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

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

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Imaging Equipment DigiRad system DigiRad system Computer acquisition and processing stationComputer acquisition and processing station Imaging Chair and the digital headImaging Chair and the digital head Three addition processing/review stations Three addition processing/review stations Networking your results Networking your results

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Anger Technology Basic Components of an Anger camera: Basic Components of an Anger camera: CollimatorCollimator NaI CrystalNaI Crystal Photomultiplier tubesPhotomultiplier tubes Positioning electronics and circuitryPositioning electronics and circuitry Lead shieldingLead shielding COLLIMATOR SHIELDING

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Anger Technology Photomultiplier Tubes (PMTs) Photomultiplier Tubes (PMTs)

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

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

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Module Operation Gamma Ray CsI Crystals Converts Gamma Ray to Visible Light Photodiode Converts Light to Electric Charge Printed Circuit Board Mounts Various Components Scintillation Photons 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

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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. 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. Gamma Photon Solid-State detector module Detector Element

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

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Digital Position Sensing TM 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. 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. Gamma Photon Solid-State detector module Detector Element

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Solid-State Gamma Camera Direct Position Sensing TM 2020tc Imager

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

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Clinical Comparison of Contrast PMT Scintillation CameraDigirad Solid-State Camera

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Digital Position Sensing TM Excellent spatial response Excellent spatial response Enhanced image contrast Enhanced image contrast Better image resolution Better image resolution PMT Scintillation Camera Solid-State Camera Planar views Equivalent counts in each image

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

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Solid-State Gamma Camera Simultaneous Event Processing Patient E1 Detector E2 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.

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

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Buying A Van Make it economical - Diesel Issues on servicing Fire damage at Cardinal Dodge Lexington during Christmas Ya need a Lift that works Dont forget the tie downs

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

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Hot Lab With A Little Extra Hot Lab Office - Storage Hot Lab Office - Storage Dose Calibrator Dose Calibrator L-Block L-Block In/Out box area In/Out box area Radioactive storage Radioactive storage Documentation Documentation NoticesNotices Analog systemAnalog system

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

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

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The Reporting Process Completed Exam Uploading The Scan Cardiologist Dictation Advanced Medical Transcription, LLC Faxing the Report Back The Prelim One to Department other to Clinic Returning the Report Cardiologist Signoff Delivering the signed Report Back to the Clinic I Didnt Get the Prelim The Exams Arent Here! Youll Sign It When? Does the Disk Have the Pt Data? 48 Hour Time Line

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

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

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

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Preparing The Clinics Developing a PPT and hard copy for physicians and staff Developing a PPT and hard copy for physicians and staff What is mobile nuclear cardiologyWhat is mobile nuclear cardiology Radiation safetyRadiation safety SchedulingScheduling Pt prepPt prep Exam informationExam information Contacts phone and pager numbersContacts phone and pager numbers BillingBilling Visiting each clinical site with equipment in hand Visiting each clinical site with equipment in hand Involving your Cardiolite Rep Involving your Cardiolite Rep

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A Day In The Life Of Mobile Headquarters Headquarters Audubon but theyre not our boss Audubon but theyre not our boss Loading the van Loading the van Utilization of the lift Utilization of the lift Tying the equipment down Tying the equipment down On the road On the road

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

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

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

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Results of the Daily Flood

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And Were Ready To Image

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

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

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Imaging Process and Results

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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

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Large patient with enlarged heart

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Filters Multiple filters available Easy change of filters

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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

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Mirage Quantification or QGS option Matching EFs on this abnormal patient - Mirage Quantification package comes with the camera

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Patient Stats

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Road Hazards

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

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Look Out For the Smokies KYs finest is out there KYs finest is out there Our speed is 69 mph and holding, besides were on the clock! Our speed is 69 mph and holding, besides were on the clock! Let someone else be the lucky one, not you! Let someone else be the lucky one, not you!

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

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

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

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Another Example Green tab down brakes the wheel Green tab down brakes the wheel Green tab jam breaks the brake Green tab jam breaks the brake End results wheels have to be replaced since theres no brake End results wheels have to be replaced since theres no brake

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Imaging Results We are very pleased with the data we are getting. But there are still questions We are very pleased with the data we are getting. But there are still questions We are incountering high false positive positive ETT negative Cath We are incountering high false positive positive ETT negative Cath Our cardiolite rep feels its the over read of certain doctor(s)Our cardiolite rep feels its the over read of certain doctor(s) She has provided a Cardiolite vs. Cath QA program via Excel that should define our questionShe has provided a Cardiolite vs. Cath QA program via Excel that should define our question

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Patient With False Positive

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Results Continued We know that we are finding disease We know that we are finding disease History 27 yr old male complains of CP when he carries his 30 pound pack of tools around at the factory he works at History 27 yr old male complains of CP when he carries his 30 pound pack of tools around at the factory he works at The cardiolite was positive The cardiolite was positive So what the Cath So what the Cath Lets look at his Cardiolite scan Lets look at his Cardiolite scan

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Cardiolite Scan

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Cardiolite Prior To PET Scan

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PET Scan

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Last But Most Important Humor is the key to success and it is something than Mona and I interject in the workplace All the time. Humor is the key to success and it is something than Mona and I interject in the workplace All the time. Think Patch Adams hes our hero Think Patch Adams hes our hero Common saying to adopt (some of the sayings must be used with discretion) Common saying to adopt (some of the sayings must be used with discretion) Cool beansCool beans Understand rubber banUnderstand rubber ban Smooth move ExlaxSmooth move Exlax Moo FooMoo Foo Im the boss applesauceIm the boss applesauce Its like a turd in a punchbowlIts like a turd in a punchbowl Hears the story morning gloryHears the story morning glory Son BeachSon Beach And now for the next victimAnd now for the next victim Babe In Total Control of HerselfBabe In Total Control of Herself Oh my god, oh my god, oh my godOh my god, oh my god, oh my god Sometimes we get in trouble and sometimes we dont. but communication and humor make the difference. Sometimes we get in trouble and sometimes we dont. but communication and humor make the difference.

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My Thanks.. K.S.N.M.T. The Graduates of U of L and JCC Mona B. Good

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And to my wife Dorsey for our son Jonathan