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DEPARTMENT OF DIAGNOSTIC IMAGING

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DEPARTMENT OF DIAGNOSTIC IMAGING DEPARTMENT OF DIAGNOSTIC IMAGING Document Transcript

  • DEPARTMENT OF DIAGNOSTIC IMAGING RHODE ISLAND HOSPITAL BROWN MEDICAL SCHOOL RESIDENCY MANUAL Initial Formulation: 1984 Most Recent Review/Revision: June 2004 1
  • 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. 2
  • 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 3
  • 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. 4
  • 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 5
  • 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. 6
  • 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 7
  • 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
  • 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
  • ER Evaluation 10
  • Tech Evaluation 11
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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 junior residents and 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 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 practice guidelines for CT examinations 3. Demonstrate knowledge of cost-effective imaging practices 4. Understand treatment implicated by findings on CT (e.g. what is the next treatment that should occur based on the CT findings). 61
  • III. RESIDENTS' EVALUATION ON CT ROTATION These are the evaluation mechanisms used to evaluate the resident and determine that the program goals and objectives are met. Evaluation Forms Monthly rotation evaluation by faculty Evaluation by CT technology staff. Exams ACR inservice exam Mock Oral Board exam Portfolio Procedure Logs The residents will also be evaluated on: 1. Attendance during CT rotation. 2. Efficiency during CT rotation. 3. Knowledge of CT protocols. 4. Knowledge of CT anatomy, physiology and pathology. 4. Knowledge of proper prescription of CT examinations. 5. Ability to provide a reasonable differential diagnosis for a CT imaging finding and suggest the next most appropriate step in the work-up of the patient. 7. Ability to appropriately book and perform CT-guided interventions. 8. Efficiency in dictating studies. 9. Quality of dictations. 10. Interactions with referring physicians. 11. Affability with coworkers, CT technologists, secretaries, nursing staff and radiology support staff. 62
  • IV. COMPUTED BODY TOMOGRAPHY REFERENCES 1. Computed Body Tomography Lee, Sagel, Stanley, Heiken Raven, 1998 2. Computed Tomography and MRI of the Whole Body Haaga and Lanzieri Mosby, 1994 3. High Resolution CT of the Lung Webb, Mueller, Naidich 1992 4. Computed Tomography of the Body 2nd Edition 1992 Moss, Gamsu & Genant 5. Head and Neck Imaging Fourth Edition Som & Curtin, 2003 6. Neuroradiology: The Requisites 2nd Edition Robert I. Grossman, David Yousem Mosby, 2004 7. Atlas of Human Anatomy Netter Ciber-Geigy, 1989 8. Textbook of Uroradiology, 2nd Edition N. Reed Dunnick, Carl M. Sandler, E. Steven Amis, Jeffrey H. Newhouse. William & Wilkins, 1997 9. Genitourinary Radiology: The Requisites 2nd Edition Ronald J. Zagoria Mosby, 2004 10. Synopsis of Diseases of the Chest, 2nd Edition Fraser, Pare Saunders, 1994 11. Robbins Pathologic Basis of Disease, 4th Edition Ramzi S. Cotran, Vinay Kumar, Stanley L. Robbins W.B Saunders, 1989 Reference to various anatomy texts and atlases will often be necessary. 63
  • C. EMERGENCY RADIOLOGY The Emergency Department rotations, and especially overnight call, offer the resident the foremost opportunity to exhibit her/his mastery of the core competencies of the training program. The priorities of emergency care differ from that offered in a general clinic or outpatient setting in that timeliness of interpretation is as important as accuracy in this environment. During the ED rotation, therefore, the imaging modality skills acquired in other sections are combined in a unique and clinically relevant manner. The department is covered by a resident and staff physician from 8:00 a.m. to 11:00 p.m. 7 days a week (the day/evening rotation). In general, different resident and staff members cover the 8:00 a.m. - 5:00 p.m. and 5:00 p.m. - 11:00 p.m. portions of this rotation. The resident covering the 8:00 a.m. -5:00 p.m. time period Monday through Friday is the resident "on" the ER rotation. From 11:00 p.m. to 8:00 a.m. (the night rotation) a senior resident is present with staff radiologists on call to provide back-up for the various radiology disciplines. Responsibilities and routine vary somewhat during these two different time frames so they will be addressed separately. However, at all times the resident is a representative of the department. Despite an often chaotic milieu which characterizes the ED reading room the Diagnostic Imaging resident is expected to maintain a professional demeanor and appearance. Day/Evening Rotation Daily Work - Junior and Senior Residents The day begins at 8:00 a.m., with resident and attending joint review of cases dictated by the night rotation resident. This is an opportunity to combine work with teaching. At the completion of film review the resident is expected to redictate cases for which an alternative diagnosis was made with assistance from the attending radiologist as needed. The resident is responsible for filling out and delivering a discrepancy sheet to the ED physicians to alert them to significant changes in the night readings. During the week this sheet should go over to the ED as soon as it is complete. On weekends it should be brought over at noon. Thereafter, the resident is expected to review studies as they are brought to the reading room in preparation for readout with the attending. The resident should also actively participate in consultations with the ED staff. The ED should be left unattended only during unusual circumstances when the expertise of those radiologists is required elsewhere in the institution. Night Rotation 64
  • Each spring, first-year residents will be tested to document their mastery of the skills necessary to manage independent overnight call responsibilities. These tests are likely to include both written and oral examinations. After consultation with the program director, residents who fail to demonstrate required skills will be asked to complete an appropriate educational process and repeat testing prior to participating in the overnight call pool. Daily Routine This rotation is part of the senior residents' "on call" requirement. He/She is responsible for all radiologic requests within Rhode Island Hospital, Hasbro and Women & Infants', including any questions regarding portable studies, specialty imaging examinations or unusual cases. Absence from the Emergency Department reading room is only permitted when imaging expertise is required elsewhere in these hospitals. All imaging studies except CT scans performed in the Emergency Department should be dictated for 8:00 a.m. review by the attending. Preliminary reports on CT scans should be written on the log sheet. the night resident will receive copies of any reports "corrected" by the attending at morning readout. Conferences: The resident assigned to the day portion of the day/evening rotation should attend the General Surgery Trauma Conference at 7:00 a.m. every Monday. Quality Assurance 1. The foundation of accurate radiograph interpretation is good radiograph quality. The unique structure of the Emergency Department Diagnostic Imaging rotation allows the resident immediate input regarding overall technical radiograph quality. Residents should review all studies for completeness and quality. Suboptimal studies should be repeated. Technologists are to be encouraged to seek the resident's opinion on difficult imaging cases. 2. Communication of imaging findings to the Emergency Department physicians is a critical part of our activity in the Emergency Department. The responsible physician should be notified immediately of any urgent imaging findings. This should be documented in the written report when possible. In the event a significant finding is not detected by the senior resident during the night rotation written notification should be sent to the Emergency Department physician. A discrepancy sheet is available for this purpose. All residents must be familiar with the protocol for using this sheet. Educational Goals and Objectives 65
  • By the end of the first year, the resident should have achieved competence in the following areas: Patient Care: 1. Participate in the real-time integration of clinical and imaging data in the formation of the treatment plan. Before the junior resident begins to take overnight call, they must be prepared to develop a patient management plan based upon available information (including plain radiography, ultrasound, CT, and in future MRI). The assimilation of information from electronic reporting databases (including the radiology information systems of RIH and TMH)is an essential component of this process. Residents will be evaluated according to their ability to provide such services, relative to their level of experience. Emergency Medicine attending staff will be given the opportunity to evaluate the performance of residents on overnight rotations. 2. Once the resident has completed a full rotation through ultrasound, they are expected to demonstrate, to either the section chief or lead ultrasound technologist, the ability to perform a focused scan for abdominal trauma (FAST) in a timely manner, according to ED protocol. Medical Knowledge: By the completion of the first year, residents are expected to demonstrate knowledge of normal anatomy and recognition of abnormal imaging findings in life-threatening or unstable conditions, such as: 1. Cervical spine, pelvic and extremity fractures 2. Pneumothorax, free fluid in the abdomen, and signs of active bleeding 3. Acute intracranial hemorrhage and cerebrovascular accident (CVA) 4. Common causes of non-traumatic acute abdominal pain (e.g. appendicitis, diverticulitis) 5. Pulmonary embolism in uncomplicated cases Interpersonal and Communication Skills: Outstanding abilities in this area are essential to satisfactory performance in the Emergency Department. The ED affords the radiologist-in-training the unique opportunity to exert immediate influence over treatment decisions in often critically ill patients; that opportunity can only be exploited by timely and lucid discussions with referring physicians from many services. For this reason it is essential that the resident be directly available at all times while assigned to the ED. Absences from the reading room should be coordinated with the attending radiologist assigned to the ED. As in the remainder of the department, all residents rotating through the ED are expected to (and will be evaluated according to their ability to): 1. Appropriately communicate and document in the patient record urgent or unexpected radiologic findings. The direct proximity of ED resident and staff physicians facilitates verbal discussions; it is the responsibility of the radiology resident to immediately locate responsible clinical staff so that they can be informed of urgent findings (e.g. tension pneumothorax). In addition, the resident is 66
  • expected communicate discrepancy reports and alterations between preliminary (i.e. resident) and final (i.e. attending) interpretations according to department protocol. A computerized log of discrepancies will be available to residents at the conclusion of their rotations, and each edited report will be returned to them for review. Both of these are truly intended to facilitate case-based learning, rather than as merely negative feedback mechanisms. 2. Produce radiologic reports that are accurate, concise and grammatically correct. The importance of all three in this environment cannot be overstated. 3. As residents change shifts, they are asked to identify outstanding issues to the arriving radiology team, in order to provide “continuity” of radiologic care. 4. Communicate effectively with all members of the health care team. Practice-based Learning and Improvement: The ED provides the resident with the opportunity to evaluate an exceptional number of unknown cases. From the resident’s perspective this is an important learning opportunity, as experience with actual cases typical offers the most indelible learning. A primary goal of all ED rotations is to incorporate and evaluate Practice-based learning and improvement of this type. To this end, as appropriate to their level, the resident is expected to: 1. Identify, rectify and learn from personal errors; for overnight residents, this involves reviewing the discrepancy sheets and revised reports on a DAILY basis. Questions regarding findings/interpretation/reports should be immediately referred to the attending radiologist (e-mail is appropriate for this); incorporate that feedback into improved performance 2. Efficiently use electronic and print resources to access information. The resident is both asked to and expected to utilize access to on-line informational databases, as well as the collection of textbooks in the ED to expand their fund-of-knowledge in as close to a real-time manner as possible whenever confronted by unfamiliar diagnoses or entities. 3. Attend trauma conference; this multidisciplinary conference offers the resident an excellent opportunity to learn how imaging tests and interpretation influence management of the traumatized patient. Professionalism: At all times, the resident is expected to adhere to high standards of professionalism while in the ED, including (but not necessarily limited to): 1) Demonstrate respect for patients and all members of the health care team 2) Respect patient confidentiality 3) Present oneself as a professional in appearance and communication. 4) Demonstrate a responsible work ethic with regard to work assignments 5) Place the interest of the patient first and appropriately consult attending radiologist on call when necessary for assistance 67
  • Systems-based Practice: 1) During the daytime rotation residents are expected to attend the weekly Trauma Conference (Monday 7 AM, George Auditorium) 2) Demonstrate knowledge of how radiologic information is integrated with the other parts of the health care system in the treatment of the patient. The radiologist, as a member of both the Department of Diagnostic Imaging and the Emergency Department, is in a unique position to help patients and clinicians navigate through the complexities of both areas. 3) Demonstrate knowledge of trauma imaging protocols Second and Third Year Residents are expected to have the following objectives in addition to those listed for first year residents: Patient care: 1. Integrate clinical history and imaging findings to provide a diagnosis or an appropriate differential diagnosis 2. Provide an appropriate management plan for the patient based upon the above. Medical Knowledge: 1. Further refinement of observational abilities and knowledge base with application into an appropriate differential diagnosis of: a. Bowel disorders (e.g. ischemia vs. infection vs. neoplasm) b. Focal diseases of solid organs c. Focal brain lesions d. Secondary signs of CVA and herniation e. Diffuse and focal lung diseases 2. Knowledge of classification systems for: a. Solid organ injury b. Facial fractures c. Pelvic fractures d. Cervical spine fractures 3. Imaging protocols for trauma Interpersonal and Communication Skills: 1. Teach first year residents and medical students emergency radiology 2. Provide consultation on imaging findings to emergency department staff Practice-based Learning and Improvement: 1. Identify, rectify and learn from personal errors 2. Efficiently use electronic and print resources to access information. The resident is both asked to and expected to utilize access to on-line informational databases, as well as the collection of textbooks in the ED to expand their fund-of- knowledge in as close to a real-time manner as possible whenever confronted by unfamiliar diagnoses or entities. 3. Attend trauma conference 68
  • Professionalism: 1. Act as a role model for medical students and junior residents Systems-based Practice: 1. Demonstrate knowledge of cost-effective imaging evaluation in the emergency department Fourth year residents are expected to have the following objectives in addition to those listed for first, second and third year resident: Patient Care: 1. Demonstrate knowledge of medical and surgical treatment of diseases and how treatment options may guide imaging Medical Knowledge: 1. Further refinement of detection abilities in subtle or complex cases Interpersonal and Communication Skills: 1. Function independently as a consultant to the emergency department attending staff Practice-based Learning and Improvement: 1. Identify, rectify and learn from personal errors 2. Efficiently use electronic and print resources to access information. The resident is both asked to and expected to utilize access to on-line informational databases, as well as the collection of textbooks in the ED to expand their fund-of- knowledge in as close to a real-time manner as possible whenever confronted by unfamiliar diagnoses or entities. 3. Attend trauma conference Professionalism: 1. Demonstrate respect for patients and all members of the health care team 2. Respect patient confidentiality 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments Systems-based Practice: 1. Demonstrate knowledge of cost-effective imaging evaluation in the emergency department Mechanism of Evaluation For the daytime rotation the monthly rotation evaluation form will be completed by the attending radiologists who have had interaction with the resident. Imaging conference 69
  • presentations and dictations relevant to emergency radiology will be reviewed at the semi-annual review with the program director. The night float resident will be evaluated by the Emergency Department staff. The night float resident will also receive feedback on performance by reviewing the discrepancy sheets and by receiving quality assurance emails regarding dictations. 70
  • EMERGENCY RADIOLOGY REFERENCES 1. *HARRIS & MIRVIS - The Radiology of Acute Cervical Spine Trauma Junior Resident - Concise, brief overview by experts in the field. Should be read prior to or during the first week of the rotation. 2. *HARRIS, HARRIS & NOVELLINE- Radiology of Emergency Medicine Junior Resident - Chapter 1, Chapter 8 (pp. 503-529 and 536-559), Chapter 3, (pp. 127-134 and 243-280). Junior and Senior Residents - Continued reading based on cases encountered in daily readout. *Rotation texts 3. Reference texts available in the Emergency Department reading room for use on an as-needed basis. 1. Meschan - Atlas of Anatomy Basic to Radiology 2. Keats - Normal Variants 3. Harris, Harris & Novelline - Radiology of Emergency Medicine 4. Osborn - Diagnostic Neuroradiology 5. Moss - CT of the Body - Abdomen/Pelvis 6. Armstrong - Imaging of Diseases of the Chest 7. Callen - US in Obstetrics and Gynecology 8. Jeffrey - Sonography of the Abdomen 71
  • D. FLUOROSCOPY/GASTROINTESTINAL and GENITOURINARY RADIOLOGY One or two residents are assigned to this area daily. If two residents are assigned, only one of the two residents is eligible for vacation at any one time. Should you contemplate a vacation during this rotation, it is incumbent upon you to negotiate with your resident colleague on the service for the leave. Daily Work The more senior resident or the single resident when only one is assigned, should arrive in the Fluoroscopy section at 7:45 a.m. and the more junior resident should arrive by 8:00 a.m. The two residents assigned to this service are responsible for all studies performed utilizing plain radiography and fluoroscopy to investigate the gastrointestinal and genitourinary tracts. All cases should be reviewed by the staff radiologist assigned to GI/GU prior to the patient leaving the department. The only examinations excepted are tube placement checks. Add-on cases should generally be accepted if the patients have been properly prepared. The residents are responsible for dictating the cases after review by the staff radiologist. In the event that the AM staff radiologist assigned to GI/GU is not available in the afternoon, staff responsibility shifts to the PM CT/GI radiologist. It is incumbent upon the residents to inform that radiologist of impending exams. Both residents should remain in the Fluoroscopy area until all exams have been completed. The more junior resident should then continue to stay in the Fluoroscopy area until 5:00 p.m. in order to handle consultations and additional exam requests. The more senior resident may work elsewhere in the hospital, but must always be available by pager to assist with any case. Conferences Uroradiology conference is held on Tuesday at 4:30 or 5:30 p.m. GI Radiology conference is held monthly at 7:30 a.m. on the first Wednesday of each month. Both residents will be expected to attend both conferences. If the GI conference lasts beyond 8:00 a.m., the more senior resident should proceed to the Fluoroscopy area at 8:00 a.m. GASTROINTESTINAL RADIOLOGY The resident is responsible for performing all enteral contrast studies of the gastrointestinal tract. Prior to each study, review of the chart and previous studies together with an interview of the patient is mandatory to establish indications and to allow appropriate "tailoring" of the examination. Review of all films obtained in a timely manner is mandatory as the resident is responsible for the quality of the examinations. Preliminary interpretations of examinations will be provided in the form of a written note in the chart of inpatients. All requests for emergency and urgent studies will be evaluated by the resident. They will be scheduled in cooperation with the technical staff. 72
  • Following review of the films with a staff radiologist, the resident will complete dictations. GENITOURINARY RADIOLOGY The resident is responsible for the performance, monitoring and quality assurance of all radiographic procedures of the genitourinary system. A complete chart review and interview with the patients is indicated. Review of prior films as well as the preliminary films for the study is mandatory. Following this review, the examination will be performed with appropriate "tailoring" for that particular patient. Treatment of contrast reactions is the direct responsibility of the resident; a staff radiologist should be notified immediately. All requests for emergency studies will be reviewed by the resident staff and scheduled in cooperation with the technical staff. Following review of all cases, the resident will dictate the studies. A preliminary report will be written in the patient's chart as noted in the Gastrointestinal portion of this manual. Before both residents leave the area, a signout of any impending cases must be completed with the on-call resident. All scheduled cases must be completed. If the on-call resident is unable to attend this area because of on-going commitments elsewhere, then one of the two residents on this service must maintain a presence until all impending cases are completed as well. In the Fluoroscopy reading room there is a list of technologist protocols for the examinations we perform in the Fluoroscopy Division. Review of these is useful to understand the preparation for examinations and the films required. General Objectives To obtain proper training in the performance and interpretation of fluoroscopic and contrast studies involving the gastrointestinal and genitourinary systems. 73
  • Educational Goals and Objectives First Year Residents Patient Care : 1. Adequately explain each examination to the patient in order to ensure that the patient is at ease 2. Be aware of the basic principles of radiation protection in order to reduce as much as possible the radiation dose to the patient 3. Understand the indications for and contraindications to the use of intravenous radiographic contrast, and be able to monitor its administration 4. Be able to recognize and treat idiosyncratic reactions to intravenous contrast 5. Understand the indications and contraindications to the different types of enteral contrast, and the differences and relative merits of single and double contrast studies 6. Develop a knowledge of the preparation and aftercare required for the common examinations Medical Knowledge: 1. Learn the basics of the physics of radiography and fluoroscopy 2. Be able to perform an adequate upper gastrointestinal series, barium swallow, barium enema and cine swallow 3. Develop a knowledge of the anatomy of the gatrointestinal tract as demonstrated on contrast studies 4. Develop a knowledge of the anatomy of the genitourinary tract as demonstrated on intravenous urography Interpersonal and Communication Skills: 1. Communicate with the patient at all times during the examination in order to ensure that the patient remains at ease 2. Communicate effectively with all members of the health care team 3. Call positive results to the referring physician 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. Respect patient confidentiality 3. Present oneself as a professional in appearance and communication 4. Demonstrate a responsible work ethic with regard to work assignments 74
  • Systems-based Practice: 1. Attend the both gastrointestinal radiology conference and the uroradiology conference and demonstrate understanding of how imaging of these systems relates to the clinical care of the patient 2. Demonstrate knowledge of ACR practice guidelines and technical standards for fluoroscopy 3. Demonstrate knowledge of ACR appropriateness criteria and cost effective imaging evaluation of common GI/GU disorders Second and Third Year Residents Patient Care : 1. Be able to perform more complex procedures such as myelography and defecography 2. Understand the physics of radiation protection and how to apply it to routine studies 3. Be able to obtain consent for more complex procedures and to answer all questions the patient may have 4. Develop a knowledge of the preparation and aftercare required for the more complex procedures Medical Knowledge: 1. Be able to recognize the more common abnormalities encountered in the GI tract, such as stricture, polyp, ulcer and mass 2. Develop a knowledge of the physics of radiography and be able to explain the function of each part of the imaging chain, including the generator, the fluoroscopy unit, grids and screens 3. Be able to recommend the appropriate study based on the clinical picture and understand the relative strengths of each modality 4. Develop a knowledge of the differential diagnoses of the more commonly encountered abnormalities Interpersonal and Communication Skills: 1. Appropriately obtain informed consent 2. Produce concise reports which include all relevant information 3. 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. Respect patient confidentiality 75
  • 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments Systems-based Practice: 1. Attend the both gastrointestinal radiology conference and the uroradiology conference and demonstrate understanding of how imaging of these systems relates to the clinical care of the patient 2. Demonstrate knowledge of ACR practice guidelines and technical standards for fluoroscopy and intravenous urography 3. Demonstrate knowledge of ACR appropriateness criteria and cost-effective imaging evaluation of GI/GU disorders Fourth Year Patient Care: 1. Be able to perform the less common studies, including fistulograms/sinograms, loopograms, pouchograms, fluoroscopy of the diaphragm, T-tube cholangiograms and enteroclysis 2. Be familiar with the utility of contrast studies of the GI and GU tracts, and their relationship to the other imaging modalities Medical Knowledge: 1. Develop a thorough knowledge of the differential diagnoses of abnormalities encountered on barium and water soluble contrast studies of the GI and GU tracts 2. Develop a thorough knowledge of the differential diagnosis of myelographic abnormalities 3. Be able to relate the imaging findings to the clinical condition and its pathology 4. Understand the clinical management of the conditions encountered Interpersonal and Communication Skills: 1. Appropriately communicate results to patients and clinicians 2. Produce concise reports which include all relevant information 3. Communicate effectively with all members of the health care team 4. Assist with supervision and teaching of medical students 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. Respect patient confidentiality 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments 76
  • Systems-based Practice: 1. Attend the both gastrointestinal radiology conference and the uroradiology conference and demonstrate understanding of how imaging of these systems relates to the clinical care of the patient 2. Demonstrate knowledge of ACR practice guidelines and technical standards for fluoroscopy and intravenous urography 3. Demonstrate knowledge of ACR appropriateness criteria and cost-effective imaging practices in the evaluation of GI/GU disorders Mechanism of Evaluation The resident will be evaluated by the faculty by means of a monthly evaluation form. In addition, the lead technologist will be responsible for providing feedback to the resident from the technology staff by means of the standard technologists evaluation form. Procedure logs and imaging conference presentations will be kept in the resident’s file for review by the program director. 77
  • GI/GU Radiology Reading List Textbook of Uroradiology by N. Reed Dunnick (Editor) Williams and Wilkins 2000 (Amalgamation of two previous texts. Excellent) Genitourinary Radiology: The Requisites (Requisites Series) by Ronald J. Zagoria, Tung, Glenn A. Tung M. D. Mosby Year Books Inc., 1997 (A superb alternative to Dunnick) Manual of Gastrointestinal Fluoroscopy: Performance of Procedures by David J. Ott, David W. Gelfand, Michael Y. M. Chen Charles C Thomas Pub Ltd; 1996 (Excellent description of the different techniques) GASTROINTESTINAL RADIOLOGY: A PATTERN APPROACH EISENBERG, Ronald L., MD, FACR, JD Publisher: Lippincott Williams & Wilkins 2002 (Definitive work) DOUBLE CONTRAST GASTROINTESTINAL RADIOLOGY, 3RD ED LEVINE, Marc S., MD. Publisher: Saunders 2000 (A good resource) 78
  • E. NUCLEAR MEDICINE I. Daily Work The hours of service on this rotation are from 8:00 a.m. until all scheduled cases including cardiac studies have been reviewed. When necessary (especially for the cardiac studies), the day may extend later than 5:00 p.m. and the resident should plan on staying until all of these studies are completed unless s/he is needed elsewhere for on-call responsibilities. The resident is responsible for monitoring and supervising all studies performed in the Division of Nuclear Medicine. Chart reviews and interviews with patients are helpful in many patients; all PET patients are to be interviewed by a physician prior to the patient leaving the department. In certain cases (e.g., thyroid examinations), a careful physical examination is necessary. Other relevant imaging studies should be located and reviewed. All cases will be reviewed by the resident prior to discharging the patient from the section and additional views requested as necessary. The quality of these examinations is therefore, the direct responsibility of the resident. After completion of the study, the resident will be responsible for insuring that accurate computer analysis of all studies that require computer processing has been performed. For PET studies, the resident will review all requests and prescribe the appropriate imaging protocol on the day before the scheduled exam. Following review of the studies with the staff radiologist, the resident will be responsible for performing the dictations and sign-off of reports in a timely manner. The resident will maintain a presence in the Department until at least 5:00 p.m. for the purpose of consultations and for monitoring any on-going examinations. Before leaving the Department, should there be any pending examinations which have been arranged by the resident assigned to that rotation, the resident will sign out in a formal manner with the radiology resident on call that evening. The daily work will be completed prior to signing out. The resident assigned to Nuclear Medicine will review requests for emergency studies and will arrange their scheduling in conjunction with the clerical and technical staff. As with routine studies, all complementary examinations will be reviewed prior to performing the emergency study. During the course of residency training, each resident must observe and participate in certain technical aspects of Nuclear Medicine (e.g., camera quality control, kit preparation). A list of these procedures will be distributed to each resident and the resident will be responsible for obtaining the necessary signatures documenting his/her participation in these procedures. In addition, the resident will be responsible for keeping a log of all Nuclear Medicine therapy cases in which the resident participates. Each resident must participate in (and document) at least three cases of radioactive iodine therapy for hyperthyroidism and an additional three cases of radioactive iodine therapy for thyroid cancer. 79
  • Nuclear medicine plays a pivotal role in emergency and on call studies. Many nuclear medicine studies are not elective (V/Q scan, bleeding scans, etc.) and part of the resident’s experience in Nuclear Medicine for these studies occurs in the call setting. It is expected that the on-call resident will be involved in triage, performance, and interpretation of these studies and recognize them as an extension of the nuclear medicine training experience. With regard to Nuclear Cardiology studies, the resident should read out with the Nuclear Medicine attending whenever they are reading the cardiac studies. On days that a cardiologist is reading the Nuclear Cardiology studies, the resident should join the read- out for as much time as their non-cardiac responsibilities permit. II. Evaluation The resident will be evaluated primarily on their performance in the daily operations of the department. This includes their general radiology knowledge, specific nuclear medicine knowledge, consultative abilities with referring physicians, and ability to run the operations of the department. In addition, the resident will be evaluated on their performance on cases shown in noon conference and the cases monitored and interpreted when on call. Third and fourth year residents will also participate in a mock-oral board exam in nuclear medicine. An evaluation will be filled out by the Division Director at the end of each monthly rotation after receiving input from all nuclear medicine physicians. IV. Didactic Conferences An average of two nuclear medicine noon conferences will be given each month. This will include a lecture series designed to cover all general areas of nuclear medicine in a two-year period. This will comprise about half of the nuclear medicine noon conferences; the other half will be teaching file case presentations with various residents evaluating the cases. V. Educational Goals and Objectives First and Second Year Residents By the end of the second year, the resident should be able to: Patient Care: 1. Perform physical examination and history relevant to the nuclear medicine study, especially thyroid examination. 2. Describe clinical indications and techniques for all frequently performed nuclear exams. 80
  • 3. Interview PET patients to obtain clinical history needed for scan interpretation. Medical Knowledge: 1. Describe basic radiopharmaceutical preparation and basic nuclear medicine physics and instrumentation. 2. Discuss common types of pathology for frequently performed nuclear medicine exams. 3. Review all types of nuclear medicine exams to ensure that the exam is complete and request additional views when necessary. 4. Use a systematic approach to identify common abnormalities on frequently performed nuclear medicine exams. 5. Describe the normal biodistribution of radiopharmaceutical for commonly performed nuclear medicine exams. 6. Participate actively in nuclear cardiology reading session and understand basic concepts of nuclear cardiology interpretation. Interpersonal and Communication Skills: 1. Perform appropriate basic consultations with referring physicians after having first reviewed scans with attending nuclear medicine physician. 2. Dictate all non-cardiac nuclear medicine examinations, including PET, performed in a routine day in a coherent fashion after having reviewed scans with attending nuclear medicine physician. 3. Communicate appropriately with all Nuclear Medicine technical and clerical staff. 4. Call referring physicians with any urgent or unexpected positive results. 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 resource to access information. Professionalism 1. Demonstrate appropriate professional behavior towards patients, nuclear medicine technical and clerical staff, and other physicians. 2. Respect patient confidentiality and privacy. 3. Present oneself as a professional in appearance and communication. 4. Demonstrate responsible work ethic. Systems-based Practice 1. Review for appropriateness any requests for studies that the technical and clerical staff are uncertain about; also, all studies that are on the list requiring pre- approval. 2. Attend multi-disciplinary conferences, including oncology conferences, when appropriate. 81
  • 3. Demonstrate knowledge of ACR standards and appropriateness criteria. 4. Demonstrate knowledge of cost-effectiveness imaging practices, including appropriate utilization of high-cost procedures like PET. Third and Fourth Year Residents By the end of the fourth year, the resident should be able to achieve all of the above (first and second year) objectives, plus the following: Patient Care: 1. Independently run almost all facets of the daily operations of the nuclear medicine department. 2. Appropriately answer questions from patients and family members, including those related to radiation safety issues from radiopharmaceutical exposure. Medical Knowledge: 1. Prepare basic radiopharmaceutical kits, describe radiopharmaceutical QC, and assay and administer radiopharmaceuticals in a proper fashion. 2. Discuss in detail nuclear medicine physics and instrumentation, as well as planar SPECT and PET camera quality control. 3. Interpret all types of nuclear medicine examinations, including an understanding of the normal biodistribution of all radiopharmaceuticals and the ability to provide an appropriate differential diagnosis list for all abnormalities. 4. Interpret all types of nuclear cardiology examinations. 5. Interpret all types of PET examinations Interpersonal and Communication Skills: 1. Independently perform consultations with referring physicians regarding appropriate choice of studies and interpretation of all types of nuclear medicine studies. 2. Actively participate in teaching of junior residents and medical students. 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 resource to access information. Professionalism: 1. Demonstrate appropriate professional behavior towards patients, nuclear medicine technical and clerical staff, and other physicians. 2. Respect patient confidentiality and privacy. 3. Demonstrate responsible work ethic. Systems-based Practice: 1. Have general familiarity with Nuclear Medicine regulatory requirements. 82
  • Mechanism of Evaluation 1. Monthly evaluation forms by all Nuclear Medicine attending physicians. 2. Evaluation by lead Nuclear Medicine technologist. 3. Mock oral board exam in Nuclear Medicine and ACR in-service exam. 4. Imaging conference presentations. 5. Nuclear Medicine technical competency evaluation; check-list of technical aspects of Nuclear Medicine that residents must observe or perform. 6. Noon conference unknown case sessions. 83
  • Nuclear Medicine Technical Competency Evaluation Tech Initials 1) Camera QC – Daily Flood – observe 2) Radiopharmaceutical kit preparation – perform 3) Lung Scan Acquisition – observe 4) PET Scan Acquisition - observe 5) Radiopharmaceutical QC – Tc-99m MAA QC – observe 6) Room survey for radiation with survey meter and wipe test – perform 7) Radiopharmaceutical administration and disposal – perform 84
  • NUCLEAR MEDICINE READING LISTS 1. Nuclear Medicine: The Requisites Thrall & Ziessman Similar in scope to Mettler, but greater detail on certain topics, especially procedures Rotation text – first and second year residents 2. Diagnostic Nuclear Medicine Sandler et al A thorough review of all current aspects of Nuclear Medicine Rotation text – third and fourth year residents 3. Principles & Practice of Positron Emission Tomography Wahl State-of-the-art comprehensive text on PET Supplemental text for third and fourth year residents 4. Essentials of Nuclear Medicine Mettler & Guiberteau A very good basic clinical Nuclear Medicine text, concise but complete, now somewhat outdated. Former rotation text - first and second year residents 5. Introductory Physics of Nuclear Medicine Chandra Basic Nuclear Medicine physics, contains most of the Nuclear Medicine physics needed for the written boards 6. ACR Syllabi: - Nuclear Medicine II, III, IV, & V Case presentations covering all aspects of clinical Nuclear Medicine. Appropriate for 3rd and 4th year residents especially 7. Atlas of Clinical Nuclear Medicine Fogelman Detailed atlas of Nuclear Medicine procedures, brief text included 8. Oncologic Imaging Bragg, Rubin, and Hricak 9. Clinical Practice of Nuclear Medicine Taylor/Datz 85
  • 10. Differential Diagnosis in Nuclear Medicine Silberstein/McAfee 86
  • F. MUSCULOSKELETAL PLAIN FILM RADIOLOGY I. General Objectives: When first confronted, the field of musculoskeletal radiology is somewhat overwhelming due to the diversity of topics covered in this field. It is important that the beginning resident learns to categorize into subdivisions of bone pathology (i.e. metabolic, tumor, dysplasias, etc.). Only by using a strict algorithmic approach will the resident be able to properly arrive at a concise and well-thought out differential diagnosis. The first year resident should be concerned with the following: A fundamental grasp of basic orthopaedic radiology. This is the bread and butter of musculoskeletal radiology, and must be thoroughly understood both for board certification as well as for future practice. A syllabus is provided which affords the basics of orthopaedic radiology. This should be supplemented with appropriate reading, and in particular, the skeletal trauma book by Lee Rogers. The first-year resident should also begin to categorize and organize subdivisions of musculoskeletal radiology such as rheumatology, neoplastic, etc. The second year resident should be increasingly facile with orthopaedic radiology, particularly with growing experience in the Emergency Room. At this point, more detailed knowledge of neoplastic and metabolic processes as well as rheumatologic disorders is warranted. Again, syllabi are available to cover the basics, and to give a fairly complete list of pathologic considerations. Supplementary reading should be obtained from Resnick. Third and fourth year residents should become increasingly facile at the algorithmic approach to differential diagnoses. Resnick is suggested for further specific reading. Greater participation in unknown case analysis at noon conferences is expected. Besides noon conferences, a host of orthopaedic lectures are available on a daily basis, with orthopaedic resident teaching conferences at 5:00 p.m., Monday through Friday. Additionally, orthopaedic Grand Rounds is held at 7:00 a.m., Wednesday mornings. Additionally, the interested resident may attend Emergency Room readout at 7:30, where specific cases from the night before are reviewed, and treatment options discussed. II. Specific Objectives: 87
  • First-year Residents Patient Care: 1. Be able to critique the technical quality of a radiograph 2. Understand the indications for more advanced imaging (ultrasound/CT/arthrography/MRI) 3. Be able to protocol, with assistance, musculoskeletal examinations Medical Knowledge: 1. Fundamental understanding of basic orthopedic radiology, pertinent normal anatomy in a musculoskeletal radiograph 2. Recognize and describe, in a systematic fashion, radiographic findings on a radiograph 3. Begin to categorize and organize subdivisions of musculoskeletal radiology such as rheumatology, neoplasm, infection, etc. 4. Should be able to distinguish an aggressive process, such as malignant tumor or infection, from a more benign process, such as a benign bone tumor, based on specific radiographic findings 5. Be facile with basic orthopedic concepts. The resident should be able to very specifically and accurately describe a fracture such that the referring orthopedic surgeon would be able to envision the fracture in three dimensions. The resident should have a grasp on basic classification systems of fractures such as intracapsular vs. extracapsular, as well as named fracture such as Monteggia, Galeazzi, etc. 6. Discuss the most common musculoskeletal pathologic entities 7. Have a basic understanding of technique and indications for arthrography, bone biopsy and other invasive procedures. Additionally, the residents should be well aware of the strengths and limitations of musculoskeletal MRI and computed tomography in the evaluation of musculoskeletal disorders. Indications for radionuclide bone scanning should also be understood, as should the basic concepts of this imaging modality, and interpretation of some of the more common bone scans. Interpersonal and Communication Skills: 1. Call referring physicians for positive results 2. Communicate effectively with all members of the health care team Practice Based Learning and Interpretation: 1. Identify, rectify and learn from personal error 2. Incorporate feedback into improved performance 3. Use electronic and print resources to access information Professionalism: 1. Demonstrate respect for patients and members of health care team 88
  • 2. Repeat patient confidentiality 3. Come to work with a professional appearance 4. Demonstrate a responsible work ethic Systems-Based Practice: 1. Demonstrate knowledge of ACR standards 2. Attend imaging conferences 3. Attend orthopedic grand rounds when possible 4. Attend orthopedic bone tumor conferences when possible Second and Third Year Residents Patient Care: 1. Protocol CT and MRI exams without assistance 2. Monitor musculoskeletal CT exams 3. Understand indications for MRI 4. Perform, with assistance, musculoskeletal ultrasound Medical Knowledge: 1. Increasingly facile with orthopedic radiology 2. More detailed knowledge of neoplastic, metabolic, infectious and rheumatologic disorders is warranted 3. Discuss the most common techniques in musculoskeletal imaging, the indications and contra-indications and complications of the following: plain film and fluoroscopy musculoskeletal scintigraphy arthrography musculoskeletal biopsy CT MRI 4. Describe pertinent normal anatomy on MRI’s of shoulder, knee, foot and ankle Interpersonal and Communication Skills 1. Communicate effectively with patients and all member of the health care team 2. Function as a consultant in musculoskeletal radiology yet be free to obtain more experienced opinions Practice-based Learning and Interpretation 1. Identify, rectify and learn from personal error 2. Incorporate feedback into improved performance 3. Use electronic and print resources to access information Professionalism: 1. Demonstrate respect for patients and members of health care team 2. Repeat patient confidentiality 3. Come to work with a professional appearance 89
  • 4. Demonstrate a responsible work ethic Systems-Based Practice: 1. Demonstrate knowledge of ACR standards 2. Attend imaging conferences 3. Attend orthopedic grand rounds when possible 4. Attend orthopedic bone tumor conferences when possible 5. Greater participation in unknown case analysis at noon conference is expected Fourth Year Residents Patient Care: 1. Protocol CT and MRI examinations without assistance 2. Monitor musculoskeletal CT and MRI exams 3. Understand indications for CT contrast and gadolinium 4. Perform musculoskeletal ultrasound of shoulder and knee Medical Knowledge: 1. Discuss the radiographic findings of all musculoskeletal pathology 2. Establish a precise diagnosis and provide a pertinent differential diagnosis 3. Orient and supervise the investigation of a patient or of a specific disease 4. Discuss MRI findings of musculoskeletal pathology 5. Understand and appreciate orthopedic procedures of greater complexity such as joint replacement, osteotomies, spinal fixation 6. Be able to streamline the diagnostic imaging work-up for a specific musculoskeletal abnormality Interpersonal and Communication Skills: 1. Communicate effectively with patients and all member of the health care team 2. Function as a consultant in musculoskeletal radiology yet be free to obtain more experienced opinions Practice-based Learning and Interpretation: 1. Identify, rectify and learn from personal error 2. Incorporate feedback into improved performance 3. Use electronic and print resources to access information Professionalism: 1. Demonstrate respect for patients and members of health care team 2. Repeat patient confidentiality 3. Come to work with a professional appearance 4. Demonstrate a responsible work ethic Systems-Based Practice: 1. Demonstrate knowledge of ACR standards 2. Attend imaging conferences 90
  • 3. Attend orthopedic grand rounds when possible 4. Attend orthopedic bone tumor conferences when possible 5. Greater participation in unknown case analysis at noon conference is expected Mechanism of Evaluation Medical knowledge in musculoskeletal radiology will be specifically evaluated by the ACR in-service examination and the mock oral board examination. Patient care, practice-based learning and systems-based practice relevant to musculoskeletal radiology will be evaluated by imaging conference presentations and monthly evaluations by the faculty on the MOC rotation. 91
  • IV. Musculoskeletal References 1. Resnick & Niwayama Diagnosis of Bone and Joint Disorders, 2nd Edition W.B. Saunders, 1988, Volumes 1-6 2. Lee Rogers Radiology of Skeletal Trauma Churchill, Livingston 1992, 2nd Edition, Volumes 1 & 2 3. Greenfield and Gershwin Radiology of the Arthridities-A Clinical Approach J.B. Lippincott, 1990 4. Clyde Helms Fundamentals of Skeletal Radiology 5. Adam Greenspan Orthopedic Radiology, A Practical Approach 6. Beltran MRI of the Musculoskeletal System 7. Weisman and Sledge Orthopedic Radiology 8. Mirra JM Bone Tumors: Clinical Radiologic and Pathologic Correlations 9. Ozonoff Pediatric Orthopedic Radiology 92
  • G. PEDIATRIC RADIOLOGY DAILY WORK The daily work begins at 8:00 a.m. The resident will review the pediatric ER board or prior night's emergency CT scans and ultrasound exams, depending on the resident's level of training; more junior residents will focus on plain film review, more senior residents will either review the board or cross-sectional studies. The resident then reads out with one of the two pediatric radiology attendings present in the section on any given day. Residents will participate in fluoroscopic examinations throughout the workday, either with the attending radiologist, under their direct supervision, or, with increasing experience, independently. All examinations will be reviewed with the attending before the patient leaves the section. Residents will also observe and at times help perform pediatric ultrasound exams in the section, and will review both inpatient and outpatient plain film and cross-sectional work throughout the day. The resident is expected to function as both a resource and a liaison between clinicians, their patients and patients' families, and the Pediatric Radiology section. Residents may observe clinical work rounds in the section during the day, and will attend Pediatric Radiology conferences as listed below. The resident will also periodically accompany the attending to Women & Infants' Hospital to observe neonatal plain film interpretation, fluoroscopy, and ultrasound examination and interpretation. Educational Goals and Objectives First Year: Patient Care 1. Perform basic pediatric fluoroscopic examinations competently, focusing on VCUG, contrast GI studies 2. Begin to develop understanding of appropriate pediatric imaging protocols for common pediatric problems. Medical Knowledge 1. Understand common clinical pediatric entities and their imaging characteristics in chest, GI, GU, Musculoskeletal 2. Focus on plain film interpretation, particularly emergency case interpretation 93
  • Interpersonal and Communication Skills: 1. Learn to work and interact appropriately with infants and children at all developmental stages. 2. Learn to work with and communicate with parents effectively 3. Work effectively with pediatric imaging technologists, ancillary staff 4. Communicate radiologic findings and their significance to clinicians in a timely and effective fashion 5. Produce concise, accurate, and grammatically correct radiologic reports 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. Respect patient confidentiality 3. Present oneself in a professional manner 4. Demonstrate a responsible work ethic System-based Practice: 1. Attend pediatric work rounds, subspecialty conferences 2. Understand how radiologic information is integrated with other parts of the health care system 3. Demonstrate knowledge of ACR standards and appropriateness criteria 4. Demonstrate knowledge of cost-effective imaging practices 5. Demonstrate knowledge of pediatric radiation safety issues is imaging Second Year: Patient Care: 1. Develop further expertise in fluoroscopic pediatric examinations, including airway evaluation and complex GI/GU studies, including post-operative imaging procedures 2. Observe pediatric ultrasound examinations 3. Observe neonatal imaging in the intensive care unit setting 4. Interpret pediatric cranial and body CT examinations Medical Knowledge: 1. Demonstrate knowledge of common pediatric entities and competence in providing imaging interpretation of plain films studies, especially emergency cases 2. Understand anatomy and pathologic entities necessary for interpretation of pediatric GI/GU cross sectional imaging 94
  • 3. Demonstrate knowledge of anatomy and pathologic entities necessary for interpretation in neonatal cranial ultrasound and cranial CT examinations Interpersonal and Communication Skills: 1. Work and interact appropriately with infants and children at all developmental stages. 2. Work with and communicate with parents effectively 3. Work effectively with pediatric imaging technologists, ancillary staff 4. Communicate radiologic findings and their significance to clinicians in a timely and effective fashion 5. Produce concise, accurate and grammatically correct radiologic reports 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. Respect patient confidentiality 3. Present oneself in a professional manner 4. Demonstrate a professional work ethic Systems-based Practice: 1. Attend pediatric work rounds, subspecialty conferences 2. Understand how radiologic information is integrated with other parts of the health care system 3. Demonstrate knowledge of ACR standards and appropriateness criteria 4. Demonstrate knowledge of cost-effective imaging practices 5. Demonstrate knowledge of pediatric radiation safety issues is imaging Third and Fourth Year Residents Patient Care: 1. Develop further expertise in fluoroscopic pediatric examinations, including airway evaluation and complex GI/GU studies, including post-operative imaging procedures 2. Participate in and interpret pediatric ultrasound examinations, including evaluation of the hips and spine 3. Participate in neonatal imaging in the intensive care unit setting 4. Interpret pediatric cranial and body CT examinations Medical Knowledge: 1. In addition to knowledge of common pediatric entities: 2. Understand anatomy and physiology of Congenital Heart Disease 3. Become familiar with Pediatric CNS abnormalities 95
  • 4. Understand anatomy and pathology related to musculoskeletal imaging of pediatric hip and spine 5. Knowledge of pediatric oncological entities and imaging Interpersonal Skills: 1. In addition to competence in communication skills listed for junior residents: 2. Effectively teach junior radiology residents, pediatric residents, medical students 3. Present imaging studies at clinical subspecialty conferences Practice-based Learning and Improvement: 1. Identify, rectify, and learn from personal errors 2. Efficiently use electronic and print resources to access information 3. Incorporate feedback into improved performance Professionalism: 1. Demonstrate respect for patients and all members of the health care team 2. Respect patient confidentiality 3. Present oneself in a professional manner 4. Demonstrate a responsible work ethic Systems-based Practice: 1. Attend pediatric work rounds, subspecialty conferences 2. Understand how radiologic information is integrated with other parts of the health care system 3. Demonstrate knowledge of ACR standards and appropriateness criteria 4. Demonstrate knowledge of cost-effective imaging practices 5. Demonstrate knowledge of pediatric radiation safety issues Mechanism of Evaluation At the completion of each rotation month the residents will be evaluated by the pediatric radiology attendings by means of the monthly evaluation form. In addition, the residents will be evaluated by the technology staff. The ACR in-service examination and mock oral board examinations will also provide evaluation of medical knowledge in pediatric radiology. 96
  • PEDIATRIC RADIOLOGY REFERENCES 1. Practical Pediatric Imaging, 2nd Edition Donald R. Kirks, Editor 2. Caffey's Pediatric X-Ray Diagnosis, 9th Edition Frederick Silverman & Jerald Kuhn, Editors 3. Imaging of the Newborn, Infant and Young Child, 3rd Edition Leonard Swischuk 4. Pediatric Orthopedic Radiology, 2nd Edition M.B. Ozonoff 5. Ultrasonography of Infants and Children Rita Teele and Jane Share 6. Pediatric Sonography, 2nd Edition Marilyn Siegel, Editor 7. Radiology of Syndromes, Metabolic Disorders and Skeletal Dysplasia, 4th Edition Hooshang Taybi, Ralph Lachman 8. Imaging of the Pediatric Head, Neck and Spine Mauricio Castillo, Suresh Mukherji 9. Pediatric Neuroimaging, 2nd Edition A. James Barkovich 10. Cardiac Imaging in Infants, Children and Adults Larry P. Elliott 97
  • H. CARDIOPULMONARY RADIOLOGY The key elements for learning thoracic radiology are: 1) daily exposure to a high volume of chest radiographs and associated CT and MR examinations and 2) an organized approach to reading a specified core of material on cardiopulmonary radiology. The chest radiology rotation endeavors to expose the resident to full range of imaging modalities including plain film; conventional and high resolution computed tomography; and magnetic resonance imaging. Participation in such interventional procedures as transthoracic, fine needle aspiration biopsy and percutaneous catheter drainage of intrathoracic fluid collections occurs in the ultrasound, CT, and special procedures rotations. Resident participation in interdepartmental conferences, including ICU radiology rounds and pulmonary medicine conferences, is expected. These enhance the resident's knowledge of the various clinical problems faced by the pulmonologist and cardiothoracic surgeon, and form a basis for helping to guide radiologic workup of such problems. Daily Work: The radiology resident assigned to the main department should begin review of cases no later than 8:00am. All pertinent previous radiographs and CT scans shall be reviewed and available. The staff radiologist assigned to the section will subsequently review cases as they are presented by the resident and provide daily teaching rounds with teaching file cases as the work load permits. A complete understanding of normal anatomy and its variations as represented on the chest radiograph and on CT imaging will be required of each resident. That knowledge will form the basis for recognizing abnormal findings and patterns on chest radiographs and CT studies. Differential diagnoses will be stressed. When MR studies are associated with a case, they will be reviewed in conjunction with plain radiographic and CT findings. Frequent requests for consultation will be made by the clinical staff. Those consultations should be made by the resident working with the staff radiologist. During their second, third and fourth months on rotation, residents should take increasing responsibility in those consultations. The staff radiologist shall be available at all times. Resident presence in the reading area, except for conference periods, is maintained until at least 5:00 p.m. All dictations should be completed prior to leaving the area. Two staff radiologists. Drs. Gerald F. Abbott and Martha B. Mainiero, have formal fellowship training in thoracic radiology and will be primarily responsible for supervising this curriculum and evaluating resident performance. Reading: 98
  • A reading list is included below. We have selected reading materials that we believe are the best sources and will guide residents to specific chapters according to their level of training. Examinations: Tests are a mechanism for organizing thoughts and stimulating further study. An oral examination will be given at the end of the second month of the chest radiology rotation. Conferences: Conferences will be presented as didactic lectures as well as the "hot seat" format in order to prepare residents for the oral board examination. General Objectives: To acquire adequate training in interpretation of chest radiographs and associated CT imaging studies. Essential elements of adult cardiac disease will be reviewed on this service. Educational Goals and Objectives First-year Residents: Patient Care: 1. Recognize normal thoracic anatomy and its most common variations 2. Differentiate airspace from interstitial disease on chest radiographs and provide an appropriate differential diagnosis. 3. Distinguish malignant and benign pulmonary nodules / masses on chest radiography. 4. Critique the technical quality of a chest radiograph. 5. Understand the indications for Computed Tomography based upon chest radiographic findings. Medical Knowledge: 1. Proper patient positioning chest radiographic views. 2. Basic technique in chest radiography, CT and PET. 3. Common radiographic manifestations of lung cancer. 4. Common radiographic manifestations of infectious disease, atelectasis, pneumothorax, congestive heart failure, aortic dissection and rupture 5. Radiographic appearance and proper positioning of common monitoring devices Interpersonal and Communication Skills: 1. Call the referring physician for positive results and document the communication in the report. 99
  • 2. Learn the recommended terminology for reporting chest radiographic and CT findings. 3. 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. Respect patient confidentiality 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments Systems-based Practice: 1. Attend Pulmonary Case Management Conference and demonstrate understanding of how chest radiographic, CT and PET imaging are integrated with the clinical care of the patient 2. Demonstrate knowledge of ACR standards for chest radiography and CT. 3. Be familiar with ACR appropriateness criteria for evaluation of pulmonary signs and symptoms Second/Third Year Residents Patient Care: 1. Be able to discuss differential features of airspace and interstitial diseases on chest radiographs and CT/HRCT. 2. Be able to construct a differential diagnosis for solitary and multiple pulmonary nodules and pulmonary masses detected on chest radiography and by CT. 3. Be able to critique the technical quality of a CT/HRCT studies. 4. Know the indications for Computed Tomography based upon chest radiographic findings. Medical Knowledge: 1. Staging and surgical management of lung cancer. 2. Uncommon manifestations of lung cancer. 3. Manifestations and clinical management of less common thoracic diseases (Idiopathic interstitial pneumonias, LCH, Vasculitis, Hypersensitivity pneumonitis, mediastinal tumors, pleural tumors, pneumoconiosis, sarcoidosis, airway diseases). 4. Familiarity with cardiac anatomy and pathology, especially radiographic manifestations of valvular heart disease 100
  • Interpersonal and Communication Skills: 1. Call the referring physician for positive results and document the communication in the report. 2. Use the recommended terminology for reporting chest radiographic and CT findings, including HRCT. 3. Communicate effectively with all members of the health care team 4. Teach medical students and medical residents basic thoracic imaging 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. Respect patient confidentiality 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments Systems-based Practice: 1. Attend Pulmonary Case Management Conference and demonstrate understanding of how chest radiographic, CT and PET imaging are integrated with the clinical care of the patient 2. Demonstrate knowledge of ACR standards for chest radiography and CT. 3. Be familiar with ACR appropriateness criteria for evaluation of pulmonary signs and symptoms Fourth-year Residents: Patient Care: 1. Apply the proper management algorithm for common and less common thoracic diseases. 2. Advise clinicians regarding case management algorithms by integrating clinical history, physical and laboratory findings, and imaging results. Medical Knowledge: 1. Imaging findings of the post-surgical chest. 2. Atypical manifestations of common thoracic diseases. 3. Adult manifestations of congenital diseases Interpersonal and Communication Skills: 1. Appropriately communicate results to patients and clinicians and document communication in the report 2. Produce radiologic reports with proper terminology, concise structure, and clear conclusions and recommendations. 3. Communicate effectively with all members of the health care team 101
  • 4. Mentor junior residents in the skills outlined in First and Second/Third Year goals. 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. Respect patient confidentiality 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments Systems-based Practice: 1. Attend Pulmonary Case Management Conference and demonstrate understanding of how thoracic imaging modalities are integrated with the clinical care of the patient 2. Apply knowledge of ACR Standards for chest radiography and CT 3. Be familiar with ACR appropriateness criteria for evaluation of pulmonary signs and symptoms Mechanism of Evaluation Each resident will be evaluated on the basis of their daily work, their behavior (including interactions with clerical and technical personnel, consultants, and other radiologists), their completion of appropriate reading materials, and the development of their interpretive and reporting skills. An oral examination on disease entities covered by assigned reading will be given at the conclusion of the second month of chest radiology. At the end of each month the appropriate faculty will complete a monthly rotation evaluation form. Resources: Doctors Gerald Abbott and Martha Mainiero are experienced chest radiologists with formal fellowship training and are responsible for the organization and supervision of the cardiopulmonary radiology rotation. Further exposure to thoracic CT and MR imaging will occur during the CT and MR rotations. Congenital thoracic abnormalities will also be taught during the pediatric rotations. Bibliography: Required reading: all books can be checked out from Dr. Abbott during a resident's months of rotation. 102
  • Radiologic Diagnosis of Diseases of the Chest. Muller, Fraser, Colman and Pare, 2001 An excellent one-volume synopsis of a large, four-volume set. The four-volume set is available in Dr. Abbott’s office during your rotation. Thoracic Radiology: The Requisites, Theresa McLoud. A concise and up-to-date overview of thoracic radiology. Computed Tomography and Magnetic Resonance of the Thorax , Naidich et al, third edition. A comprehensive text of thoracic CT imaging. High Resolution CT of the Lung, Webb, Muller and Naidich, third edition, 2001. An excellent book with extensive illustrations. Other resources: World Wide Web: The Society of Thoracic Imaging maintains a web page at: http://www.thoracicrad.org which includes the syllabus (text and images) from the annual meetings of the Society. Several excellent lectures are available at: http://www.thoracicrad.org/str99/TI2002/default.asp An excellent and educational web page is maintained and frequently updated by Dr. Jud Gurney from the Mayo Clinic. Dr. Gurney is one of the most entertaining and authoritative teachers in thoracic imaging. www.chestx-ray.com CD-ROM: A highly recommended CD-Rom is the Chest Learning File produced by the ACR. It is a recent and comprehensive review of chest imaging. 103
  • I. PHYSICS AND RADIOBIOLOGY All medical imaging is based on general physics principles. An understanding of these principles assists the practicing radiologist to optimize and interpret medical images. The Medical Physics Department offers a twenty-week course covering the Physics of Medical Imaging and Associated Risks (two sessions per week for 1 1/2 hours/session) from the beginning of May to the beginning of September. Attendance at these lectures is mandatory. A preparatory RAPHEX exam is given in June. All first year residents are expected to sit the ABR physics exam in September. 104
  • PHYSICS AND RADIOBIOLOGY REFERENCES Primary Textbooks and Examination Preparation Bushberg, Seibert, Leidholdt, Boone, The Essential Physics of Medical Imaging, The Williams & Wilkins Company, Baltimore Huda, Slone, Review of Radiologic Physics, Williams & Wilkins Instructor handouts and questions General Wolbarst, Physics of Radiology Curry, Dowdey, Murry, Jr. Christensen’s Introduction to the Physics of Diagnostic Radiology Hendee, Ritenour, Medical Imaging Physics Stanton L. Basic Medical Radiation Physics Sprawls, Physical Principles of Medical Imaging, Aspen Publishers, Inc. Maryland Sprawls. Physical Principles of Medical Imaging Radiobiology Radiation Biology Syllabus and Questions For Diagnostic Radiobiology Residents, Radiological Society of North America, 1999 Nuclear Medicine Chandra, Introductory Physics of Nuclear Medicine, 3rd Edition, Lea & Febiger, Philadelphia Sorenson, Physics in Nuclear Medicine, Current Edition, Grune & Stratton, Inc. MRI 105
  • Horowitz, MRI Physics for Radiologists, A Visual Approach, Second Edition, Springer- Verlag Ultrasound Hedrick, Hykes, Starchman, Ultrasound Physics and Instrumentation, Mosby Fish, Physics and Instrumentation of Diagnostic Medical Ultrasound, John Wiley & Sons 106
  • J. VASCULAR AND INTERVENTIONAL RADIOLOGY The purpose of the training program in Vascular and Interventional Radiology is an introduction of the field, to familiarize residents with the clinical accumen and technical skills necessary for the practice of Vascular and Interventional Radiology, and stimulate resident interest in this field. It is expected that after completion of the program, residents will be capable of performing basic diagnostic and interventional procedures. Those interested in performing advanced diagnostic and interventional procedures should pursue further training in a Vascular and Interventional Radiology Fellowship. Performance criteria for each level of training are included within these requirements. The residents' evaluations will reflect heavily on their compliance with these expectations. A supplemental evaluation will be appended to the departmental evaluation for this rotation. I. DAILY PROTOCOL A. Start time: Residents are to report to the Vascular and Interventional Radiology section promptly at 7:30 a.m. daily unless inpatient rounding necessitates earlier arrival. They are to report at 7:00 a.m. on Thursday morning for combined vascular conference at conference room A, and are to arrive at conference room A on the third floor in the main building at 7:30 a.m. Friday morning Interventional Radiology didactic conference. Active inpatients should be seen prior to reporting to the Vascular and Interventional Section. B. Pre-morning report: Residents must evaluate any patient in the department scheduled as "first case" prior to morning report. The procedure must be explained to the patient and consent obtained. Problems such as missing necessary History and Physical, labs or absence of premedication are to be addressed at this time. Questions should be resolved with the assistance of senior residents, fellows, or staff. A thorough understanding of the patient's condition, the indication for the procedure, and the technique involved in performance of the procedure is mandatory. In many cases, this will require specific reading and preparation the evening prior to performance of the procedure. This preparation is prerequisite for any direct resident involvement as the primary operator in the procedure. It is also strongly urged that reading each evening should include material on cases scheduled for the next day, regardless of the anticipated level of involvement in the performance of the procedure. The schedule should be reviewed. History and physical examinations done at the VIR Office Clinic and physician consult sheets filled out during floor consults should be gathered in preparation for morning report. All pertinent images relevant to the diagnostic or therapeutic procedure should be reviewed and hung or opened on PACS in preparation for morning report. Referring physicians should be consulted if appropriate. 107
  • C. Morning report: Morning report begins promptly at 8:00 a.m. each morning. The schedule for the day is reviewed at this time. The fellow and residents are responsible for presenting all available information on patients who are undergoing procedures that day, including a preliminary assessment and plan. A finalized assessment and plan will be generated at this time after discussion with staff radiologists. The "inpatient and consult list" (see below, Section G) is reviewed after discussing scheduled cases. A brief sentence describing each patient should be provided, followed by an update on hospital course, and plan. Following review of inpatients, any hardcopy films should be removed from the viewbox. D. Preprocedure assessment: Preprocedure assessment optimally will occur either in the VIR Clinic or on the wards. Alternatively, this will occur in the department prior to the procedure if it has not previously been done. Preprocedure evaluation includes a history, physical examination, review of pertinent labs and other examinations, formulation of a likely plan, and obtaining informed consent. Informed consent includes 4 parts: 1.) explanation of the procedure in terms that the patient will understand, 2.) expected benefit(s) of the procedure, 3.) expected potential risks of the procedure, 4.) explanation of alternative diagnostic procedures or treatments. E. Procedures: Procedures begin after completion of morning report, which is approximately at 8:30 a.m. Residents ideally should be involved with procedures for patients that they evaluated prior to the procedure. Patients who present to the department without prior assessment should undergo the same evaluation as those seen in the VIR Clinic or on the wards. Residents should not view room turnover time as a chance to take a break. Rather, when a case that a resident is involved in is completed (including a procedure note and postprocedure orders or POM), the resident is expected to seek out tasks necessary for optimal care of our patients, such as performing clinical assessments, counseling of patients, obtaining informed consent, performing ward rounds, or observing/assisting other procedures. If a physician second assistant (in addition to the primary operator and physician first assistant) is already present in an ongoing procedure, then the resident should observe the case from within the room if there are no other clinical demands. If no physician second assistant is present, the resident should gown and glove, and assist in completion of the procedure. Active patients requiring attention during the day will be specified during morning report or during the day by an attending physician or fellow. These clinical duties may at times supersede involvement in procedures. Finally, residents, fellows, and staff are expected to assist with patient preparation if no procedures are occurring, and they are free of other clinical, administrative, or academic tasks. At all times while residents are in procedure rooms, whether performing, assisting, or observing, they are required to wear proper eye, nose and mouth protection. Face shields or goggles with side shields are mandatory. Eyeglasses alone are not sufficient. 108
  • For cases that continue after 5:00 p.m., significant teaching value remains for a physician first and second assistant. It is expected that residents who are not on call will remain in the section after this hour if there is no physician second assistant involved in the case. A break for lunch may be taken at the option of the resident. All procedures are reviewed with an attending prior to the patient being discharged from the department. It is from this review that the dictated report is generated. If more than one resident is on rotation, both residents are equally responsible for all types of procedures and all clinical responsibilities. Seniority will determine case selection and level of involvement in procedures. One didactic presentation is required each month; if more than one resident is on rotation, this will be the responsibility of the senior resident. This presentation must be given prior to completion of the rotation. Degree of involvement in procedures will be determined based on demonstrated ability. Familiarity with the clinical presentation, including history, physical examination, laboratory and other tests, pathophysiology of the disease process, and an appropriate assessment should precede resident involvement in any case. This means that upon entering a procedure room, the chart must be reviewed. The ability to maintain a neat and organized procedure tray, including flush and contrast syringes, is required prior to assisting in the performance of procedures. Residents who perform this duty adequately may then progress to assisting with performance of procedures, which requires familiarity with procedure techniques and understanding of the procedure in progress. Needs of the primary operator should be anticipated and prepared for prior to request. Residents who acquire competent clinical skills and adequacy in the roles of first and second assistant will graduate to primary operator on appropriate cases. F. Dictations: Cases may be dictated during the work day only if there are no ongoing procedures without physician first and second assistants. Otherwise, dictations should be done after completion of all procedures and readout. ALL cases must be dictated prior to departing for the evening. G. Inpatient service: Most inpatients are to be seen daily. This may be accomplished prior to start of the work day or after completion of all procedures and readout in the department. More active patients may be seen both prior to and after the work day. Less active patients may be seen less frequently or dropped from the inpatient list. This will be determined on a case-by-case basis by the attending Interventional Radiologists. As above, experience with performance, assisting in, or observing procedures should not be sacrificed for routine ward rounds. However, active inpatients may require attention during the day concurrent with other procedures. This will be specified during morning report or during the day by an attending physician or fellow. Residents not on the VIR service may occasionally be called on to help cover the VIR inpatient service after hours but prior to 11:00 p.m., when there are two residents and an attending in house. Requests for assistance with the VIR inpatient service will usually come from VIR fellows who take call from home. The requests will be for tasks that are regularly accomplished by junior residents, such as assessing an inpatient’s new 109
  • complaint, examining an access site, or performing a neurovascular assessment. This work will be coordinated with the on call fellow or attending. After 11:00 p.m., residents should not be routinely called to cover VIR clinical service, except as they would normally be contacted for imaging services by other clinical services, such as for performance of a CT scan or providing a wet reading on an imaging test. H. Readout: In addition to review of the procedure which occurs immediately after its completion, all studies will be reviewed a second time exclusively for the teaching benefit of all of those in the section, regardless of whether they were involved in the case or not. Readout will be performed each day after completion of procedures. As this function exists purely for the educational benefit of the trainees, responsibility for its occurrence will rest significantly with them. This entails not leaving the section prior to completion of all procedures, not removing films from the alternator until procedures have been completed, congregating in the reading room at the time that completion of procedures is anticipated, and gathering fellows and staff needed for readout. Films should not be removed from the viewbox before all procedures are completed and there has been an opportunity for readout. I. Film removal: Residents and fellows are responsible for removing any hardcopy films from viewboxes or conference room alternator at the end of the day, and for making sure that they are filed properly in the Interventional Radiology jacket and the master film jacket. J. Call: Residents share "first call" responsibilities with the fellow and PA’s. Emergency call coverage is 24 hours a day, 7 days a week. There is always a staff Interventional Radiologist on call with the resident or fellow. The call schedule is posted in the division and maintained by the Interventional Radiology secretary. It is the residents' responsibility to know when they are on call. In addition to being responsible for emergencies and other pages when on call, the on- call resident, fellow or PA must round on all inpatients on the weekends or other holidays. Preprocedure evaluations also will be done by the on-call resident, fellow or PA on non-working days if procedures are to be performed the following day. If a resident is on call the night before changing rotations, he/she must attend morning report to give preprocedure assessments on patients scheduled for that day and follow-up on inpatients. Any questions about either an emergency call, the course of an inpatient, or about the procedure work-up of any patient, should be addressed with the on-call attending. K. Didactic presentation: A didactic presentation of approximately 30 minutes is required. This will usually be given prior to morning report during the last week of the rotation by the resident. The subject of the presentation will be selected from a list kept by the fellows. The subject should be chosen in conjunction with the fellows and the Division Director to avoid duplication of a previously presented topic within the same academic year. The rotation will be considered incomplete without this presentation.All 110
  • presentations should be in powerpoint or similar format and all will be permanently kept by the section Director. L. Log-book: All residents are required to maintain a log of their procedures to document the type and number of procedures performed during their residency, as well as the outcome and incidence of their complications. This should be done on the computerized database in the Interventional Radiology section (HI-IQ). Resident membership in the SIR is also strongly encouraged. II. PERFORMANCE CRITERIA FOR RESIDENTS In addition to the staged expectations for daily performance of the residents depending on level of training, residents' work done outside of the section will be assessed during morning report, during procedures, and at evening readout. Diligent reading of core text books (see reading list) and literature to result in familiarity with concepts of Vascular and Interventional Radiology commensurate with level of training is expected. Reading should be dictated in part by cases scheduled for the next day or another day in the future. At times, patient care may mandate literature review of a particular disease or procedure. Resident evaluations will depend in part on their achievement of these performance criteria. This will be reflected in the evaluation form included at the end of this document. Level of performance for each of the criteria are expected to vary based on experience. Fulfillment of expected level performance will be categorized as introductory, familiarity, competency, or mastery. At all levels, achievement of performance criteria for previous levels is subsumed. Definitions of these categories are given below. 1.) introductory--the resident has observed at least one of the procedures, and has seen or assisted another person performing the task 2.) familiarity--the resident has seen the task performed enough times to accurately describe technical factors necessary for performance of the task, and may have performed the task with supervision 3.) competency--the resident has observed and performed the task with supervision enough times to be capable of performing the task with direct or indirect supervision, but without explicit direction 4.) mastery--the resident has observed and performed the task with supervision enough times to be capable of performing the task without direct or indirect supervision Educational Goals and Objectives A. First year residents: Patient care: 1. Accurately perform a history and physical examination. 111
  • 2. Reliably handle daily requirements of the inpatients in cooperation with other residents and fellows under staff supervision. 3. Understand endpoints for treatment of inpatients 4. Formulate and execute patient care plans. 5. Diligently review relevant clinical data, e.g., chart, outpatient record, labs, prior imaging exams. 6. Acquire familiarity with the role of first and second assistant for major diagnostic and interventional procedures. 7. Achieve competency with minor invasive procedures, such as myelography, arthrography, and tube maintenance. 8. Gain an introduction to vascular access techniques. Medical knowledge: 1. Understand the physiology and clinical impact of noninvasive procedures such as ankle brachial indices, pulsed volume recording, opening pressure, recirculation times, etc. 2. Discuss the technical skills required for independent performance of minor procedures, such as arthrograms and drainage catheter checks. 3. Describe the clinical relevance of catheter checks, including the need for preliminary films. 4. Participate in daily readout. Interpersonal communication skills: 1. Provide concise and accurate patient presentations. 2. Appropriately obtain informed consent. 3. Produce radiologic reports that are accurate, concise, and grammatically correct. 4. Effectively teach medical students. 5. Communicate effectively with technical and nursing staff in the section. Practice-based learning and improvement: 1. Learn to address each problem individually, tailoring the performance of the diagnostic test to fit the clinical needs. 2. Pursue opportunities for procedural observation and performance, aggressively organize readout and other educational opportunities. 3. Efficiently use Lifelinks and the radiology information system as well as the link to the Brown library to access information. 4. Attend the weekly VIR Fellows’ conference and combined Vascular conference. Professionalism: 1. Demonstrate respect for patients and all members of the healthcare team. 2. Serve as a role model for junior residents and medical students. 3. Respect patient confidentiality. 4. Present one’s self as a professional in appearance and communication. 5. Demonstrate initiative by being available and volunteering services during procedures and between cases. 112
  • 6. Demonstrate willingness to perform additional duties that contribute to the overall patient care and academic interests of the section. Systems-based practice: 1. Attend the vascular VIR conference on Thursday mornings. 2. Demonstrate knowledge of cost effectiveness of procedures such as prophylactic filter placement, endovascular treatment of aneurysms, and peripheral vascular disease vs. surgical intervention B. Second year: Patient care: 1. Demonstrate accurate clinical assessment of the patient, particularly those with vascular disease. 2. Further clinical and patient assessment skills. 3. Improve the ability to tailor diagnostic and therapeutic procedures to suit individual needs. 4. Formulate a treatment plan based on a synthesis of clinical presentation, natural history of disease, and invasive findings. 5. Improve performance of minor procedures. 6. Knowledgeable in performing as first assistant in major interventions. 7. Acquire familiarity with first order selective catheterizations below the diaphragm. Medical knowledge: 1. Develop a working knowledge of the natural history, prognosis and need for therapy in patients with vascular disease. 2. Discuss fluid dynamics and the physiology of noninvasive tests such as ankle- brachial indexes, exercise testing, pulsed-volume recordings. 5. Accurate interpretation of angiograms and pressure measurements. 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 nurses and technologists in the VIR section. Practice-based learning and improvement: 1. Effectively use Lifelinks and radiology information system to access prior labs and reports. 2. Incorporate feedback obtained during morning report and afternoon readout into improved performance. 3. Attend fellows’ VIR conference on Friday mornings. 113
  • Professionalism: 1. Demonstrate initiative by being available and volunteering services during procedures and between cases. 2. Demonstrate willingness to perform additional duties that contribute to the overall patient care and academic interests of the section. 3. Demonstrate respect for patients and all members of the healthcare team. 4. Serve as a role model for junior residents and medical students. 5. Respect patient confidentiality. 6. Present one’s self as a professional in appearance and communication. Systems-based practice: 1. Attend the vascular VIR conference on Thursday mornings. 2. Demonstrate knowledge of cost effectiveness of procedures such as prophylactic filter placement, endovascular treatment of aneurysms, and peripheral vascular disease vs. surgical intervention C. Third Year: Patient care: 1. Master understanding the significance of the clinical presentation and its relevance to the planned procedure. 2. Assimilate available clinical and verbal history prior to initiating any invasive procedure. Medical knowledge: 1. Master the first assistant role during major interventions. 2. Master the understanding of the significance of the clinical presentation and its relevance to the planned procedure. 3. Gain competency with basic diagnostic and interventional procedures. 4. Gain competency with selective catheterization below the diaphgram. 5. Get an introduction to selective catheterization above the diaphragm. Interpersonal communication skills: 1. Become competent in interdepartmental presentation of diagnostic findings and therapeutic interventions. 2. Appropriately obtain informed consent. 3. Produce radiologic reports that are accurate, concise, and grammatically correct. 4. Effectively teach medical students. 5. Communicate effectively with technical and nursing staff in the section. Practice-based learning and improvement: 1. Effectively use Lifelinks and radiology information system to access prior labs and reports. 2. Incorporate feedback obtained during morning report and afternoon readout into improved performance. 3. Attend fellows’ VIR conference on Friday mornings. 114
  • Professionalism: 1. Demonstrate initiative by being available and volunteering services during procedures and between cases. 2. Demonstrate willingness to perform additional duties that contribute to the overall patient care and academic interests of the section. 3. Demonstrate respect for patients and all members of the healthcare team. 4. Serve as a role model for junior residents and medical students. 5. Respect patient confidentiality. 6. Present one’s self as a professional in appearance and communication. Systems-based practice: 1. Attend the vascular VIR conference on Thursday mornings. 2. Demonstrate knowledge of cost effectiveness of procedures such as prophylactic filter placement, endovascular treatment of aneurysms, and peripheral vascular disease vs. surgical intervention. D. Fourth year: Patient care: 1. Master clinical skills. 2. Properly synthesize data including lab and imaging results prior to initiating any procedure. 3. Achieve competency with all invasive diagnostic procedures including first-order selective arteriography, transhepatic cholangiography, antegrade nephrostogram, venography and biliary drainage. 4. Acquire familiarity with advanced interventions such as vena cava filter replacement, angioplasty, intravascular stent placement, central venous access. 5. Get an introduction to complex state-of-the-art intervention such as TIPS procedures, chemoembolization, and neurointervention. Medical knowledge: 4. Gain a thorough understanding of pathophysiology of vascular disease, noninvasive tests, hemodynamics, and angiograms. 5. Read and retain pertinent literature, including research for cases of particular interest. Interpersonal and communication skills: 1. Achieve mastery in departmental presentation of diagnostic findings and therapeutic options. 2. Appropriately obtain informed consent. 3. Produce radiologic reports that are accurate, concise, and grammatically correct. 4. Effectively teach medical students. 5. Communicate effectively with technical and nursing staff in the section. Practice-based learning and improvement: 115
  • 1. Effectively use Lifelinks and radiology information system to access prior labs and reports. 2. Incorporate feedback obtained during morning report and afternoon readout into improved performance. 3. Attend and present at fellows’ VIR conference on Friday mornings. Professionalism: 1. Demonstrate initiative by being available and volunteering services during procedures and between cases. 2. Demonstrate willingness to perform additional duties that contribute to the overall patient care and academic interests of the section. 3. Demonstrate respect for patients and all members of the healthcare team. 4. Serve as a role model for junior residents and medical students. 5. Respect patient confidentiality. 6. Present one’s self as a professional in appearance and communication. Systems-based practice: 1. Attend the vascular VIR conference on Thursday mornings. 2. Demonstrate knowledge of cost effectiveness of procedures such as prophylactic filter placement, endovascular treatment of aneurysms, and peripheral vascular disease vs. surgical intervention. 3. Be able to discuss the relative merits of endovascular versus surgical approach to oncologic, peripheral vascular and neurovascular diseases; i.e. chemoembolization, cholangiography, port placement, metastatic liver disease, uterine artery fibroids, etc. Mechanism of Evaluation Evaluation of residents is performed in an ongoing manner during morning report and afternoon readout. In addition, the attending physicians in the department provide a monthly evaluation of the resident’s performance based on the goals and objectives, as described previously, and finally the residents must maintain a procedure log which is reviewed on an ad hoc basis to assess their level of procedural competence. 116
  • VASCULAR AND INTERVENTIONAL RADIOLOGY READING LIST The core reading is listed below. These references are available in the department. Familiarity with the first two by completion of the second month in the department is expected. 1.) Strandness DE, van Breda A. Vascular diseases: Surgical and Interventional Therapy. Churchill Livingstone; New York, New York 1994. 2.) Kadir S. Diagnostic Angiography. W.B. Saunders; Philadelphia 1986. 3.) Kadir S. Current practice of interventional radiology. B.C. Decker, Inc.; Philadelphia, 1991. 4.) Kadir S. Atlas of normal and variant angiographic anatomy. W.B. Saunders Co.; Philadelphia, 1991. 5.) Abrams HL. Abram's Angiography. Little, Brown and Company; Boston 1996. 6.) Rutherford R. Vascular Surgery. W. B. Saunders Co.; Philadelphia 1989. 7.) Perler B, Becker G. Vascular Intervention. Thieme, New York, 1997. 8.) Connors J, Wojak J. Interventional Neuroradiology. W.B. Saunders Co.; 1999. 9.) Kaufman J, Lee M Vascular and Interventional Radiology;the Requisites; (?ed) 2003 117
  • K. ULTRASOUND Overview: Ultrasound is and will always be one of the primary imaging modalities for rapid noninvasive evaluation of many regions of the human body. Unlike CT and MRI, ultrasound can provide real time multiplanar assessment that requires that the radiologist play an active role during the examination. Therefore, to become an expert in ultrasound a radiologist must be able to scan a patient while understanding the complex anatomy and pathology. I. Introduction: Ultrasound remains the most versatile cross-sectional imaging modality due to its real time nature and multiplanar capabilities. Despite the advances in other modalities such as MR and CT, the volume of ultrasound studies continues to increase, newer applications are discovered and the technology continues to advance. Therefore, it is essential that each radiology resident become well trained in not only the indications and interpretation of ultrasound studies but also in their performance. The learning objectives of a radiology resident in ultrasound should be to develop a working familiarity with the technology and imaging anatomy initially and apply these techniques to answer specific diagnostic questions as deemed appropriate in a current high volume tertiary care academic center. The resident should become skilled at US-guided procedures. The American College of Radiology appropriateness criteria should be used as a guide and learning tool and incorporated into the daily clinical decision making when deemed necessary. Educational Goals and Objectives Resident years I-II A.Patient Care 1. Identify normal ultrasound anatomy and state the indications for examination of a. abdomen b. female and male pelvis c. neck (eg. carotid, thyroid) d. scrotum e. lower extremity deep venous system f. RLQ 2. Perform an ultrasound-guided thoracentesis and paracentesis 3. Perform an ultrasound of the RUQ including assessment of the liver, biliary tree, GB and pancreas 4. Perform an ultrasound of the lower extremity deep venous system from the groin to the popliteal vein. 5. Be able to critique the technical quality of an ultrasound examination 118
  • B. Medical Knowledge 1. Discuss the ultrasound features of the most common diseases involving the - liver - RLQ - gall bladder - uterus - spleen - ovaries - pancreas - prostate - kidneys - bladder - thyroid - testicles/scrotal contents C. Interpersonal and Communication Skills 1. Respond to clinical service requests for interventional ultrasound, portable ultrasound, and routine departmental studies in a logical, professional and organized fashion (eg. insure appropriateness and obtain necessary information for interventional study). 2. Assist ultrasonographers with scanning and medical questions in a timely and professional manner. 3. Participate in the ultrasound sections teaching program by helping with the creation of teaching files and assisting student ultrasonographers with daily interaction and in-service participation. 4. Interpret and dictate all the ultrasound studies in which the resident was directly involved with before the end of the working day. D. 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 E. Professionalism 1. Demonstrate respect for patients and all members of the health care team 2. Respect patient confidentiality 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments F. Systems-based practice 1. Attend GI tumor board and demonstrate understanding of how US imaging is integrated with the clinical care of the patient 2. Demonstrate knowledge of ACR standards for diagnostic ultrasonography 3. Demonstrate knowledge of ACR appropriateness criteria when applicable to ultrasound examinations Residents III & IV 119
  • A. Patient Care 1. Diagnose and discuss the ultrasonographic findings of diseases related to the following organ systems: A. liver and biliary including pancreas B. adrenal, renal, bladder C. spleen D. female GU system including uterus, adnexae, and fallopian tubes E. male GU system including prostate, penis, seminal vesicles, scrotum F. pleural space G. upper and lower extremity deep venous systems H. thyroid I. arterial tree including carotid and intra-abdominal arteries J. neonatal brain (see pediatric radiology rotation) K. musculoskeletal system (optional) L. obstetrical (see Women & Infants' rotation) 2. Demonstrate proficiency at thoracentesis, paracentesis, complete abdominal, pelvic (including transvaginal), vascular and small parts ultrasound during working hours and in the Emergency Room if needed. 3. Perform ultrasound-guided solid organ biopsy and abscess draining using either free hand or transducer guided approaches. B. Medical Knowledge 1. Demonstrate ability to supervise the appropriate imaging evaluation of a specific disease or patient using the ACR appropriateness criteria when appropriate. 2. Demonstrate a working familiarity with all ultrasound machines in the section. C. Interpersonal and Communication Skills 1. Demonstrate interest and ability in teaching first and second year residents. 2. Call the referring physician for positive results 3. Communicate effectively with all members of the health care team D. 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 E. Professionalism 1. Demonstrate respect for patients and all members of the health care team 2. Respect patient confidentiality 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments 120
  • F. Systems-based practice 1. Attend GI tumor board and demonstrate understanding of how US imaging is integrated with the clinical care of the patient 2. Demonstrate knowledge of ACR standards for diagnostic ultrasonography 3. Demonstrate knowledge of ACR appropriateness criteria when applicable to ultrasound examinations III. Resources 1. Teachers Doctors Atalay, Brody, Cronan, Dupuy, Januario, Mayo-Smith, Murphy, Nogueira, Pezzullo, Patil, Ridlen and the cross-sectional imaging fellow are active staff members, one of who will be present during normal working hours. Pediatric ultrasound will be taught by Drs. McCarten, Piccolello, Wallach, Cassese and Januario during the residents pediatric radiology rotation. Obstetrical ultrasound will be taught by the staff radiologists at Women & Infants' Hospital including Drs. Spencer, Koelliker, Lazarus, Golding and Nogueira. Breast ultrasound will be taught by Drs. Koelliker, Lazarus, Mainiero, Schepps and Song. 2. Required Reading A. First two rotations 1. Diagnostic Ultrasound. Rumak CM, Wilson SR, Charboneau JW. Second edition, Mosby Year Book, St. Louis, 1998. Part I Physics Part II Abdominal, pelvic and thoracic sonography Part III Intraoperative sonography Part IV Small parts, carotid artery and peripheral vessel sonography 2. ACR sonography video disk. B. Second two rotations 1. Ultrasonography in Obstetrics and Gynecology. Callen PW. Fourth edition, W.B. Saunders Co., Philadelphia, 2000. 2. Color Doppler Flow Imaging. Foley DW. Andover Medical Publishers, 1991. 3. ACR video disk. 121
  • 3. Additional Reading A. Ultrasound, the Requisites. Kurtz AB, Middleton WD. Mosby, St. Louis, 1996. B. Diagnostic Ultrasound. Rumack et al. Volume II. Obstetrics and Fetal Sonography. Chapters 32-52. Chapter 53, the pediatric brain. C. Gamuts in Ultrasound. Williamson M and Williamson S. W.B. Saunders Co., Philadelphia, 1992. IV. Learning Techniques 1. Daily Work Daily work starts no later than 7:30 a.m. and finishes not earlier than 5:00 p.m. A. Interpretation /dictation of ultrasound examinations. B. Exam supervision. The resident is the initial consultant for the ultrasound staff and clinical staff regarding the indication, scheduling, type of exam to perform and technical quality. The resident consults with the cross-sectional imaging staff and staff radiologist in US or CT regarding any add-on interventional procedures. The resident should scan each patent he or she is involved with and obtain additional hard copy images in complicated or difficult cases. Additional images of interesting cases should be made for the sectional teaching collection. C. Procedures All procedures in the ultrasound department are to be performed by the resident or fellow with direct supervision by the staff radiologist. Certain cases booked for specific attending radiologists may only require resident or fellow assistance. 2. Teaching Files A. The ACR ultrasound video disc should be viewed by the residents during their ultrasound rotation either before the work day commences or after hours. 3. Conferences - GI tumor board every other Thursday 7:00 a.m., George Auditorium - GU radiology Tuesday 4:30 or 5:30 p.m., conference room A 122
  • - breast tumor board every other Thursday 7:00 a.m., conference room A - daily noon conference - GYN oncology conference, Tuesday 7:30 a.m., Women & Infants' conference room - bimonthly imaging conference V Resident Evaluation Tools 1. Monthly evaluations submitted by all participating staff in US ( see monthly evaluation form) 2. Technical staff feedback to Director of Ultrasound regarding resident performance regarding: 1. interaction with support staff 2. technical expertise regarding equipment utilization All evaluations are based on the specific objectives stated in this manual. -Daily work habits and performance assessed -Interactive skills with clinicians and section members assessed -Individual feedback given at end of rotation unless requested earlier by staff or resident 123
  • L. BREAST IMAGING Breast Imaging is located in Suite G 85 in the Medical Office Building. The facility, named in memory of Anne C. Pappas, is a state-of-the-art center that performs not only screening mammography but also diagnostic mammography and a full range of diagnostic breast imaging procedures with the exception of MRI. The Center is open weekdays from 7 A.M. to 5 P.M. The facility accepts both appointments and walk-in patients. The resident rotation begins at 8A.M. In this rotation the resident shall learn BIRADS nomenclature and become proficient in using the PENRAD system for reporting. The resident will also learn the difference between screening and diagnostic mammography and how to perform a diagnostic work-up. (S)he will become familiarized with mammographic positioning and technique and quality assurance including MQSA and ACR requirements. The resident will learn to interpret mammographic images and the use of additional mammographic views for problem solving. (S)he will learn when and how to employ sonography in patient evaluation. In addition, the resident will learn to perform needle localization procedures with both mammographic and sonographic guidance. (S)he may have the opportunity to see ductography performed. Due to the limited number of such cases, it is unlikely that the resident will perform this procedure. The resident will become familiar with needle biopsies of the breast performed with stereotactic and ultrasonographic guidance. Cyst puncture techniques with imaging guidance will also be observed and performed. By the end of the residency program it is expected that each resident will have observed all procedures and become proficient in needle localization with mammographic guidance. Residents will perform some breast interventional procedures. Because of patient or referring physician preference, there are times when the resident may not be permitted to perform, or possibly even observe, certain procedures. The indications and use of radionuclide imaging and magnetic resonance imaging will be discussed. It should be stressed that all diagnostic mammography examinations will be reviewed before the patient leaves the department. If additional views are deemed necessary, they should be performed at the time of the patient's visit. IT IS ESSENTIAL THAT THE REFERRING PHYSICIAN BE NOTIFIED PERSONALLY OF ALL MAMMOGRAMS OR BREAST IMAGING WORK-UPS FOR WHICH BIOPSY IS RECOMMENDED (ALL CODES 4 AND 5). It is also imperative that all breast sonograms be viewed real-time. The resident will be required to know and use BIRADS terminology in reporting. No study shall be reported until it has been checked by the attending radiologist. Educational Goals and Objectives 124
  • First Year: Patient care : 1) Be able to differentiate solid from cystic masses on breast ultrasound 2) Be able to describe the features of malignant and benign lesions on mammography and ultrasound 3) Be able to critique the technical quality of a mammogram 4) Observe breast ultrasound and interventional procedures 5) Understand the indications for interventional breast procedures Medical knowledge: 1) Proper patient positioning for mammography 2) Basic mammographic physics 3) Manifestations of the most common benign and malignant breast diseases such as invasive ductal carcinoma, ductal carcinoma in-situ, fibroadenoma and fibrocystic changes. 4) Sensitivity and specificity of mammography in the detection of breast cancer Interpersonal and communication skills: 1) Call the referring physician for positive results 2) Learn BIRADS terminology for mammography reporting 3) 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) Respect patient confidentiality 3) Present oneself as a professional in appearance and communication. 4) Demonstrate a responsible work ethic with regard to work assignments Systems-based practice: 1) Attend breast tumor board and demonstrate understanding of how breast imaging is integrated with the clinical care of the patient 2) Demonstrate knowledge of ACR standards for diagnostic mammography 3) Demonstrate knowledge of ACR recommendations for screening mammography Second/Third Year: Patient care: 1) Perform breast ultrasound 125
  • 2) Perform ultrasound-guided cyst aspiration 3) Perform needle localization 4) Monitor diagnostic mammograms, selecting the appropriate next study 5) Understand the management of the symptomatic patient, including evaluation of palpable mass, discharge, redness, and pain 6) Appropriately select screening patients for recall 7) Understand indications for breast MR Medical knowledge: 1) Staging of breast cancer 2) Surgical management of breast cancer 3) Manifestations and clinical management of less common breast pathology such as Paget’s disease, inflammatory breast cancer, phylloides tumor, invasive lobular carcinoma, and lobular carcinoma-in-situ. Interpersonal and communication skills: 1) Appropriately obtain informed consent 2) Produce radiologic reports with BIRADS terminology in the PENRAD system 3) 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) Respect patient confidentiality 3) Present oneself as a professional in appearance and communication. 4) Demonstrate a responsible work ethic with regard to work assignments Systems-based practice: 1) Attend breast tumor board and demonstrate understanding of how breast imaging is integrated with the clinical care of the patient 2) Have familiarity with MQSA and its requirements Fourth Year: Patient care : 1) Supervise screening and diagnostic mammography 2) Supervise and perform breast ultrasound 3) Perform uncomplicated ultrasound-guided biopsies 4) Be familiar with the use of stereotactic equipment. 5) Understand the indications and technique of ductography 126
  • 6) Understand indications and technique for breast MR Medical knowledge: 1) Imaging findings of breast reconstruction 2) Evaluation of the patient with breast implants Interpersonal and communication skills 1) Appropriately communicate results to patients and clinicians 2) Produce radiologic reports with BIRADS terminology in the PENRAD system 3) 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) Respect patient confidentiality 3) Present oneself as a professional in appearance and communication. 4) Demonstrate a responsible work ethic with regard to work assignments Systems-based practice: 1) Attend breast tumor board and demonstrate understanding of how breast imaging is integrated with the clinical care of the patient 2) Understand MQSA requirements Mechanism of Evaluation Residents will be evaluated on the above goals and objectives by means of a monthly evaluation form filled out by the breast imaging faculty. In addition, interpersonal and communication skills and professionalism will be evaluated by the mammography technologists. Medical knowledge in breast imaging will be further evaluated by the ACR in-service examination and mock oral board examination. 127
  • Breast Imaging References 1. Teaching Atlas of Mammography 3rd Edition, L. Tabar, P.B. Dean, Thieme Verlag-Stratton, Inc, 2001 2. Breast Imaging. UCSF Interactive Radiology Series, E. Sickles, Lippincott- Williams & Wilkins, 2002 3. Breast Imaging, 2nd Edition. D. Kopans, J.B. Lippincott, 1997 4. The Breast: Comprehensive Management of Benign and Malignant Disease, 2nd Edition. Kirby I. Bland and Edward M. Copeland, Editors. W.B. Saunders, Philadelphia, 1998 5. Diseases of the Breast. Harris, Lippman, Morrow and Hellman. Lippincott- Raven, Philadelphia,1996 6. Practical Breast Pathology. T Tot, L Tabar, PB Dean, Theime, 2002 7. Breast Imaging: A Correlative Atlas. B Hashimoto, D Bauermeister, Theime, 2003 8. Diagnosis of Diseases of the Breast. L. Bassett, V. Jackson, et al, W.B. Saunders, 1997 9. Breast Imaging Companion. G. Cardenosa, Lippincott Raven, 1997 10. Breast Imaging. The Core Curriculum. G. Cardenosa, Lippincott, Williams and Wilkens, 2004. 128
  • M. WOMEN & INFANT’S HOSPITAL INTRODUCTION: The Radiology Department at Women & Infants' performs a wide range of radiology services related to women’s imaging. The resident will be exposed to a high volume of ultrasound, mammography, fluoroscopy, plain film radiography and CT during the rotation and will be directly responsible for these examinations under supervision of an attending physician. It is important for the resident to gain expertise in performing the examination, not only the interpretation of the examination. Resident time performing OB-GYN ultrasound examinations will be encouraged. The resident will be expected to read a specified core of material on women’s imaging and will prepare teaching file cases during the rotation. Emergency exams are performed 24 hours a day, 7 days a week. Emergency exams are to be read after hours by the resident on call. Reports are to be called or faxed to the appropriate ordering physician, with a preliminary report recorded on the patient’s requisition form. DAILY WORK: The radiology resident is in charge of the section with guidance and direction provided by the staff. The resident should report to the department by 8 am. The resident hangs cases, obtains relevant studies and reviews prior reports if indicated. The resident will then review the films and form an impression. All cases will be reviewed by an attending prior to dictation. Any emergent findings will be communicated to the referring physicians during the course of the day. All positive ultrasound examinations are to be reviewed by the resident before the patient is discharged from the department. The positive findings should be confirmed by direct real-time evaluation by the resident. If emergent, the appropriate physician should be contacted. Residents need to review and sign all dictated reports at the beginning of the work day and as often as possible through the day. Resident presence is required in the reading area until the day’s work is finished, usually around 5:30 pm. All dictations for the day should be completed prior to leaving the reading room. The resident is primarily responsible for OB-GYN cases. If staffing allows, the resident will be included in operation of the mammography section and in breast interventional procedures. The staff and residents will be responsible for performing interventional procedures. These include breast biopsies, needle localizations of the breast, stereotactic biopsies, hysterosonograms, hysterosalpingograms, paracenteses and thoracenteses. On the days of the procedure, the resident should review the relevant films with the attending to 129
  • decide on the appropriate approach. The resident will be responsible for obtaining informed consent from the patient. All procedures are performed with the attending present, documented in the final dictation. Residents are responsible for the appropriate labeling of all the specimens and for discharge instructions to the patient. All diagnostic mammograms performed during work hours will be checked by staff or by a resident with attending supervision prior to the patient leaving the department. Additional views and, if appropriate, ultrasound should be performed at the time of the patient’s visit. All breast ultrasound cases should be reviewed real time. Screening exams will be hung on the alternator by the mammography technologist for batch reading. READING: The reading list covers the basic aspects of women’s imaging. Mandatory reading is divided into sections based on the level of the resident. 1. Required Reading A. First Year Residents Kurtz, A, Middleton, W. Ultrasound, the Requisites. Mosby, 1996. Chapters 7-16- Obstetrics Chapters 17-19- Gynecology B. 2nd to 4th Year Residents Callen, PW. Ultrasonography in Obstetrics and Gynecology, W.B. Saunders, 2000. Chapters 10-17- Fetal abnormalities Chapters 29, 31, 24- GYN, US and MRI Chapters 2, 3, 4- Chromosomal abnormalities 2. Supplemental Reading Fleischer AC, et al Sonography in Obstetrics and Gynecology McGraw-Hill 2001 Hunt RB, Seigler AM Hysterosalpingography Techniques and Interpretation Year Book- 1990 130
  • Kopans DB. Breast Imaging Lippincott, 1998. TEACHING CASES: One “case of the week” presentation will be submitted by the resident during each rotation. The resident will choose an interesting case, display it as an unknown “case of the week” in the department and write a page summary of the case for display. The teaching file for the department is in the Chief’s office. The resident has access to the file during the rotation. The resident also has access to the internet for teaching. CONFERENCES: The resident is expected to attend the noon Radiology conference at Rhode Island Hospital. In addition, the resident should attend one GYN-ONC Tumor Board conference during their rotation. These are held at 7:30 am every Tuesday. The Breast Tumor Board and Antenatal Management Conference are at noon on Thursday and Friday and should be attended if no radiology conference is scheduled. The GI Tumor Board is held on Monday twice a month at 7:30 am. The resident is encouraged to attend. Women & Infants' Grand Rounds are every Thursday at 7:30 am. The topics for Grand Rounds are posted in the reading area. The resident should attend the Grand Rounds presentations which are relevant to women’s imaging. GENERAL OBJECTIVES: The general objective of the rotation is to become familiar with the scope of women’s imaging and to receive adequate training in the interpretation of women’s imaging studies and in performance of OB-GYN ultrasound interventional procedures in the department. EDUCATIONAL GOALS & OBJECTIVES: A. Residents on the 1st & 2nd month of rotation: At the end of the second month a resident should have the following objectives and will be evaluated on these objectives as outlined below. Patient Care: 1. Perform fluoroscopy for all radiographic procedures. 2. Perform pelvic examinations and insert intra-uterine catheters for interventional procedures. 131
  • 3. Understand the reasons for performing needle localizations, breast cyst aspirations, breast biopsies and be able to perform the procedure. 4. Perform paracenteses and thoracenteses. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. Medical Knowledge: 1. Describe the pertinent anatomy on ultrasound, CT, mammography and plain film exams. 2. Recognize and describe radiographic findings. 3. Discuss the most common pathologic entities and an appropriate differential diagnosis should be provided. 4. Understand the reasons for performing an interventional procedure. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. 2. ACR in service exam. 3. Mock Oral Board exam. 4. Imaging conference presentations. Interpersonal and Communication Skills: 1. Appropriately obtain informed consent. 2. Appropriately communicate and document urgent or unexpected radiologic findings. 3. Produce radiologic reports that are accurate, concise and grammatically correct. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. 2. Dictation sample review. Practice-based Learning and Improvement: 1. Attend Tumor Board conferences and Grand Rounds when appropriate. 2. Efficiently use electronic and print resources to access information. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. 2. Conference attendance. 132
  • Professionalism: 1. Demonstrate respect for patients and all members of the health care team. 2. Respect patient confidentiality. 3. Present oneself as a professional in appearance and communication. 4. Demonstrate a responsible work ethic with regard to work assignments. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. Systems-based Practice: 1. Attend Tumor Boards and Grand Rounds when appropriate. 2. Demonstrate knowledge of ACR standards and appropriateness criteria for OB/GYN imaging. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. 2. Imaging conference presentations. 3. Conference attendance. B. Residents on the 3rd & 4th months of rotation will have additional goals and objectives beyond the 1st & 2nd month rotation as follows: Patient Care: 1. Develop a management plan based on radiologic findings and clinical information. 2. Plan and perform all interventional cases competently. 3. Perform a proficient obstetrical and gynecological ultrasound examination. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. Medical Knowledge: 1. Establish a precise diagnosis and provide pertinent differential diagnosis. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. 133
  • 2. ACR in service exams. 3. Mock Oral Board exam. 4. Imaging conference presentations. Interpersonal and Communication Skills: 1. Effectively teach junior residents and medical students. 2. Communicate effectively as a women’s imaging consultant with all members of the health care team. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. Professionalism: 1. Serve as a role model for junior residents and medical students. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. Systems-based Practice: 1. Demonstrate knowledge of cost-effective imaging practices. 2. Demonstrate knowledge of how radiologic information is integrated with the other parts of the health care system in the treatment of the patient. The above will be evaluated by: 1. Monthly rotation evaluation by faculty. RESOURCES: Drs. Spencer, Koelliker, Golding, Hillstrom, Lazarus and Livingston are responsible for the organization and supervision of the Women & Infants’ rotation. 134
  • N. AFIP During the third year a one month rotation has been set aside to allow the resident an education in areas not available at Rhode Island Hospital. The department hopes that all third year residents will spend six (6) weeks at AFIP. If, however, because of time constraints or financial considerations, this is impossible, other alternatives may be made available. If a suitable rotation in an area not otherwise available at Rhode Island Hospital or Women & Infants' Hospital can be arranged, it would occur during this time. All such rotations must be approved in advance by the Education committee and no assurances of funding are to be assumed. Should no such imaging rotation be arranged, the Education committee will assign a rotation to the resident based upon consideration of a) the resident's overall interests, b) the residents performance on previous rotations, and c) the availability of rotations. In no way should this month be assumed to be an elective month based upon the discretion of the resident alone. By design this program is a structured one. Request for "elective" time will be weighed on their individual merit. 135
  • O. ELECTIVE An additional month of elective time is available in the fourth year and, potentially, in the third year if the schedule permits. The decision as to whether or not elective time is granted is at the discretion of the education committee. Requests for elective time must be submitted to Dr. Mainiero by February of the preceding year. In order for an elective request to be granted, the elective must be of equal educational value to the standard rotations of the curriculum. The elective must have a defined set of goals and objectives and there must be a designated faculty advisor from the Department who is responsible for obtaining a written evaluation for the month. Elective time can be spent in a variety of educational endeavors, including clinical or lab research, electives at the medical school, or time on other clinical services. 136
  • P. NEURORADIOLOGY/MRI NEURORADIOLOGY General Objectives: An integrated approach to neuroradiologic training is obtained for the resident during their rotations through MRI, CT and Interventional radiology. A rich experience in all forms of neuroradiologic imaging and in depth exposure to the evaluation and treatment of neuroradiologic diseases is obtained primarily at the Rhode Island Hospital campus, which serves as the primary and tertiary referral site for most significant neurologic diseases with a referral population base of approximately one million people. Additional exposure to community based neuro MR is obtained through a one month rotation at the Miriam Hospital. Attendance at weekly clinical neurosurgery and neurology conferences is encouraged. Here active imaging cases of the week are discussed in terms of patient clinical presentation, imaging findings, treatment and outcome. Neuroradiology lectures are also presented to the residents by Brown Neuroradiology Faculty on a bimonthly basis that adhere to a defined syllabus. Syllabus topics are then supplemented with case conferences and board review sessions as the year progresses. Daily Work: During CT and MRI rotations the resident is responsible for determining patient history, assessing the relevance of the imaging exam and its relationship to prior imaging, reviewing the study and coming to an independent assessment of the findings. All cases are then reviewed with the Attending Radiologist. The resident is then responsible for formulating and performing the study dictation which is subsequently reviewed and corrected by the Attending. During the interventional radiology rotation the resident is responsible for patient history review and formulation of a procedure plan. All procedures are performed under the guidance of the Attending Radiologist. Residents are trained in the performance of basic and advanced diagnostic and interventional neuroradiologic procedures. Resources: Neuroradiology Attending Staff Drs. Rogg, Davis, Tung, Haas, Gold, Boxerman Cross Sectional Attending Staff Drs. Brody, Dupuy, Mayo-Smith, Murphy Interventional Attending Staff Drs. Lambiase, Murphy, Dubel 137
  • Neuroradiology film and computer based teaching file in MR Web-based neuroradiology teaching program(developed at Brown) ACR Teaching File Internet Resource Capability AJNR, pub med etc. Educational Goals and Objectives First and Second Year Residents: Patient Care: 1. Develop an understanding of the strengths/weaknesses of diagnostic tests for achieving a neuroradiologic diagnosis (CT, MRI, Angiography, Myelography) relative to other diagnostic tests for achieving a diagnosis. 2. Become familiar with the risks/contraindications of neuroradiologic procedures. 3. Become familiar with the contrast agents doses/risks/contraindications used in neuroradiologic imaging. 4. Become familiar with the protocol for treatment of contrast reactions. 5. Demonstrate proper technique and planning in performing myelography and angiography. Medical Knowledge: 1. Become familiar with Neuroanatomy (brain/spine/vascular). 2. Develop an understanding of the MRI features of neoplastic/inflammatory/ degenerative/metabolic/congenital diseases of the CNS. 3. Be able to develop an image based differential diagnosis for brain and spine. Understand principles of CT/MR Imaging (Physics of image acquisition) 4. Understand MRI sequence design-strengths/weaknesses for achieving an expected diagnosis. Interpersonal Communication Skills: 1. Consultation with clinicians who come to review imaging studies. 2. Verbalization of observation and interpretation leading to a useful differential diagnosis. 3. Organize cases and present a lucid description of patient’s clinical problem as well as past medical history and surgical history prior to image interpretation. 4. Dictate cases in an organized, succinct and informative fashion. Practice Based Learning and Improvement: 1. Review all cases and present findings with differential diagnosis to the attending. The attending interprets and modifies or corrects preliminary interpretation. 2. Review attendings' Resident Evaluation form. Discuss comments when pertinent. 3. Learn to access and incorporate Pub Med and Google Searches in interpretive armamentarium. 138
  • 4. Attend Clinical Conferences in Neurology, Neurosurgery, and Neuropathology (RIH) Professionalism: 1. Demonstrate respect for all patients. 2. Serve as role model from medical students and residents in other specialties. 3. Respect patient confidentiality. 4. Present oneself as professional in appearance and communication. 5. Demonstrate a responsible work ethic with regard to work assignments. Systems-based Practice: 1. Attend clinical conferences in Neurosurgery, Neurology, and Neuropathology (RIH) 2. Gain an understanding of the integration of imaging findings with clinical findings in obtaining a focused differential diagnosis. 3. Gain an understanding of the relative costs and benefits of MRI, CT, myelography and angiography. 4. Demonstrate knowledge of ACR appropriatness criteria through discussion with attending Staff and case presentation at Imaging Conference. Third and Fourth Year Residents Patient Care: 1. Demonstrate an understanding of the strengths/weaknesses of diagnostic tests for achieving a neuroradiologic diagnosis (CT, MRI, Angiography, Myelography) relative to other diagnostic tests for achieving a diagnosis. 2. Obtain informed consent, explaining to patients the risks/contraindications of neuroradiologic procedures. 3. Demonstrate knowledge of contrast agents doses/risks/contraindications used in neuroradiologic imaging. 4. Appropriately treat contrast reactions. 5. Demonstrate proper technique and planning in performing myelography and angiography. 6. Produce an appropriate differential diagnosis based upon imaging findings Medical Knowledge: 1. Demonstrate knowledge of neuroanatomy (brain/spine/vascular). 2. Understand the MRI features of neoplastic/inflammatory/ degenerative/metabolic/congenital diseases of the CNS. 3. Understand principles of CT/MR Imaging (Physics of image acquisition) 4. Understand MRI sequence design-strengths/weaknesses for achieving an expected diagnosis. Interpersonal Communication Skills: 139
  • 1. Consultation with clinicians who come to review imaging studies. 2. Verbalization of observation and interpretation leading to a useful differential diagnosis. 3. Organize cases and present a lucid description of patient’s clinical problem as well as past medical history and surgical history prior to image interpretation. 4. Dictate cases in an organized, succinct and informative fashion. Practice Based Learning and Improvement: 1. Review all cases and present findings with differential diagnosis to the attending. The attending interprets and modifies or corrects preliminary interpretation. 2. Review Attendings' Resident Evaluation form. Discuss comments when pertinent. 3. Learn to access and incorporate Pub Med and Google Searches in interpretive armamentarium. 4. Attend Clinical Conferences in Neurology, Neurosurgery, and Neuropathology. Professionalism: 1. Demonstrate respect for all patients. 2. Serve as role model for junior residents. 3. Respect patient confidentiality. 4. Present oneself as professional in appearance and communication. 5. Demonstrate a responsible work ethic with regard to work assignments. Systems-based Practice: 1. Attend clinical conferences in Neurosurgery, Neurology, and Neuropathology (RIH) 2. Gain an understanding of the relative costs and benefits of MRI, CT, myelography and angiography. 3. Demonstrate knowledge of ACR appropriateness criteria through discussion with Attending Staff and case presentation at Imaging Conference. Mechanism of Evaluation Medical knowledge in neuroradiology will be assessed by the ACR in-service examination and the mock oral board examination. In addition, after the completion of each month on MRI and at The Miriam Hospital a global evaluation form will be completed by the neuroradiology faculty. 140
  • NEURORADIOLOGY REFERENCES HEAD CT: There are two alternate basic textbooks which are particularly helpful in terms of normal anatomy and evaluation of trauma. Cranial Computed Tomography Williams & Haughton or Cranial Computed Tomography Lee & Rao Good supplements to these textbooks particularly in regards to white matter disease and tumors is MRI of the Brain and Spine by Atlas, Ruth Ramsey's Textbook on Neuroradiology or the two volume set by Latchaw. SPINE: The standard reference for myelography continues to be the textbook Myelography by Shapiro. MRI references include MRI of the Brain and Spine by Atlas or Cranial and Spinal MRI by Daniels and Diagnostic Neuroradiology by Osborne. MRI: 1. Neuroradiology :The Requisites by Grossman and Yousem, 2003. This book seems to have been accepted by the recent residents as favorite, readable text. Some of the information is a bit diffuse and incomplete however it is an overall excellent text. Make sure you get the new edition. 2. Neuroradiology Companion by Mauricio Castillo, 2002 is a short overview of the field of neuroradiology. 3. An excellent read is Osborn AG. Diagnostic Neuroradiology. Mosby-Yearbook, 1994. This has always been my favorite overall neuroradiology text but does not include such newer techniques as perfusion, diffusion and spectroscopy. 4. Osborn has recently come out with a new text in the format of The Neuroradiology Companion entitled Diagnostic Imaging:Brain by Amirysis Publishers. This book is organized into typical categories of disease found in other textbooks however information is presented in outline format This format is difficult to understand as an initial read in neuroradiogy. 5. Atlas S. Magnetic Resonance Imaging of the Brain and Spine. Lippencott/Raven 2002. An excellent reference for in-depth reading on a neuroradiologic topic. 6. Barkovich AJ. Pediatric Neuroimaging. Raven Press 2000. An excellent pediatric neuroradiology text that should be read if possible during later rotations through MR to supplement Osborn. 7. Harnsberger HR. Handbook of Head and Neck Imaging Mosby, 1995. An excellent review of head and neck anatomy and pathology. This book should be 141
  • reviewed prior to boards as it contains essential information not available in general neuroradiology texts. 8. Som PM and Curtin HD. Head and Neck Imaging. 3rd Edition. Mosby- Yearbook, 1996. This is a comprehensive text on head and neck imaging and should be read as the specific need arises. Grossman's Neuroradiology: The Requisites should be considered the primary resourse for neuroradiology rotation.. This should be supplemented with review of Pediatric Neuroradiology by Barkovich for congenital spine and toxic metabolic brain disorders. ARTERIOGRAPHY: Osborne's textbook Cerebral Angiography remains easily readable and comprehensive. More detailed anatomic data can be found in the 5-volume set by Newton and Potts. PEDIATRICS: The handiest reference to use is Pediatric Neuroradiology by Bakovich, copyright 2000. Barkovich also has an excellent textbook particularly in terms of normal development, ischemic changes and congenital abnormalities. HEAD AND NECK: Head and Neck Imaging by Som, Curtin et al, 2000. This is an excellent reference for pathology and CT imaging as well as less commonly performed imaging tests such as sialography and dacrocystography. The paperback edition from Harnsberger, Synopsis of Head and Neck Imaging, is a comprehensive review of the anatomy, basic pathology and differential diagnosis of head and neck radiology. Review of this work is encouraged during the neuroradiology rotation 142
  • MAGNETIC RESONANCE IMAGING INTRODUCTION The key elements for learning magnetic resonance imaging are: 1) Didactic instruction concerning the physical principles of the technique. 2) Exposure to a large volume of cases that include an array of neuro (brain and spine), musculoskeletal, and abdominal MRI exams. 3) An organized approach to studying a specified core of material concerning MRI physics and the anatomy and pathology of the body systems where MRI has its greatest application. DAILY WORK/RESPONSIBILITIES The radiology resident is key to the smooth operation of the MRI section. At the beginning of the work day the resident with the assistance of the cross-sectional fellow should review all exam requests for appropriateness and assign a focused imaging protocol. The resident will then hang all cases available for review (to be evenly divided with the cross-sectional fellow), and make an assessment of the study supported by provided clinical information, consultation with the referring clinician (when necessary), and comparison with prior studies (when necessary). When this review is completed the attending radiologist reads out with the resident with attention to the salient anatomic and pathologic features presented by the case and develops with the resident a focused differential diagnosis. At the end of this review the resident is responsible for dictating all cases reviewed with him/her by the attending. The quality of this dictation is then checked by the attending and discussed when necessary. Each resident will be responsible for approximately twenty-five to thirty cases per day. Throughout the day the resident will serve as the consult to his colleagues or referring physicians. The fellow and attending covering the sections are available throughout the day to support these consults. READING A reading list is enclosed that covers a review of the physical principles of MRI. Other components of the reading list include texts dealing with magnetic resonance imaging in neuroradiology, musculoskeletal radiology, and portions of selected texts in MRI applications in body imaging. A teaching file is available for resident review that includes an assortment of neuro., musculoskeletal, and abdominal imaging cases. 143
  • A computer resource center is available for residents use adjoining the MRI reading room. Currently available to the resident is a computer based neuroanatomy teaching file, a neuroimaging/neuropathology teaching file developed at Brown, and a musculoskeletal teaching file developed by Nycomed. CONFERENCES Didactic conferences are provided concerning MRI physics as part of the general radiology physics curriculum. Two additional hours of practical imaging physics are provided as a part of the clinical conference curriculum. One hour conferences are provided during the lunch hour daily with approximately four hours per month dedicated to MRI imaging in neuro., musculoskeletal and abdominal applications. The curriculum is attached. All residents are required to attend clinical conferences. These are 1) neurosurgery, Monday morning 8:00 a.m. to 9:00 a.m. (resident should arrive in department at 7:30 a.m. to organize films on Monday); 2) neurology, Wednesday 9:40 a.m. to 10: 30 a.m.; 3) sports medicine, 7:00 a.m., specific dates to be announced; and 4) foot and ankle conference, 7:00 a.m., specific dates to be announced. GENERAL OBJECTIVES The residents will acquire adequate training in triaging, protocoling and interpreting MRI examinations. Specific Educational Goals and Objectives First and Second Year Residents: Patient Care: 1. Develop an understanding of the strengths/weaknesses of MRI relative to other diagnostic tests for achieving a diagnosis. 2. Learn the risks/contraindications of the MR examination. 3. Become familiar with the contrast agents used in MRI as well as doses and risks. 4. Learn the protocol for treatment of contrast reactions. 5. Become familiar with MRI protocol design for evaluating the various organ systems and disease processes studied by MRI. Medical Knowledge: 1. Become familiar with anatomy of CNS, joints of the body, general cross sectional anatomy. 2. Develop an understanding of the MRI features of neoplastic/inflammatory/ degenerative/metabolic diseases of the body. 3. Understand basic principles of MR Imaging (Physics of image acquisition) 144
  • Interpersonal Communication Skills: 1. Communicate results to clinicians who come to review imaging studies. 2. Verbalization of observation and interpretation leading to a useful differential diagnosis. 3. Organize cases and present a lucid description of patient’s clinical problem as well as past medical history and surgical history prior to image interpretation. 4. Dictate cases in an organized, succinct and informative fashion. Practice Based Learning and Improvement: 1. Review all cases and present findings with differential diagnosis to the attending. The attending interprets and modifies or corrects preliminary interpretation. 2. Review Attendings' Resident Evaluation form. Discuss comments when pertinent. 3. Learn to access and incorporate Pub Med and Google searches in interpretive armamentarium. 4. Attend Clinical Conferences in Neurology, Neurosurgery, Foot and Ankle, Musculoskeletal Imaging (RIH). Professionalism: 1. Demonstrate respect for all patients. 2. Serve as role model for medical students and residents in other specialties. 3. Respect patient confidentiality. 4. Present oneself as professional in appearance and communication. 5. Demonstrate a responsible work ethic with regard to work assignments. Systems-based Practice: 1. Attend clinical conferences in Neurosurgery, Neurology, Neuropathology, Foot and Ankle, Sports Medicine (RIH). 2. Gain an understanding of the integration of MR imaging findings with clinical findings in obtaining a focused differential diagnosis. 3. Gain an understanding of the relative costs and benefits of MRI compared to CT and other imaging modalities. 4. Become familiar with ACR appropriatness criteria through discussion with attending staff and case presentation at Imaging Conference. Third and Fourth Year Residents Patient Care: 1. Understand the strengths/weaknesses of MRI relative to other diagnostic tests for achieving a diagnosis. 2. Be familiar with the risks/contraindications of the MR examination. 3. Be familiar with the contrast agents used in MRI as well as doses and risks. 4. Treat contrast reactions appropriately 145
  • 5. Utilize appropriate MRI protocols for evaluating the various organ systems and disease processes studied by MRI. Medical Knowledge: 1. Be familiar with anatomy of CNS, joints of the body, general cross sectional anatomy. 2. Understand the MRI features of neoplastic/inflammatory/ degenerative/metabolic diseases of the body. 3. Be able to develop an image based differential diagnosis for anatomic regions typically imaged by MRI (CNS, MSK, Vascular, Liver and Abdomen, Pelvis/Urogenital). 4. Understand principles of MR Imaging (Physics of image acquisition) 5. Understand MRI sequence design-strengths/weaknesses for achieving an expected diagnosis. Interpersonal Communication Skills: 1. Function as a consultant for clinicians who come to review imaging studies. 2. Verbalization of observation and interpretation leading to a useful differential diagnosis. 3. Organize cases and present a lucid description of patient’s clinical problem as well as past medical history and surgical history prior to image interpretation. 4. Dictate cases in an organized, succinct and informative fashion. 5. Teach junior residents MRI skills. Practice Based Learning and Improvement: 1. Review all cases and present findings with differential diagnosis to the attending. The attending interprets and modifies or corrects preliminary interpretation. 2. Review Attendings’ Resident Evaluation form. Discuss comments when pertinent. 3. Learn to access and incorporate Pub Med and Google Searches in interpretive armamentarium. 4. Attend Clinical Conferences in Neurology, Neurosurgery, Foot and Ankle, Musculoskeletal Imaging (RIH) Professionalism: 1. Demonstrate respect for all patients. 2. Serve as role model for junior radiology residents as well as residents and students in other specialties. 3. Respect patient confidentiality. 4. Present oneself as professional in appearance and communication. 5. Demonstrate a responsible work ethic with regard to work assignments. Systems-based Practice: 146
  • 1. Attend clinical conferences in Neurosurgery, Neurology, Neuropathology, Foot and Ankle, Sports Medicine (RIH). 2. Understand the integration of MR imaging findings with clinical findings in obtaining a focused differential diagnosis. 3. Understand the relative costs and benefits of MRI compared to CT and other imaging modalities. 4. Demonstrate knowledge of ACR appropriatness criteria through discussion with Attending Staff and case presentation at Imaging Conference. Mechanism of Evaluation At the completion of each monthly rotation the MRI faculty will complete a global rating evaluation form. In addition, the technologists will also evaluate the residents by providing feedback to the lead MR technologist who will complete a monthly evaluation form. RESOURCES Drs. Jeffrey Rogg, Glenn Tung and Jeffrey Brody are responsible for the organization and supervision of the MRI rotation. Drs. Jeffrey Rogg, Glenn Tung, Jerrold Boxerman and Lawrence Davis are primarily responsible for the supervision of instruction in neuroradiologic applications of MRI. Drs. Scott Levine, Damien Dupuis, Glenn Tung, and Jeffrey Brody will be primarily responsible for the supervision of instruction in musculoskeletal applications of MRI. Drs. Jeffrey Brody, William Mayo-Smith, and John Pezzullo will be primarily responsible for the supervision of instruction in abdominal and pelvic imaging applications of MRI. Approximately 16,000 exams are performed each year. The resident will be exposed to high field (1.5T Siemens Vision and Symphony) A computer MRI resource center is available for the residents use, as is an extensive teaching file. A complete list of subjects to be covered in MRI will be provided in the core curriculum syllabus. 147
  • MRI REFERENCES The resident is advised to plan a schedule for regular reading and study based on the following references: Physics 1. Mitchell D. MRI Principles. Saunders 1999. A new comprehensive but readable text written by an MRI clinician. Contains explanations of basic and advanced techniques. 2. Edelman RR and Hesselink JR. Clinical Magnetic Resonance Imaging. WB Saunders, Co. 1996 Recommended reading as an introduction to MRI physics includes selected chapters in Part I. Physics and Instrumentation: Chapters 1,3,4,5,7,8,9,10 and 13. Neuro See Neuroradiology Section. Musculoskeletal 1. Stoller DW. Magnetic Resonance Imaging in Orthopedics and Sports Medicine. Lippincott, 1993, . Ch 3,4,5,6,7,8,12,13. A good general reference textbook on musculoskeletal imaging that should be read during the 2nd and 3rd rotations. Additional texts specific to knee, ankle and foot, and shoulder are available on request. 2. Stoller DW. MRI, Arthroscopy and Surgical Anatomy of the Joints. Lippincott- Raven 1999. A beautifully illustrated atlas presenting difficult anatomy. Should be reviewed during 1st two months in MRI. 3. Stoller DW. Imaging:Musculoskeletal. Amirysis. A beautifully illustrated, complete book presented in outline form. Excellent for review. Difficult first read on a topic. Abdomen and Pelvis 1. Edelman, Hesselink, Zlatkin. Clinical Magnetic Resonance Imaging. W.B. Saunders Comp., 1996. Ch. 45,46,48,49,50,51. An excellent general text 148
  • covering essential areas of abdominal MRI. Should be read during 3rd rotation through MR. 149
  • Q. MEDICAL OFFICE COMPLEX (MOC) The Medical Office Complex provides a unique opportunity for the resident to focus on outpatient imaging since the services offered are identical to those of a private practice office. The emphasis will be on prompt delivery of service to outpatients. An attending radiologist assigned to this area will permit the resident participation in office operations consistent with their level of experience. As in an outpatient office setting, there are a number of different examinations being performed. The resident will participate in plain film interpretation. CT scan requests in the MOC should be evaluated prior to the patient entering the scan room. The patient should be interviewed when appropriate. In addition, determination of the need for contrast should be made. The study should be previewed prior to the patient being discharged. Interpretation of these CT scans will be done under the direction of the attending physician, and when necessary consultation will be obtained with the CT service in the main hospital. Outpatient ultrasound offered in the MOC provides a mixture of all types of examinations. In general outpatients are more mobile than those in the hospital and provide the resident also with an opportunity to perfect the scanning technique. Thus, it is important that the resident utilize whatever free time available to actually perform scanning. Again, interpretation of the ultrasounds will be done with the attending radiologist. If need be, these scans can be brought to the main ultrasound area for further consultation. The MOC offers an extremely high volume of plain films involving sports medicine, trauma, orthopedic oncology, and rheumatology. Therefore, the MOC will serve as the primary plain radiography musculoskeletal rotation. The resident will be required to submit two musculoskeletal cases to the teaching file per each month. Educational Goals and Objectives First-year Residents Patient Care: 1. Be able to critique the technical quality of a radiograph 2. Understand the indications for more advanced imaging (ultrasound/CT/arthrography/MRI) 3. Be able to protocol, with assistance, musculoskeletal examinations Medical Knowledge: 1. Fundamental understanding of basic orthopedic radiology, pertinent normal anatomy in a musculoskeletal radiograph 150
  • 2. Recognize and describe, in a systematic fashion, radiographic findings on a radiograph 3. Begin to categorize and organize subdivisions of musculoskeletal radiology such as rheumatology, neoplasm, infection, etc. 4. Should be able to distinguish an aggressive process, such as malignant tumor or infection, from a more benign process, such as a benign bone tumor, based on specific radiographic findings 5. Be facile with basic orthopedic concepts. The resident should be able to very specifically and accurately describe a fracture such that the referring orthopedic surgeon would be able to envision the fracture in three dimensions. The resident should have a grasp on basic classification systems of fractures such as intracapsular vs. extracapsular, as well as named fracture such as Monteggia, Galeazzi, etc. 6. Discuss the most common musculoskeletal pathologic entities 7. Have a basic understanding of technique and indications for arthrography, bone biopsy and other invasive procedures. Additionally, the residents should be well aware of the strengths and limitations of musculoskeletal MRI and computed tomography in the evaluation of musculoskeletal disorders. Indications for radionuclide bone scanning should also be understood, as should the basic concepts of this imaging modality, and interpretation of some of the more common bone scans. Interpersonal and Communication Skills: 1. Call referring physicians for positive results 2. Communicate effectively with all members of the health care team Practice Based Learning and Interpretation: 1. Identify, rectify and learn from personal error 2. Incorporate feedback into improved performance 3. Use electronic and print resources to access information Professionalism: 1. Demonstrate respect for patients and members of health care team 2. Repeat patient confidentiality 3. Come to work with a professional appearance 4. Demonstrate a responsible work ethic Systems-Based Practice: 1. Demonstrate knowledge of ACR standards 2. Attend imaging conferences 3. Attend orthopedic grand rounds when possible 4. Attend orthopedic bone tumor conferences when possible Second and Third Year Residents 151
  • Patient Care: 1. Protocol CT and MRI exams without assistance 2. Monitor musculoskeletal CT exams 3. Understand indications for MRI 4. Perform, with assistance, musculoskeletal ultrasound Medical Knowledge: 1. Increasingly facile with orthopedic radiology 2. More detailed knowledge of neoplastic, metabolic, infectious and rheumatologic disorders is warranted 3. Discuss the most common techniques in musculoskeletal imaging, the indications and contra-indications and complications of the following: plain film and fluoroscopy musculoskeletal scintigraphy arthrography musculoskeletal biopsy CT MRI 4. Describe pertinent normal anatomy on MRI’s of shoulder, knee, foot and ankle Interpersonal and Communication Skills 1. Communicate effectively with patients and all member of the health care team 2. Function as a consultant in musculoskeletal radiology yet be free to obtain more experienced opinions Practice-based Learning and Interpretation 1. Identify, rectify and learn from personal error 2. Incorporate feedback into improved performance 3. Use electronic and print resources to access information Professionalism: 1. Demonstrate respect for patients and members of health care team 2. Repeat patient confidentiality 3. Come to work with a professional appearance 4. Demonstrate a responsible work ethic Systems-Based Practice: 1. Demonstrate knowledge of ACR standards 2. Attend imaging conferences 3. Attend orthopedic grand rounds when possible 4. Attend orthopedic bone tumor conferences when possible 152
  • 5. Greater participation in unknown case analysis at noon conference is expected Fourth Year Residents Patient Care: 1. Protocol CT and MRI examinations without assistance 2. Monitor musculoskeletal CT and MRI exams 3. Understand indications for CT contrast and gadolinium 4. Perform musculoskeletal ultrasound of shoulder and knee Medical Knowledge: 1. Discuss the radiographic findings of all musculoskeletal pathology 2. Establish a precise diagnosis and provide a pertinent differential diagnosis 3. Orient and supervise the investigation of a patient or of a specific disease 4. Discuss MRI findings of musculoskeletal pathology 5. Understand and appreciate orthopedic procedures of greater complexity such as joint replacement, osteotomies, spinal fixation 6. Be able to streamline the diagnostic imaging work-up for a specific musculoskeletal abnormality Interpersonal and Communication Skills: 1. Communicate effectively with patients and all member of the health care team 2. Function as a consultant in musculoskeletal radiology yet be free to obtain more experienced opinions Practice-based Learning and Interpretation: 1. Identify, rectify and learn from personal error 2. Incorporate feedback into improved performance 3. Use electronic and print resources to access information Professionalism: 1. Demonstrate respect for patients and members of health care team 2. Repeat patient confidentiality 3. Come to work with a professional appearance 4. Demonstrate a responsible work ethic Systems-Based Practice: 1. Demonstrate knowledge of ACR standards 2. Attend imaging conferences 3. Attend orthopedic grand rounds when possible 4. Attend orthopedic bone tumor conferences when possible 5. Greater participation in unknown case analysis at noon conference is expected 153
  • Mechanism of Evaluation At the completion of each month, the appropriate faculty will complete a global rating evaluation form. 154
  • Required Reading 1. The Language of Fractures. Robert J. Schultz. Chapter 1. 2. Orthopedic Radiology, a Practical Approach. Adam Greenspan. Lippincott (read trauma section only - chapters 2 through 8). 3. Bone and Joint Imaging. Donald Resnick. W.B. Saunders. The first chapters you read should be: Chapter Title 62 Physical Trauma 19-20 Postoperative Imaging 4. Arthritis in Black and White. Ann Brower. W.B. Saunders. 5. Read the remaining required chapters in the baby Resnick in any order you want during the third and fourth months of bone: Chapters 1, 2, 11, 14, 18, 28, 30, 32, 33, 34, 38, 45-61, 63-85. ** The following chapters in Resnick’s book are good for learning but NOT required: 3, 4, 5-10, 12, 13, 15-17, 21-27, 29, 31, 35-37, 39-44 155
  • R. THE MIRIAM HOSPITAL (TMH)/MRI Daily work begins at 8:00 a.m. The resident will preview the overnight MRI exams. There are typically 20 exams performed daily at TMH. The breakdown is about 50% brain, 25% spine, 15% musculoskeletal and 10% body. The resident will then read with the MRI attending of the day. The resident will also be responsible for protocolling exams, prioritizing inpatient studies and be available for answering questions from technologists and referring clinicians. The afternoon rotation is generally less busy and, in addition to MR, there may occasionally be CT scans to be read, since the MRI attending is responsible for MRI and CT in the afternoon. Educational Goals and Objectives Please refer to the MRI section Conferences: The resident is encouraged to attend the noon RIH conference. Recommended Reading: (all available at TMH MRI Department) 1. MRI Imaging of the Brain and Spine – Scott Atlas 2. Head and Neck Imaging – Som & Curtin 3. MRI in Orthopedic and Sports Medicine –Stoller 4. MRI Clinics of North America 5. MRI –Stark and Bradley 6. MRI Teaching Tapes 7. Musculoskeletal MRI - Helms 156