Member

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I started writing this on the way back home from a meeting that I attended over last weekend. This has remained a rough draft for the past three days. I decided to publish it now with minimal changes. Else this too shall remain in my drafts folder for a long enough time to become irrelevant.

The meeting that I attended was the SOMATOM CT Users’ Meet 2010. The event was entirely sponsored by Siemens. They brought together about one hundred and fifty radiologists from all over India who use their high-end CT scanners and a few who are potential buyers. The meet was held in the opulent Oberoi Hotel in New Delhi. I could see Humayun’s tomb at a distance from the large window in my room.

Though an entirely Siemens sponsored event, the packed academic schedule was independently organized by a small committee of experienced radiologists from Mumbai and Delhi. There was one half hour session allotted to the company for demonstrating their new CT workstation. Other than that, there was no marketing pitch allowed.

In the initial email informing me about the meeting, the company representative had told me that the focus would be on Low Dose CT imaging. I was skeptical about that. I thought it would be the usual PR exercise with probably a short talk about radiation exposure and dosage awareness. When I got the full agenda, I was pleasantly surprised to see that a half day session with five speakers was dedicated to the topic of Radiation Dose Reduction in CT. That was the inaugural session of a two day meeting. I have never seen that happen in any radiology meeting in the past decade.

One of the points that was emphasized by all the speakers in that session was the need to do away with “pretty pictures.” All of us, radiologists and referring clinicians, like CT images of superb quality with life-like coloured 3D reformations. But that kind of quality comes with a price, especially with the newer multislice and dual source CT scanners - increased radiation exposure for the patient. What is required in radiological imaging of any kind is the procurement of images that are adequate to arrive at a diagnosis with reasonable accuracy. We do not have to produce images from every patient that are good enough to put on product brochures. This fundamental shift in thinking has to occur among radiologists and radiographers first. Then we have to educate referring clinicians that they do not always have to get “pretty pictures” in all their patients. They, the referring clinicians, will have to trust us, the radiologists, when we say that images of diagnostic quality can be obtained for significantly lesser radiation exposure to the patient.

Among the speakers were some vastly experienced radiologists who shared technical tips and modifications of existing body imaging protocols that would allow us to significantly reduce radiation exposure in our scanners. There was some lively discussion particularly about a modified CT Urography protocol presented by a radiologist from New Delhi.

Now that the role of Coronary CT Angiography has been established, the major worry is about the “excessive” radiation that patients are exposed to. I used the quotes for “excessive” because it has also been established that with the currently available 64 and higher slice CT scanners, the average radiation exposure falls under 10 mSv. On average the radiation dosage for CCTA in scanners similar to the one that I use is 5 - 7 mSv, which is equivalent to a CT scan of the chest. The kind of scanner that I use also allows me to further reduce exposure to less than 3 mSv (equivalent to a brain CT) by using a prospective-ECG-gating protocol. It takes anywhere between 4 to 7 seconds for the scanner in my department to complete a CCTA.

All of that changes with the latest scanner from Siemens. It’s a dual source 128 slice scanner, they call it the Definition Flash. The Siemens executive showed some current data from their worldwide installations of this particular scanner. After thousands of CCTAs being done on this scanner worldwide, the average radiation exposure is less than 1 mSV. And the scan time is less than 1 second. Mind-blowing stuff. This was independently confirmed to the audience in ensuing talks by a visiting academic radiologist from Erlangen, Germany and two Indian radiologists, one from New Delhi and the other from Mumbai.

There was a heated discussion about the indications for Coronary CT Angiography. The moderators stuck to the published and agreed upon guidelines, but there were some vociferous members in the audience who argued that with the current low radiation dosage; the non-invasive nature of CT and its speed make CCTA an attractive screening tool. Thankfully, that view was only held by a very small number of people. But that might change in the future. Which bodes ill for healthcare costs in India.

There was a collective jaw-drop moment for most of the audience when one of the company people mentioned that one particular hospital/diagnostic center in western India performed on average about fifty Coronary CTAs per day. Since there was a palpable sense of incredulity and there were some loud questions about how the workflow was managed, one of the radiologists from that center, who was sitting modestly way back in the hall, stood up and told all of us that they used three work stations and routinely did about fifty-five to sixty CCTAs EVERY DAY!! Wow!!!

We were also shown some great images of Pediatric cardiac anomalies diagnosed / confirmed on CT. There is no doubt that Echocardiography with or without cardiac catheterization and angiography are the standards for diagnosing congenital heart disease. Cardiac MRI and CT are relatively new things that have developed over the past decade. The problem with Echo & Catheter Angiography is that of availability and expertise. Echo is almost universally available, but the requisite expertise in pediatric echo is not available in all places. In fact there is no pediatric cardiologist / cardiothoracic surgeon in my town. MRI takes longer time and requires the child to be sedated or anesthetized. With the current multislice CT scanners, it’s a matter of few seconds, or less than a second if you are lucky to have the Definition Flash.

It was great to be in the presence of some of the brightest and most successful radiologists in the country. The sessions were very interactive with a good amount of active participation from the audience. Some members of the audience, especially a dashing young radiologist from Delhi, were extremely articulate and cogent. He put forth a radical idea: do we radiologists really have to give images on film in the current day? Why not just our typed report and a CD or DVD containing all the images? This again will depend wholly on the referring clinicians.

I liked how the focus of the entire meeting was on knowledge-sharing between users from various regions of the country. Siemens seems to be the only company that has consistently tried to have such user meets. Probably because they hold the lion’s share of the market in India.

The only bad thing about the meeting was the travel, more importantly the time it took to reach from Salem to Delhi and back.  The fledgling Salem airport only connects to Chennai. I opted to fly from Coimbatore. It seems there are no direct flights from Coimbatore to New Delhi. I had to wait for 50 minutes inside the plane in Mumbai airport during the the onward journey and for 30 minutes in Hyderabad airport during the return journey.

One thing I was genuinely thankful for - my mobile phone’s Aircel GPRS connection worked in Delhi. It did not work when I was in roaming mode in Bangalore last month. So I could keep up with emails and take a peek at twitter occasionally.

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