Monday, April 10, 2017


United Airlines just crossed a line. Please read this article from USA Today, and watch the disturbing video clips:

LOUISVILLE — A video posted on Facebook late Sunday evening shows a passenger on a United Airlines flight being forcibly removed from the plane before takeoff at O’Hare International Airport.

The video, posted by Audra D. Bridges at 7:30 p.m. Sunday, is taken from an aisle seat on a commercial airplane that appears to be preparing to take flight. The 31-second clip shows three men wearing radio equipment and security jackets speaking with a man seated on the plane. After a few seconds, one of the men grabs the passenger, who screams, and drags him by his arms toward the front of the plane. The video ends before anything else is shown.

A United spokesperson confirmed in an email Sunday night that a passenger had been taken off a flight in Chicago.

"Flight 3411 from Chicago to Louisville was overbooked," said the spokesperson. "After our team looked for volunteers, one customer refused to leave the aircraft voluntarily and law enforcement was asked to come to the gate.

"We apologize for the overbook situation. Further details on the removed customer should be directed to authorities."

Bridges, a Louisville resident, gave her account of the flight Sunday night.

Passengers were told at the gate that the flight was overbooked and United, offering $400 and a hotel stay, was looking for one volunteer to take another flight to Louisville at 3 p.m. Monday. Passengers were allowed to board the flight, Bridges said, and once the flight was filled those on the plane were told that four people needed to give up their seats to stand-by United employees who needed to be in Louisville on Monday for a flight. Passengers were told that the flight would not take off until the United crew had seats, Bridges said, and the offer was increased to $800, but no one volunteered.

Then, she said, a manager came aboard the plane and said a computer would select four people to be taken off the flight. One couple was selected first and left the airplane, she said, before the man in the video was confronted.

Bridges said the man became "very upset" and said that he was a doctor who needed to see patients at a hospital in the morning. The manager told him that security would be called if he did not leave willingly, Bridges said, and the man said he was calling his lawyer. One security official came and spoke with him, and then another security officer came when he still refused. Then, she said, a third security official came on the plane and threw the passenger against the armrest before dragging him out of the plane.

The man was able to get back on the plane after initially being taken off — his face was bloody and he seemed disoriented, Bridges said, and he ran to the back of the plane. Passengers asked to get off the plane as a medical crew came on to deal with the passenger, she said, and passengers were then told to go back to the gate so that officials could "tidy up" the plane before taking off.

Bridges said the man shown in the video was the only person who was forcibly removed.

"Everyone was shocked and appalled," Bridges said. "There were several children on the flight as well that were very upset."

The flight was delayed about two hours before it could fly to Louisville, and it arrived in Kentucky later Sunday night. No update was given to the passengers about the condition of the man forcibly removed, Bridges said.

The videos are all over Twitter and Facebook.

I have no clue what was going through the United employees' minds when they authorized this nightmare. No doubt they carry quite a level of hatred toward their customers in general, and probably some huge level of fear of punishment for not getting the United personnel to Louisville where they were needed for a flight the next day. Hey, could have hired a limo and driver to ferry your personnel to Louisville, about 200 miles from Chicago. It would have cost, oh, maybe $500 or even $1,000 including tip. But no, United had to make it clear how much it despises its own passengers, the folks who pay United salaries. This is going to cost millions of dollars in lost revenues and legal defense.  The gate agents need to be fired, the "security" folks need to be arrested for assault and battery, and the entire C-suite of United needs to resign. But you saved $1,000 and made your gate people feel ever so important.

Fine, respected operations such as Pan Am and TWA disappeared years ago, and this poor excuse for an airline lives on. Unbelievable.

United has earned my utter and permanent contempt. I will NEVER fly them again, not that I do now if I can possibly avoid it. I urge you to shun them as well, and spread the word far and wide. #putunitedoutofbusiness.

And sell United stock if you happen to have any.


In this age of leaks, it was inevitable that the United CEO's message to his flock would become public, and here it is in a Tweet from Ryan Ruggiero of CNBC. Basically, CEO Munoz blames the passenger and stands behind the United personnel. Nice for morale, bad for business. Very bad.

Sunday, March 26, 2017

The Best Designs Of (For) Mice And Men

Of all the things you didn't know about me, perhaps the most irrelevant is the fact that I'm a frustrated inventor. Periodically, I come up with ideas of things that should exist but don't, and in general they don't for some very good reason. I did once go so far as to retain a patent attorney to research one of my brilliant intellectual offspring. He found the same thing had been "discovered" and patented four times before. That knowledge cost me $500. Of course, one would search the U.S. Patent Database today with Google. How times have changed.

The Agfa Daily Blog Update recently linked to an article celebrating some of the best designed products of all time.  It's a good read, although I found the selection a little, well, optimistic for that particular blog. Still, it prompts some interesting discussion. Five design professors were interviewed, and asked for their choice of the best-designed product of all time. I won't go through the entire list, but the one that took my fancy was the lowly old dial telephone, as described by Professor Kalle Lyytinen of Case Western Reserve University:

American industrial designer Henry Dreyfuss’ AT&T Model 500 phone is one of the most iconic and recognizable products of the 20th century. The phone – together with its design process – was a harbinger of many design principles used today.

Rotary phones – which feature a round dial with finger holes – first emerged in the early 20th century. But many of these were bolted to the walls or required two separate devices for speaking and listening.

In addition, early telephone users would call into operators, who would use a switchboard to connect callers. When this process became automated, designers needed to figure out a way to offer an intuitive interface, since callers would be dialing more complicated number sequences (essentially doing the “switching” on their own).

Though earlier models came close to addressing these needs, the 500 model elevated the design, adding several functions that forever changed the way phones would be used.

AT&T’s first rotary phone in 1927 (dubbed “the French Phone”) had an integrated handset for both the loudspeaker and the microphone, but it was cumbersome to use. Meanwhile, Dreyfuss’ earlier model from 1936, the 302, was made out of metal and also had an awkwardly shaped handset.

Then, in 1949, his Model 500 came along.

Employing new plastic technology, the phone’s handset was smooth, rounded and proportional, an improvement on unwieldy earlier versions. It was the first to use letters below the numbers in the rotary – a boon for businesses, since phone numbers could now be advertised (and remembered) as mnemonic phrases (think American Express’ “1-800-THE-CARD”).

The 500 phone was also the first to undergo a design process that used ergonomic (comfort) and cognitive experts. AT&T and Dreyfuss hired John Karlin, the first industrial psychologist in the world, to conduct experiments to evaluate aspects of the design. Through extensive consumer testing, the designers were able to tweak all minutiae of the product – even minor details like placing white dots beneath the holes in the finger wheel and the length of the cord.

Including its later incarnations, the phone would go on to sell nearly 162 million units – around one per American household – and become a presence in living rooms, kitchens and offices for decades to come.
Italics mine.

It should be intuitive that a well-designed product does what it is supposed to do, does it well, and is easy to use. Compared to this old phone, the 500 was quite an advancement in each of those criteria:

As I've said on numerous occasions, Apple (whose products were curiously not mentioned among the top five) has mastered this concept. The late, great Steve Jobs quite literally used Zen philosophy in his product design. As Drake Baer writes in Business Insider:

When you look back at Jobs' career, it's easy to spot the influence of Zen. For 1300 years, Zen has instilled in its practitioners a commitment to courage, resoluteness, and austerity — as well as rigorous simplicity.

Or, to put it into Apple argot, insane simplicity.

Zen is everywhere in the company's design...

It's the industrial design equivalent of the enso, or hand-drawn circle, the most fundamental form of Zen visual art.

But Zen didn't just inform the aesthetic that Jobs had an intense commitment to, it shaped the way he understood his customers. He famously said that his task wasn't to give people what they said they wanted; it was to give them what they didn't know they needed.

"Instead of relying on market research, [Jobs] honed his version of empathy — an intimate intuition about the desires of his customers," Isaacson said.
It is rather ironic that Agfa itself attempted to develop a PACS interface in a vaguely similar manner using Alan Cooper's Persona approach with limited success, depending upon whom you ask. We still use IMPAX 6.x, which is the one of the later descendant of Agfa and Cooper's Odyssey PACS prototype. It does work, but takes approaches I would not, as a practicing radiologist, have recommended, and I continue to despise. As usual, the bottom line is this: those who design products MUST get into the heads of those who will USE those products. It really is that simple. Steve Jobs got it. Tim Cook, maybe not so much. Some PACS companies, well, not much. Maybe not at all.

I've been blogging about PACS for over 12 years now, and I'm not seeing a whole lot of improvement in this regard. Here's a good example. I've spoken previously about our Centricity Universal Viewer, which is not universal in any real sense, although as the heir to Dynamic Imaging's IntegradWeb, it had great potential. We have been able to come to terms with it, and GE has actually fixed many of the problems we've had with it. But as my senior-most partner puts it, the enemy of good is better. Exhibiting the faith of those who walk on hot coals and handle snakes, we agreed to have the embedded version of the Advantage Workstation placed on the system. It seemed like a good idea...we would be able to view PET/CT's and do high-level imaging things on any workstation. The number-crunching is done on a separate AW server with server-side rendering, so there should be no ill-effect upon PACS. Right.

In practice, well, we've had some trouble. The integration of these two VERY different products could not have been easy, but it could have been done better. As usual, it appears that no radiologists were killed in the making of this product. Or consulted, for that matter. And, those at GE who know the UV well don't have expertise in the eAW (embedded Advantage Workstation) and vice versa. So it is no surprise that the integration of the two is not what it should be. Without going into painful detail, say we are viewing a PET/CT with a comparison conventional CT. I'll have the CT images from both arranged on the left side of the 6MP monitor, and the server-side rendered (but still SLOW) AW windows the right. As originally configured, scrolling through the CT was supposed to synchronize all windows. But that ended up moving images around in an uncontrollable way. I asked for this connection to be severed, and GE tried to do so, but some crosstalk does remain. For example, changing a CT window on UV changes it on eAW as well. Trying to load a different comparison CT restarts the eAW window altogether. And so on.

Had I been called upon to choreograph this dance, I might have been tempted to do some of the synchronization, but I would have limited the depth of the connection. It needs to be kept simple, in my humble (and simplistic) opinion. One side really must not be allowed to interfere with the other. I should think it would have been easier to make the windows totally separate in their operation, so what we see here is a perversion of Job's philosophy. We are given something we didn't know we wanted, and lo and behold, we really don't want it after all!  There are additional problems with hanging protocols, which are completely different entities on the UV and the eAW, but may create overlap. GE has been helpful, but I have the feeling they have not encountered these problems before. Perhaps we are doing something very wrong, or maybe this is one of the first installations of this particular patois of hardware and software. We await further tweaking.

I'll keep you posted.

I was once asked if I planned to create my own PACS. For better or worse, I don't have the resources, the backing, or the expertise to try this, but I am available for consultation (for a very reasonable fee) should anyone with a lot of money and a team of software engineers be interested in making The Best PACS. I'll be waiting by the phone. If contracted for this lofty purpose, I'll certainly do my best to channel the spirit of Steve Jobs. I can try, anyway...

Post Script: My friend Phil sent this comment concerning PACS development, and it is certainly worthy of inclusion into the main post:
When will they ever learn, oh when will they every learn?

Answer - When it affects the bottom line.

Question: When will that happen?

Answer - When radiologists are empowered to decide which product to buy (Oh - and will spend the time to actually evaluate them).

Question: When will that happen?

Answer: ????????????

Sunday, March 19, 2017

Hello, (Friends of Doctor) Dolly!

I know many of you are landing here thanks to my daughter, Dr. Dolly. She was just published on, and my celebratory post on Facebook labeled her a "chip off the old Doctor Dalai". Thus, her friends are now discovering what I do in my spare time. Hopefully this won't reflect badly on Dolly. She is, after all, at the beginning of her career, and I'm at the end of mine. We don't want potential employers, colleagues, administrators, scrub-nurses, or Uber-drivers to think she might turn out like me! (For privacy reasons, I'm not linking back to KevinMD.)

In some ways, I've taken a page from her book. While in medical school, Dolly went on a number of mission trips to such amazing places as Oaxaca (Mexico), Nicaragua, and Uganda. And South Dakota. Having more time available and more training behind me, it occurred to me to do the same while bouncing around the purgatory of quasi-retirement. Once I found RAD-AID, the die was cast. Both of my loyal readers know that I've been to Korle Bu Teaching Hospital in Accra, Ghana, an incredible trip. You can read about it right here on my blog if you haven't already. A medical mission trip is not something you do once; the experience changes you (for the better). The desire to give back, and the growth involved in the process, is addictive. The friends you make, the things you see, the joy of being out of your comfort-zone all necessarily call for an encore performance.

Thanks to a tremendous opportunity provided by RAD-AID and SNMMI, I will be going to Tanzania this summer to provide what little expertise I can muster for the Nuclear Medicine program at the Aga Khan Hospital in Dar es Salaam.

The whole thing comes as a bit of a surprise to me, as I will be the recipient of a Hyman-Ghesani RAD-AID SNMMI Global Health Scholarship, which will cover much of the expense of the trip. The surprise is that this program seemed to be geared more toward academia, and I applied with little hope of success. But I seemed to have impressed the committee to an adequate degree and so off to Tanzania we go. I am truly honored and humbled by the confidence and trust in me. I do have to say that in my 27 years of private practice, I've come to find that experience is the best teacher. Of course, experience and brilliance would have been a better combination, but we can't have everything.

The mission has only one downside. I'm committed to present a report at the subsequent Society of Nuclear Medicine and Molecular Imaging meeting, and in 2018, it's in...Philadelphia. Meh. Oh, well, we have to make some sacrifices here and there.

I've said it before, and I'll repeat...RAD-AID is an incredible operation, worthy of your donations of money, and better, of your time. There is tremendous need out there for your radiological expertise, and yes, your cash. There is a lot of work to be done. Come join me.

Saturday, February 18, 2017

Out Of Antarctica

I had intended to post from Antarctica itself, but time somehow gets away from you wile in a place like this. So, I'm posting instead from the Scotia Sea en route to the Falklands.

You might have heard of the Drake Passage between Ushuaia and the Antarctic. It is often windy and treacherous, and has become known to those with weak stomachs (such as yours truly) as the Drake Shake. Fortunately, we had one of the quieter rides, and so we refer to this area alternatively as the Drake Lake. (We've had some rough seas here and there anyway, and I'm trying to keep my meals from repatriating themselves to the outside world with an Australian drug called TravaCalm. So far, so good.) And believe it or not, there were a number of other cruise and expedition ships down there with us. Antarctica is becoming a major eco-tourist attraction.

Our week in the REALLY Deep South included four trips out to land, twice to islands, and twice to the mainland peninsula itself. Given the latter, I have officially joined the 7 Continents club, having now set foot on all seven continents. (Naturally, some academic types have just now come up with a possible eighth continent, Zealandia, but it's mostly under the ocean, so in my book, it doesn't count.) There were two days with weather rough enough to keep us away from shore, so we got to steam around and see the incredible territory instead. That's a reasonable consolation prize.

Photos do not do this area justice. At all. At least mine don't. Of course, my photo equipment includes a Sony RX100 M3, a GoPro with stabilizer gimbal grip, and my iPhone. I'm thinking the iPhone is probably the best of the lot. I've had some terrible cases of lens-envy when observing the setups some of the other passengers have with them. I attempted to ask someone who was showing off a few really incredible whale pics about his set-up. "It's a Canon 5D Mark you know cameras?" When I said I did know something about them, but was not in possession of this $5K setup, the gentleman then made it a point to ignore me. See my comments about class in the previous entry.

But I do have hundreds of photos, and I'm proud of them. When I get back home, and have something to process them beyond Mrs. Dalai's old MacBook Air, I'll try to compile the best of them. In the meantime, here are a few random pics:

You'll notice white lines in some of the images of the penguins. I don't have to tell you what they are, do I? But where there's grant money, there will be someone to claim it. The image below is from an honest-to-gosh scientific paper about...penguin defecation:

Yes, this was the topic of an on-board lecture. No guano. 

And finally, it wouldn't be Valentine's Day in Antarctica without a dip in the hot tub! It wasn't too bad getting in...

We were to get one last penguin visit in the Falklands, but gale-force winds forced us to carry on toward Uruguay. So w are now officially in penguin withdrawal, if there is such a thing. Oh must be flexible when traveling in this part of the world.

Friday, February 10, 2017

Politicians and Penguins

My level of love for animals is mostly restricted to our two little fluff-balls at home, whose vet and kibble bills top the GDP of several small nations. Mrs. Dalai, however, LOVES animals, especially penguins. And so, when deciding where to go for our next big trip, she was quite clear on where she wanted to go. Antarctica!

When Mrs. Dalai speaks, I listen. And so, we are presently on a ship traversing the Drake Passage, and will indeed reach Antarctica by tomorrow morning.

Yes, it's getting colder...Supposedly the temperatures on the Antarctic Peninsula itself will be in the low 30's Fahrenheit, not quite as bad as I expected. 

We started the cruise in Valparaiso, Chile, heading down the west coast of South America, stopping at various ports in Chile, and then Ushuaia, Argentina, the southern-most city in the world. 

From Puerto Montt, we bussed to the Pertohue Falls:

On the island of Chiloe', we visited a number of wooden churches, designated UNESCO World Heritage sites, and these palafitos, houses on stilts, in the city of Castro.  

From Punta Arenas, we took a speedboat to Magdalena Island, and finally saw penguins! There are a number of penguin species, and these are Magellenic, also known as Jack Ass Penguins. 

There are a number of glaciers this far south, including this one in the Chilean Fjords:

And tomorrow, we reach our first adventure stop, Half Moon Island, in the South Shetlands just off the coast of Antarctica. We'll be here for a week, with an hour out on the ice each day. We've brought enough winter gear, including hand and foot warmers, to last a lifetime. Weather-wise, at least, I prefer my version of the South to this version of the South, but I must admit that the scenery here is much more dramatic.

You might wonder who would undertake such a trip; I certainly did. As you would guess, the passengers are by and large older, almost all are older than we are. Who else is going to take almost 4 weeks to make this trip? (The cruise goes on to the Brazilian Amazon and then to Florida for those who can take two MONTHS off.)  The average is somewhere south of dead, but on its last run through this area, the ship had to leave the Antarctic on an emergency basis as two passengers took ill. There is NO way to evacuate someone whilst here. One of the two did not survive, I'm told, but was content to leave this Earth doing what he loved best. If I ran the cruise line, I would require medical certification before ever allowing anyone on this sort of cruise, but that's just me.

Part of the fun of this trip, however, is indeed the folks we meet. We've come to know the retired CEO of a large aircraft company, several self-made men (and women), the retired head of the Social Security equivalent of a major Scandinavian nation, and while I've not tried to disturb his privacy, a former presidential candidate and his perfectly-coiffured wife are on the trip as well. And there are the usual complement of folks we try to avoid. "You're from the SOUTH? We don't know anyone from the SOUTH. They don't think like WE do." "Morris!!!!!! They're all out of cucumbers at the salad bar! DO SOMETHING!" "We only get a few weeks off. Not like Jewish people who always have extra holidays..." Money doesn't buy class, it seems...

Anyway, we are on the first group to hit the land tomorrow, so off to bed. Stay tuned for the Penguin Report, coming to these pages very soon.

Tuesday, January 17, 2017

Fovia Utopia

I've found over the years that the PACS field is rather mobile. A friend that worked for company A might now be found at company C having arrived there after doing time at firm B. You might remember back when Merge first bought out Amicas...there were some discussions about whom to keep and whom to let go, and I was rather vocal in urging (begging?) Merge to keep the folks who made Amicas Merge PACS what it is. That didn't work out, but one of my friends from that realm is now with an amazing little company called Fovia. I sought him out at RSNA, as I usually do, and he showed me some cool stuff. Due to some personal things, I've been too lazy to write postponed my brief but exciting RSNA report from Fovia, but here it is. Finally.

Fovia is in some ways the biggest PACS company you've never heard of. Although it isn't a PACS company, and you have heard of it here on these very pages.

Fovia is a "behind the scenes" company. Think Intel. They make the chips, but you can't buy an Intel-branded computer. Fovia makes rendering software used by many PACS companies, including Merge. In case you didn't know, Fovia:
  • Founded in 2003 and inventor of High Definition Volume Rendering®
  • Provides a highly scalable CPU-based, server-side rendering solution delivering images to clients applications anytime and anywhere
  • Optimized for the CPU and delivers near perfect linear scalability as the # of cores increases. Does not require a GPU, or the headaches associated with OpenGL drivers.
  • Scales well with dataset size. There is almost no visible difference in performance or quality when rendering 500 slices or 4000 slices (maybe 10% slowdown)
  • Scales well and preserves the quality and performance when rendering to large displays. This is critical for larger medical monitors such as 4K or 6+ MP displays.
  • Provides a “Fovia Inside” solution that is directly integrated into OEM customers’ solutions. The benefit is that OEM customers retain their own user interface and workflows, but gain HDVR inside their products. 
  • Fovia products are integrated into products and PACS from quite a few names you know, including GE, Sectra, Merge/IBM, and Intelerad.
 At RSNA, Fovia introduced us to their two latest technologies: XStream® HDVR® WebSDK and F.A.S.T.® Interactive Segmentation.


An SDK is a Software Development Kit, and this one delivers Fovia’s High Definition Volume Rendering from the enterprise or cloud over cellular and Wi-Fi networks directly to desktop or mobile devices with no compromise in performance or quality. This yields a zero-footprint application that will run on almost any platform, be it desktop, tablet, iOS, Android, what-have-you. But this is far from just another run-of-the-mill basic viewer. With HDVR, one has access to fully interactive 2D, MPR, and even 3D workflows. The software vendor can use these building blocks to create workflows within their own products.

Click below to experience, first-hand, the incredible rendering power available from the cloud:

F.A.S.T. Interactive Segmentation

Three-Dimensional images are pretty, and often useful on their own. But the real magic comes when you can pick some particular part of the rendering to play with, which we call segmentation. F.A.S.T. Interactive Segmentation (and I'm not sure what the acronym stands for, but the darn thing is indeed fast!) F.A.S.T. Interactive Segmentation provides real-time (yup, that fast) 3D interactive segmentation on 2D and 3D views.

Now we've all seen segmentation with the various advanced visualization programs out there. But F.A.S.T. Interactive Segmentation is different: it is intuitive and easy to use. One simply clicks and drags, be it with a finger or mouse, and voila! Your favorite body part is selected and highlighted in the color of your choice. This process can work independently or can be used to augment an automatic segmentation algorithm. F.A.S.T. Interactive Segmentation is ideal for the challenging or non-perfect scans where it is critical that the case can be segmented for analysis of the disease.

With F.A.S.T. Interactive Segmentation, segmentation workflows can be completed interactively in well under a minute on a variety of studies, and not the “perfect case.” I saw the following cases demonstrated live. The screen captures don't do the process justice, but you can easily see the quality of the end result.

Low-dose lung screening using MIP or Faded MIP, can quickly identify lung nodules, segment the nodules and determine volumetric measurements (this literally takes just a few seconds). Here, the trachea and the pulmonary vasculature are segmented to determine if this lesion could be accessed via transbronchial biopsy (it could NOT)...

Here, is an example of surgical planning for a partial nephrectomy. Typically, segmentation might take between 30 and 45 minutes per case, but using F.A.S.T. Interactive Segmentation (and no pre-processing), the Fovia folks were able to do this in under 3 minutes:

  • segment the aorta and the renal arteries
  • segment the lesions
  • segment the kidneys
  • segment the renal veins

    The images are impressive, but actually watching this process take place is staggering, particularly to those of us who use advanced visualization products regularly. Frankly, I was so impressed, I declared, "Why aren’t others, like TeraRecon using this???" It seems that Fovia and TeraRecon have been unable to connect. So, believing myself to be far more important in this space than I really am, I grabbed my iPhone and called our TeraRecon rep...who happened NOT to be at RSNA. But he made some calls and we all sent texts...and nothing happened. At least not yet. As usual, my influence is less than I would like it to be, and far less than some of you out there might think.

    But I still hope TeraRecon will get around to talking with Fovia about F.A.S.T. Interactive Segmentation. Trust me, it would significantly improve the TR segmentation interface.

    Frankly, in my humble opinion, it wouldn't be such a bad idea for Fovia to offer its own PACS or advanced visualization product. Don't tell anyone I said so...