tumor Adamantinoma Synovial cell carcinoma Chordoma Ewing’s sarcoma Leukemia Lymphoma PVNS Cortical avulsive irregularity Tumors of vascular origin Intraosseous lipoma Metastatic disease Miscellaneous III. Rheumatologic and Connective Tissue Disease Rheumatoid arthritis Juvenile chronic arthritis Ankylosing spondylitis Psoriatic arthritis Reiter’s syndrome Osteitis condensans ilii Systemic lupus erythematosus Scleroderma Dermatomyositis Mixed connective tissue disease Miscellaneous IV. Degenerative Osteoarthritis Erosive osteoarthritis DISH Spinal degenerative disease Ossification of the posterior longitudinal ligament V. Crystal Deposition Disease CPPD (chronic and pseudogout Gout Calcium hydroxyapatite crystal deposition Hemochromatosis Tumoral calcinosis Chrondrocalcinosis 14
  15. 15. Miscellaneous Oxalosis VI. Metabolic Osteoporosis Osteomalacia and Ricket’s Scurvey Menke’s Paget’s disease Hyperphosphatasia/hypophosphatasia Hyperparathyroidism Hypopara-, pseudohypopara-, and pseudopseudohypoparathyroidism Homocystinuria Wilson’s disease Fluorosis PVC toxicity Heavy metal poisoning Renal osteodystrophy Ochronosis Hypervitaminoses Miscellaneous VII. Hematopoetic Anemias Multiple myeloma and plasmocytoma, Poems Storage diseases (Gaucher’s, histiocytosis, amyloid) Hemophilia The angiomatoses VIII. Infection Active and chronic bacterial osteomyelitis Fungal Viral Tuberculosis Disc infection Parasites IX. Congenital Dysplasias (epiphyseal, metaphyseal and diaphyseal, SED) Mucopolysaccharidoses 15
  16. 16. Stippled epiphyses Osteopetrosis Pychnodysostosis Sclerosing bone dysplasias (osteopoikilosis, striatum, mixed) Wormian bone Cleidocraniodysostosis Myositis ossificans progressiva Osteogenic imperfecta Van Buchen’s The angiomatoses Miscellaneous Osteochondroses X. Pediatric Congenital hip dysplasia Perthes Blounts PFFD Primary coxa vara Caffey’s disease Talipes equinovarus Miscellaneous XI. MRI/Sport Knee Shoulder Wrist/elbow Ankle/foot Hip Ultrasound Renal/adrenal Carotid Musculoskeletal Ultrasound intervention Thyroid/Parathyroid Pancreas and spleen Upper extremity Prostate/scrotum Acute venous disease Chronic venous disease Adnexa Uterus/endometrium Liver and biliary 16
  17. 17. Fetal CNS (brain, spine) Gestational trophoblastic disease Normal fetal exam/measurements Fetal abdomen/pelvis Infertility/HSG First trimester/ectopic Placenta, umbilical cord/amniotic fluid Fetal thorax Fetal chromosomal abn GI/GU Anatomy I – GI Testes and scrotum Anatomy II – GU The IVP Barium studies Renal masses Renal infectious disease Renal obstruction Barium I – GI Barium II – SB and colon Focal liver lesions ERCP Adrenal Urethrography Pancreas/spleen Diffuse liver disease Urolithiasis Defecography Contrast media Abdominal intervention Cardiopulmonary Normal pulmonary/mediastinal anatomy Signs and patterns in chest radiology Interstitial lung disease and HRCT Atelectasis, airways and obstructive lung disease Mediastinal masses and mediastinal /hilar enlargement Solitary and multiple pulmonary nodules Bronchogenic carcinoma Staging lung cancer Chest wall, pleura and diaphragm 17
  18. 18. Infectious disease Uncommon malignant tumors of the lung Congenital lung disease Cardiovascular disease I Cardiovascular disease II Monitoring devices and the post-op chest Trauma Neuro I. Brain Introduction to neuroimaging Trauma Tumor – intra-axial Tumor – extra-axial and intraventricular Infection White matter Congenital - migration, sulcation and cleavage Congenital – neural tube closure and neurocutaneous syndrome Vascular – aneurysm and vascular malformations Vascular – stroke, hemorrhage other than aneurysm/vasc malformation Vascular – external carotid MR spectroscopy - Rogg II. Spine Degenerative disease and infection Congenital Tumors Trama III. Head and Neck Tumor 1 Tumor 2 Skull base and temporal bone Orbits Sinuses Vascular and Interventional Radiology General Pharmacology Anesthetics Analgesics Antibiotics 18
  19. 19. Vasoactive agents Relevant hormones Anti-coagulants Thrombolytics Anti-platelet agents Sclerosing agents Noninvasive testing Pulse volume recording Segmental pressures Ankle brachial index Duplex ultrasound Equipment Catheters Wires Embolic materials Radiation safety Arterial peripheral Diagnostic arteriography Approaches Filming Injection technique-contrast/co2 Pathophysiology Atherosclerosis Neoplasm Trauma Infection Inflammation AVM Intervention Angioplasty/stent Embolization Thrombolysis Venous peripheral Occlusive disease Chronic insufficiency Thrombolysis Filters Malformations Dialysis Clinical parameters Tunneled catheters Creation Management Fistulas Declotting Angioplasty 19
  20. 20. Mesentery Ischemia Acute Chronic Bleeding Diagnosis Treatment Infusion Embolization Hepatic-splenic Portal dynamics Varicele bleeding Portosystemic shunts Trauma Chemoinfusion Neuro Brachiocephalic vessels Atherosclerosis Trauma Inflammatory Congenital Brain Aneurysm AVM Infection Inflammation Neoplasm Trauma Intervention Thrombolysis Embolization Chemoinfusion Venous disease Occlusive Anomalous Biliary Cholangiography Drainage Stent Irradiation Genitourinary Renal Renal artery disease Diagnosis Intervention Venous sampling 20
  21. 21. AVM Collecting system Nephrostomy Ureteral access Stone Varicocele Impotence Uterus UAE Post-partum bleeding Musculoskeletal Joint injection aspiration Vertebroplasty Head and neck Chemoinfusion Dacrocystography Pulmonary Hypertension Embolism AVM Hemoptysis Imaging Conference Departmental noon conference stresses image interpretation and differential diagnosis. However, an effective radiologist must not only be able to interpret an imaging study but must serve as a consultant to the referring clinician. In order to be an effective consultant, the resident must be versed in the appropriate imaging evaluation of a variety of clinical conditions in order to be able to recommend the most useful, cost-effective studies. In the language of the ACGME, imaging conference addresses “systems-based practice, with emphasis on an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.” In addition, this conference provides a forum in which the resident refines his or her public speaking and teaching skills while conveying important imaging evaluation information to members of the department. Imaging conference is held twice a month at 7:00 a.m. Each resident’s presentation should be no more than seven minutes long and should be a very brief presentation of an imaging case, followed by a succinct discussion of the relevant literature and any applicable ACR Appropriateness Criteria, which is accessible online and can be downloaded into a PDA from the ACR website www.acr.org.. First year residents should discuss the case they plan to present to the appropriate attending. 21
  22. 22. Interdepartmental Conferences Interdepartmental conferences within our institution will often require the participation of a radiologist and in most cases, necessitates the expertise of a staff radiologist. By the fourth year, the resident is expected to have gained sufficient expertise to be able to function as the primary radiologist at the Medical Resident Conference and the Medical Oncology Conference. In the Medical Resident Conference, the resident will assemble teaching cases in order to instruct the medical residents in basic plain film interpretation. For Medical Oncology Conference, as this is a working patient management conference, the list of cases must be made available to the resident for the resident to have sufficient time to review the films. New England Roentgen Ray Society Meeting The residents who are not assigned to specific rotations will be excused at 1:30 p.m. to attend the New England Roentgen Ray meeting, traditionally held from 3:00 pm to 6:45 pm in Boston, MA. At least three residents must remain in the hospital on the afternoon of the NERRS meeting to cover MD, GI/GU, CT/US, NM/W&I. Coverage of these areas will be assigned by the chief residents. There will be no noon conferences on these days. National Meetings It is the intent of the Department to encourage attendance at meetings and national courses. During the third year of training, the Department will pay tuition only for residents to attend the Armed Forces Institute of Pathology (AFIP) course. The Department will also pay for the attendance of any resident to a national meeting when a resident presents a paper. Three days off of service will be provided for the resident to attend the meeting to allow for travel to the meeting, day of presentation, and day of return travel. Receipts for the meeting must be submitted and only reasonable expenses related to the meeting will be reimbursed. SELF-STUDY In addition to learning from supervised, progressive experience on service and didactic instruction in conferences, residents must develop self-study habits that will strengthen medical knowledge during residency and provide a foundation for life-long learning. In the resident room there is a book cabinet in which basic texts for each rotation and the ACR syllabi are kept. These texts can be signed out through the chief resident. Additional texts can be found in each clinical section. Teaching discs are kept in the learning lab for computer-based instruction. The ACR teaching file is in Conference Room B. 22
  23. 23. RESEARCH During the four years of training in Diagnostic Radiology, there will be opportunities to participate in both clinical and basic science research. Participation in research will deepen the resident’s understanding of literature review, research study design, and statistical methodology. Quality research enhances the image of Rhode Island Hospital and the training program as well as the resident's stature within the radiology community. For those residents desiring fellowship training, participation in these activities enhances one’s application competitive fellowship programs. Residents must first establish a basic knowledge base in radiology before committing time to research activities. First year-resident’s first priority must be to establishing that base, and therefore research should not be undertaken during the first year until after the Program Director has evaluated the resident’s performance at the 3-month review in October. Many of the staff radiologists are excellent mentors for writing papers and/or preparing exhibits. Participation in these projects must be under the tutelage of an attending radiologist; no material should be submitted for publication or presentation without the supervision of a staff member. Prior to completion of the residency, an academic project must be completed. For the neophyte, a case report submitted to an imaging journal will be an obvious starting place. For those residents interested in a specific area of radiology, a complete article could be undertaken. The national meetings of the Radiological Society of North America (RSNA), Association of University Radiologists (AUR) or the American Roentgen Ray Society (ARRS) are excellent arenas for abstract presentations. These national meetings allow 10-12 minute presentations on a concise topic, which can be submitted as a manuscript for publication. As with papers, staff guidance and supervision is mandatory. The ARRS and the AUR have annual competitions limited to residents for outstanding research and/or publications. In addition to prestige, these awards carry the additional bonus of a monetary award. In summary, there are numerous avenues for the resident to become acquainted with the "academic" aspects of radiology. The requirement to participate in this area should be approached as an opportunity to evaluate possible career opportunities, demonstrate hidden talents, and to understand the unique opportunities available in diagnostic radiology. 23
  24. 24. RESIDENT ON-CALL RESPONSIBILITIES All radiology residents will share overnight call responsibilities. The resident assigned to Vascular and Interventional Radiology will be taking call in that section and therefore, will be removed from the general call rotation. 1. During the week, first year residents will take in-house call from 5:00 to 10:00 p.m. The first-year resident is assigned to the Emergency Department where s/he will provide interpretation and consultation under the direct supervision of an attending radiologist. 2. On Saturday and Sunday call for the first-year residents will be from 8:00 a.m. to 5:00 p.m. The first-year resident will report to Ct at 8:00 a.m. to monitor contrast injections. When relieved by the more senior resident later in the morning, the first-year resident will be assigned to the Emergency Department. After the first- year resident has experience with the CT (by the second half of the year), the first-year resident can do the morning readout in the Ed and the senior resident can report to CT first thing in the morning. 3. Second, third and fourth year residents will be scheduled for overnight “night float” rotations and evening ER rotations. Night float begins at 8pm and goes to 8 am the next day. The night float rotation is Sunday through Friday nights, usually either 1 or 2 weeks long. The evening ER rotation is 5pm-2am, Thursday through Monday. On Tuesday and Wednesday, there will be “short call” coverage by a second, third or fourth year resident covering CT until the night float resident arrives at 8pm. 4. The night float resident will be present in the CT area to monitor contrast injections and assist referring physicians until 10pm. From 10pm until 8am, the resident will cover the Emergency Department. The evening ER resident is assigned to the ER 5pm-2am. 5. Saturday day and night and Sunday day call is assigned to second, third and fourth year residents. The Saturday and Sunday day call resident should report to the ER by 8am to assist with morning read out. After readout in the ER, the resident is assigned to CT until the day’s CT work is done. The Saturday night call is 8pm-8am in the ER. 6. The senior resident in house will respond to beeper requests for consultations. In the second half of the year, the first year resident will begin to handle beeper requests in order to gain experience in consults prior to beginning night float. 7. Holiday call will be evenly distributed. 8. All final call and vacation schedules should be reviewed and adjusted as needed by the chief resident. 24
  25. 25. The on-call resident shall: • Maintain a constant presence in the Emergency Room in order to assist the Emergency Room physicians in film interpretation. • Provide preliminary interpretations on ER studies. • Provide consultation for the ER/House physician • Screen and determine eligibility for all imaging examinations (portable, ultrasound, CT, nuclear medicine and emergency fluoroscopy) and provide initial interpretation • Supervise the administration of all intravenous contrast material • Provide consultations at Women & Infants' Hospital DUTY HOUR POLICY Duty hours are specified in this manual with the description of each rotation and night call. These duty hours meet the ACME requirement that “duty hours and night and weekend call must reflect responsibility for patients and provide for adequate patient care. Residents must not be required regularly to perform excessively difficult or prolonged duties. It is recommended that residents should be allowed to spend at least 1 full day out of 7 away from the hospital and should be assigned on-call duty in the hospital no more than, on average, every third night.” Resident duty hours must not exceed 80 hours per week, averaged over a 4-week period and the resident must have a 10 hour period of rest between each duty period VACATION POLICY PGY 1-3 residents are entitled to three (3) weeks of paid vacation per year, and PGY 4-5 residents are entitled to four-(4) weeks vacation. All vacation requests should be directed to the chief resident. The number of resident s permitted away per week will vary depending upon the schedule. Emergency request for absences will be evaluated on merit and charged against vacation time. Unexplained absences will influence the monthly evaluation and may constitute grounds for dismissal. No more than one (l) week can be taken during a given service each year. No more than two (2) consecutive weeks at a time can be taken. The resident will not be routinely allowed to take single vacation days. No vacation is permitted during the week of the oral or written boards, ACR in-service exam week, the first week of July, and the last week of June (except fourth-year residents). During the RSNA, ARRS, and AUR meetings, no time relieved from clinical duties is allowed except for those residents wishing to attend these important national meetings. 25
  26. 26. INTERVIEWING FOR FELLOWSHIP: If more than 5 days, including travel, are needed for fellowship interviews it will be required to be taken as vacation time. LEAVES OF ABSENCE "Leaves of absence and vacation may be granted to residents at the discretion of the Program Director in accordance with local rules. Within the required period(s) of graduate medical education, the total such leave and vacation time may not exceed six calendar weeks (30 working days) for fellows in a program for one year, twelve calendar weeks (60 working days) for residents in a program for two years, eighteen calendar weeks (90 working days) for residents in a program for three years, or twenty four calendar weeks (120 working days) for residents in a program for four years. If a longer leave of absence is granted, the required period of graduate medical education must be extended accordingly." (excerpted from the ABR Booklet of Information for Diagnostic Radiology 1997-1998, page 8) SICK TIME The Chief Resident or resident on call must be informed regarding absences due to illness prior to 8:00 a.m. The attending on the involved service will be immediately notified so appropriate arrangements for clinical coverage can be provided. RELIGIOUS HOLIDAYS Prior notification to the Director or Supervisor of the training program is necessary two weeks in advance. Based upon the number of residents desiring to be free of clinical responsibilities, a lottery may be necessary to maintain sufficient clinical coverage. Religious holidays will be charged against vacation time. MOONLIGHTING POLICY The Accreditation Council for Graduate Medical Education (ACGME) requires the Residency Program Director to monitor resident work hours and progress. The Program Director must approve any moonlighting activities before such activities are undertaken. Work hours, including moonlighting, must not exceed 80 hours per week, averaged over a 4-week period. Moonlighting is not permitted until the Program Director has determined that the resident’s educational program will not suffer. Therefore, each 26
  27. 27. resident must have approval from the Program Director before engaging in any moonlighting activities. The Program Director must then monitor the number of hours worked outside the educational program. In this program, once approval is received, moonlighting opportunity is provided through the department at The Miriam Hospital (TMH). For the resident who has shown appropriate knowledge, professional skills and the capacity to function independently, this moonlighting activity can be a growth experience. Faculty members of the department are able to monitor the resident’s performance and provide feedback to the resident and the Program Director. Moonlighting must not interfere with the necessary educational and personal development that will allow the resident to mature into a well-rounded physician. There is a limit on the number of hours of moonlighting permitted, and the moonlighting schedule at TMH will be reviewed to ensure compliance. The number of shifts allowed increases with resident experience, with a maximum of four shifts per month at the senior level. First year residents are not permitted to moonlight. Second-year residents may begin moonlighting in the second half of the year. This will allow sufficient experience as “night float”, which provides the independent experience necessary for moonlighting. Second-year residents are permitted up to two shifts per month. Third and Fourth year residents may sign up for four shifts per month, as long as the average work week does not exceed 80 hours. It is not imperative that all shifts at TMH be filled. Moonlighting is completely voluntary, and each resident must decide if he or she will participate. The attending staff will cover any unfilled shifts. 27
  28. 28. REPORT OF THE COMMITTEE ON THE IMPACT OF MATERNITY ON RADIOLOGISTS The large number of women entering medical schools has added to the human resources available and should result in improved quality of medical care. Since the qualities necessary to be a good physician are also desirable in a parent, professional women should not be discouraged from motherhood. A favorable environment allowing them to combine comfortably a career and family life will thus increase their contribution to society. With that goal in mind, the following recommendations regarding pregnancy and childcare have been formulated. PERFORMING FLUOROSCOPY PROCEDURES DURING PREGNANCY A radiologist performing routine fluoroscopic procedures in a large metropolitan hospital, without special precautions, would be expected to expose her fetus to no more than a 50 mR dose over a 9 month period. There is a theoretical risk to the fetus from such a small amount of radiation [Wagner, L.K. and Hayman, L.A. Pregnancy and Women Radiologists. Radiology 1982; 145:559-562]. From NCRP estimates, the worst possible effect of a 50 mR dose would be to increase the chance of childhood cancer and malformation only by 0.005% (from 4.100% to 4.105%) [NCRP Report No. 53 Review of NCRP radiation dose limit for embryo and fetus in occupationally exposed women. March 1977]. To reduce even this small exposure a contoured, appropriately reinforced maternity apron has been designed [Witrak, B.J. and Sprawls, P.: Maternity Lead Apron. Radiology 1984; 150:597]. Based on the data, the elimination of fluoroscopy at any time during pregnancy cannot be justified on scientific grounds. It can, however, be argued that if fluoroscopy is to be curtailed, it should be done when the fetus is most sensitive to radiation, i.e. 2 to 6 weeks old. This precaution is, of course, impractical since most pregnancies are undetected during this time. Lead-lined underwear is available to women who are apprehensive about radiation to the gonads or contemplating pregnancy. The exclusion of fertile women from fluoroscopy on the basis of radiation risks to the fetus is both unnecessary and undesirable as it may encourage discrimination. Rationally, women of child-bearing age who enter into the specialty of radiology should be willing to accept the theoretical risks involved in fluoroscopy. Counseling and information about radiation during pregnancy should be given to all women considering making Radiology their career choice. Indeed, all physicians would benefit by being better informed and more emphasis should be placed on teaching radiation biology at the medical school level. 28
  29. 29. HOSPITAL LEAVE POLICY The state of Rhode Island has a Parental and Family Medical Leave Act, instituted in 1990, and the hospital does conform to that policy. Eligible employees may be granted formal leaves of absence from work for a period of more than two weeks for reasons of: 1. The employee's own illness or disability (to include disability due to pregnancy, childbirth or related conditions), 2. The employee's family obligations (to include the serious illness of a family member, caring for a newborn child or adoption of a child), or, 3. Active or inactive military duty training or service. If a resident is to make a timely request for a leave of absence for reasons provided in the policy, the leave must be granted. However, it must be remembered that within the required period of graduate medical education, the total of such leave and vacation time may not exceed twelve weeks in any two years. There must be extension of the training program if this amount of time is surpassed. BCLS/ACLS Certification Basic Cardiac Life Support (BCLS) certification is required by the Accreditation Council for Graduate Medical Education (ACGME) and by the American Board of Radiology (ABR). Residents are also expected to be certified in Advanced Cardiac Life Support (ACLS). ACLS training is provided by the hospital during orientation. It Is the responsibility of the resident prior to entrance into the second year to obtain ACLS certification. A resident in need of training should contact the office of Emergency Medicine to make arrangements. 29
  30. 30. RESPONSIBILITIES OF THE CHIEF RESIDENT(S) It is an honor and privilege to be selected as the Chief Resident. The major responsibilities of this position are typically accorded to a senior resident (with assumption of these duties beginning in January of the third year). These responsibilities consist of: I. RESIDENT ASSIGNMENTS A. Responsible for the resident rotation schedule, including the assignment of overnight call coverage and weekend/holiday coverage; B. Assigns coverage as needed for areas requiring physician supervision during routine hours when staff are otherwise occupied; C. Approve resident requests for vacation or meeting/conference time; D. Assigns resident coverage as needed in event of illness, approved leave of absence, or vacation; E. Arranges the noon conference schedule. II. RESIDENT LIAISON A. Attempts to represent the consensus resident viewpoint to the Director and Department Chairman when issues affecting the department arise; B. Communicates announcements to the resident group; C. Addresses issues affecting other resident groups and the radiology residents; D. Attempts to communicate departmental staff (technologists and secretaries) concerns to the residents. III. GRAND ROUNDS A. Assists with audiovisual needs. IV. RESIDENT SELECTION A. Participates in the interview process; B. Arranges resident applicant dinner and tours and oversees resident interactions with candidates. V. MEMBER OF RADIOLOGY EDUCATION COMMITTEE VI. COORDINATES RESIDENT RESPONSIBILITIES TO BROWN AND OTHER VISITING MEDICAL STUDENTS 30
  31. 31. BROWN MEDICAL SCHOOL DEPARTMENT OF DIAGNOSTIC IMAGING ACADEMIC TRACKS (as of 7/1/04) Full Time Professor John J. Cronan, M.D. William W. Mayo-Smith, M.D. Glenn A. Tung, M.D. Associate Professor Damian E. Dupuy, M.D. Thomas K. Egglin, M.D. Robert E. Lambiase, M.D. Timothy P. Murphy, M.D. Jeffrey M. Rogg, M.D. Assistant Professor Gerald F. Abbott, M.D. Michael K. Atalay, M.D. Jerrold L. Boxerman, M.D. Gregory J. Dubel, M.D. Peter T. Evangelista, M.D. Holly Gil, M.D. Elizabeth Lazarus, M.D. Martha B. Mainiero, M.D. John A. Pezzullo, M.D. Gregory M. Soares, M.D. Don C. Yoo, M.D. 31
  32. 32. Clinical Educator Professor (Clinical) Barbara Schepps, M.D. Associate Professor (Clinical) Douglas F. DeOrchis, M.D. Richard L. Gold, M.D. Richard A. Haas, M.D. Michael T. Wallach, M.D. Richard B. Noto, M.D. Assistant Professor (Clinical) Sun Ho Ahn, M.D. James C. Bass, M.D. Jeffrey M. Brody, M.D. John A. Cassese, M.D. Lawrence M. Davis, M.D. Daniel M. Golding, M.D. Mary M. Hillstrom, M.D. Susan M. Koelliker, M.D. Linda Livingston, M.D. Scott M. Levine, M.D. Kathleen M. McCarten, M.D. Jonathan S. Movson, M.D. Brian Murphy, M.D. David P. Neumann, M.D. Marcelle L. Piccolello, M.D. Mark S. Ridlen, M.D. Julie Song, M.D. Patricia K. Spencer, M.D. Instructor (Clinical) 32
  33. 33. Hanan Khalil, M.D. Eric Yun, M.D. Clinical Clinical Associate Professor No Physician currently at this level Clinical Assistant Professor Gary K. Lundstrom, M.D. Arthur W. Noel, M.D. Michael J. Ryvicker, M.D. Sanford L. Schatz, M.D. Bradley A. Shapiro, M.D. Casimara Sta.Ines, M.D. Clinical Instructor Edward Chernesky, M.D. Ronald H. Cohen, M.D. Timothy Cotter, M.D. Mark Shafer, M.D. 33
  34. 34. Emeritus Allan Deutsch, M.D. Clinical Assoc. Prof. Emeritus Gary J. Dorfman, M.D. Professor Emeritus Daniel Hanson, M.D. Clinical Professor Emeritus Francis H. Scola, M.D. Clinical Professor Emeritus Radiation Oncology & Diagnostic Imaging Douglas R. Shearer, Ph.D. Associate Professor of Radiation Oncology & Diagnostic Imaging 34
  35. 35. ROTATIONS A. CONCIOUS SEDATION POLICY Page 37-41 B. COMPUTED TOMOGRAPHY Page 42-63 C. EMERGENCY DEPARTMENT Page 64-71 D. FLUOROSCOPY/GASTRO- INTESTINAL/GENITOURINARY Page 72-78 E. NUCLEAR MEDICINE Page 79-86 F. MUSCULOSKELETAL RADIOLOGY Page 87-92 G. PEDIATRIC RADIOLOGY Page 93-97 H. CARDIOPULMONARY RADIOLOGY Page 98-104 I. PHYSICS/RADIOBIOLOGY Page 105-107 J. VASCULAR & INTERVENTIONAL RADIOLOGY Page 108-119 K. ULTRASOUND Page 120-125 L. BREAST IMAGING Page 126-130 M. WOMEN & INFANTS' HOSPITAL Page 131-137 N. AFIP Page 138 O. ELECTIVE Page 139 P. NEURORADIOLOGY/MRI Page 140-154 Q. MEDICAL OFFICE COMPLEX Page 155-160 R. TMH/MRI Page 161 35
  36. 36. A. CONSCIOUS SEDATION POLICY Department of Diagnostic Imaging Lifespan Academic Campus Guidelines for Sedation These policies must be applied to all patients receiving sedation within the Lifespan Department of Diagnostic Imaging Academic Medical Center Campus. The policies are in compliance with standards established for sedation by the Department of Anesthesiology at Rhode Island Hospital (revised June, 1996). These guidelines do not apply to the VIR section. Definitions Conscious Sedation- A state of minimally depressed consciousness wherein a patient's protective reflexes and ability to maintain a patent airway continuously and independently are not compromised. Additionally, the patient remains able to respond appropriately to physical stimulation and verbal commands. Deep Sedation- A controlled state of depressed consciousness, accompanied by partial loss of protective reflexes, including but not limited to the gag reflex and airway patency. The ability to respond purposefully to verbal commands is partially or completely lost. Response to pain is preserved. General Anesthesia-A controlled state of unconsciousness with complete loss of protective reflexes including the inability to maintain a patent airway independently. The terms "conscious sedation" and "deep sedation" will not be used in this document and instead the term "sedation" will be used because it is acknowledged that "sedation" is a continuum and that the loss of protective airway reflexes may be unpredictable after the administration of sedatives. General anesthesia will be performed when necessary under the direct guidance of members of the Department of Anesthesiology. Sedation of patients will be performed under the direction of Radiology personnel except in emergency off hours time periods when radiology personnel are not available. During these periods a qualified nurse or physician from the emergency department , unit, or ward will need to accompany the patient, administer sedation ordered by the clinical physician responsible for the patient's care, and monitor the patient during the examination and recovery phase. Consultation is available from the on-call radiology physician during hours when a nurse is not in the department, however, the responsibility for sedation lies with the clinical service caring for the patient. Scheduling of Radiological Examinations Requiring Sedation 36
  37. 37. Examinations may be scheduled by the referring physician or their designees. Determination as to the need for sedation is the responsibility of the referring clinician. To schedule patients requiring sedation the requesting physician is required to complete a detailed requisition form. This form describes: 1) Reason for the examination (presumptive diagnosis). 2) Patient's experience/complications with sedatives in the past. 3) List of current medications. 4) Past medical history, including allergies. 5) Past surgical history. 6) Brief review of systems with emphasis on airway, pulmonary, cardiac and neurological status. 7) Recent vital signs(when available). Completion of this form is required before sedation can be considered. Patient Selection- All examination request forms will be reviewed by the radiologist before they are scheduled to assess whether the patient is appropriate for sedation. Only patients who are ASA Class I or II will be considered as routine patients for sedation by Radiology Department personnel. Patients in Class III or IV will be evaluated on an individual basis and will only be considered for sedation after consultation with the referring physician or a physician from the Department of Anesthesiology. Definitions of ASA Classification: 1) Normal, healthy patient. 2) Mild systemic disease. 3) Severe systemic disease. 4) Severe systemic disease with constant threat to life. Additional relative contraindications include but are not limited to: 1) Congenital or acquired abnormalities of the airway. 2) Congenital or acquired abnormalities of the upper gastrointestinal tract. 3) Congenital or acquired abnormalities of the lung. 4) Congenital or acquired abnormalities of the heart. 5) Clinical brainstem dysfunction. 6) History of apnea or hypotonia. Upon approval for sedation the referring physician and/or patient will be contacted by Department personnel regarding the scheduling of their examination. At that time the patient will be instructed to: 1) Have no solid food for 6 hours prior to the procedure. Breast milk may be given up to 4 hours prior to the procedure. 2) Have only clear liquids until 2 hours prior to the procedure. 37
  38. 38. Medications other than insulin should be taken as routine. Half- normal dose of insulin may be taken in consultation with the referring physician. Presedation Evaluation All patients presenting to the Department of Diagnostic Imaging for sedation will be evaluated by physician personnel prior to receiving any sedating agent. This evaluation will include: 1) Discussion of the risks, benefits, and alternatives to sedation for the patients scheduled procedure. A consent form for sedation will be signed by the patient or their designee. 2) Verification of the data provided on the requisition form including ASA classification. 3) Verification of compliance with NPO status. 4) Brief ROS to exclude recent illness. 5) Directed physical exam to assess upper airway/pulmonary status. This information will be documented on the sedation flow sheet. If the patient does not meet ASA physical status 1or 2, or if other contraindications to sedation exist, consultation with the Anesthesia Department or other appropriate specialist is recommended. Patients requiring intravenous medication or contrast medium will have establishment of intravenous access. Vital signs to be recorded prior to sedation include: 1) Blood pressure. 2) Temperature. 3) Heart rate. 4) Oxygen saturation. 5) Respiratory rate. Performance of Examination Personnel- The performance of the examination is the responsibility of the Attending Radiologist or his/her designate. Nurses and radiologists responsible for sedation administration must be familiar with sedative drugs and reversal agents, their dosages and physiologic and adverse effects, and must be certified in basic life support. All members of the sedation team must be ACLS certified. PALS training is recommended. 38
  39. 39. Equipment- The following constitute minimal accessory equipment for the performance of sedation and during the recovery phase from sedation. 1) Appropriate sized equipment for establishing a patent airway and providing positive pressure ventilation with 100% oxygen from an oxygen source must be present whenever sedation is administered. 2) Appropriate sized resuscitation equipment. 3) Suction apparatus. 4) Opioid and benzodiazepine reversal drugs must be available in all sedation areas. Recovery When the examination is completed, the patient will continue to be monitored with a pulse oximeter until appropriate discharge criteria are met. Vital signs and respiratory function should be monitored by qualified monitoring personnel at appropriate intervals (at least 15min) until suitable discharge criteria are met. Discharge criteria are as follows: 1) Patients should be alert and oriented; infants and patients in whom mental status was initially abnormal should have returned to baseline. Vital signs should be stable and within acceptable limits. 2) Reasonable hydration status should be ascertained. 3) Sufficient time (up to 2 hours) should have elapsed after last administration of reversal agents to ensure that resedation does not occur. 4) Outpatients should be discharged in the presence of a responsible adult who will accompany them home and be able to report any post-procedure complications. 5) Outpatients should be provided with written instructions regarding post-procedure diet, medications, and activities, as well as a phone number to use in case of emergency. Patients will be discharged by the supervising physician. Appendix Sedatives- Chloral Hydrate- The recommended agent for children 1mo.-2yrs of age unless otherwise contraindicated or if the child has I.V. access for administration of contrast material. Children less than one month of age have increased risk for sedation and therefore all agents should be avoided unless necessary. Initial oral dose of 75mg/kg should be administered 45min prior to the procedure. If at 15min prior to the procedure adequate sedation has not occurred an additional dose of 25mg/kg may be administered. 39
  40. 40. Sodium pentobarbital- Recommended agent for all children >2yrs of age and for children >6mo of age when intravenous access has been obtained for the purpose of contrast administration. Contraindications include previous negative experience with agent, allergy, porphyria. Use with caution when renal or hepatic insufficiency is present. To minimize discomfort, sodium pentobarbital is diluted in normal saline. 5mg/kg is drawn into a syringe, and diluted to a concentration of 10mg/ml. 2.5mg/kg(max.50mg)is administered over approximately 30seconds. If the patient is not adequately sedated within one minute, the remaining 1.25mg/kg is titrated in small increments. If the patient is not adequately sedated after receiving the total 5mg/kg of sodium pentobarbital, a total of 2mcg/kg additional fentanyl may be administered intravenously in increments. If more sedation is required an additional 2.5 mg/kg of sodium pentobarbital may be administered as above. Patients receiving chronic barbiturate medication for seizure disorders may receive up to 9 mg/kg of sodium pentobarbital intravenously. Treatment of Adverse Effects of Sedation- In the case of a drop in oxygen saturation, the monitoring nurse and attending radiologist or physician designate will institute basic resuscitation techniques. These will include head repositioning, positive pressure oxygen administration and suctioning if necessary. Concomitant with these maneuvers appropriate reversing agents (Narcan) may be administered. If the patient does not respond immediately to basic resuscitation techniques, a code will be called. Attending radiology personnel or physician designate should continue to institute appropriate resuscitative measures. Monitoring and Recording of Vital Signs During the Examination- All patients receiving sedation are monitored continuously by pulse oximetry. Use of an EKG is recommended when possible. Heart rate and oxygen saturation are recorded every 5 minutes during the procedure and every 15 minutes during recovery. 40
  41. 41. B. COMPUTED TOMOGRAPHY Table of Contents I. General Description of CT Division at Rhode Island Hospital II. Educational goals and Objectives by Core Competency III. Resident Evaluation IV. Reference Sources 41
  42. 42. I. General Description There are currently four helical CT scanners at Rhode Island Hospital which perform in excess of 50,000 examinations per year. There are two multidetector scanners, a 4 slice scanner in the Meehan building and a 16 detector scanner in the ER. A second 16 slice multidetector CT will be purchased in 2004. Resident and fellow exposure to CT occurs in the Emergency Room, at the Medical Office Center, at the Meehan Building and pediatrics. Computerized tomography is used within all subspecialties of Radiology and this section will refer to the general daily operation of residents rotating through the Meehan Building. Reference will be made to neuroimaging, thoracic imaging and abdominal, pelvic and musculoskeletal imaging. Pediatric scans are performed in the Meehan Building and interpreted in via our Picture Archiving System (PACs) by the pediatric radiologists. Emergency CT scans are interpreted in the Emergency Department. CT Rotation The rotation in CT through the Meehan Building begins with rounding on patients in the hospital who have had tubes placed by the CT/US radiologists. Any resident or fellow that has placed a tube in an inpatient, should round on the patient to learn about follow- up catheter management. Brian Hoell, a nurse practitioner who is employed by Rhode Island Medical Imaging, will round on patients who are not seen by the resident or fellow. At 7:30 a.m. the resident/fellow reports to the CT area and “pulls” cases from the completed cases bin adjacent to the door. Tube rounds take place at 8 a.m. to manage inpatients. The day concludes at 5:30 p.m. or when the work is completed, whichever is later. Readout of CT scans in the Meehan area is divided between the residents rotating in the section and the cross-sectional imaging fellow. The resident/fellow should review relevant prior exams on PACs to help with accurate interpretation of the current exam. The resident/fellow should review prior discharge dictations and relevant pathology and surgical reports from the Lifelinks computer system. All residents and fellows are expected to have activated Lifelinks account which are activated through the IT help desk (4-6381). The resident/fellow should then review the films and form their own impressions. At this point, all cases will be reviewed with the attending. At mid-day and at the conclusion of the day the resident/fellow should review and sign all of their reports, making sure their queue is empty on the computer system before leaving work. Any unexpected or emergent findings should be communicated to the referring physician during the course of the day. If relevant prior studies are not available on PACs, they should be ordered from the file room. If studies cannot be retrieved or reprinted, the exam should be interpreted without the priors. All studies should be dictated within 24 hours of the exam. Second through fourth year residents are expected to be able to form basic interpretations of neurological, thoracic, abdominal and pelvic examinations. These residents are 42
  43. 43. expected to help referring physicians interpret studies performed at Rhode Island Hospital when they come to the CT section. When residents are having difficulty interpreting these cases, the attending or fellow in the CT section should be consulted immediately. As PACs is still relatively new at this point, our current Chief Resident Crispina Chong- Han has written the following suggestions for how to pull and organize exams in PACs on the CT rotation. Select the studies to be reviewed from the “CT unread nonED adult” list and add to your workstation folder (CT workstation 1, 2, and 3). Once you have read the studies, write a short preliminary report and mark the studies as “dictated” by either hitting “F6” or clicking the “dictated” button. Keep the work list as short as possible. If you see undictated cases more than 48 hours old, ask the secretaries to print the requisition and dictate the case as soon as possible. Protocolling Cases There is a comprehensive protocol book for CT examinations performed at Rhode Island Hospital. These are also on line at the department web site or can be seen at www.brownct.org. Residents/fellows should read through the Rhode Island Hospital protocols and be able to describe them in detail to the attending in the section. First year residents should not protocol CT examinations. Please note that there is increasing scrutiny about how radiological examinations are performed and there will need to be careful attention to protocolling CT examinations. For example, if the history given is “liver disease” then the appropriate examination is a three phase liver CT not an abdominal CT. Likewise, if an abdominal CT is ordered, it does not necessarily mean a pelvic CT should also be performed. If we perform a pelvic CT in this circumstance, we will not be reimbursed for that study and in fact could be found guilty of over-billing Medicare with a possible $10,000.00 per incident penalty. The resident and fellow should protocol all upcoming cases in the morning and in the evening before leaving for the day. All electively scheduled cases should be protocolled at least 24 hours in advance. When protocolling a case, the clinical history and prior findings of earlier radiology reports should be acknowledged. The relevant results of prior study should be entered in the appropriate portion of the CT protocolling sheet. On Friday, the resident should protocol all cases for the upcoming weekend and Monday. If abnormalities are found in the examination requested and prior studies, the referring physician should be called to confirm the area of interest to be scanned. The resident/fellow should print their name legibly at the appropriate position on the protocolling sheet so they can be contacted if further information on the patient is needed. Contrast Administration 43
  44. 44. It is our routine to use "ionic" contrast agents unless there is a contraindication. Technologists screen patient for the use of low osmolar agents in the appropriate clinical setting. In this event, an appropriate ICD9 code is listed by the tech on the requisition and on the PACs screen in the lower left corner. Dictations on patients who receive low osmolar contrast should include the appropriate reason the agent was administered. American college of Radiology indications for utilization of low osmolar intravenous contrast are listed below: Indications for the Use of Low-Osmolar Contrast Media Previous reaction to contrast medium History of asthma or allergy History of cardiac disease or dysfunction Generalized debilitation Blood dyscrasia Risk of aspiration Age less than 1 year Othera aSituations in which the supervising radiologist believes that the patient would benefit from low- osmolar contrast media. Such cases might include patients with poor communication skills, severe anxiety, or a patient preference for low-osmolar contrast media. Modified from the Manual on Iodinated Contrast Media, ©1991, American College of Radiology Residents and fellows should be familiar with adverse contrast reactions and be able to treat the patient appropriately. A set of guidelines for treatment of contrast reaction (Appendix 1) is included at the end of the CT section. If a patient has a history of a serious contrast reaction and is scheduled for a CT scan with contrast, then an alternative exam should be attempted (noncontrast CT, ultrasound or MR). If contrast is required and there is a strong clinical indication, then the premedication regimen recommended by the American College of Radiology should be followed. Methylprednisolone (Medrol) 32 mg. p.o. 12 hours and 2 hours before the contrast injection. In addition, the patient should receive low osmolar contrast material. In general, H2 blockers (cimetadine) are not recommended. The above assumes the patient does not have a contraindication to steroids (pediatric, pregnant, fungal infection, diabetes, immunocompromised patients, lymphoma, leukemia, peptic ulcer). Metformin (Glucophage) is an oral hypoglycemic for which precautions should be taken when giving intravenous contrast. Our protocol for administering intravenous contrast in patients on Glucophage is approved by the ACR and is as follows: 1) patients undergoing intravenous contrast agents should stop taking Glucophage either before or at the time of the contrast examination. 2) Patients should remain off Glucophage for 48 hours after their contrast study and then have a serum creatinine drawn. If the creatinine 44
  45. 45. is normal, the patient can resume medication. In the CT section, we will fill out a lab slip for creatinine to be drawn with the results to be sent to the patient’s referring internist. The patient will be instructed to call their internist one day after the blood test to decide whether the medication can be restarted. This will save a step for the patient and the internist as the decision to restart the medication can be made by phone call rather than a visit. 3) Patients with elevated creatinine (greater than 1.5) and on Glucophage should have the contrast administered only if there is a high diagnostic yield to be obtained from the contrast. 4) Note the patients do not need to be off Glucophage for 48 hours before the contrast examination is started. Evaluation of Serum Creatinine before IV contrast Administration. It is the policy of the Rhode Island Hospital CT Scan Department to check the creatinine on all inpatients. The Patient Screening/Consent Form is completed for all patients with the assistance of a technologist. All creatinine levels above 2.0 mg% will be referred to the Radiologists. All out patients must fill out the Patient Screening/Consent form. The creatinine level is not needed for outpatients. All Emergency Patients will be treated as outpatients; hence, a creatinine is not necessary to the performance of a contrast CT study. If the Ordering Physician is concerned that the patients creatinine level is elevated, he/she should wait until the blood work is back from the laboratory before ordering the test. Women and Infants inpatients that are accompanied by the patient’s chart will have the creatinine level checked and Patient Screening/Consent form completed. Patients from Women and Infants Emergency Room will be treated as outpatients. Visipaque is a nonionic dimer shown to reduce the incidence of contrast nephropathy in high-risk patients. In patients with a serum creatinine of greater than 2.0 and in whom CT with contrast must be performed as an emergency (usually pulmonary CTA) Visipaque may be used. In other patients with elevated creatinine and less urgent indications for CT it should be possible to perform a noncontrast CT or an alternative study such as ultrasound or MRI. Visipaque may be used in individual cases with the approval of the attending or if requested by the referring clinician. Note that Visipaque is of no benefit in prevention of idiosyncratic contrast reactions, and does not reduce the incidence of renal failure in patients who do not have an elevated creatinine. Contrast Extravasation Our policy for contrast extravasation follows ACR guidelines. A staff physician (fellow or attending) should evaluate all extravasations. Evaluation should include a neurological exam of the affected extremity, documentation of presence or lack of capillary refill and skin ulceration and documentation of presence of distal 45
  46. 46. pulses and presence of pain. The patient should be observed in the CT suite for 2-4 hours after the extravasation with the arm maintained in an elevated position above the heart. The patient should be instructed to apply dry warm packs to the site of extravasation and to keep the arm elevated overnight. For large volume extravasations (>50) the patient should return to the Radiology suite the following day to the same physician. If there were some findings at the time of the exam (increased pain or swelling), decreased capillary refill, change in sensation or skin ulceration, a plastic surgery consult should be obtained at the time of extravasation. If the extremity looks particularly ominous and needs immediate attention, consult with the Emergency Department is necessary. As a courtesy, the patient’s referring physician should be informed of the extravasation and our management. The extravasation, physical exam and steps taken in management should be dictated in the reports. The CT scan should not be sent to another area for reading (from the MOC to the Meehan reading area for example). An addendum can be dictated the following day when the patient is seen in follow-up. If contrast extravasation does occur in the evening (from 5-11PM) when the resident is covering, the findings on physical exam and actions taken should be written on the patients requisition and the details related IN PERSON to the CT attending at 8 AM the following morning. Dictations Dictations should be performed and signed at the end of the day. Dictations in CT should include the relevant patient history, pertinent other studies and the CT technique. The CT dictation should include the reason that low osmolar contrast was administered. The body of the report should include the pertinent positive and negative findings given the clinical history. The conclusion should be short and have a new sentence for each important impression. Due to legal issues and appropriate reimbursement, multiple CT examinations in one patient should be dictated in separate paragraphs. For accuracy of communicating the aggregate results, the conclusion of the dictation should contain the results of all the CT examinations performed. Thus for a chest, abdomen and pelvis CT to follow-up for lymphoma the dictation should read as follows: “The patient is a 35-year-old male with lymphoma treated with chemotherapy, question recurrent disease. Helical scanning using 5 mm collimation was performed from the lung apices through the pelvis after dynamic administration of low osmolar contrast material. Low osmolar contrast was given due to a history of asthma (ICD9 code: 493.0-9). Comparison is made with prior CT from 5/15/02. CHEST: The lungs are clear. There is no evidence of hilar or mediastinal adenopathy. The heart and bones are normal 46
  47. 47. ABDOMEN: The liver, gallbladder, pancreas, kidneys and adrenal glands are normal. The spleen remains enlarged measuring 20 cm in cranial- caudal dimension. There is no evidence of retroperitoneal adenopathy. The bowel within the abdomen is normal. PELVIS: There is new left iliac adenopathy with the largest node measuring 3 cm. The bowel, bladder and bones are normal. IMPRESSION: 1. Normal Chest CT 2. Stable splenomegally 3. New left pelvic adenopathy since prior exam suggesting recurrent lymphoma Important or unexpected clinical findings should be called to the referring physician at the time of the dictation. CT GUIDED PROCEDURES The residents and fellows will be responsible for performing interventional procedures in Ultrasound and CT. Interventional procedures include lung, abdominal, and bone biopsies, abscess drainages and radiofrequency (RF) ablations. General guidelines for performing procedures follows. We require referring physicians call directly to book procedures so there is accurate transmission of clinical information. Procedure booking sheets should be filled out for all patients when taking the request, and the person filling out the sheet should print their name legibly. First year residents should not book procedures. RIH films can be reviewed on PACs and RIMI exams can now be accessed via the web on a computer in CT. Outside films reviewed for upcoming cases are kept in the biopsy bin area in CT and ultrasound. When the procedure sheet is completed, it is brought to the CT secretary who then books the case and can call either the patient of the booking doctor’s office with the time. Patient procedure information sheets are kept in referring physicians offices and should be given to the patient so they know what to expect in advance. If the referring doctor is seeing the patient in his/her office, they can be given a patient information sheet at the time of the booking. Two days before the procedure, the secretary in the radiology recovery room calls all patients at home to confirm the date and time of their exam to minimize no-shows. On the evening before the procedure, the fellow and resident should review upcoming cases for the following day to assure that all films and laboratories are in order. If the relevant films are not present, they can be retrieved or restored. On the morning of the procedure, the cases will be reviewed with the attending to decide the appropriate approach to a lesion. The plan for the procedure (patient position, side of lesion, area to be scanned and collimation) should then be entered into the biopsy book 47
  48. 48. which is kept near the interventional CT console. This information should then be reviewed with the charge technologist (Eric) so he can plan the day. When the patient arrives in the CT section, the secretary will stamp a procedure packet and the resident/ fellow will obtain informed consent from the patient. Informed consent includes 1) an explanation of the procedure, 2) expected benefits of the procedure, 3) risks of the procedure and 4) alternatives to the procedure. These all need to be documented. Pre- procedure assessments should be completed by the senior resident or fellow and the appropriate documentation completed in the Radiology holding area before the procedure. That assessment should include review of the indications for the procedure, relevant blood work and a brief physical exam. All procedures are performed with the attending present. After the procedure, outpatients are observed in the holding area and inpatients are returned to the floor. A procedure note should be left in the chart. The format for a radiology procedure note should be as follows: Date: Radiology Procedure Note Procedure: Operators: Medications: Findings: Complications: Orders for monitoring of vital signs and catheter irrigation should be entered on inpatient order sheets and the Vascular and Interventional section should be notified of all inpatients who have catheters left in place. Specimens obtained from biopsies should be hand delivered by the residents/fellows to the Pathology Department. Specimens for microbiology should be placed in a sterilized red top tube. This tube can be used for aerobic cultures, anaerobic cultures and gram stains. Blood culture bottles should not routinely be used for cultures of aspiration specimens. Dictations of procedures should include a brief history and indication for the procedure, the findings on the localizing CT images, the type and amount of anesthesia used and note of the follow-up period in the radiology holding area. The size and number of lesions, the type and gauge of needle (or catheter) and number of passes made should be included in the dictation. The resident should dictate that the attending radiologist was present during the entire procedure for all interventional cases. All interventional procedure are dictated at the conclusion of the procedure, these should never be dictated on the following day. There is an interventional database sheet which should be filled out for every CT guided procedure and placed in the green interventional database binder kept in the interpretation room. Pre-operative blood work is not necessary or essential in most cases. A routine bleeding history should be obtained from the referring physician and from the patient. Has the patient had any difficulty with bleeding in the past, with dental extractions or prior 48
  49. 49. surgery? If the patient is on any anticoagulants or drugs which could effect coagulation, this should be noted. When blood work is deemed necessary because of an underlying bleeding history or drug history, baseline hemoglobin and hematocrit, INR, pro-thrombin time, thromboplastin time, and platelet count should be obtained. Patients with a history suggesting the potential for coagulopathy such as those with liver disease, sepsis, or poor nutritional status should be screened. The department policy on use of anticoagulants and indications for transfusion have recently been modified and are outlined below 49
  50. 50. Guidelines for Hematologic Values and Medication Usage Prior to Invasive Diagnostic Procedures Procedure PT INR Rx Notes Thoracentesis < 20 sec < 2.5 No FFP or Paracentesis 20-24 sec 2.5-4 FFP10 mls/Kg Order 4 hrs before procedure > 24 > 4 FFP 15mls/Kg Order 6 hrs before procedure Liver, Renal or < 16 sec < 1.8 No FFP Lung Biopsy 16-20 sec 1.8-2.5 FFP10 mls/Kg Order 4 hrs before procedure > 20 > 2.5 FFP 15mls/Kg Order 6 hrs before procedure Lumbar or < 14 sec < 1.4 No FFP other CNS Puncture 14-16 sec 1.4-1.8 FFP10 mls/Kg Order 4 hrs before procedure > 16 > 1.8 FFP 15mls/Kg Order 6 hrs before procedure Aspirin (Excedrin, Bufferin) should be withheld for 36 hours before the procedure (not 7 days) NSAIDs (Advil, Motrin, Ibuprofen, Naprosyn, Aleve, Indomethacin) should be withheld for 24 hours before the procedure ADP receptor antagonists (clopidogrel or Plavex) should be withheld for 10 days before the procedure Selective Cox 2 inhibitors (Celebrex, Robecoxib) do NOT need to be discontinued before a procedure. 50
  51. 51. In general we do not perform biopsies in patients with <50,000 platelets. Avoid platelet transfusions prophylactically but if there is a bleed in a thrombocytopenic patient, give 5 units of platelets promptly. Joseph Sweeny, M.D. Director of Lifespan Blood bank 6/02 (jm, wm-s) 51
  52. 52. An outline of specific procedures follows. 1. Abscess Drainage: Abscess drainages should be performed with antibiotic coverage. If it is desirable to hold antibiotics until a specimen is aspirated, antibiotics should be initiated immediately following the procedure. It is the recommendation of the Infectious Diseases Division that 3 grams of Unasyn be given intravenously for broad spectrum coverage of abdominal abscess drainages. Alternatively, 1 gram of Ancef and 80 mg. of Gentamicin may be given intravenously at the time of procedure. Outpatients undergoing an abscess drainage generally should be admitted for overnight observation as all patients have a transient bacteremia from the procedure and may have an episode of hypotension. Inpatients and outpatients who have tubes placed in CT/US are followed by the residents, fellows and attendings in the CT /US area. In addition, our Nurse practitioner Brian Hoell also rounds on some inpatients. A bulletin board in the CT/US area has a list of patient name, location, tube type, date of tube, referring MD and plan. When a procedure is done, the patient data is entered on the bulletin board by the resident/fellow who performed the procedure. Each morning a resident and or fellow will round on all patients and gather information on 1. overall patient status, 2. fever 3. white count, 4. tube drainage and 5. Irrigation. Residents and fellows will irrigate the tubes on the floor themselves if there is not drainage. A radiology progress note should be written in the chart. At 8 in the morning, we will have "tube rounds" with the residents, fellows and either the CT or US attending to decide on a plan. The person coordinating who will see each patient is the CT fellow (as this fellow is in the CT/US area for a week, unlike the US fellow, residents and attendings). Who sees which patient should be set up the afternoon before. Decisions on patient management, tube pulling, flushing, changing etc. will be made during tube rounds and communicated in the chart and with the appropriate referring service. 2. Renal Biopsies - Benign Disease: Renal biopsies for benign disease require an 18 gauge automated biopsy needle, i.e. Biopty gun. They still are considered a high risk procedure, and at this institution are admitted the day of the biopsy. No patient can be on aspirin, and routine blood work is mandatory. In addition, they must have a type and cross match. The Quality Assurance Committee has necessitated that a pre-biopsy form, which is available in CT Scan be filled out on each of these patients and attached to the medical record. There also is a post-biopsy order sheet which has been endorsed by the Quality Assurance Committee. It is therefore necessary that you be sure both of these forms are filled out and attached to the record before the patient leaves the department. A copy of these forms is included at the end of this manual. In general, these procedures are now performed under ultrasound guidance. 3. Renal Biopsies (Renal Mass) 52
  53. 53. In this circumstance we follow the same protocol that is used for a liver biopsy. This includes the appropriate lab work (PT, PTT, INR, platelets, hemoglobin, hematocrit, and if necessary, a bleeding time). An intravenous line should be placed prior to the procedure. These procedures can be performed on an outpatient basis and patients do not need to be admitted. 4. Lung or Mediastinal Biopsy: CT guided lung biopsies are booked in a standard fashion using the CT booking sheet. It is the responsibility of the fellow and attending performing the procedure to review all relevant films before performing the actual procedure. Occasionally, patients with a lung lesion will have other intra-abdominal lesions such as an adrenal mass that are amenable to image-guided biopsy with fewer complications. In addition, for patients with old films showing a benign lesion which is stable, a biopsy may not be necessary. While the "booking" radiologist will attempt to get as much information as possible, it is the responsibility of the fellow and attending performing the procedure to biopsy the most appropriate area Management of Pneumothoraces • In general, if the patient develops a pneumothorax before the lung biopsy is completed on the CT table, we will place a chest tube on the CT table and attach it to the pleurevac to reinflate the lung. There is a Pleurevac within the CT suite at all times specifically for this purpose. After the chest tube has been placed, while the patient is on the CT table, the lung biopsy is then performed. The patient is then brought to the recovery room and if there is no persistent air leak, the chest tube may be placed on straight drain and eventually removed in the recovery room and the patient sent home. • The literature suggests that up to 15% of patients will have a delayed pneumothorax. Most of these occur within the first hour and a small percentage can be delayed as much as three or four hours. It is necessary, therefore, that the patient be in the department at least for two hours so the absence of a pneumothorax can be re- documented. If a small pneumothorax is detected on the immediate post biopsy CT images, I obtain a chest x-ray (PA only) immediately after the CT and at two hours. This way, I can compare chest x-ray to chest x-ray to assess for interval change. If the patient is asymptomatic, hemodynamically stable, the pneumothorax is stable and the patient is reliable and lives near Rhode Island Hospital, he may be sent home with instructions to return to the CT area the following morning. The patient should be given a stamped requisition, told to have a chest x-ray performed the following morning in the General Radiology area, and to bring the chest x-ray to the CT suite and contact the responsible fellow. In general, if the patient remains asymptomatic the following day and the pneumothorax is stable, the patient does not need follow- up. Obviously if the pneumothorax is bigger or the patient is symptomatic, then a chest tube should be placed. 53
  54. 54. • For a patient who develops a pneumothorax post-procedure and becomes symptomatic, a chest tube should be placed either in the recovery room or in VIR. If a chest tube is placed in the recovery room, I prefer using a 10 French drainage catheter inserted along the anterior axillary line at the level of the nipples. A chest x- ray should then be performed to assure resolution of the pneumothorax. If the patient is reliable, asymptomatic and there is no air leak, he may be sent home with a Heimlich valve with instructions to return if symptomatic. As stated above, these patient should be given a chest x-ray requisition and instructed to have a chest x-ray performed in the Main Department and to bring the radiograph to the CT suite. • For patients with a pneumothorax who are old, unreliable, live far from the hospital or desire to be admitted, admission is generally performed to the radiology service. We do not admit patients for observation if they do not have a chest tube. Admitting Patients Patients admitted for overnight observation can be admitted to the Radiology service. Unstable patients with complex medical patients should be admitted to the medical service. It is critical to get the bed assigned early in the day, so that the patient does not remain in the radiology recovery room after 5 p.m. It is responsibility of the fellow/ resident who did the procedure to write the admit note and admitting orders. Tips on how to expedite an admission. 1- Do it as early in the day as possible. The later you wait, the more painful it is and the longer it takes. 2- DON'T call "admitting". DO call "Bed Control" (x44523) 3- Know the admitting diagnosis 4- Know patient's name, DOB, MR# 5- Know the admitting attending. They can't begin to book a bed without this. 6- If the plan is to discharge the patient the next day, make sure you book an "OBSERVATION BED". This costs a lot less than a "general" bed. You can't make the mistake of booking a general bed and try to change it to observation-----they won't allow it. You can, however go the other way (i.e. change from observation to a general bed.) 7- Make sure an H&P and Ordered are done ASAP. Use "ADCVANDISL:" Admitting Orders using the POM System There is a new computerized system for placement of orders called POM – Physician order management system. There is a link on the lifespan intranet home page under the medical section named POM video training tutorial for physicians, which is a useful guide at the beginning of the rotation to learn about the system. 54
  55. 55. You will need a Lifelinks password. The login ID is the same as the six digit number assigned to you for Radiology dictation system. You will be assigned a password at orientation or you can contact Lifelinks help desk at 46381 to get your password. After logging in click on Rhode Island hospital, and go to the Nurses station census. Pick up the nurses station that the patient is being admitted to, for e.g. JB 3 for Jane Brown third floor. The patient’s name should already be on the list of that station. Double click on the patient’s name. By default it opens the last lab result page. Click on Write orders/ Post procedure transfer orders. Go to order sets and pick up admit/dsch/order. Alternatively go to New orders and pick Admit orders. It gives you various options like- Admit to Dr ….., Status observation vs inpatient. Highlight the option you want by single click on it and hit o.k. tab at the bottom of the screen. • Remember the basic format of writing orders, which should cover the following points: • Admit to Interventional Radiology, Dr Mayo-Smith • Condition: Good • Activity: ad lib, or ambulate with assistance • Nursing: chest tube to wall suction at 20 mm hg. There is a comment box for each order in which you can put the changes you want like - change chest tube to water seal at 4.00 am following admission. WE have written two macro orders sets for routine chest tube and abscess catheter maintenance on inpatients which are being incorporated into the POM system. • Diet: Liquids and advance as tolerated • Vitals: Routine, or q shift with pulse oximeter • IV: Int after po. • Meds: you can go to new meds order, which gives a list of common meds to search from and includes the doses. There will be a prompt about frequency, if prn then reason for prn etc. After filling all the fields hit o.k. at the bottom. • Tests: Go to Radiology and select CXR. Add in comments – CXR on waterseal and call CT section 444-4123 once it is done (you can check it on PACS). • There is a prompt for all these choices and you can select one and further add additional comments as needed. After you have put in all the orders, click the Sign orders tab, and put in your password in the space provided. When the patient is DISCHARGED (usually the following day) the resident/fellow should write a brief DISCHARGE NOTE. This is important so that the admitting 55
  56. 56. attending does not get nasty letters from the medical records department about suspension of admitting privileges. Discharge notes are required in all patients who are in the hospital for 48 hours or less. Patients admitted for more than 48 hours require a discharge dictation. The discharge note should be written in the following format and include the following information: DATE: Date of Discharge TITLE OF NOTE: “Final Note” FINAL DISCHARGE DIAGNOSIS: Whatever the diagnosis is. SIGN THE NOTE Sign and print your name Other General Comments Re Lung Biopsies: • If the patient has a chest tube placed, it is usually a good idea to check the pathology results to confirm a diagnosis has been made before withdrawing the chest tube. If the findings are nondiagnostic, it is best to re-biopsy the patient with a chest tube still in to obtain an adequate sample. In this scenario a “wet-read” can be performed by the pathology service to assure diagnostic material. • The above outlines are general procedures and clinical judgment obviously needs to be exercised for each individual case. • In general, you should strive to perform lung biopsies early in the morning as the patient can be discharged even if a pneumothorax develops if there is adequate observation period in the afternoon. Late lung biopsies in outpatients often require admission to the hospital which could be avoided if the procedure is performed early in the morning. Also, whenever possible it is best to schedule elective lung biopsies Monday through Thursday to avoid admission and rounding of the patients on the weekend. 5. Abdominal Biopsy: Abdominal biopsies can be performed in either Ultrasound or CT. The patient should be stable for at least two hours. 6. RF Ablation: Patients undergoing RF Ablation are not routinely admitted. All of these patients have conscious sedation and the specific protocol varies depending on the location to be treated. Consult with the CT attending when booking or performing these procedures. 56
  57. 57. 7. Observation of the Patient: The patient should be observed in the radiology holding area or on the floor for inpatients. For inpatients, follow-up orders for vital sign monitoring and catheter irrigation should be made. A form regarding the history, physical, procedure and observation care should be filled out on each patient. A pulse oximeter should be utilized whenever conscious sedation is given and vital signs recorded. The hospital mandate for conscious sedation does indicate that patients must have basic monitoring with pulse oximeter if they are medicated with intravenous sedation. 8. Discharge of Patient: A discharge form is available in the department that should be given to each patient documenting the instructions you have given them. You should be aware that the Interventional Radiology nurse calls each patient whose name is given to them the next day and verifies that the patient is well. 9. Conscious Sedation: Following conscious sedation the patient must be alert and awake prior to discharge. Type and amount of sedation administered should be dictated in all interventional cases. The medication used for conscious sedation in adults are listed in appendix at the end of this manual. 10. Needlestick injuries Should the resident suffer from a needlestick injury, s/he should be evaluated at employee health at Rhode Island Hospital. PEDIATRIC SEDATION As of 2002, all pediatric sedation is performed by pediatricians on inpatients and by the pediatric sedation team on pediatric outpatients. All pediatric CT’s are protocolled by the pediatric radiologists. The physicians on the patient’s floor sedate all inpatient patients. All patients must be monitored by a floor nurse or doctor who brings the patient to CT. All outpatient pediatric patients, who need sedation, will be sedated by the Hasbro Sedation Team. Dr Linda Snelling, MD Joan Holden, RN CPNP A pediatric sedation referral must be faxed to the department, before the patient is scheduled for the exam. Once the booking secretaries in each area schedule the patient, Joan Holden will call the parents and give directions according to department guideline. Outpatient pediatric sedation is performed on the second and 4th Tuesday morning of each month. 57
  58. 58. All MR and CT scans must be checked by a radiologist at the completion of the study, prior to the patient being moved. The Hasbro Sedation Team must approve all emergency referrals for outpatients. Linda Snelling,MD, Director 444-4201 Beeper 350-0355 Joan Holden,RN, CPNP 444-8834 Beeper 350-6379 Fax 444-8816 For booking general anesthesia cases for pediatric interventional procedures, the referring doctor and or radiologist should contact the Anesthesia Department at 444-5142 or 444- 6030. Dr. Andrew Triebwasser is in charge of pediatric anesthesia. 58
  59. 59. EDUCATIONAL GOALS AND OBJECTIVES First and Second Year Residents: Patient Care: 1. Become familiar with CT protocols 2. Be able to manage contrast reactions Medical Knowledge: 1. Describe the basic physics of computerized tomography 2. Describe Hounsfield units, window and level settings 3. Describe proper CT protocols for specific disease processes 4. Describe dynamic vs. equilibrium phase imaging and differentiate between these entities 5. Describe normal neuroanatomy of the intracranial fossa and the spine 6. Describe normal thoracic parenchymal, mediastinal and vascular anatomy 7. Describe normal abdominal and pelvic anatomy 8. Describe normal musculoskeletal anatomy 9. State indications for a routine chest CT vs. a high resolution chest CT 10. State indications for aortic dissection CT and the protocol to be followed with this examination 11. Describe the differences between conventional axial CT and helical CT Interpersonal and Communication Skills: 1. Appropriately obtain informed consent 2. Appropriately communicate and document in the patient record urgent or unexpected radiologic findings 3. Produce radiologic reports that are accurate, concise and grammatically correct 4. Communicate effectively with all members of the health care team Practice-based Learning and Improvement: 1. Identify, rectify and learn from personal errors 2. Incorporate feedback into improved performance 3. Efficiently use electronic and print resources to access information Professionalism: 1. Demonstrate respect for patients and all members of the health care team 2. Serve as a role model for medical students 3. Respect patient confidentiality 4. Present oneself as a professional in appearance and communication. 5. Demonstrate a responsible work ethic with regard to work assignments 59
  60. 60. Systems-based Practice: 1. Demonstrate knowledge of how radiologic information is integrated with the other parts of the health care system in the treatment of the patient 2. Demonstrate knowledge of ACR standards and appropriateness criteria 3. Demonstrate knowledge of cost-effective imaging practices Second and Third Year Residents: Patient Care: 1. Develop a management plan based upon CT findings and clinical information. 2. Demonstrate proper technique in planning and performing CT procedures 3. Know the appropriate indications for CT examinations and alternatives depending on the suspected diagnosis. 4. Appropriately protocol CT cases based upon the indication for the examination 5. Minimize adverse reactions to iodinated contrast through appropriate patient selection and medication. Medical Knowledge: 1. Respond logically and with competence as a CT Radiology consultant. 2. State the indications for all neurological examinations including but not limited to temporal bone imaging, CT myelograms, and CT cisternograms. 3. Prescribe and interpret CT angiography in the head, neck, chest and abdomen. 4. Indications for CT angiography. 5. Describe volume, doses and administration rates of contrast for CT examinations. 6. Provide a differential diagnosis for a) neuro pathology d) vascular pathology b) thoracic pathology e) musculoskeletal pathology c) abdominal pathology 7. Indications for CT-guided chest interventions. 8. Indications for abdominal and pelvic CT interventions 9. Indication and techniques of CT-guided abscess drainages and biopsies. 10. Orient and supervise the proper imaging investigation of a patient or of a specific disease. Interpersonal and Communication Skills: 1. Appropriately obtain informed consent 2. Appropriately communicate and document in the patient record urgent or unexpected radiologic findings 3. Produce radiologic reports that are accurate, concise and grammatically correct 4. Effectively teach junior residents and medical students 5. Communicate effectively with all members of the health care team Practice-based Learning and Improvement: 1. Identify, rectify and learn from personal errors 60

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