It is Friday afternoon, 3 pm, and I am finally sitting down to finish the last bank of films when, with the precision of a Swiss watch, my friend The Oncologist enters my office with a stack of film jackets bursting at the seams. The Oncologist is not a small man—perhaps 6’4″, 225 pounds, with shoulders and biceps so large that he cannot button his white lab coat without popping a few seams himself. And then he asks his usual Friday afternoon question: “Gregg, can you go over this case with me?” I conceal a mental sigh as I realize it is going to take at least a half hour to organize the film chaos he created in his office as he thrashed through the jackets seeking the appropriate studies. But on I labor. Sort, hang, sort, rehang, move, drop on the floor: it is the world of films. It is an atomic world of matter and weight and motion. And it is exhausting and time-consuming.
And it is not precise. At the end of the hour consult, I am no further into my work, the filing personnel are anxiously waiting to hang more, and Friday afternoon has become Friday evening. In the middle of a Wisconsin winter, it is BLACK outside. I will head home in the dark, hoping I miss the plentiful deer that torture the drivers in our Great Lakes state.
This world (except for the dark and the deer) no longer exists for me. As in many modern radiology departments, our technologists hang no films, physicians carry no jackets into my office (with rare exception when we have to read outside films from institutions that have not heard that bytes have replaced atoms). The static images of the films are relics of an era when one had to capture and print images that could not be manipulated with desktop computer-driven technology. In fact, physicians needing an understanding of the images from a CT scan need only log onto the thin client viewers of our PACS and thin client viewer of our 3D software, and they can “tag along” as I take them on a digital journey from the comfort of, well, anywhere they happen to be where they have broadband access and a PC, as well as the appropriate passwords.
A WELCOME REVOLUTION
The “atoms to bytes” revolution has had a particularly welcome impact on the evaluation of peripheral vascular and aortic disease in our institution. The hallmark of this revolution—best expressed as Moore’s Law—has been the development of advanced CT scanners with multiple rows of detectors and submillimeter slice thickness in three dimensions. While the technical challenges of inventing a rotating x-ray tube capable of resolving the vascular system as it reaches peak enhancement over the entire area of the body while limiting radiation doses within acceptable parameters were not trivial, it is the continued development of the computer chip capable of rapidly processing the extreme data loads of CT angiograms that has turned old-fashioned angiography into bytes. These bytes can be simultaneously viewed by the interventional radiologist and vascular surgeon as soon as the data is transferred to a PACS or, more important, to a thin client server capable of performing the complex reconstruction needed for interventional and/or surgical planning.
As an example, the images presented represent a patient with severe left calf claudication. In the prior age of atoms, this patient would have had a conventional angiogram and, possibly, angioplasty of the left superficial femoral artery. She then would have recovered a few days, weeks, or months, and then possibly had a right leg femoral-popliteal bypass. The films acquired from the diagnostic angiogram that probably would have been performed (in a pre-multidetector CTA/MRA world) would have to be reviewed by a surgeon coming down to the angiography suite—and possibly disrupting surgery or office time—or the films would have been reviewed at a later date without the surgeon participating in the decision to perform angioplasty and without collaborative input from a vascular team. The atoms-to-bytes revolution changes all of this. After the patient has a CTA (see images, page 30) at our institution, the thin client viewer is opened simultaneously by the interventional radiologist at the hospital and the vascular surgeon in their office. Nearly any view can be created by either physician and either physician can permanently store images on the PACS system—which both physicians can also simultaneously view—or e-mail as JPEG so that specific views can be saved on any physician’s desktop PC. MRA can also be viewed with MIP and 3D software used by each physician. Computer software is not sensitive to the modality that creates the bytes as long as the information is in a format that can be displayed as MIP or 3D reconstructions. The helical slice images are, of course, also readily available for review on the 3D software for multiplanar reformatted reviews. Precise aneurysm size measurement is possible (as shown in this case), which further aids therapeutic planning (surgery was not indicated at this time for the distal abdominal aortic aneurysm).
Figures 1-7. CTA is performed on patient with prior right ileo-femoral patent placed at another institution. Thin client viewer was opened simultaneously by the interventional radiologist and the off-site surgeon, and study reviewed as both MIPs and multiplanar reformat. After precise aneurysm size measurement, it was determined that surgery was not indicated. Study also revealed that the ileo-femoral stent remained patent.
Not a film need be exchanged. No grunting surgeons need compete for room time with The Oncologist. Decisions are a phone call away. No burdensome film jackets need to be pulled from the file room and transferred back and forth where one is never certain as to whether the correct films were included, lost, or damaged. A surgeon need not interrupt their surgery or office hours to review the diagnostic images and plan, with the interventional radiologist, the approach to revascularization. In many cases, an expensive conventional angiogram need not even be performed.
In this case, the patient had a prior right ileo-femoral stent graft that remained patent (placed at another institution) and the images were also reviewed by desktop PC by the physician that placed the stent graft.
So when did the past go away? We still have a few problems to solve at our institution. As of this writing, we do not have computer monitors in the operating room. Films occasionally need to be printed and transported from the first to the second floor. Of course, we can be very selective about which films are printed, which does improve efficiency. Even here the bytes are beginning to crowd out the atoms. But for now, I will not miss The Oncologist with his arms full of film jackets. On any Friday at 3 PM, when I have to “click as read” the last 10 remaining cases, no one is crowding my door waiting to rip down the rows of films on my old viewbox. And I just might catch the last glimpse of daylight as I drive home without fear of icy roads and darting deer.
Gregg Gaylord, MD, FSIR, is director of diagnostic imaging, St Nicholas Hospital, Sheboygan, Wis.