Doctor Dalai To The OR - STAT!!!

 

As a non-interventional radiologist, I rarely get to the OR.  (I do sometimes wander by the ER to discuss some weird finding.  This has morphed into the positive Dalai sign; the docs know something bad is afoot if I've made the effort to travel over to their neck of the woods.)

Yesterday, the rad tech working surgery came running down the hall.  "How do I get in touch with your IT guys?" he yelled.  It seems that one of the surgeons needed to look at images on my group's PACS (not the hospital system) and couldn't get the client running on the hospital computer in the OR.  I bravely volunteered to go to the OR myself, and after throwing on some scrubs (and hoping the nasty surgeons wouldn't raid the unlocked locker containing my valuables) I sauntered into the OR like a real surgeon.  There, on the table, was the patient with his internal anatomy revealed, and a very frustrated surgeon nearby.   I went immediately to the computer in question, and indeed, our AMICAS client wouldn't load, because the bloody computer was locked down, and it wouldn't accept the necessary JAVA run-time code.  I quickly called our HELP desk and explained the problem, noting that Dr. X had a patient filleted open on the table, thus requiring assistance NOW.  The fellow on the other end apologized, noting that he couldn't do anything, but would contact the DESKTOP help area immediately.  In the meantime, I decided to try our program on the computer that was used for patient monitoring and data collection (yes, somewhat risky, but...) and lo and behold, I was able to bring up our client!  The surgeon was happy, and I left the OR still not having heard from DESKTOP.

The moral of the story:  PACS involves patient care.  If a department, be it Radiology or IT, is given the mandate to control and maintain PACS, it has to realize that this is a mission-critical, literally life-and-death proposition.  Sometimes, we just don't have five or ten minutes to wait.  Yes, I understand that this was an aberrant situation, and I suppose we should be forever grateful that we are allowed to view our "foreign" system from within the hospital at all.  Still, this is the way it is, and we need help, not hindrance in these situations.  Remember, we're all here to promote patient care.  That's the bottom line.

ADDENDUM

I've received two interesting comments on this post.  Anonymous (1) said:

"technically arent you messing with the warrenty on the monitoring system by runing external software on a "closed system"?


Sure you might be lucky and everything works nicely with the java runtime and everything, but you might have affected the system in a manner where other patients life are put at risk?


I am certain this isnt adviceable behavior and that it can indanger patients and/or deaths."

and Anonymous (2) said...

"Moral of the story:


Before anything else, preparation is the key to success AGB


In the days of film key images would have been displayed on the light box BEFORE the start of the operation.


If the PACS workstation stopped working without warning, good on you Dr Dalai, I would have been tempted to get a lap-top or pinch a workstation from next door though."

I think Anonymous (2) is right on.  Definately, scalpel should not have touched skin before the images were on-screen.  YOU tell that to the surgeon. 

As for Anonymous (1). . . He/she embodies the IT mentality that drives me up the wall.  Yes, I was taking a risk, although I believe it was minor. The computer I ultimately got running was actually the data-collection station (drugs, toys used, etc.), and not a true patient monitor.  It fortunately already had the proper Java in place.  No damage done there.

The patient who is cut open on the table HAS to be one's primary concern in this instance. PERIOD. It seems there are some IT types who would have told the surgeon, "too bad, chump" and walked away because we might have done something to their precious computers. If you are going to deal in health care issues, friends, you need to realize that someone might die if the computer doesn't do what it's supposed to do.  Yes, one can hide behind the mantra that altering the computer might harm the next patient.  In situations like this, you have to realize that NOT altering the computer had an immediate risk of harm to the patient that was there bleeding (a little) on the table right then.  Somehow, IT has to be made to understand the criticality of PACS and patient care. 

I'm trying to educate them, slowly but surely. 

Merge-ing with AMICAS?

Mike Cannavo, the One and Only PACSMan, broke the news to me.  "Say it ain't so, Joe!" he began, then presented the following press release:

MILWAUKEE--(BUSINESS WIRE)-- Merge Healthcare Incorporated (NASDAQ: MRGE) today announced its pending $6.05 cash per share offer for AMICAS, Inc. (NASDAQ: AMCS). Merge’s proposal, for an aggregate of $248 million, represents a 13% premium to the previously-announced offer for AMICAS from a newly-formed affiliate of Thoma Bravo, LLC for $5.35 cash per share. Merge’s current offer follows its offer of $6.00 cash per share that was made during the “go-shop” period contemplated by AMICAS’ merger agreement with Thoma Bravo. Last week, Merge intervened in Massachusetts litigation challenging the adequacy of AMICAS’ disclosures relating to this transaction, as well as the process by which its proposals have been considered by the AMICAS Board of Directors.

Merge has received a signed bridge financing commitment from Morgan Stanley to provide $200 million of debt financing, and is subject only to standard and customary conditions. Based on that commitment and available cash, including $40 million of pre-funded equity investments from mezzanine investors, Merge has proposed to commence a $6.05 cash per share tender offer for all AMICAS shares and to close the acquisition as quickly as possible thereafter.

I nearly aspirated when I read this. MERGE? Buying AMICAS? Give me a break! The folks that brought you eFilm, one of the most ubiquitous but primitive clients out there are mounting a hostile takeover of AMICAS? With borrowed money? MERGE? The company that bought eMed and Cedara, and didn't ever do much with either product line? MERGE? The company that was at death's door not so long ago? MERGE? The folks whose CD's have to be taken out only AFTER one closes the eFilm program, or your computer must be rebooted to clear their tracks? MERGE? The company that utilized Indian radiologists to provide prelims? MERGE????????????

AMICAS seems to agree with me.  In their own press release, the Merge offer was termed "illusory and risky".  PLEASE read the dozen plus problems AMICAS has with being purchased by Merge.  Did you know that this represents the SIXTH attempt by Merge to buy AMICAS?  That should tell us something.

"Merge's highly-conditional proposal is (i) dependent on third-party financing, (ii) subject to a "reverse break" fee, which essentially gives Merge a $10 million "option" to buy Amicas; (iii) subject to a number of additional conditions, the satisfaction of which are within Merge's control, and (iv) has been characterized as Merge's "best and final" proposal," according to the statement. "Given the highly-conditional nature of Merge's most recent proposal, the Amicas board of directors believes that the Merge proposal is illusory and risky to Amicas stockholders."



The Amicas board noted that the cash for the Thoma Bravo buyout "is fully financed and guaranteed by Thoma Bravo and other first-tier private equity funds and is not dependent on unguaranteed, third-party financing" and that the equity firm was set to close the deal as planned Feb. 19. The board said it believes "the Thoma Bravo Merger provides Amicas stockholders with immediate and certain cash value."

I know that AMICAS stockholders (I am NOT one of them, by the way), as well as those who dabble in the financial message boards such as Yahoo and Google look at this blog periodically.  I hope you will look today.  PLEASE do not be swayed by this marginally-better offer.  I have spoken with some of the big wigs at AMICAS, who assure me that Thoma Bravo, like Warren Buffet's Berkshire Hathaway, allows the companies they purchase to go on doing what they were doing.  They don't go in and "fix" something that wasn't broken, breaking it in the process, like some larGE companies I can cite.  I cannot prove it or document it, of course, but if Merge buys AMICAS, the latter company and its product line will suffer.  And if AMICAS suffers, my PATIENTS suffer.  This mustn't happen. 

So, shareholders...PLEASE vote for the Thoma Bravo offer.  Please.  If you go to the Dark Side, you will destroy a fine company with a fine product, and you could conceivably impair the ability of radiologists like me to deliver patient care.  That is my only motivation; I have no financial stake in this.  Please do the right thing.

Thank you.

Catching Up

OK, OK.  I've been lax about posting, but there's been a lot going on.  Last weekend, I gave a talk to our state chapter of the Society of Nuclear Medicine.  It was a real snoozer, discussing the application of PACS to Nuclear Medicine, or is it the other way around?  Perhaps the high point of the talk was this picture of an early PACS, Picture Applied to Cave Surface:

A second item of note is that I actually wore a tie, and a PET tie to boot:

Some people have a Pet Rock, I have a PET tie. 

After returning from the meeting, I turned right around and headed for Orlando with Mrs. Dalai.  Yes, we did do Disney, but the point of the trip was to attend the Johns Hopkins CT meeting, chaired by Dr. Elliot Fishman.  Elliot is acknowledged to be the world's finest radiologist.  I wouldn't know about that, but he is certainly one of the best lecturers on the circuit, and the rest of the faculty was superb as well.  Best of all, most, if not all, of the slides were given to us on a USB drive, eliminating the need to furiously scribble notes that I wouldn't be able to decipher later anyway. 

The weather in Orlando was nasty, cold, and rainy.  However, it beat the 7 inches/18 cm of snow we had back home in South Carolina:

My poor baby still has some lingering snow on her roof!

With bad weather comes poor attendance at Disney, although the economy and the fact that a lot of North-easterners couldn't escape from their own snowy prisons didn't help.  Of all the rides in all the parks, only Everest and Soarin' had much of a wait.  The Great Movie Ride at Disney's MGM Hollywood Studios was so sparsely utilized that we had to wait until enough people showed up to fill the tram before the ride started.  Some of the robots in the various movie scenes are showing their age, and don't look quite as real to me as they did in years past.  Maybe I'm just getting jaded.

Certainly a highlight of the trip was meeting up with Mike Cannavo, the One and Only PACSMan, who joined us for dinner at a Brazilian restaurant (off the grounds; there is no Brazil pavilion at EPCOT, but there should be!)  The "gaucho" approach to meals suits me well:  every few moments there was another skewer of luscious beef, lamb, ribs, or whatever coming by to be loaded on my plate.  This was certainly a testimony to the old anti-vegetarian saying, "If God hadn't meant us to eat animals, he wouldn't have made them out of meat."  Don't tell my daughter I said that!

I won't bore you with the details of our other meals save this unfortunate event.  Mrs. Dalai and I tried the German Biergarten restaurant for dinner one night.  After waiting our turn (we had made on-line reservations) we were herded with a family of six to the eight-person table.  The other family promptly jumped into seats, scattered hither and yon about the table, preventing Mrs. Dalai and I from sitting next to each other (yes, we still want to do so!)  We nicely asked if they would shift around a bit, but Big DamYankee Daddy (based on his accent and attitude) wouldn't budge, and in fact growled at us, "I wanna sit by my wife too.  You wanna sit by your wife, and I wanna sit by mine."  I wasn't asking him not to sit by his wife, even though said wife had been in the bathroom for 30 minutes anyway, but simply to shift his nasty DamYankee carcass and maybe some of his progeny around a bit.  I turned to the hostess (a college kid from Germany) and asked to be seated elsewhere, which she promptly accomplished.  I'm amazed that some of us blame George W. for our poor reputation amongst our European comrades.  Try looking in the mirror first, guys.  OOOMPAH!

The trip home was marked by a two-hour delay trying to bypass Daytona Beach on race-day.  I'll never quite understand why thousands and thousands and thousands of people want to watch cars that from their viewpoint are about the size of bugs going round and round and round the track for hours on end.  Maybe everyone is hoping for a wreck.  Yes, I know, the fans all have their favorite driver and team and all that, but really, to tie up I-4 and I-95 in both directions for hours just to see this spectacle, come on.  Oh well, it could have been worse.  Those same fans could have all descended upon Disney World while we were there.  

My poor puppy Sophie was quite distraught at being left in the boarding kennel and showed us just how worried she was that we wouldn't return:

  

Finally, a bit of advanced warning to all my readers in Australia:  I'm coming back!  I've been in touch with one of the physicians making up the program for RANZCR 2010, and I've been asked to give a reprise to last year's extravaganza, this time at the meeting and not in private (although a private audience might still take place.)  It seems the rads in Perth (where the meeting will be held this year) are not terribly enamored with their new PACS:

Perth public hospitals are about to undergo their much delayed (since October) “up”grade to Impax 6 (only 2 years old I think). Even the PACS admins (a minority of whom are A*** fanboys) are embarrassed about it as it seems even more pointless clicks that the previous version. I figure there’ll be plenty of locals at least who will be keen to hear other points of view.

I didn't know A*** was a bad word in Australia, although it approaches that status amongst some of my partners.  

By the way, can you guess what the main difference is between signage, labels, etc. in Australia vs. the US?  Answer:  Everything in Australia is in ENGLISH, and only in English.  Throw some shrimp on the barbee, mates!  I'm on my way. . .

EU Disturbs The Magnetic Force

When we're done here, I want you to sign THIS petition.  You'll see why momentarily. 

The European Union, perhaps the prototype for a world-government that some in our country seem to desire, is about to do radiology, and thus humanity, a disservice.  It seems that the folks over there in charge of such things issued a Phyical Agents (Electromagnetic Field) Directive in 2004, which was to take effect in 2008, but has now been postponed to 2012.  Feel free to read the entire Directive at your leisure, but here are some of the salient Whereases: 

(1) Under the Treaty (creating the European Union) the Council may, by means of directives, adopt minimum requirements for encouraging improvements, especially in the working environment, to guarantee a better level of protection of the health and safety of workers. Such directives are to avoid imposing administrative, financial and legal constraints in a way which would hold back the creation and development of small and medium-sized undertakings. . .

(4) It is now considered necessary to introduce measures protecting workers from the risks associated with electromagnetic fields, owing to their effects on the health and safety of workers. However, the long-term effects, including possible carcinogenic effects due to exposure to time-varying electric, magnetic and electromagnetic fields for which there is no conclusive scientific evidence establishing a causal relationship, are not addressed in this Directive. These measures are intended not only to ensure the health and safety of each worker on an individual basis, but also to create a minimum basis of protection for all Community workers, in order to avoid possible distortions of competition.

And then, the commandments:

Article 1

 Aim and scope

1. This Directive, which is the 18th individual Directive within the meaning of Article 16(1) of Directive 89/391/EEC, lays down minimum requirements for the protection of workers from risks to their health and safety arising or likely to arise from exposure to electromagnetic fields (0 Hz to 300 GHz) during their work.


2. This Directive refers to the risk to the health and safety of workers due to known short-term adverse effects in the human body caused by the circulation of induced currents and by energy absorption as well as by contact currents.


3. This Directive does not address suggested long-term effects.


4. This Directive does not address the risks resulting from contact with live conductors.


5. Directive 89/391/EEC shall apply fully to the whole area referred to in paragraph 1, without prejudice to more stringent and/or more specific provisions contained in this Directive.

Article 5

Provisions aimed at avoiding or reducing risks

1. Taking account of technical progress and of the availability of measures to control the risk at source, the risks arising from exposure to electromagnetic fields shall be eliminated or reduced to a minimum.

.and in the Annex (I think we Yanks call that an Appendix):

A. EXPOSURE LIMIT VALUES

Depending on frequency, the following physical quantities are used to specify the exposure limit values of electromagnetic fields:


— exposure limit values are provided for current density for time-varying fields up to 1 Hz, to prevent effects on the cardiovascular and central nervous system,


— between 1 Hz and 10 MHz exposure limit values are provided on current density to prevent effects on central nervous system functions,


— between 100 kHz and 10 GHz exposure limit values on SAR are provided to prevent whole-body heat stress and


excessive localised heating of tissues. In the range 100 kHz to 10 MHz, exposure limit values on both current density and SAR are provided,


— between 10 GHz and 300 GHz an exposure limit value on power density is provided to prevent excessive tissue heating at or near the body surface.

Well, I, for one, don't approve of any nasty effects upon my cardiovascular or central nervous system, and we certainly don't want any whole-body heat stress.  But, the protective action of the EU might have some unforseen consequences.  From S. F. Keevil, writing in the British Journal of Radiology in 2005: 

Not that I mind US researchers getting the upper hand in something, but you know very well that if the limits go into effect in Europe, they will eventually find their way across the Pond, given our admiration for all things European. 

In the absence of a static field limit, the gradient field limit poses the greatest problem. It will exclude staff from the vicinity of the bore during imaging, with the extent of the exclusion zone depending on magnet and gradient system design and choice of sequence. Since the limits are absolute, without scope for time averaging or relaxation for brief exposure, it will become illegal for an anaesthetist to lean into the bore even for a moment to check a patient, or for a radiographer or nurse to hold an anxious patient’s hand.


Incorporation of these limits into law will make many interventional MR procedures illegal in Europe, closing off development of a field with tremendous clinical potential. It will make it more difficult to provide appropriate care for anaesthetised, monitored and anxious patients. It will affect manufacture of MR equipment, particularly if a static field limit is adopted, and hence threaten the UK’s global position in this sector. It will give US researchers a significant advantage over European competitors, both in th development of MR methodology itself and in the growing exploitation of these techniques, for example in the pharmaceutical industry. Most importantly, it will mean that current and future MR techniques may be denied to patients, in many cases necessitating an examination with X-rays instead, with the resulting dose of ionizing radiation to both patient and staff.

But Keevil then reveals the basis for the proposed limits: 

What are the known short-term adverse effects that the Directive seeks to avoid? A recent paper [4] has considered ICNIRP and NRPB documents [2, 5] in more detail than is possible here. In the gradient frequency range, peripheral nerve stimulation (PNS), due to induction of electric currents by time varying magnetic fields, is an adverse effect that forms the basis for limitation of patient exposure [6, 7]. PNS occurs at a threshold current density of around 1 A m22 – 100 times higher that the limit set in the Directive. The difference arises because ICNIRP occupational exposure guidelines rely on less well-established phenomena, such as alteration of visual evoked potentials and subtle cognitive effects. Evidence for most of these effects is sparse, often dating from the 1980s, in some cases presented in preliminary form at conferences rather than in full papers, and in other cases reported only in the 10–100 Hz frequency range but extrapolated to higher frequencies in the absence of more appropriate data.


ICNIRP concludes from these data that thresholds for acute CNS effects are exceeded above 100 mA m22, but in view of the sparse evidence, applies a safety factor of 10, resulting in the 10 mA m22 limit. In supporting the same limit, the NRPB acknowledges adoption of ‘‘a cautious approach… to indicate thresholds for adverse health effects that are scientifically plausible’’ [3]. Many things are scientifically plausible, but the exposure limits are supposed to be based not on hypothetical possibilities but on ‘‘known adverse health effects’’ causing ‘‘detectable impairment of… health’’, as opposed to biological effects that may or may not be harmful [2] if they exist at all. There is no substantial evidence for any such effects in the gradient frequency range below the PNS threshold.

Could it be that the EU overreacted?  Keevil hammers the point home in in a report prepared for the Institute of Physics in London: 

Keevil goes on to outline the actions taken by the MRI community, as well as possible outcomes and alternatives.  The Directive is, as noted above, currently on hold until 2012. 

The members of ICNIRP are internationally acknowledged experts in their fields, but the guidelines that they produced are based on the cautious interpretation of sparse data and are essentially precautionary in nature. It has since come to light that the possibility of the directive causing problems with MRI was raised by some MEPs at an early stage. However, it was dismissed because the European Commission received assurances from ICNIRP that the ELVs would not be exceeded by MRI workers. It has not been possible to determine the precise nature, timing and basis of this erroneous advice. . .

For practical reasons, when an MR scan is performed the operator normally leaves the room and operates the scanner from a separate control room. However, there are instances in which a member of staff remains in the examination room and close to the scanner while it is operating. Examples of these situations include:


● interventional MRI, where a radiologist or other clinician may be reaching inside the bore of the magnet to carry out invasive procedures during scanning;


● some types of functional MRI, such as research studies on deaf-blind subjects where a member of staff touches the palm of the patient’s hand during scanning;


● imaging of children, where the close presence of a nurse or radiographer may avoid the need for anaesthesia to obtain satisfactory images;


● imaging of patients who are anaesthetised or require monitoring, where it is common for an anaesthetist to remain in the room and visually assess the patient during scanning;


● research applications, where a researcher may need to adjust experimental equipment during imaging.


Initial estimates showed that for workers remaining close to the magnet bore in these situations, when the switched gradients are operating, the exposure is likely to exceed the AV for 500–1000 Hz magnetic fields by a factor of around 504,5 and the ELV by an order of magnitude. . .

(I)t is difficult to avoid the conclusion that a range of current and emerging MRI procedures would be rendered illegal by the directive. Some of these techniques simply cannot be performed in other ways, and in other cases the only possible option would expose both the patient and workers to ionising radiation. So, far from protecting worker health and safety, in the context of medical imaging the directive might have quite the opposite effect: a recent study found that almost 40% of interventional radiologists who perform X-ray-guided procedures have signs of radiation damage to their eyes.

Electromagnetic radiation is scary to the public, be it X-rays, gamma rays, or even magnetic and electric fields.  In its zeal to protect EMF workers, the EU appears to have used questionable science and just a tincture of panic, without complete understanding of the consequences of its actions.  I am sorely tempted to compare this to the Cap and Trade/Global Climate Warming Change fiasco, but at least in this case, the data was probably misunderstood and not falsified.  That counts for something. 

I would urge all of my readers to go HERE and sign the petition that reads in part:

I urge decision-makers at all levels in Europe to endorse the position of the Alliance for MRI requesting an EU-wide exemption for the medical use of MRI and related research from any exposure limit values set in the Physical Agents 2004/40/EC (EMF) Directive and the implementation of user guidelines.

Please sign, even if it helps our European friends get ahead of us in research.  While politics may be local, science is global, and there needs to be no unnecessary restriction on this aspect of imaging.