Thursday, August 24, 2017

Flavors of DVI

I just completed (a rather long) Day 4 at Aga Khan Hospital, here in Dar es Salaam, Tanzania (in case you didn't know where I was). As usual, time flies when you're having fun, and I really am enjoying my time here.

Today was a day of many hats. In the morning, I played "real doctor" and attended an OB Gyn lecture series beamed over from the Aga Khan University Hospital in Nairobi. The full title was "Female Sexual Dysfunction and its Effects upon Fertility" and it was quite well done. While the lecture will have little impact upon my medical practice, I'm trying to get the staff used to me hanging around, and I had high hopes of amusing the residents with my tales of the wonders of Nuclear Medicine. Which didn't happen today. That will hopefully come tomorrow, when I give the "Introduction to Nuclear Medicine" talk. Maybe there will be a great turnout. They sometimes offer breakfast with the talks around here, and residents anywhere in the world will do anything for free food. 

The rest of the day I became everything from Nuclear Medicine junior technologist to junior Nuclear Medicine Staff to IT assistant. Raghu, the absolute genius running this department, had an onslaught of patients, as the Molybdenum/Technetium generator arrived yesterday from South Africa:

In many ways, this symbolizes the problems of Nuclear Medicine in a place like Tanzania...even something as simple (to us) as a Technetium generator must be shipped by air from South Africa, via Nairobi. And due to various regulations, it can take several days to arrive in country. This generator actually got here almost a day early. (I'm told of an incident wherein the guards at the airport wanted to disassemble a generator...the doc in charge said something like, "Go ahead, I'll be on my way to Zanzibar as fast as I can go.." 

Because of all this, Raghu must tightly schedule his patients for the days following delivery. He can hope to have some extra activity remaining for emergencies, and it is possible to get a dose here and there from the Cancer Center down the street. (Their cameras have been out of service this week, and Aga Khan hospital has stepped up to scan some of their patients.) I am constantly reminded of just how spoiled I really am back home. We NEVER have to wait on a generator, and something like a CCK shortage is an incredibly rare pain in the backside about which we whine incessantly. 

I was able to help with some of the clinical duties as well, taking histories, and even writing notes for the patients! I signed them all, "Visiting Nuclear Medicine Physician". I hope I don't get in trouble with any boards here. 

The Siemens Symbia SPECT (sadly not SPECT/CT) is a battleship of a camera, and Aga Khan Hospital is incredibly fortunate to have one. I'm a reluctant fan of the eSoft computer system, however, and at several points, Raghu and I struggled a bit to force the thing to do what we wanted it to do. Scaling of one image vs. another for subtraction of a parathyroid image should be easy, for example, but Siemens hides the key to activating the Scaling feature. So I put on my Engineer cap, and started clicking buttons until I found the right one.

Soft-tissue attenuation can be a problem in cardiac Nuclear Medicine. Now, I'm somewhat removed from this as the Cardiologists have stolen/taken over now read the MIBI perfusion scans. My newly minted Chief Tech back home reminded me before I came here that prone scanning would help here, and I suggested we try this with today's solitary MIBI patient. (There was a second, but he had to meet with government officials, and apparently my letter did not get him out of whatever it was he had to do.)

The Siemens eSoft interface is not incredibly intuitive for setting scan protocols (but the hardware is bullet-proof, so I give them a pass), and we had to resort to hand-drawn schematics to confirm to ourselves that when prone, the patient should be scanned from LPO to RAO, and that a 90-degree orbit of the two heads opposed at 90 degrees would yield 180 degrees of coverage. The things I do for my patients...

The rest of the day was consumed with monitors and their connections to Ultrasound scanners. While the Radiology Department is about to go completely digital with Agfa PACS (don't say anything), moving off the venerable Clear Canvas (which actually works quite well here), the U/S scanners do NOT have DICOM licenses. This is a sad situation I faced in Ghana. It seems that over here, the vendors charge EXTRA for DICOM. Not nice, folks. Not nice at all. So the three U/S machines here aren't connected to anything except printers. Now supposedly there will be funds allocated to get the DICOM running once full PACS is here, but in the meantime, there is the desire to view the images in real-time. Which means looking at the monitor. Originally, the thought was to purchase a large monitor and a KVM switch to multiplex the inputs from the three scanners into one station. But by the time I got here, the idea had gelled a bit and the Chairman realized that three small monitors cost less than one big one and a multiport, multi connection KVM. So I spent a good bit of time with one of the guys from IT, connecting a monitor to the various scanners. One scanner, fortunately in the room right next to the reading room, has only a DVI output. The other two have VGA. So it now becomes a matter of figuring out how to string cables to connect the various rooms. That one is above my pay-grade at the moment.

We did discover whilst trying various DVI cables in various sockets that there are two main (actually more) versions of DVI, DVI-I and DVI-D. (And DVI-A, but that's beyond our scope)...

DVI-I has extra pins not found with DVI-D, and so a male DVI-I plug won't fit in a female DVI-D socket. Sounds like some dysfunction to me after the morning lecture. But the good news is that we now know what cables we need, and the only remaining question is how to run them.

But here's a question for the audience...the hospital would like to be able to transmit studies outside the hospital, say a NM study to me or the NM doc down the road, or an MRI perhaps to my place back home. HOW do we go about this? Keep in mind, WAN bandwidth is limited.  A signed DoctorDalai business card to the person with the best answer.

And all that solved, I shall now have some dinner, finish my packing for my quick trip to Ngorongoro Crater tomorrow, and turn in early to be ready for my early morning talk.


Monday, August 21, 2017

Patient ID

Hello from the Aga Khan Hospital, Dar es Salaam, Tanzania!

Just wanted to let you know that I'm here and on the job. I've met so far with the head of Radiology (who is also the Chief of Staff of the Hospital), the head of IT, the Nuclear Medicine technologist/physicist, and briefly with the Regional CEO and the COO of the hospital. Everyone has gone out of their way to make me feel welcome here, and their warmth, and their pride in this amazing place is incredible.

I am quite taken with the facility as it stands, but the additions, and plans for the future, will certainly propel AKH well into the forefront of patient care in this region. I was most impressed to find that the AKH has passed the stringent Joint Commission standards, which is quite an achievement for any hospital.

The plan will be for me to talk about Nuclear Medicine with the clinical staff one-on-one as the opportunities arise. There may be a chance to give a talk to a larger grouping of the staff, and the request has been that I discuss PET/CT at that time. I plan to have a presence in the Imaging reading room as well, and hopefully IT can put me to work with some connectivity tasks.

At the end of the day I met with the Nuclear Medicine Consultant, who comes in after her regular stint at the Ocean Road Cancer down the street. She works closely with the physicist who essentially runs all of Nuclear Medicine, juggling the schedule to match the delivery of the Mo/Tc generator from South Africa, serves as RSO, and cleans up radiopharmaceutical spills. And he's a physicist, not a technologist!

I talked a bit about PACS with the head of the department. We have had Agfa PACS at home since 2003, and apparently this will be the replacement for the venerable Clear Canvas installation here. Any of you who have read my blog know of my trials and tribulations with Agfa, and I expect our experience has been parlayed into a better product on Agfa's part. We briefly discussed CT protocols, and I'm going to have a peek at those. AKH has a very capable Philips 128 slice scanner, (and some very capable people running it) and I'm sure it won't take much tweaking to optimize it.

It seems the major staff CME occurs on Tuesday mornings. I've missed getting on the schedule for tomorrow's session, but we ran into the pediatrician in charge of staff education, and I'm set to give a talk next Tuesday. I plan to give my introductory lecture about Nuclear Medicine. We are going to try a different idea for some of the remainder of the time; I'm going to try to approach the clinicians in one-on-one fashion, perhaps join in on rounds if that is permissible, and suggest the appropriate Nuclear Medicine studies when, well, appropriate. I'm not certain we can gather more than a handful of physicians at any other time, but if so, I've got other talks to give.

These are exciting times at Aga Khan Hospital. The expansion, physically, strategically, and if I can make up a term, informatically, appears very well thought-out. It is ambitious but rational, and achievable in scope. In particular, the outreach to outlying clinics seems to be quite logical, with development paced by the best connectivity available to the individual site. I can tell you, when the head of IT said the entire process is built around the Patient ID, I was hooked. This is exactly the problem we faced (and continue to face) at Korle Bu, and it is gratifying to see it addressed from the very start.

All in all, this has been a wonderful first day on the job. Again, I'm very grateful for the opportunity to be here.

More to come!

Oh, by the way, I had to miss the eclipse to be here. As seen from my backyard by my wife and friends, it might not have been all that spectacular...

Sunday, August 20, 2017

I Bless The Rains Down In Africa...

You just can't be in Africa without thinking of Toto's song by the same name, and I can't resist offering both the original and a very moving chorale version:


Now that we have that accomplished, let me say Jambo to everyone from here in Dar es Salaam, United Republic of Tanzania. I got in last night, and to adjust to the time zone (7 hours ahead of Eastern Daylight Time), I've done my usual brief walk-about. (I have to admit that it actually did rain today, and I was rather disappointed by the rain, as it made me decide not to take a boat-ride to the nearby island of Zanzibar. Oh, well.)

Dar is a large city, the capital of Tanzania. It is somewhat similar to Accra, my only other personal reference point within Africa, but there are some profound differences. You may recall my comment that Accra contained throngs of people. People everywhere! Milling about, selling stuff in roadside or sidewalk stands, and so on. Now I haven't seen that much of Dar es Salaam, but what I have seen is much different. Things are much quieter, there are far fewer people on the streets and sidewalks, the traffic isn't quite as congested. I'm not sure what to make of this, and perhaps it will gel as time goes on. My initial thought was that Tanzania might be a wealthier nation due to tourism, but it turns out that the economy is mainly agrarian, and tourism has not yet been effectively tapped. Tell that to the vast majority of folks on my flight from Amsterdam last night who got off at the Mount Kilimanjaro airport to go on safari. Ghana has far more natural resources, according to the Wiki, so I'm probably missing something.

Unlike last time, I'm staying in a hotel rather than the hospital guest house. The Aga Khan Hospital is undergoing major construction and expansion, and no one was sure if there even are any guest rooms on campus at the moment.

So I'm staying in the Marriott Courtyard. Here's the courtyard of the Courtyard:

I hit two of the highlights of Dar on my little trek, the National Museum and a waterfront area called Slipway. The Museum is quite near the hotel, located in an area full of government buildings. As I walked by the Prime Minister's office, a monkey dashed across the street directly in front of me. That's something you don't see in Washington, D.C. No comments, please.

The small but fascinating museum had a nice display of artifacts, fossils, and replicas thereof from Oldavi Gorge, the birthplace of human-kind (which I might get to see over the weekend). I found an old your great^1,000,000th grand-daddy, Mr. Hominid:

Do you remember hearing about David Livinstone, the great explorer ("Dr. Livingstone, I presume...")? Here's his writing desk:

Slipway is a nice waterfront area with several restaurants, shops, and a craft market. Here I am enjoying a libation, which you can't see in the photo, but rest assured, it was only bottled water:

This was my first view of the Indian Ocean from its western shore; I had the chance to stick my foot in it from the Australian side when I spoke in Perth in 2010. Dug-out canoes are ubiquitous near the shore:

The craft market featured lots of paintings and wood carvings, as well as bright fabrics and clothing:

I was quite taken with the carved birds. Might have to go back to get a few.

I did stop at the hospital to say hello on the way to the National Museum. I was able to speak with the ER physician, but apparently the Radiologists (and Nuclear Med physicians) are not in-house on the weekends, and come in on call. How often that happens, I don't know, but I'm already wondering if they need more rads. I'm sure some of my colleagues would be interested, although I wouldn't trust them to drive on the left side of the street. (I don't trust some of them to drive on the right side of the street.)

Tomorrow, I hit the ground running. The plan is to give lectures and see if there is anything I can do to help with workflow in the Nuclear Medicine department. But if this trip turns out to be anything like my last mission, I'll be the one who learns the most.

As I found in Ghana, one is greeted here in Tanzania with "You are welcome!" which I think makes far more sense that saying it after being thanked as we do in the US. However, the word for "You are welcome" in Swahili is Karibu, and the first few times I heard it, I wondered if the speaker was directing me to look at some wildlife that had wandered into the hotel lobby. Hopefully by the end of two weeks here, I'll catch on a bit better.

But in the meantime, I'll bid you kwaheri.

Stay tuned!

Tuesday, August 01, 2017

Life Imitates Art: Apple Listens to Doctor Dalai

I'm sure this is all my doing. Remember my April Fool's Day post a couple of years ago about the "NEW Apple EMR"?

Well, it seems Apple has taken the hint. From Healthcare IT News:

Rumors are at a fever pitch that Apple has big plans for healthcare, including putting a medical record on the iPhone, possibly acquiring its way into the EHR market.

From its leap into healthcare in 2014 with its HealthKit application programming interface in September 2014 to the June 19 revelation of Apple’s work with the tiny start-up Health Gorilla, Apple has made a series of moves in healthcare that clearly indicate the company has plans for the space that will somehow manifest on its mega-popular iPhone and iPad products.

Here’s a look at how Apple got to where it is today in healthcare.
The article proceeds to describe recent Apple acquisitions in the healthcare space which appear to point to an eventual (huge) presence in the HIT realm:

I'm going to direct you back to the original article, titled, "Timeline: How Apple is piecing together its secret healthcare plan" for the details, but suffice it to say, they are pretty clearly targeting the healthcare market. An EMR is the next logical step.

Could Apple PACS be lurking in the wings out there in Cupertino???