The Needs Of The Many Outweigh The Needs Of The Few...

[On whether Kirk should assume command from Spock]
Spock: If I may be so bold, it was a mistake for you to accept promotion. Commanding a starship is your first, best destiny; anything else is a waste of material.
Kirk: I would not presume to debate you.
Spock: That is wise. Were I to invoke logic, however, logic clearly dictates that the needs of the many outweigh the needs of the few.
Kirk: Or the one.
Spock: You are my superior officer. You are also my friend. I have been and always shall be yours.

from: www.imdb.com

I peek in at a number of websites and groups on Google and Yahoo to glean PACS material for this blog as well as my own edification. Recently, I stumbled upon a conversation that really got me going, as it illustrates the audacity of dopes, in this case some IT arrogance and paranoia that certainly goes above and beyond. I'm not going to link to it, so just read the following and laugh, or weep, as the mood strikes you.

We open with a simple question:

Up to recently most users were able to autoplay an outside CD in order to view the PACS images. Something changed (could be IT-Dept’s group policy) and now nobody’s CD drive auto-plays. Does anyone know the steps on a PC to enable the Autoplay feature in the Windows permissions/policy? Would Corporate Group Policy over-ride the local PC policy once the PC re-booted or logged off?

Many posters tried to answer the question objectively, as we see here:

Re: CD's do not autoplay
Most cases, the auto-play has been disabled.

http://support.microsoft.com/kb/971029

But then, Mr. Stonn, with a significant dose of paranoia (or maybe a bit of Socialism?) intrudes on the discussion:

Assuming you have desktop administrative privileges, hiding a workstation in another OU and adjust the GPedit to make it automatically run outside CD's (even USB drives) is still endangering your corporate network as it could easily be bringing in a Trojan or other mal-ware on it. You may think there is nothing on it but I know for sure that there can and will be. The infection is silent to those inserting the CD but it lights up the control panels in the back end and infects other workstations everywhere in a very short time requiring scores of hours eradicating it from where it spread. It can also disable many workstations it hits and the lost productivity time for your other care providing colleagues is incalculable.

If it were to infect an unprotected computer in a nuclear medicine camera gantry, it could lead to crushing and killing a patient, so you should think long and hard before you boldly insert any outside data into your workstation. Hope is not a security strategy and trust is not a control. Everyone is responsible for protecting your own network. As Spock would have told you himself: "The Needs of the many outweigh the needs (desires really) of the comparison images of the single patient. Work closely with your IT department, there are solutions that bring a balance between flexibility and security. Don't substitute deliberate ignorance for thoughtful planning.

We specifically push a GP disabling the auto-run feature as most CDs that come in are unknown and recently one had a Trojan virus on it. We have recently upgraded the enterprise to the new Symantec Endpoint protection software that when the local auto-run policy is re-enabled - will scan the CD first before running it which is much more secure and yet flexible model. Works for film rooms and OR's but does require some custom tailoring with the administrator running the Symantec systems. That would be the thoughtful planning phase.

Wow. This IT giant does actually make sense with the last paragraph, and actually shows some vague realization of the scope of the situation. Unfortunately, the preceding prose makes it clear that his priorities are completely those of the network and the IT department, with zero regard to the needs of the individual patient. I guess they should all be assimilated into the collective, eh?

Fortunately, someone with a good dose of common sense (who happens to be a friend of mine, too!) stepped in:

While I sympathize with the need to protect the network, (and yes other patient's records which are backed up somewhere as well)...I have never bought into Spock's (Dr. or Mr.) socialist musings that sanctions mob rule to override the needs of individuals. Ah, nothing like some more sci-fi metaphors to address an issue. Why should some ficitional character's philosophy be brought to bear on this issue as though there was no question that they would be correct? Why should anyone give a damn what Spock would think?
Perhaps if that "single patient" were the writer himself, or a member of their family, and the comparison images were of utmost importance in the diagnosis, they might think a bit differently. Never dismiss the needs of a single patient! Perhaps stepping out of the sci-fi world and into the real, medical one for a period of time, would be helpful for some.
Thoughtful planning and communication does indeed negate the need to endanger any lives. It is a shame that in order to save the life of one patient, a physician or resourceful pacs admin might have to thwart and possibly endanger a network. Gasp!

Well said.

Now, Mr. Stonn had this to say in response:

Lighten up and get a grip. We are all entitled to our opinions. I respect yours also. Clearly you don't know your Star Trek and don't know what viruses and malware can do to a network. I would also pose that you probably don't know how the modalities physically and electrically work and what safeties are in play to prohibit them from over radiating or killing the patient. As an example, have you ever seen where a Nuc Med gantry crushed and killed a patient? I have. Was it due to a network virus or technologist neglect?, that is unknown. Hmmm, how do you call that really? Destroy a person's career or blame it on a virus. If it was caused by the gantry computer losing software control due to a virus that some patent care flag-waving rationalizer failed to engage proper outside image ingest protection procedures, then how do you feel when this give a damn about the network attitude wins over and you bypass the needs of other patients safety for that one single patient? Put you own family member under the gantry as you load an un-scanned outside CD. Again, just because you can't see it infect doesn't mean it is not happening, you will never know. It like shooting bullet straight up into the air while in a crowd, maybe it will come down without hitting someone and killing them, maybe it won't. That's hope. Not a good plan.

Sci fi references make us all take a step back and try to look at things from another and different even perhaps comical perspective. References to Spock were taken from one of the full length Star Trek Movies where Mr. Spock (not Dr. Spock) sacrificed his life in order to save the entire crew of the ship. I will omit the details but summarize this by saying that the philosophy in play was "The needs of the one outweigh the needs of the many." Based on what you have said, in reality, you are actually sanctioning using this philosophy you recently professed against by allowing viruses (always potentially) brought in by a CD, into a network. You seem to say is "okay" to blindly get ingested what are essentially just comparison images in front of the next care provider. Put it into perspective. Can anyone really demonstrate where a CD not ingested into PACS will "save the life" of any patient? Come on. Doctors, Nurses and other providers save lives. Images that "save lives" start in the ER/ED and those go into PACS immediately after scanning. Patient care flags need to be carried with respect on both sides of the fence.

The solution that satisfies both "needs" is to ensure that whatever you plug into a hospital/clinic workstation is scanned for virus and malware as it is being inserted. Free software is not the solution, you get what you pay for and nobody will support free software in any organization (except efilm). Just encourage your IT group to invest into the software.

This is how he respects other opinions? Yeah, right. THIS is why I have harped on the necessity of Radiology control or co-control of PACS. Medicine is a business unlike any other, and the lives of individuals are at stake here. We CANNOT cavalierly dismiss the needs of the individual patient. As a radiologist, I can state unequivocally that having a prior exam that might be encased on a CD-ROM is critical, and yes, it IS worth risking a virus infestation to have that data. Really. And just two nights ago, I read a trauma CT series including scans of the head, c-spine, t-spine, l-spine, chest, abdomen, and pelvis. The resident looking over my shoulder casually remarked that the patient had undergone the exact CT series three hours before. Why were we rescanning? Because the outside hospital "didn't send a disk." So we have just double-irradiated the patient for someone's omission. Mr. Stonn would approve, as long as his precious network wasn't compromised. Here's the balance: someone's LIFE vs. damage to the network and inconvenience to some IT folks. This one isn't even close.

And by the way, friends, I have spent hours searching through the web for any tale of a "nuclear medicine" camera that went haywire and crushed a patient BECAUSE of a computer virus. I've dug into the FDA complaint list, and Googled till the cows came home. Nothing. Nada. This was either an out-and-out lie, an exaggeration, or maybe the poster was simply delusional or just quite gullible. This incident never happened. It can't happen with a modern machine. Maybe, possibly, some pervert could write a STUXNET-like virus designed specifically to disable a gamma camera, but come on. 

The utter arrogance is galling. The sad fact is, Mr. Stonn's solution is really ideal, security software that preempts a virus before it can be admitted (or "ingested") into the network. We can all agree that this is a great solution, favorable to all involved. Why couldn't Mr. Stonn acknowledge the necessity of receiving outside information rather than dissing the concept before presenting his answer? I expect he has been indoctrinated by the usual IT attitude that their precious computers and networks would be ever so much better off without being polluted by grimy non-IT types. Sorry, pal. We all work for the patients, and in the great scheme of things, YOUR job is to help me do MY job, not stand in my way. If you worked for me, you wouldn't work for me long.

And besides...

Captain Spock: My father says that you have been my friend. You came back for me.
Kirk: You would have done the same for me.
Captain Spock: Why would you do this?
Kirk: Because the needs of the one... outweigh the needs of the many.
Captain Spock: [pacing] I have been and ever shall be your friend.
Kirk: Yes. Yes, Spock.
Captain Spock: Ship, out of danger?
Kirk: You saved the ship. You saved us all. Don't you remember?
Captain Spock: Jim. Your name is Jim.
Kirk: Yes.

Sometimes, saving the individual saves the entire Enterprise, yes?

Sophie in the Grass

Shot by Dalai, Jr., with my Leica D-Lux 4.

Tornadoes Happen Here

The South has experienced more tornadoes in the past few days than ever seen before. I'm waiting for someone to blame global-warming-climate-change, but hopefully the dirt-worshipers will keep that opinion to themselves out of respect for those injured. An unprecedented 280+ people were killed in this unholy battering from Mother Nature, and thousands more were injured or lost their worldly possessions.

I would urge you to donate to the Red Cross, or whatever agency you prefer. There is tremendous need, right now.

My heart goes out to those who were caught in these horrific storms. I had the joy of riding out a tornado in Omaha in 1975, and it remains the most frightening experience of my life. Below is an artist's rendering of the storm, that coincidentally depicts the funnel roughly one minute before it hit the building I was in at the time, Temple Israel Synagogue. The steeple of the church across the street is visible to the left of the image; the church was hit as well, but the steeple remained standing. (Image courtesy shayden.com)

Here is an aerial view of the Temple (to the right) and the adjacent Playhouse Theater after the storm (image courtesy noaa.gov):

I got a few scratches, and a few of the other kids got cut up a little, but we were otherwise OK. "Only" three people died in this terrible storm.

We tend to forget just how powerful these natural events can be, but trust me, the view from the middle of a tornado is pretty awe-inspiring. That is if you happen to be looking and not kissing your ass goodbye as I was...

Seriously, be generous to the Red Cross or the charity of your choice in this time of need. Tell 'em Dalai sent you, and when they stop laughing, give. From the heart.

ADDENDUM

Sometimes I hate to be right.  Here's a dirt-worshiper's comment on the storms:

Storms Kill Over 250 Americans In States Represented By Climate Pollution Deniers
Today, news agencies are still tallying reports of deaths from the most devastating storm system in the United States in decades:

Dozens of massive tornadoes tore a town-flattening streak across the South, killing at least 250 people in six states and forcing rescuers to carry some survivors out on makeshift stretchers of splintered debris. Two of Alabama’s major cities were among the places devastated by the deadliest twister outbreak in nearly 40 years.

 “Given that global warming is unequivocal,” climate scientist Kevin Trenberth cautioned the American Meteorological Society in January of this year, “the null hypothesis should be that all weather events are affected by global warming rather than the inane statements along the lines of ‘of course we cannot attribute any particular weather event to global warming.’”

The congressional delegations of these states — Alabama, Tennessee, Mississippi, Georgia, Virginia, and Kentucky — overwhelmingly voted to reject the science that polluting the climate is dangerous. They are deliberately ignoring the warnings from scientists.

So "ignoring" the proclamations from the dirt-worshipers' High Priests of Gaia brought about tornadoes that killed 300 people, eh?  Talk about supreme arrogance....I just can't wait to see what they'll come up with next.

Read 'Em And Weep

I'm a little leery of Klas results on occasion.  The surveys are not quite scientific, and commentary is occasionally several versions behind on any particular product.  Still, Klas is about the only compiled source of such information, and it cannot be ignored.

Klas just published the latest Ambulatory RIS/PACS review.  I've seen it, but I don't want to violate copyright laws by reproducing it here.  But I'll share a few results:

Number 1 out of 18, with a score of 88.9....Intelerad IntelePACS.
Number 13 out of 18, with a score of 79.8....Merge/AMICAS PACS.
Number 17 out of 18, with a score of 73.6....ScImage PicomEnterprise.
Number 18 out of 18, with a score of 64.6....Agfa IMPAX.

Now I realize this is for the ambulatory space, which not Agfa's strongest market.  But...

Listen to the customers.  They are saying something, although it isn't always clear just what that might be.

Toshiba Acquires Another Advanced Visualization Company

It's deja vu all over again. I reported back in 2008 that Toshiba had purchased Barco's Advanced Visualization Imaging System (AVIS), which used to be Voxar, Ltd. Today, we have this report:

Toshiba Medical Systems and Vital Images have signed a definitive agreement for Toshiba to purchase Vital Images’ stock for a total of $273 million, putting the cap on a decade-long partnership between the two companies.

Under the agreement, which is expected to close by the second or third quarter of 2011, a Toshiba subsidiary will acquire all outstanding shares of Vital Images’ stock at $18.75 per share. The merger has been unanimously approved by the boards of directors of both companies, Tustin, Calif.-based Toshiba said.

Minneapolis-based Vital Images, which develops advanced visualization software and other health IT products, has relied heavily on a partnership with Toshiba over the last ten years.
"After a decade-long successful partnership spanning more than 50 countries, [Toshiba] is taking the partnership to the next level. We have enormous respect for Vital Images' products, pipeline and people, and look forward to working with their highly skilled team to enhance clinical value for patients throughout the world,” saidSatoshi Tsunakawa, CEO of Toshiba Medical Systems.

Michael Carrel, CEO of Vital Images, expressed enthusiasm over the deal, saying “This transaction means we can now accelerate our global presence with the strength and backing of [Toshiba].”

The $18.75 share price Toshiba agreed to pay for Vital Images represents a 39 percent premium over the volume-weighted average of the company’s 30-day stock, Toshiba reported.

The bid follows Toshiba's 2009 purchase of Barco's advanced visualization business, which resulted in the formation of Toshiba Medical Visualization Systems Europe.

I guess TeraRecon and Visage will be next, eh?

My dealings with Vital have not been spectacular over the years, as I reported a while back. Hopefully, Toshiba can make good use of its Advanced Acquisitions.

Hat tip to 23 Skidoo.

Dalai's Rules, II

Since my last post on the topic, I've acquired more classroom-sized slide rules.  At this point, I've got a reasonable sample of most of the brands and variations of these things.  There are really only two or three that I need to have a really complete collection.  But as you can see, I'm running out of wall space.  My ultimate plan is to donate the entire collection to my alma mater, if they have enough wall-space.  At least my old engineering school will know what a slide rule is...

Dalai's Birth Certificate

I've resisted and stonewalled all I can. I must now bow to public pressure and reveal my actual, long-form Certificate of Live Birth. Now, can we drop the silliness and get on to really important PACS issues? Please?

And The Answer Is....BGO!!!

I tried and tried to confirm which crystals are being used in GE's new PET/CT, the Kia Optima PET/CT 560, but GE just wouldn't answer my emails.

Fortunately, I have friends in high places. I posed the question to MedGadget, wherein we find another review of the Optima. Somehow, their email was answered, and here is the response:

You can tell him/her we chose the BGO crystal as it delivers a proven track record of speed and performance and is optimized for oncology imaging especially for Fluorine-based tracers.

I don't like to parse words, but this basically says that "we've used it before and we're using it again." And the energies of the other PET tracers all peak at 511 KeV, standard for positron/electron annihilation. So what's this about being best for F-18? (As we will see below, F-18 might be best for a machine with BGO crystals, but not vice versa.) If BGO is the end-all to end-all, why not mention it in the extensive Optima product brochure? If BGO is the best choice, pat yourselves on the back for making it.

Personally, I'm not buying any of this. Literally or figuratively. As I mentioned in the initial post, this is a deal-breaker, not that I have the funding to buy a new PET/CT in the immediate future.

I think we can assume that the rationale behind the decision not to go with LYSO as used in the Discovery 690 was cost. BGO is cheaper, and adequate (barely) for the job. (Ummm, by the way, did GE ever actually make any 690's? Did they sell any? Reports from the field appreciated...)

As I've said again and again, LSO beats BGO hands down for positron imaging.

AuntMinnie has a great reference paper on PET fundamentals.  Therein, we find this passage (emphasis mine):

Bismuth germinate oxide (BGO) crystals are generally used in conventional PET imaging systems. BGO crystals have a high stopping power (high efficiency), high spatial resolution, and are 50% more efficient than thallium-doped sodium iodide -- NaI (Tl) -- crystals. Most crystals are 3-6 mm thick and they are not hydrophilic. The detection efficiency for 25 mm BGO crystal is approximately 80% [31]. The spatial resolution approaches 5 mm, which nears the theoretical limit of resolution. The disadvantages of BGO crystals are that they have a much lower light output (15% of NaI (Tl) crystals), long photofluorescent decay times (decay constant of 300 ns which limits count rates/coincidence timing resolution [31]), and poorer energy resolution than sodium-iodide crystals. Energy resolution of BGO is normally worse than 20-25% in FWHM at 511 keV. A typical energy window for a BGO scanner is 300-350 keV to 650 keV [18]. This poor energy resolution makes it difficult to remove scattered events by energy discrimination. Therefore, lead-tungsten septa are interposed between detector rings to reduce interplane scatter [18]. The coincidence time window is normally set for 10-20 ns. The inferior time resolution causes larger accidental detections and greater dead times. BGO detectors are best suited for imaging isotopes with long half-lives such as F-18 and C-11.

Lutetium Oxyorthosilicate (LSO) crystals offer the best combination of properties for PET imaging [2]. LSO has a higher effective Z (number of protons per atom) and density compared to BGO which results in an equal or higher detection efficiency [3,31]. It has very good energy resolution (about 12% [21]- with a typical energy window set to 425-650 keV), a short decay constant for good coincidence timing (a decay constant of 40 ns and coincidence time window of 4.5 ns), and higher light output (five fold more light compared to BGO crystals [31]) [2]. The coincidence time window is set to 4.5 ns. These characteristics enable image formation is less time when LSO crystals are used [31]. The crystal is rugged and nonhygroscopic.

BGO versus LSO detector: The images below were acquired in 2D mode with a scan time of 5 min/bed emission and 3 min/bed transmission. The upper row of images were acquired on a BGO camera system and the lower row of images were acquired on a ECAT Accel LSO PET camera system. The data was reconstructed using normalized attenuation weighted OS-EM reconstruction. Image courtesy of Northern California PET Imaging Center, Sactamento, CA and CTI, The Power Behind PET.

'Nuff said.  The great Crystal Caper is solved at last.  Many thanks to MedGadget!

Advancing The Cloud

I've been a TeraRecon fan for quite a while now. Sadly, I'm not a customer as yet, since we cannot convince our administration to cough up come up with the cash in these hard economic times.

But TeraRecon has recently provided a very economical alternative. How does FREE sound? Yes, for the time being, you can have the power of TeraRecon at no charge.

In a recent article in ImagingEconomics.com, TR president Robert Taylor, PhD, outlines the problem many of us out in the boonies face when trying to implement (or justify) advanced imaging:

Advanced visualization—for all of its benefits—also comes with its challenges, said Robert Taylor, PhD, president and CEO of TeraRecon, who outlines the challenges in this way: it is expensive (you have to have enough volume to justify investment in a complete system); it is an IT deployment (you need an IT department to deploy and manage it); and it is confined to your organization (if you need to reach outside your organization to share or collaborate, it can get complicated).

In order to respond to these challenges, the company announced iNtuition CLOUD late last year. With this new solution in place, new customers can have their iNtuition UNLIMITED licenses hosted within the company's cloud solution. To date, more than 400 users have signed up for evaluation accounts, which were offered free of charge to professional attendees at RSNA '10 and continue to be available at www.terarecon.com/cloud.

I'm one of those 400 users, and I can vouch for its functionality. Maybe it isn't quite as seamless as having an in-house installation, but iNtuition CLOUD does work, and it works very well. For all intent and purpose, you have a full iNtuition product at your disposal via the Internet, I mean Cloud.

On the client side, iNtuition CLOUD functions as a browser link, according to the company. After logging in, the user can start to work with their studies. On the server side, when a user connects and logs in to their account, the cloud establishes a secure link to an appropriate server from the company's global network that has the user's data and is located in a geographically appropriate location.

To be fair, I haven't tried it out on the iPhone or iPad, but I see no reason why it won't work on these devices, as the image above suggests.

Naturally, there are a few areas where one must convince the IT folks and lawyers that this is a kosher approach:

Taylor concedes that one of the biggest challenges is that health care providers have to get comfortable with the legal, regulatory, and security aspects of putting patient data into the cloud and entrusting it to a third party like TeraRecon. He's aware that legal and regulatory departments within health care facilities will need to develop the right contractual and policy frameworks that will allow them to use iNtuition CLOUD and still comply with HIPAA, HITECH, and all of the other applicable obligations. The company's immediate goal is to get health care facilities talking about the possibilities related to iNtuition CLOUD.

Hey, if you can't trust TeraRecon, who can you trust? Stated differently, if you can trust certain larGE companies, you can certainly trust TeraRecon.

Dr. Taylor concludes:

"2011 will be the year that iNtuition CLOUD 'arrives' in a very meaningful way as a part of the advanced visualization landscape."

It has definitely arrived. Anyone looking into advanced visualization should certainly check out iNtuition CLOUD. Having the power of TeraRecon for free is like having Hanukkah in July.

ADDENDUM

Dr. Taylor sent some comments on this post:

The article references 400 users but we're actually past 1000 now and just made a PR about it. You can find a link to the PR at the top of the press releases column on the right of our homepage: www.terarecon.com

iNtuition Cloud is working out really well, and some surprising ways. We are starting to commercialize it now, with several heavy evaluators turning into paying customers, even at their own request - people need a contract in place to use the service formally, I suppose.
But in addition to this, we have found Cloud to be very helpful for our prospective customers to user in a "try before you buy" mode. We used to feel that if we didn't provide a carefully controlled demo with a specialist there in person, we couldn't do our product justice and we may leave a sub-optimal impression, but with Cloud, people are trying it, digging in, figuring things out, asking us questions, and getting a sense of comfort that our solution will work for them, without any major issues. It's very exciting.

I would say that in 2011 so far, I can point to several significant purchases that were driven by Cloud evaluations. One was an extremely famous cancer center that wanted to first make sure we could load their data and perform the specific measurements they needed, and another was a major radiology group that wanted to see how the system could work for their distributed group of interpreting physicians, before jumping in to buy a tool to enable them to offer wider interpretation services, including brain perfusion, cardiac, EVAR, etc.

In some cases, people try the Cloud and buy the Cloud. In others, they try the Cloud and then buy a system. In a couple of cases, we have even sold "Private Clouds" where the customer buys a set of the equipment we use to operate the Cloud, and then sets it up in their own datacenter and operates and controls it for their staff only (e.g. radiologists working from a wide range of remote locations needing access from a browser).

We have also been adding features, like automatic anonymized, compressed DICOM routing to the cloud, relay back to the site of derived results, and PACS integration, so you can launch the Cloud client from a supported PACS system (instead of needing a local client installed).

It's definitely picking up speed and we're having a lot of fun with this!

Watch The Birdie!!!

LEICA 'BIRDIE" from Philip Escobar Jung on Vimeo.

Speaking of civility, or lack thereof....

STFU! And Be Civil About It!

This post should be filed under "Social Commentary", so if you are going to get upset about a non-PACS entry, then feel free to GTFO (which means Gallantly Try Finding Other sites, I believe).

I had to travel last night to be with the rest of the family for a relative's birthday. Flying is the usual drudgery, with the added joy of every last possible piece of luggage being brought into the cabin so as to avoid the $20 fee. I hope the airlines are pleased with themselves for this rather nasty money-grubbing move, and the unintended consquences thereof.

Anyway, I made it through the hub airport without difficulty, and boarded my next plane. I settled into my seat, and tried to catch a nap on this 45 minute flight. Unfortunately for me and the rest of the passengers, two rows behind me, a bearded gentleman in his thirties began nattering away at the top of his lungs about various engineering topics to his seatmate. And he continued without pause through the entire flight, the taxiing to the gate, the retreival of everyone's life-possessions from the overhead bins, the lineup out the door and even down at Baggage Claim. Naturally, his voice and the volume thereof carried quite nicely through the remainder of the DC-9. Often, I can simply block out such things, but having the engineering background myself, and being in just the right state of fatigue, I kept latching onto familiar phrases. So much for my nap.

At the end of the flight, I turned around to see several other gentlemen, who were wearing suits and ties, balling their fists and rolling their eyes, as Mr. Nerdy continued his unending, LOUD babbling.  How we all managed to keep from delivering an even louder chorus of "STFU!!!!" I'll never understand.

I wish I could say this sort of thing is an isolated incident, but it isn't. One of our X-Ray techs, who is a great person, and does incredible work, cannot speak in tones softer than a freight train at 10 feet.  By some wonderful bit of luck, my reading room is indeed 10 feet from the patient prep area, and I'm interrupted every 5 minutes by a blast of "HI!  I'M JOE AND I'M GOING TO GET YOU READY FOR YOUR CAT SCAN!!" or "TIME FOR YOUR CHEST X-RAY!  ARE YOU WEARING A BRA? GOOD! COME ON IN HERE AND HUUUUUUUUUUUUG THIS BOARD!!!"  I've tried slamming the door to my office, but the message never gets across.  Perhaps JOE can't hear (or grasp) the slam.  And there are similar examples in my workplace, and elsewhere.

Please understand, I'm not thinking all of the ultra loud folks in my life are trying to annoy me, even though they succeed quite readily. I have to wonder if the new norm of CONSTANT music via iPod/iPhone/etc. headphones is literally deafening our society. And maybe some have been affected by undertreated otitis in their youth, yielding deafness near and far.  I was of the generation that received antibiotics for earaches.  Lots and lots of antibiotics.  I'm told this is (or at least was) passe, and I've run into docs who are petrified to hand out a Z-Pack to a kid with otitis for fear of causing the next flesh-eating-bacteria epidemic.  (I'm not kidding.)  Could we have thus created a generation of kids with hearing loss? 

Realizing that you are annoying other people is one facet of courtesy.  Rather ominously, there is a general trend away from gentility, and toward such selfish, and even entitled behavior.  (And by the way, I'm not accusing either the Very Acoustic Engineer or JOE of this, but the description will apply to some of the LOUD folks.)  More and more, we see the tendency for some to do what they please, without regard to how it might affect others.  I'll stick my iPod in my ears, and turn it up so loud everyone around me can hear the music coming out of the headphones.  I'll then shout because I can't hear, or maybe I just feel like shouting.  The yellow light, or even the red light at the corner simply means I'm supposed to speed up and be the last one through, even if your light has been green for 10 seconds.  That's not my problem.  I demand my entitlements, and I demand that you pay for it, because you are richer than I am, and that just isn't right.  And so on.

I have to ask, is there some connection between political orientation and civility?  From Georgetown's Patrick Deneen in the Washington Post:

For all the the lamentation about the rise of incivility in our culture today, there was little understanding of the deeper sources of modern incivility - indeed, the connection between incivility and liberalism itself. Civility requires a certain set of preconditions and even deeper prevailing norms about the nature of political life itself. Modern liberalism has systematically sought to disassemble those conditions, and those prevailing norms. Complaints about the decline of civility are thus more than a little disingenuous.

One should expect little deep thought about such a matter as "civility" in contemporary political and social life, but there seem to me to be fewer more important questions facing our society today. Yet, the fact is, for all the hew and cry about the dearth of civility in our lives and times, as a culture we are actually more deeply opposed to civility than might even be suspected by its passing proponents. Modern - especially liberal - society is designed largely to undermine civility. Rather than lament its dearth, we should understand more fundamentally the deeper systemic causes of its decline. . .

To hear contemporary liberals lament the decline of "civility" is thus more than a little galling. Modern liberals are the heirs of a longstanding effort to liberate people from the "little platoons" that tempered individual self-expression. Hearing their decrying of contemporary "incivility" is a bit like the man who, after insisting on his wife dress as revealingly as possible, gets upset that other men are leering at her. By that same token, "conservative" defenses of "incivility" are even more aggravating, perhaps even more than the well-publicized "conservative" re-introduction of polystyrene coffee cups in the House cafeterias.

Civility is indeed a lost art of our time, but not because of talk radio or growing partisanship. These are symptoms of a deeper disease. Until we frankly diagnose our condition, we remain a patient whose diseases continue to metastasize, all the while complaining that what really bothers us is a hang-nail.

And what is that deeper disease?  It isn't something we can cure with antibiotics.  I've heard that the lack of civility has much to do with the increasing pressures of our day.  But when we look at the incredible patience, and, yes, civility, of the Japanese victims of the earthquake and subsequent tsunami, I have to question that. These are a people who have endured a huge tragedy, and must be under incredible stress.  But they stand patiently in queues for water and supplies, there is no pushing or shoving, and no price-gouging on the part of the stores.  No, I fear the deeper disease is the false narcisism, the "Me, Me, Me!" of entitlement and the false generosity of gallantly demanding justice for the needy via confiscation from others. 

What? Sorry, I couldn't hear you over my loud little rant...

Number Three Blog!!!!

RadiologyTechnician.com has this to say about Radiology Blogs:

Everytime you get an X-Ray, something special takes place: your insides are put on black-and-white display right before your very eyes. It may seem like a commonplace medical practice (and it is), but still, there's something really cool about what radiology allows us access to when it comes to our bodies and minds. Learning how to interpret these charts and graphs is not particularly simple, but it's a much needed skill. Radiologists (and those in training) sacrifice a lot of time and energy to perfecting their science, and luckily many of them are blogging about their toil. Here's the best selection of fifty radiology-related blogs out there.

Here's what they say about DoctorDalai.com:

Dalai's PACS Blog: The first thing that intrigued us about Dalai's blog was his inclusion of the term "PACS" in the site's title. Though at first glance it's easy to assume he's making an allusion to political funding, he quickly defines the word as a picture archiving and communications system, or also pain and constant suffering. That sense of wit and redefinition permeates this site.

Why We Love It: A clever and comprehensive blog reflects the jovial expertise of its head radiology writer.

Favorite Post: Radiology App

(The link to the Favorite Post should probably have been:  http://doctordalai.blogspot.com/2011/02/first-diagnostic-radiology-application.html and not the link to the FDA website...)

Sometimes, my expertise isn't jovial, and sometimes there isn't much expertise in my joviality, but I do appreciate the sentiment.  Also, while it's true that I'm the head writer, for the foreseeable future, I'm the only writer.  As for wit, well, I'm reminded of a little poem often inscribed where few women may see it:

Those who write on sh*thouse walls,
Deserve a monument in Heaven's halls.
Something fitting for their wit,
A monument of solid sh*t.

But, once again, I am very honored to be on the list, let alone showing at Number Three!

I have to republish something that was republished on Blog #5, Scan Man's Notes, which was in turn copied from Life in the Fast Lane: 

The ‘Ten Commandments of Emergency Radiology’ according to Touquet et al (1995):

Treat the patient, not the radiograph

Take a history and examination before ordering a radiograph

Request a radiograph only when necessary

Never look at a radiograph without seeing the patient, and never see a patient without looking at the radiograph

Look at every radiograph, the whole radiograph, and the radiograph as a whole
- remember the ABCS: alignment/ adequacy, bones, cartilage (joints) and soft tissues.

Re-examine the patient when there is an incongruity between the radiograph and the expected findings

Remember the rule of twos
— two views, two joints (above and below the injury), two sides (for comparison), two occassions (may need a follow up x-ray) and two radiographs (compare to a normal radiograph)

Take radiographs before and after procedures

If a radiograph does not look quite right ask and listen: there is probably something wrong.

Ensure you are protected by fail safe mechanisms
— establish a quality control system

Are you ER docs listening?  I didn't think so...

Congrats to my fellow Radiology Bloggers!

I Really DO Own Some GE Stock...

Got this in the mail today.  Personal data redacted, of course.

Texas Two-Step

The University of Texas Medical School at Houston is a fine institution, although it has lived somewhat in the shadow of its more famous neighbor, Baylor College of Medicine.  I'm a proud alum of the latter, although Baylor might not want me to publicize that fact.

UTH has found a way to stand out, although not in the way I would recommend.  On a web-page that appears somewhat cobbled-together, UTH offers us a wonderful new service:

Need answers? It's easy!
Offering second opinion and medical legal consultation for patients, medical professionals, and legal professionals.

Sharing this banner is an introduction to the UTH Radiology Consultation services from Dr. Susan John, Department Chair:

A message from Dr. John…


Susan D. John, M.D. Professor and J.S. Dunn Distinguished Chair In Radiology

It is my pleasure to welcome you to the Department of Diagnostic and Interventional Imaging at The University of Texas Medical School at Houston. The need for prompt, readily accessible, high quality consultation with experienced imaging subspecialists is growing in healthcare. We have created this website to help fill that need, providing you, our visitor, with the opportunity to seek a Second Opinion Consultation or a Medical Legal Consultation service with one of our distinguished faculty members. Our staff consists of board certified radiologists who have outstanding training and extensive experience in all imaging subspecialties. All faculty are actively involved in academic medicine and are conversant with state of the art imaging techniques and modalities. We are committed to providing the highest quality of information with competitive turnaround times.

To view our services, please select the service that you desire, and register with the site. One of our faculty will in contact you in the manner of your choosing. We look forward to serving you!

And serve you they will...on a silver platter.

Medical Legal Consultation

The Department of Diagnostic and Interventional Imaging at The University of Texas Medical School at Houston feel we have a responsibility to patients, society, and the medical profession to participate in medical legal consultations that ensure that these cases are properly, ethically, and accurately assessed at the highest level of integrity. We consider these services to be an essential part of the practice of medicine as advocated by both the American Medical Association and the American College of Physicians. No direct remuneration is received for these services, with proceeds from these activities used to fund medical student, resident physician, and faculty educational and research activities and services vital to the competent and excellent practice of diagnostic radiology at the UT Medical School.

Legal consultation is performed at an hourly rate to be negotiated between the attorney and the consulting radiologist. Cases will be reviewed by the most appropriate or requested expert subspecialist with a 3-hour advance payment for the confidential and full review of all of the initial documents and images as a consultant medical expert, including the radiologist’s analysis of the case and a verbal preliminary medical opinion on the merits of the case.

Following this review, if the consulting radiologist is requested to become an expert witness and agrees the case has merit, and after both the radiologist and requesting attorney sign the Health Care Consultant, Medical Expert Engagement Agreement, a 10-hour initial fee will be paid to the consultant as detailed in the contract, and the radiologist can then be officially named as an expert witness for the case. Further fees and expectations of payment for expenses, travel, deposition, reports, etc. are as detailed in the contract.

Try as I might, I can't torque this into anything that sounds at all like help for the defense.  The oft-repeated clause "merits of the case" speaks volumes.  If you are being sued and need an expert to testify on your behalf, the "merits of the case" don't affect you in the least.  Of course the case has no "merit" in the eyes of the defendant, but so what?  Clearly, UTH's efforts are directed toward helping the plaintiff and his attorney, and not their colleagues.  Nice.  Really nice.

If you have a problem with this practice, you might want to contact someone at The University of Texas Medical School at Houston and let them know.  Yee-haw.

Dalai's Missed Files

We radiologists do a pretty good job overall, but we are human, and we miss things. After all, we are expected to read 100-200 or more examinations a day, and some of those studies might have upwards of 1,000 images. It would be miraculous if we only miss a few things every day! 

Finding each other's (and our own) errors is a daily occurrence in this business. The question then becomes: What should I do about it? Some of us simply forge on ahead, and don't let the prior reader know of his or her miss. Some of us call or email with details. Some mention the miss in the current report, with phraseology such as, ". . . in retrospect, this lesion was clearly present." What these folks don't realize is that to a plaintiff attorney, such language is tantamount to saying, "The idiot who read the prior study missed something a large as an elephant, but I, The Great Doctor OZ of Radiology, have saved the day." You think I'm exaggerating? I wish.

After being the recipient of "the call" telling me I had missed something, I got to thinking of a better way to accomplish this distasteful task. I generally don't make "the call" for a perceptual miss. Sometimes, the lesion hides from our vision, or the PACS skipped a slice, or the phone rang, or the clinicians wanted the study reviewed RIGHT NOW while the patient was still getting off the gantry, etc., etc. I really doubt there is much to be learned from getting poked with a sharp stick every time this happens.

That being said, it is doctrine that we can and should learn from our misses, and I firmly believe this to be true. So I have established a new blog, Dalai's Missed Files (http://missedfiles.blogspot.com) as a safe-haven for us to share the misses we find in daily practice, our own, and those of others. Please send the pertinent image(s), ANONYMIZED (or I'll do it for you) to me, and I will post them. Add a line or two of explanation if needed.

I would ask that you NOT tell the person that missed the finding that you have submitted it to the new blog, or I'll probably receive a bunch of angry comments...("I didn't miss that!" "No one would have seen that!" "Dr. X is after me!") I don't need that grief, and I won't post such things if I receive them.  Ultimately, I would like to see the new blog become a regular stop for those surfing around for radiological information.  I want to facilitate better understanding of our field and our perception, and occasional lack thereof.

Please send cases to doctordalai(AT)gmail.com, and visit Dalai's Missed Files regularly.

Safe Strutting

The Okra Strut is a big deal in a neighboring small town here in the Deep South.  From the looks of things, Mr. Okra is well-protected for his next, ummmm, strut.

True PACS

I've just spent another afternoon, and a significant amount of money, at the hoity-toity fashion mall in the Big City nearest our average small town in the South. Dalai Jr.'s birthday approaches, and he needed some clothes. Lots and lots of clothes. What ever happened to a pair of Levi's and a T-shirt being the standard kids' uniform?

Plenty. Have a look at True Religion Brand Jeans, and you'll see. Here, you will find delightful blue jeans, with signature detailed pockets, and prices up to $400 per pair. Pictured below is the Ricky Old Multi Super QT model in Nashville wash.

Through some good fortune, these lovely things don't fit my son, so we avoided this $400 joy. And equally fortunately, he wasn't interested in the $70 T-shirt (OK, this one's only $60 but others are $70):

And he scorned the $75 baseball cap as well:

Hmmmm. $550 for jeans, a T-shirt, and a baseball cap. I'm in the wrong business.

Perhaps I'll remedy that. Here is the symbol for True Religion Jeans:

Remind you of anyone you know? Yup. So, I hearby coin the term "True PACS" and I plan to build a PACS with fancy detailing on the home screen. In the next few days, I'm going to copyright the phrase and apply for a trademark for my symbol:

Ha! Two can play this game, Bucko! And to complete the scenario, any study read on Dalai's True PACS carries a quintuple charge. Why? Because...it's from True PACS! What more do you need!

Please stand by for more details on a True PACS retailer near you...

A Very StranGE Document

Dalai's Note:

The Internet is a wonderful place, truly the rival of the Library of Alexandria, which once contained all the world's knowledge.

While surfing around, my son, Dalai, Jr., stumbled upon this document, buried in a government archive.  I have a feeling he shouldn't have been in that particular database, because what he found will completely change the way we view our world.  Sadly, though, I think I knew, deep down, that the truth was out there. . .

A New PET/CT! With XXX Crystals...

GE has a new PET/CT, the Optima PET/CT 560.   It's quite nice looking:

I'm assuming GE subcontracted the cowling design to Kia, and they did a very nice job with their Optima as well:

Given the presumed cost of the scanner, I think the car should be included.

I'll let you read through GE's brochure on the 560, which is quite informative.  We learn within that:

. . .powerful and versatile, the Optima PET/CT 560 is an all-around remarkable scanner designed to meet the demands of today’s mainstream clinical imaging environment. It’s a scanner we built both for you and around you, by combining superb image quality, high productivity, and a patient–friendly experience. All in a system that can continuously deliver ongoing value for you over time, while helping you maintain high standards of patient safety and care.

A full 2-meter scan range.The Optima PET/CT 560’s carbon fiber table extender enables a full 2-meter scan range–the longest in the industry. You can do a full head-to-toe scan in one pass for greater patient comfort and convenience, and position taller patients on the table with greater ease. Save up to 15 minutes per exam by eliminating patient repositioning–and potentially boost your scanning efficiency and patient throughput. WideView imaging lets you easily see everything in the large, 70-cm bore, giving you more flexibility in positioning patients comfortably for their scans.

Flexible, full FOV imaging.

With GE’S WideView imaging, you can position and image the complete patient in the large, 70-cm bore more comfortably and easily. You get a fully reconstructed, 70-cm field of view for both PET and CT to enable accurate radiation treatment planning–especially critical for obese patients and scans where the skin surface is important.

The brochure emphasizes something extremely, incredibly important, much more so than any scanning or imaging parameter:

Boost your patient volumes and revenues.

Your Optima PET/CT 560 can be operated as a standalone 8- or 16-slice ct scanner. With its exceptional power, remarkable speed, high-resolution/low-dose imaging, and full diagnostic capabilities, it can help increase your patient imaging volumes and revenues.

As a Nuclear Radiologist, there is one thing I want to know about a PET/CT scanner: What crystals are being used in the PET section? As I've outlined in a previous article about the last new GE PET/CT, crystals are critical to PET performance. And GE has, to this point, used what I consider to be the lesser of the commercially-available crystals, bismuth germinate (BGO), as compared to the more advanced cerium-doped lutetium oxyorthosilicate (LSO) crystal found in Siemens scanners.

The fact that GE has chosen not to mention which crystals are used in the new toy make me think that we're probably looking at good old BGO's.  If so, that's a deal-breaker for me, period.  If not, we can talk. Of course, given the current state of financial affairs, I'm not going to be replacing my Biograph anytime soon.

I've submitted the question to GE. I'll let you know the answer.

Imagining...No Taxes!!!!

No doubt you realize that as of today, you are still working to pay your tax bill.  Most of us have to work until sometime in late May to pay our share (image courtesy taxfoundation.org):

A corporation in the US is supposed to pay tax as well, up to 35%, one of the highest corporate rates in the world. But wait! Even though all animals are equal on this animal farm, some are more equal than others.

From the NYT (!!!):

(G.E.) reported worldwide profits of $14.2 billion, and said $5.1 billion of the total came from its operations in the United States.
Its American tax bill? None. In fact, G.E. claimed a tax benefit of $3.2 billion.
That may be hard to fathom for the millions of American business owners and households now preparing their own returns, but low taxes are nothing new for G.E. The company has been cutting the percentage of its American profits paid to the Internal Revenue Service for years, resulting in a far lower rate than at most multinational companies.
Its extraordinary success is based on an aggressive strategy that mixes fierce lobbying for tax breaks and innovative accounting that enables it to concentrate its profits offshore. G.E.’s giant tax department, led by a bow-tied former Treasury official named John Samuels, is often referred to as the world’s best tax law firm. Indeed, the company’s slogan “Imagination at Work” fits this department well. The team includes former officials not just from the Treasury, but also from the I.R.S. and virtually all the tax-writing committees in Congress. . .
In a regulatory filing just a week before the Japanese disaster put a spotlight on the company’s nuclear reactor business, G.E. reported that its tax burden was 7.4 percent of its American profits, about a third of the average reported by other American multinationals. Even those figures are overstated, because they include taxes that will be paid only if the company brings its overseas profits back to the United States. With those profits still offshore, G.E. is effectively getting money back. . .
Even as the government faces a mounting budget deficit, the talk in Washington is about lower rates. President Obama has said he is considering an overhaul of the corporate tax system, with an eye to lowering the top rate, ending some tax subsidies and loopholes and generating the same amount of revenue. He has designated G.E.’s chief executive, Jeffrey R. Immelt, as his liaison to the business community and as the chairman of the President’s Council on Jobs and Competitiveness, and it is expected to discuss corporate taxes.
“He understands what it takes for America to compete in the global economy,” Mr. Obama said of Mr. Immelt, on his appointment in January, after touring a G.E. factory in upstate New York that makes turbines and generators for sale around the world. . .

And Immelt's Army knows how to get what G.E. needs:

A review of company filings and Congressional records shows that one of the most striking advantages of General Electric is its ability to lobby for, win and take advantage of tax breaks. . .

The head of its tax team, Mr. Samuels, met with Representative Charles B. Rangel, then chairman of the Ways and Means Committee, which would decide the fate of the tax break. As he sat with the committee’s staff members outside Mr. Rangel’s office, Mr. Samuels dropped to his knee and pretended to beg for the provision to be extended — a flourish made in jest, he said through a spokeswoman.

That day, Mr. Rangel reversed his opposition to the tax break, according to other Democrats on the committee.

The following month, Mr. Rangel and Mr. Immelt stood together at St. Nicholas Park in Harlem as G.E. announced that its foundation had awarded $30 million to New York City schools, including $11 million to benefit various schools in Mr. Rangel’s district. Joel I. Klein, then the schools chancellor, and Mayor Michael R. Bloomberg, who presided, said it was the largest gift ever to the city’s schools.

G.E. officials say the donation was granted solely on the merit of the project. “The foundation goes to great lengths to ensure grant decisions are not influenced by company government relations or lobbying priorities,” Ms. Eisele said.

Mr. Rangel, who was censured by Congress last year for soliciting donations from corporations and executives with business before his committee, said this month that the donation was unrelated to his official actions. . .

G.E. officials say that neither Mr. Samuels nor any lobbyists working on behalf of the company discussed the possibility of a charitable donation with Mr. Rangel. The only contact was made in late 2007, a company spokesman said, when Mr. Immelt called to inform Mr. Rangel that the foundation was giving money to schools in his district.

But in 2008, when Mr. Rangel was criticized for using Congressional stationery to solicit donations for a City College of New York school being built in his honor, Mr. Rangel said he had appealed to G.E. executives to make the $30 million donation to New York City schools.

G.E. had nothing to do with the City College project, he said at a July 2008 news conference in Washington. “And I didn’t send them any letter,” Mr. Rangel said, adding that he “leaned on them to help us out in the city of New York as they have throughout the country. But my point there was that I do know that the C.E.O. there is connected with the foundation.”

In an interview this month, Mr. Rangel offered a different version of events — saying he didn’t remember ever discussing it with Mr. Immelt and was unaware of the foundation’s donation until the mayor’s office called him in June, before the announcement and after Mr. Rangel had dropped his opposition to the tax break.

Asked to explain the discrepancies between his accounts, Mr. Rangel replied, “I have no idea.”

It seems this is nothing new:

In the mid-1980s, President Ronald Reagan overhauled the tax system after learning that G.E. — a company for which he had once worked as a commercial pitchman — was among dozens of corporations that had used accounting gamesmanship to avoid paying any taxes.

“I didn’t realize things had gotten that far out of line,” Mr. Reagan told the Treasury secretary, Donald T. Regan, according to Mr. Regan’s 1988 memoir. The president supported a change that closed loopholes and required G.E. to pay a far higher effective rate, up to 32.5 percent.

That pendulum began to swing back in the late 1990s. G.E. and other financial services firms won a change in tax law that would allow multinationals to avoid taxes on some kinds of banking and insurance income. The change meant that if G.E. financed the sale of a jet engine or generator in Ireland, for example, the company would no longer have to pay American tax on the interest income as long as the profits remained offshore.

G.E. has responded to the New York Times story:

G.E. subsequently pointed out what it says is a significant flaw in the story: That the Times did not take into account the impact of its GE Capital losses in the financial crisis. G.E. said that if you exclude GE Capital its tax rate has been about 21 percent.

At his press briefing Friday afternoon, White House press secretary Jay Carney was asked to square Mr. Obama's call for corporate tax reform with his embrace of Immelt. Asked if the story bothered the president, Carney responded that "he is bothered by what I think you're getting at, which is that Americans, I'm sure, who read that story or heard about it are wondering, you know -- you know, how this could be."

I'm bothered, too. I certainly believe everyone should pay their fair share, and not one cent more. But most of us can't lobby Congress to lower our taxes, or (legally) move our profits offshore so as to subvert the system. This doesn't quite smell right, does it, folks?

IT Strikes Back

I threw out the gauntlet with my last post about IT Follies, which prompted the following comment from an anonymous Australian reader via Telstra:

I'm IT manager for a private practice and used to work for a medical software company.

Problems with the software very rarely get fixed unless it is a show stopper. Mouse trails making your screen flicker? Laughable. Developers won't spend their time trying to fix something like that. It is not a good use of their time, unless the contract is up for renewal. Annoying to you but this is the way it is. And small things like this can be ignored because you're locked into a contract for x amount of years, and changing from a PACS/RIS system is a big investment with many things that can go wrong, and the vendors know this.

With regards to the IT support points, I personally do not lock down radiologists systems heavily as they are my bosses. They do know to consult with me before installing anything as many times before installing software can cause unexpected problems. Things like not changing the background; with our agfa systems the background contains important information. IP address, storage cache levels, etc. It saves us (and you) lots of time when having to deal with support calls. I can only assume that is why they don't let you change the background.

Disabling usb ports is a bit extreme, however I have had a workstation crippled due to a virus that got onto the system and interfered with the RIS and PACS (oh, and the user thought disabling the antivirus was a good idea because "it made the system too slow"). In my job, we are afraid to make any change to a doctors reporting station, because if that f***s up, you won't be able to report. The complaint of not having an RSS reader is minimal compared to not being able to work, for example.

Security risks are always a big concern. We're dealing with people's personal medical records. I highly doubt you understand the seriousness of this, and the amount of vulnerabilities in flaws in todays computer systems. Any preventative measure that can be taken to secure a system/network should be. The moment security is breached in your systems - you will be condemning IT for allowing it to happen. (Had this happen a number of times to myself before also, maybe you yourself will be more understanding but others will not).

I also find your use of words to be rather harsh and are kicking up a storm over trivial matters. You earn ridiculous amounts of money and are complaining about "draconian manners" such as disabling right click on the desktop. My heart goes out to you.

Generally, IT know what they are doing (some have no clue, but they are gone after a month or two usually), and the regular users don't. It doesn't sound like you have any relationship with your IT team, and most likely would come across as an overpaid, arrogant doctor with trivial demands. They won't give you the time of day.

Apologies if this is a bit all over the place, typing paragraphs in between other duties here.

Cheers

Wow. Darth Croc definitely has an opinion, doesn't he? Rather than lash out in return, I sent the comment to several of my friends and colleagues.

One of my Australian friends said, "Typically, the default answer (of IT) is “no”. Yet in our private practice, I have IT staff who manage a larger PACS system than the whole of the state public system. . .The difference is that they consider themselves (and are regarded by all) as an important part of the practice, and take pride in what they can deliver. The default answer when a doctor or tech asks is usually (as it should be), is “how can we do it, and what else could we do or combine to make it better, simpler, cheaper or useful for more people?”.

Let it be known that I DO consider IT people (both those within my group and those employed by the hospital) a VERY important part of what I do.  Sadly, there are those who don't hold ME and my colleagues in the same regard.  Clearly, Darth Croc resents the arrogant, overpaid docs under whom he toils, those who don't understand the seriousness of security.

Mike Cannavo, the One and Only PACSMan, simply said, "but as they say you can't fix stupid so why bother?" Ah, but I must, I must...

My friend, 23 Skidoo, who also has experience with the software end of things, as well as time as a PACS Administrator, is the author of the very well-written X-Ray Vision Blog.  23 Skidoo has this response:

Wow...Well, he/she has some points with respect to vendors only fixing major items...

It is sloppy coding but when it comes down it, I wonder if the problem is more about the CIO/administrators making the final purchase decision instead of the radiologists who have to use the dang thing.  I couldn't imagine any radiologist picking GE, particularly after using/demo-ing most other pacs systems...

I don't like the "IT knows what's doing and doesn't need your input" attitude that comes from this person because that indicates a lack of willingness to cooperate. "We know best, and that's that" is what I hear coming from him. I think your main point is not the "smallness" or "bigness" of the issues but the lack of desire on IT's part to even consider cooperation. What they dismiss as small, or in his words "trivial" may be truly small at the computer level, but not on your, life and death, or even just work aggravation level. Perhaps if they took the time to see what you have to do to deal with what they consider small, they just might come around. But it sounds like this person has already made up their mind and is patronizingly treating you like the spoiled child he already presumes you must be, because you are a DOCTOR. Perhaps it's an unconscious or even conscious, passive/aggressive way to lash out at people and throw some authority around. Like TSA agents. TSA is what happens when you give a high school dropout a uniform and a clipboard...

Perhaps if there were more of a spirit of cooperation it wouldn't be such an adversarial US vs. THEM atmosphere and real things could be accomplished. Maybe if they explained to the docs about USB's and viruses, and possibly discussed workable alternate solutions...and gave them heads up when changes were being made instead of sneaking the changes in without any warning docs wouldn't phone in furious. But if one day I can do something and the next day I can't occurs, and no one said a word, I'd be livid. That's patronizing, and wrong. IT folks are not generally known for their ability to communicate to anyone other than machines, and while that is a bit of a harsh stereotype, I have found it to be true. They don't see a reason, (because they have no clue clinically) why they shouldn't do something, take a function away and are "surprised" when they get an onslaught of calls regarding the missing function.

So a better willingness to cooperate and communicate will go a long way for them.. They will get greater compliance with the items they feel they do need to restrict, and gain a better understanding about why they shouldn't do other things.

Both sides need to: Cooperate and Communicate... no condescension....leave attitudes at home.

Well said.  My own PACS Guru, who is not at all afraid to say what he thinks, even (especially) if I might disagree with him, comments thusly:

I think the response should be to politely let him know that you do have a higher than normal understanding of both IT and the security risks involved when dealing with patient records. Tell him that IT personnel that understand what is required to deal with and keep a PACS running and secure without putting up roadblocks that inhibit it's functionality and the users ability to do everything needed so they can take care of patients are the EXCEPTION rather than the rule. Most IT departments are only concerned with the security NOT the usability with a system. It's like welding a Porsche into the garage to protect it.

The animosity and arrogance he displayed in his post IS the norm for IT folks and that too is part of the problem. You can also tell him that your group's IT/PACS team doesn't seem to have a problem protecting your machines,servers, or network without locking your machines down to the point of being unusable.

I think we have the proper responses to Darth Croc.  Many thanks to my guest contributors.  When you have friends like mine, it's really easy to write a blog!

As I've said at every opportunity...PACS is a team effort.  We need cooperation and discussion to go forward.  The Rads, the Vendors, and IT all need to work together to HELP OUR PATIENTS.  That's what it's all about, folks.  I've tried to spread this message everywhere from Perth to the Deep South, but I'm not sure everyone is listening.

Still, saving a life does take precedence over saving the integrity of a computer, at least in my book.

I await Darth Croc's angry response.

G'day!

More IT Follies

Having just visited a friend in need, Mrs. Dalai and I decided to keep on driving, and found ourselves in this sub-tropical beach paradise. There's nothing like a few days of R&R with sun, sand, and a few Landsharks to keep us going.

But I can never quite leave the office and PACS completely at home (although I'll give it a good try this summer).

A thread on AuntMinnie.com started by Midwest Eastern Rad has been gnawing at me for a while, and now is as good a time as any to grace you with my thoughts on the subject. M.E.R. sounds a bit like me and some of my partners, not to mention some of my friends around the world:

I want a discussion relating to one's attempting to change workflow (improving ergonomics) vis-a-vis institution reluctance to adapt and change.

Basically, how can a radiologist supplement the "out of the box" software settings for workstation to work in his/her favor, by creating personalized more ergonomic workflows? This can involve hardware--such as your own USB mouse with programmable buttons, or an input device such as a gaming mouse or ShuttlePro. Can involve Windows display or mouse settings. Also may involve installing small software programs on the host computer (macro programs, mouse software in order to program the buttons). This is all driven by wanting to reduce repetitive motions, reduce mouse clicks, avoid eye strain (i.e. increase DPI on 5 MP monitors so you can actually read the text or increase text size, all Windows properties), reducing excessive mouse motion (i.e. 3,4,5 monitors vs. 2), and trying to rid myself of the body aches that I have gotten from work.

My experience has been that IT support has no interest, and I don't want to be problem for them, but I need to take it on myself to improve ergonomics, and don't know how to proceed. The manufacturers (PACS, VR, hardware) also have no interest that I have found.

How do people deal with trying out new devices, new workflows, changes in the PACS settings, automated steps (macro creation) to try to eliminate the excessive number of mouse clicks that we undergo when using PACS (and RIS)? I ask this especially in light of the restrictions that IT people put on the PACS workstations to not allow access to key areas in Windows OS or even locking down USB plugs, programs, windows, etc. Do you do it "behind the back" of IT? What if there is lockdown? How much do you fight for yourself?

If IT does not wish to work with you (which I suspect many IT people do not want to do because it complicates their lives), how do you proceed? If we all stayed stagnant, we'd be doing the same thing we did 50 years ago, yet often, I find that pushing the envelope on standard workflow gets you into trouble. Hard to put into words, but I'd love to hear comments.

Gee, M.E.R., this sounds rather familiar, and I haven't even tried to do anything with mice or other hardware enhancements. I have, however, had they joyous experience of having my right click cut off by IT so as to keep me from defacing the desktop's AGgravating logo from their FAvorite vendor. (Fortunately, I'm much more resourceful than that, and it turns out to be rather simple to circumvent this little problem.) I was also told that I couldn't deploy a simple macro to keep open a RIS window that would otherwise close after 30 minutes because someone might use the program to circumvent a password entry. I'm reminded of my friends in Western Australia, whose IT departments progressively cut off all input paths to their workstations so as to block the installation of a "foreign" PACS client, as this might "void the warranty".

Do read the various responses to Midwest's post. Of course, I have some comments on the topic as well.

The friction between Radiology and IT is a world-wide phenomenon. You should have heard the chuckling and grunts of agreement when I presented Dalai's XIth Law of PACS at RANZCR in Perth last year:

XI. If IT doesn’t like something, it will be termed a security risk.

And herein lies the rub. Actually, there are a number of problems, really, which fall into several general categories. One or more may apply at your particular shop.

1. IT doesn't want to do the work of accommodating the rads.
2. IT has a paranoid-level level of anxiety about any possible security breach.
3. The vendor has made life difficult via threats of voiding the warranty and/or FDA certification.
4. IT is afraid of what any (and I mean ANY) change might do to the vendor's software.

Before we go any further, two elements need to be brought to the forefront of the discussion. First, everything we do is intended to promote patient care. Second, we all need to work together toward that end.

I have what IT might consider a biased view: PACS exists to help the radiologist perform his or her job of caring for the patient. It is frankly asinine for IT to take complete ownership of PACS in such a draconian manner as to limit its use to whatever IT thinks appropriate. This is not acceptable. I am the radiologist. I have to use this technology to care for my patients. I am the one who will face legal remedies if something goes wrong. There is no justification for being told "NO" when asking for something reasonable.

But I'll be conciliatory here. Not every idea is a good one, even those hatched in my devious little mind. Some might possibly impact security. Not many, but maybe some. And some might truly interfere with PACS software. Which gets us into another discussion.

PACS software is extremely complex, lying somewhere on the continuum between Microsoft Office and Windows 7. Now, give me an honest answer: If Word acted weird when you plugged in a new mouse, would you blame: a. Yourself for being such a stupid fool as to have tried this; b. Your computer for malfunctioning; or c. Microsoft for writing poor code. I'm picking c. You would be on the phone to Bangalore immediately trying to get Microsoft to fix their glitch. And if Peggy on the other end of the phone tried to tell you that your plugging in the non-Microsoft mouse might have voided your warranty, you would jump through the phone all the way to whatever subcontinent was appropriate.

Microsoft Office runs about $150 for the home version. The average PACS runs about $250,000 at the minimum. Why do we tolerate bad behavior from such an expensive product? Good question. Ask your IT people.

But this is what I mean by being conciliatory. There is a kernel of truth in IT's fear of something interfering with the PACS software, because that software might not be properly written. I've seen this happen firsthand. Our IMPAX system went wacky on the third monitor's color display when I activated "mouse trails" to better see the cursor. That, folks, is a software glitch, and tells us that something wasn't written correctly. Maybe there was a shortcut in some video card call, maybe there is some strange memory leak, or maybe "mouse trails" somehow interferes with the electrical stimulation of the gnomes that live in the CPU. Whatever. This tells us there is a glitch. I don't have to wonder if some of our other problems are due to similar weirdness. I'm of the opinion that every manifestation of this sort of thing discloses bad programming on the vendor's part until proven otherwise. Period. Thus, IT needs to work with us to identify these things, and demand patches or updates when we find them. The easiest solution, having IT lock down everything simply to avoid this sort of thing, is not the best solution, nor is it at all acceptable.

And for the record, I believe the ideal way to go forward is to work together. I've said that many times. We, the users of PACS, our IT support, and the vendors all need to coordinate our efforts. I'm not asking anyone to rewrite all PACS software to work the way I want it to work. I've found that more or less in AMICAS 6 (there are some glitches even in this program but Merge is actually listening to me and others to effect improvements), but several of my partners still pine for version 5. This goes to show that you can't totally please everyone at all times. I do have faith that my colleagues will come around to my way of thinking, or I'll throttle them. But if what happened to Midwest Eastern Rad EVER happens in one of my shops:

Well, to make matters worse, the IT folks have now disabled our "Display properties" tab on Windows, so we can no longer adjust text size larger, smaller, disable monitors, etc.  When I called and asked why, I was given a very terse answer, something like "part of the lockdown".

I asked why again, and was hung up on.

I wouldn't rest until I have the head (or at least an apology) from the miscreant in question. As Xrayer31 put it:

Sounds to me like your hospital IT dept. has forgotten how their salary gets paid. I believe billing for performed medical procedures is what gets it done. They aren't treating you like the customer you are.  Hanging up on you?  Who are these trolls? Too busy? What are they doing, arguing over whether Star Trek or Star Wars is the coolest?  Time to take it up the chain and report not only the poor customer service, but blatent disrespect and unprofessional behavior. 

Capish?

Bear-ium Enema

They have to stuff those Build-A-Bear's somehow.....