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Mobile Nuclear Cardiology

Mobile Nuclear Cardiology. An Idea .. A Concept .. Reality The Kentucky Society Of Nuclear Medicine Technology July 25, 2005. A Look At The Mobile Business. Purchasing the equipment Camera/computer = DigiRad Hot Lab Truck or Van License application Clinical sites Nuclear Personnel

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Mobile Nuclear Cardiology

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  1. Mobile Nuclear Cardiology An Idea .. A Concept .. Reality The Kentucky Society Of Nuclear Medicine Technology July 25, 2005

  2. A Look At The Mobile Business • Purchasing the equipment • Camera/computer = DigiRad • Hot Lab • Truck or Van • License application • Clinical sites • Nuclear Personnel • Cardiologists and Nurse Practitioners • When are we going on the road? • Adventures in fine driving, scanning, and transcribing

  3. Imaging Equipment • DigiRad system • Computer – acquisition and processing station • Imaging Chair and the digital head • Three addition processing/review stations • Networking your results

  4. Anger Technology • Basic Components of an Anger camera: • Collimator • NaI Crystal • Photomultiplier tubes • Positioning electronics and circuitry • Lead shielding SHIELDING COLLIMATOR

  5. Anger Technology • Photomultiplier Tubes (PMT’s)

  6. Digirad Camera • 1 Anger Camera • 0.8 • 0.6 Relative Response • 0.4 • 24.5 • 20.5 • 0.2 • 16.5 • 12.5 Y mm • 8.5 • 0 • 3 • 4.5 • 0.5 • 8 • 5.5 • 13 • 10.5 • 18 • 0.5 • 15.5 • 23 • 20.5 • 25.5 X mm Point Response Weighted average method produces a probabilistic response. Bell shaped (Gaussian) curve.

  7. CsI/Si Detector Module CsI (TI) Scintillation Crystal Si Photodiode Readout Electronics Circuit Board

  8. CsI Crystals Converts Gamma Ray to Visible Light Gamma Ray Scintillation Photons Photodiode Converts Light to Electric Charge Printed Circuit Board Mounts Various Components Pins Conduct Signal to Motherboard Analog ASIC Amplifies Electric Charge to Useful Signal Level Electromagnetic Shield Protects Analog ASIC from Digital ASIC Mounting Stud of Heat Sink Conducts Heat Away from Module Module Operation

  9. Detector Element Gamma Photon Solid-State detector module Tiled Modular Construction The camera head is made up of 2” x 1” modules tiled to configure an 20 cm x 20 cm camera head. Each module consists of 128 individual solid-state detector elements or a total of 4092 elements.

  10. CsI/Si Imager Head Collimator Array of Detectors Lead Shielded Head

  11. Detector Element Gamma Photon Solid-State detector module Digital Position SensingTM The point at which a gamma ray strikes the detector element determines the spatial positioning of the event, not a probabilistic estimation algorithm as is used in Anger camera technology.

  12. 2020tc Imager™ Solid-State Gamma CameraDirect Position SensingTM

  13. Digirad Camera • 1 Scintillation Camera • 0.8 • 0.6 Relative Response • 0.4 • 24.5 • 20.5 • 0.2 • 16.5 • 12.5 Y mm • 8.5 • 0 • 3 • 4.5 • 0.5 • 8 • 5.5 • 13 • 10.5 • 18 • 0.5 • 15.5 • 23 • 20.5 • 25.5 X mm Point Response Comparison Direct digital positioning provides for excellent spatial response and enhanced image contrast and resolution. Consider analog an digital response.

  14. Clinical Comparison of Contrast PMT Scintillation Camera Digirad Solid-State Camera

  15. Digital Position SensingTM • Excellent spatial response • Enhanced image contrast • Better image resolution PMT Scintillation Camera Solid-State Camera Planar views Equivalent counts in each image

  16. Spatial Response and Source Energy Digital Position SensingTM Anger Technology 99mTc 201Tl With Digital Position SensingTM, intrinsic spatial response is independent of source energy, unlike Anger technology. This means fewer uniformity calibrations and excellent clinical image quality.

  17. Solid-State Gamma CameraSimultaneous Event Processing Patient E2 Detector E1 In original Anger cameras, all events (E1+E2+…) that fall in the energy window are positioned using a probabilistic algorithm. In modified Anger cameras, positioning logic is revised to imitate digital positioning, however, it is still an approximation. Pending the amount of light received by the surrounding PMTs. In the 2020tc Imager™, all events (E1, E2, …) are treated separately with individual energies leading to true digital position addressing and excellent clinical performance.

  18. Solid-State Gamma CameraOverall System Improvements • No image distortions. Spatial linearity is fixed. • Edge effects do not exist. • Non-hygroscopic detector. No hydration or yellowing occurs. • Routine quality control comparable the PMT system. • Solid-state reliability.

  19. Buying A Van • Make it economical - Diesel • Issues on servicing • Fire damage at Cardinal Dodge • Lexington during Christmas • Ya need a Lift that works • Don’t forget the tie downs

  20. Tie Downs and Lifts • Maxon Lift • The flapper problem • Three repairs later • Look out for your fingers • Refrib was free if you B .. Enough • Tie downs • This is the Norton way • There is a better design • - The DigiRad Way

  21. Hot Lab With A Little Extra • Hot Lab – Office - Storage • Dose Calibrator • L-Block • In/Out box area • Radioactive storage • Documentation • Notices • Analog system

  22. Other Odds and Ends • Fax machine • File cabinet • Cardinal Health connection • Lawson – ordering the day to day stuff • Treadmill at every clinical site • Cell phone and pagers

  23. Personnel • Two nuclear technologists and backup • They do it all: Secretary, EKG tech, billing, and bungling. • Involving the cardiology groups • Blue Grass Cardiology • Cardiovascular Associates • Commonwealth Cardiology • Transcription connection • Nurse Practitioner at every clinic • Billing – getting all the coding

  24. The Reporting Process Does the Disk Have the Pt Data? Completed Exam Uploading The Scan The Exams Aren’t Here! Cardiologist Dictation 48 Hour Time Line Advanced Medical Transcription, LLC Faxing the Report Back – The Prelim One to Department other to Clinic I Didn’t Get the Prelim Returning the Report Cardiologist Signoff You’ll Sign It When? Delivering the signed Report Back to the Clinic

  25. What About The License? • State license • Understanding the mobile perspective • They liked the idea so much the State went mobile • Form 421 and the NRC • Reciprocity agreement • A missing link • Defining the days your in Indiana • Indiana – What about 57Co? • Treat every clinic as a separate department • Daily wipes and surveys

  26. When Do we get started? • Hiring Date 8/01/2004 • Procedures to write • Protocols to define • In service on the equipment to be completed • Clinic educations • The new kid on the block – Mobile mania • Docs and office staff • Logistics and the equipment • First patient scanned 10/07/2004

  27. Clinical Sites • Concepts • Going to the Norton clinics and providing a service within our system – is this self defeating? • Rural nuclear medicine • Patients enjoy visiting their clinic instead of driving into Louisville • Economics – ETT to Cath – keeping the health care $$ in our system • Carroll County Hospital • NMA Suburban and Dupont • CMA Clarksville • NMA Mount Washington • Should we be looking beyond the NMAs?

  28. Preparing The Clinics • Developing a PPT and hard copy for physicians and staff • What is mobile nuclear cardiology • Radiation safety • Scheduling • Pt prep • Exam information • Contacts – phone and pager numbers • Billing • Visiting each clinical site with equipment in hand • Involving your Cardiolite Rep

  29. A Day In The Life Of Mobile • Headquarters • Audubon – but they’re not our boss • Loading the van • Utilization of the lift • Tying the equipment down • On the road

  30. Arrival In Carollton • One-Way = 1 hour • Entrance is in the back of the hospital • Issue is the ramp into the hospital • Cardiac Rehab is right inside

  31. Setting Up the Mobile Unit • Perhaps the hardest aspect • Attaching the Head • Requires removal From one unit and attachment to the other • It does get easier to do over time

  32. QC • Daily Flood • There is no weekly bar • Weekly COR check • All other aspects of camera QC are completed by the Service Dude

  33. Results of the Daily Flood

  34. And We’re Ready To Image

  35. Patient Setup • Unique to the traditional approach • Setting reduces certain artifacts • When asked most patients prefer this to laying down • Motion is still a problem whether upright or supine

  36. Procedures • Nuclear Cardiology Stress Test • Treadmill in every clinic • Routine protocol for stress • Adenosine (pump) • The six minute protocol • Dobutamine (Grasbey pump) • 10mL, 20mL, etc.

  37. Imaging Process and Results

  38. Patient with bowel and liver activity Separation between activity and heart Heart is always acquired in the center of axis or rotation Images can be viewed on Mirage or QPS

  39. Large patient with enlarged heart

  40. Filters Multiple filters available Easy change of filters

  41. Normal-1 GSPECT patient First Row – Stress Second Row – Rest Third Row – Gated PC based workstation with easy ability to capture JPEG and BMP images Flexible workflow with forward and backward processing capability

  42. Mirage Quantification or QGS option • Matching EF’s on this abnormal patient • Mirage Quantification package comes with the camera

  43. Patient Stats

  44. Road Hazards

  45. Road Kill • Winter AM hours brings out the best • Hunting season is another hazardous time • Counted 15 kills within 15 miles • They live in the median where have lots of food and water

  46. Look Out For the Smokies • KY’s finest is out there • Our speed is 69 mph and holding, besides we’re on the clock! • Let someone else be the lucky one, not you!

  47. Turkey Buzzards • Is this a prelude to a bad day? • Always in the AM • On the way to Mount Washington • If they are a circling you can almost guaranty there’s road kill ahead

  48. Our Evaluation on DigiRad • In nine months we have never been down = 100% uptime • Find yourself an applications specialist and make her your best friend • California is 3 hours behind us so thank god for Alabama (Jim) • The wait time when calling is always 3.5 minutes

  49. On The Downside • If your system is mobile you’re going to have a lot of wear with certain results • Example 1 - pin locking mechanism to camera arm • Example 2 - Tray that stores your cable

  50. Another Example • Green tab down brakes the wheel • Green tab jam breaks the brake • End results wheels have to be replaced since there’s no brake

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