A Simple Choice: Rejecting Fear & Hate

I have something on my mind and this is the perfect opportunity to share it since I am in between some heavy marketing projects at work. I am writing tonight to challenge all of you to join me in rejecting fear and being the change that we would all love to see in our wonderful world.

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Louis Armstrong – Photo Courtesy of The Louis Armstrong House Museum https://www.louisarmstronghouse.org/louis-armstrong/

Yes, we live in a wonderful world here in the United State of America…despite what you may be consuming on social media and TV. In the wake of two hurricanes on the gulf coast, we all have seen what Americans really are at our core. We respond in love and compassion when times get tough for our neighbors. That is who we are as Americans! However, there remains this pipeline of fear and hate that is fostered by all media.

We live in a nation of many different types of people who come from places all over the globe. Each person in this country can choose to be more educated or less educated. We can choose to vote or not to vote for our officials in leadership. We can choose to work hard or not work at all. We are free to speak our minds, even though speaking our minds may not be the best choice. We are free to earn the respect of others or lose it. No matter who you are or where you grew up, you can choose to be a better person or not. We can choose to engage the purveyors of fear and hate or we can choose to ignore them and move on with our daily lives working and raising our children to make wiser choices than we made. The United States of America was founded on the simple principle of the freedom to choose. If you consistently choose wisely in life, you will eventually be in a position to have a chance at owning a home and starting a family. Everything is a choice. When you say you do not have a choice, you have accepted fear as something that is real and you are defeated by your own choice to believe that there is not a choice to be made. Confused? I hope not.

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Photo by Caleb Fisher on Unsplash

Fear and hate are commodities which are purveyed through all information outlets. We see and hear about people in our country who are rioting and raising hell against…well…everything. I see my friends on social media constantly getting up in arms against this group or that group because of rhetoric about racism, classism, liberalism, or some other “ism” that is supposedly rampant and about to destroy our country and society as we know it.

jordan-whitt-145327Photo by Jordan Whitt on Unsplash

Friends, please read my words and take them to heart! Our world is not as bad as the talking heads would like for us to believe. Besides, do you really think that posting crafty replies to articles and memes will change hearts and minds? If you do, then you are deceived. When we do that (and I have) we are wasting our time and energy that we should be investing in something more tangible. Invest in your kids, invest in your neighbors, and your co-workers. Remove fearful thoughts and replace them with hopeful and positive thoughts. Each one of us, individually, gets to decide how we will treat other people when we engage them in our day to day lives. We can all choose to be a$$holes to one another or we can choose to be good to one another. I will be the first to plead guilty to being a horse’s a$$ to certain folks when it would be better to simply give them a smile and move on. Fear sells so well in our society only because many of us choose to react poorly to it. STOP! Stop engaging the fear and hate mongers. The tongue and the keyboard are both very powerful tools. It always amazes me how hateful people can get when they are behind the keyboard of a computer. We tend to write things we would never say to people in person. We can choose words which will unite or we choose words that will divide. Sometimes, no reaction is the best practice. Fear sells and words of division should not be our default reaction to any situation.

I encourage each of you to pay close attention to what you are consuming each day on your devices and social media accounts. I challenge you to stop reacting out of fear. Here is why:

https://youtu.be/wSKzLtRzY78?t=10s

I have seen this movie, “After Earth” twice. It is quite the Sci-Fi story about a father and son who are stranded on Earth far into the future (supposedly) when humans can no longer subsist here. Of course, there is a political message to this movie and I simply chose to ignore it. There is truth in this particular clip. Fear, is not real. It (fear) only exists in our thoughts of the future. So why are we so quick to be fearful? We are conditioned by nearly everything we see and consume on a daily basis to be fearful about our future as Americans or our future as humans. Reject this. It is a choice. Know that no human can truly predict the future. It is up to each of us to choose how we treat one another on a daily basis. Join me in this daily challenge. We can choose hope and love instead of fear and hate. We can choose not to respond to fearful and hateful rhetoric. We can choose to only engage things which are good and positive. If we do this, then we can starve fear and hate completely out of the picture. We give life and momentum to fear and hate when we respond negatively to that rhetoric. Do something radical today! Ignore it…all of it.

-RW

 

 

 

My Scar is a Miracle of God

God works in mysterious ways. I think most folks have heard that at least once in their lifetime from a parent or a pastor. I have seen God work miracles both large and small in my lifetime. I have never once questioned a miracle that I witnessed. Why? Faith. My faith in God took root when I was only 4 years old on our farm. We had a cow that was paralyzed in the rear limbs due to a rough delivery of a baby calf. She was down for a few days and she could not nurse her calf. Dad had to milk her while she was laying down and then bottle fed the vital colostrum to the calf. Dad discussed euthanizing the cow with my mom and I overheard this conversation. It brought me to tears. I did not want the baby calf to go on without a mother. I could not imagine it. I ran out of the house and came to the side of the momma cow and I laid my hand on her and prayed for God to heal her. Well…she got up…right then and there. It was awesome and I went running back to the house screaming in joy to my parents that she was up and she was okay. I do not know how many years she stayed with our herd after that. I do know that my parents both recognized it as a miracle of God.

I work in veterinary medicine and I will admit that cows with acute onset paralysis from dystocia can sometimes suddenly recover, however, it is rare. Does this make the miracle a non-miracle? If one has no faith in God and the healing power of Jesus Christ, sure you can dismiss it as purely a fluke, a medical recovery. However, one who has faith and stood there as a witness would not dismiss this event as anything less than a miracle of God.

Fast forward about 37 years and we arrive at August 12, 2017. Holly, Sam, and I were moving into our new home on Creekside street in San Antonio. We had been living in College Station and decided to move back to San Antonio so that I could be close to Sam during his high school years. We brought with us a Murphy bed. For anyone who does not know, a Murphy bed is a bed that attaches to a wall and folds straight up parallel with the wall when not being used. I had assembled that bed only once before about 4 years prior when Holly and I were first married and had moved into a home together.

The entire summer of 2017 was consumed with much work and preparation for this move to San Antonio. I was being quite a grouch that day. I was weary and had been working hard. We all had been working hard. I had enlisted Holly and Sam to help position and mount the heavy bed frame into its place on the two spring loaded steel arms which control the lowering and raising of the bed.

I was being a cowboy and not being safe. The bed was finally mounted on the guide bolts of the spring-loaded steel levers. I was dangerously crouched over the spring-loaded steel arm on the left side of the bed.

Bed 2

I thought the guide bolts would hold everything in place while I inserted the mounting bolts. I took a bad risk. The weight of the bed was unbalanced on my side because I was squatted inside and on the frame with all my 240lbs. This unbalance eventually made the frame shift downward and that is when the steel lever dislodged and hit me in the face. It was just like lightning at close range. A flash with an immediate BANG! I saw blood and clutched my face.

 

Bed 3

 

I was bleeding everywhere and cursing like a sailor.  Holly ushered me to the kitchen where we had water, ice, and towels. She saw the wound and it was bad. She said we had to leave for the ER immediately. A cable guy was in our home installing our internet when this all took place. Sam had to stay behind to make sure that work was completed while we took off to Methodist Hospital in Stone Oak. Holding a towel with ice to my face on one side, I used my free hand to call my friend Kevin on the way to the ER and asked if he would go to our house and look after Sam and/or take him back to his mother’s house. He responded and took care of Sam for us. Not 3 weeks prior to this event, I took Kevin to the same ER for stitches in his hand from an accident working on his flip house.

This entire event that I experienced, as bad as it marked me, I will always claim as a miracle of God’s mercy. I did not realize the miracle until I was sitting in the triage area. I was seen to immediately in the Methodist Hospital ER. The physical exam revealed that I had a laceration on my face and another on my left forearm. The forearm laceration I had not noticed until I was in triage. It was 2 inches long and it was wide open where I could see my muscle tissue but it did not go deep enough to hit any tendons. They performed a CT scan of my head and determined that there were not any broken or cracked bones in my skull. All my teeth were unharmed. My sinus cavities and orbitals were perfect. The only trauma was a 4-inch laceration from just beneath my nose stretching directly out to my right cheek and it was deep. This laceration was 1 cm deep. Any deeper, the laceration would have removed my entire upper lip from underneath my nose and it would have penetrated my oral cavity.  The doctors and nurses were astonished and kept asking me how it happened over and over. They could not picture the injury happening from a bed. Some of them did not understand the concept of a Murphy bed. They had never seen one.

 

Left Arm

There was some bad news. Methodist Hospital of Stone Oak did not have a plastic surgeon on call and I needed one. They would need to transfer me to University Hospital over in the Medical Center. This had to be done by ambulance. I spent approximately 2.5 hours at Methodist. As soon as they had stitched my laceration on my left forearm, I was placed in an ambulance for transfer so I could be seen by a plastic surgeon for the delicate repair. Upon arrival at University, I was sent into their trauma unit. I was met by several doctors and nurses. They stripped my clothes off me and began taking vitals and placing an IV catheter for fluids. I was not happy about being naked. They also took a chest x-ray and the entire time they are asking me all the same questions I had been answering at Methodist. Again, I had to explain the basic mechanical principles of a murphy bed. Most had never heard of such a thing. Last thing, we need to check your rectum sir. AHHHH! I was flipped over and violated and then everyone just left except my charge nurse who just threw a hospital gown over me. I never knew what our calves felt like at branding until that day. I was processed into that place like a baby calf. Thank God, they did not put a fire brand on my ass. I did compliment their work as a team. It was fast but still…I was left anally violated and naked.

I was moved into a private room. It was only private because it was still 8pm on a Saturday and the usual crowd of stabs, gunshot wounds, and car accidents would not get going until later in the night. I was by myself except for the nurse. I was asking for Holly. The nurse went and got her from the waiting room and brought her back. The admissions person came in and began collecting all my insurance and other pertinent information. The charge nurse was great. He told us not to expect anything to happen fast. He said that nothing happens fast in this place and to expect no discharge until early morning the next day. It was almost 9pm when an attractive lady came into my room in green scrubs. She began asking me questions and performing an exam. Great, a tourist wanting to see the slashed up naked guy…so I thought. She then introduced herself as the plastic surgeon. You got here fast! She left the room and came back with her kit. It was her and us. No nurses were present. She washed the wound for what seemed like an eternity and it was unpleasant but not too painful. She began to inject my wound with the lidocaine. It stung like hell and that was painful. I then noticed that I had not really felt much pain before that. She delicately began to stitch the inside layers of the wound. I could feel some of the pokes and after 20-30 minutes, I began to feel more and more of the pokes and the pulls. I just kept still and put on my game face. Holly saw my demeanor change and asked me if I felt it and I nodded. The surgeon then placed more lidocaine injections. These hurt much worse than the first ones as they were right under the bridge of my nose. I believe this may have been the worst physical pain I have ever experienced. She began stitching slowly, diligently, and delicately. I still felt about every third poke but I just kept still and quiet. After just over 1 hour of stitching she was finished. The charge nurse came in and told me that I was lucky she showed up so quickly. He has regularly seen people wait 6 to 8 hours for plastic surgeons to show up. What a miracle. Again, the charge nurse warned us that nothing happened fast there and that we would need a few more hours to have my IV antibiotic delivered and then administered. Not 10 minutes later my IV antibiotic showed up and they placed it into my IV line told me it would take about 30 minutes to finish. Holly had left by this time to go get me more clothes at Walmart. When she came back, my IV was finished. I was up and getting dressed into my new clothes. The charge nurse came back again and told us that they were waiting for my CT report to come in for their records. They could not discharge me without that. An hour later, the report was there and our discharge papers were signed. I was released around midnight. The charge nurse said he had never seen anyone come in with my type of wounds that needed that level of care and the person be able to leave so quickly. It was a miracle. I was cleared to operate my life normally with two exceptions: no direct sunshine on my face and no submersing my face underwater. I could eat / drink normally and go back to work as long as I cared for the wound properly.

Face

We left the University Hospital parking garage at 12:30am and headed straight to Whataburger and then to Kevin’s house for my first K-Laser treatment. I have been sold on therapy laser as a treatment option on animals and people since Kevin first began working for K-Laser. This technology uses different frequencies and wavelengths of light to program the body’s cells to do what they do naturally but to do it faster and more efficiently. I have seen wounds on horses, dogs, and cats heal at a significantly faster rate than normal. We were home and in bed by 2:00am and I slept well. I woke up with a new perspective. Holly and I discussed how this event was a series of small miracles from God.

  1. Somehow, supernaturally, I was removed from the direct hit of this spring-loaded steel lever. It should have hit me directly on my left side of my skull. Instead, it somehow hit my left forearm first. My left arm was not in the path as the bed frame shifted. But it hit my left arm first and then it struck the RIGHT SIDE of my face as if my had turned just at the right moment and I was just sliced instead of directly struck. Had I received a direct hit on the left side of my skull it could have shattered any bone in its path. It could have gouged out my sinus or my eye or both. It would have knocked me unconscious and rendered Holly and Sam powerless to help without dialing 911 and waiting for EMS to show up. I am convinced this was divine intervention. Why did God allow it to even slice me? Because I was being stupid. I could have suffered more for the bad decision of working too closely and being careless. Now I have a mark to remind me that I am not invincible and that I need to think more when doing projects. I have that scar to remind me that God can protect us from much worse harm, even though we do get harmed. Could He have saved me completely? Yes. Then what? I would still have been a grouchy ass barking at my wife and kid to help install the bed. No lesson would have been learned. I would only have counted the incident as a near miss and moved on as the same person. Today, I am different than I was then. On the outside and on the inside.
  2.  Time is precious. When you have deep lacerations, time is precious. The longer they stay open, the higher the chance that it becomes infected. I received that injury around 5:00pm. My wounds were closed and healing began at 10:45pm. The charge nurse and the plastic surgeon said that I was lucky to have been tended to so quickly. This is also miracle status. They each told me that people never get treated as quickly as I did. I thank God for this. It was a miracle.
  3. The wheels of bureaucracy are slow. I was admitted to a publicly funded, university owned, teaching hospital. Nothing happens there at a rapid pace when it comes to paperwork. The charge nurse and the doctors were all surprised at my rapid discharge. This may be the largest of all miracles contained within this event.

I did not want to finish installing the Murphy Bed. It sat in my office for almost 4 days before I could bring myself to deal with it. I decided to destroy it. It is a dangerous piece and it is not worth the risk of it hurting anyone else in this family or other families. I could have sold it. I could have given it away to a family that needs it. No. I committed it to destruction. IT WILL BURN! Piece by piece in my backyard firepit over the next few months this bed will be consumed by fire. Sound familiar? Our struggle is not against flesh and blood. Someday, those powers, principalities, and dark forces that are bent on destroying humans…they will burn too. It says so in God’s Word. Want to learn more? Start reading. I will let you know where to go for study resources that can last you months. My journey in God’s Holy Word has been ongoing since I was a kid. But in the last few years I have learned more and studied it more than I ever have. You can too, if you choose to.

Bed 4

Bed 5

Bad things happen to good people every day. Good things happen to bad people more often. This confuses many and creates animosity toward God. Sometimes it can be what inspires a person to not believe in God. I do not have the answer as to why I was spared from a more severe injury. I can only say that I hope I will make this miracle count. My life is a gift. Each of us are only given one life to live. It is special. Each day that I get to be a husband, a dad, and a friend is a miracle.

Aug 21

I hope I can continue to be a better person than I was the day before. I hope I can work smarter on my projects in such a way that I do not endanger myself or others. I hope that I can help others know God and His love, His Mercy, and His story. Each time I look in the mirror, that scar will be there. I hope it will always remind me that God is there for us all. I hope it will remind me that it is not about me. It is about Him. -RW

Veterinary Medical and CT – Part 2 – Is CT right for my veterinary practice?

Learning about CT and Cone Beam CT in veterinary medical applications.

Considering investing in a CT for your vet practice? Read this first.

You’ve probably already spoken to at least one sales person who has promised you the moon, and you’d like to trust that they have your best interests at heart. But how can you be sure that you’re investing in the right CT system that will help you round out your hospital’s imaging capabilities? You use ultrasound like a champ and your techs take fantastic digital radiographs. So…what about CT or Cone Beam CT? Purchasing one of these units is a lot more expensive than your ultrasound and your DR combined! You probably have more questions than a sales rep has good answers to.

What about asking a veterinary radiologist?

It is wise to seek good counsel from an experienced veterinary radiologist. I’ve talked to many veterinary radiologists about CT, and I’ve found two camps. The first is of the opinion that general practice veterinarians should avoid purchasing a CT, leaving specialty imaging to those who will “do it right” – which gets you high quality images that support accuracy of diagnosis. The second camp recommends CT as a good investment for a general practitioner. They believe that CT imaging in general practice, with proper staff training, continues the advancement of patient diagnostics at that level. In other words, a rising tide floats all boats.

Radiology Humor

A quick laugh about radiologists. A human radiologic technologist once told me that if you put 5 radiologists in a room and you will get 6 different opinions.

Investing in a CT scanner is no small decision

Before diving in, you must learn what CT is as a technology and what it is designed to be used for in veterinary applications. Not all CT machines are created equal in form and function. As stated in Part I of this blog, there are two types of CT technology available to veterinarians today, Spiral or Helical CT and Cone Beam CT.  This post goes into detail about the differences between Spiral or Helical CT and Cone Beam CT.

cone-vs-helical

What sales reps probably don’t know about Cone Beam CT (CBCT)

Why CBCT was developed

CBCT technology was originally developed for diagnostic applications in human dentistry for oral surgeons and dentists. These units are designed to produce high resolution cross-sectional exams of the human skull. The factory software in all CBCT machines can render the exam into a 3D model onscreen or into a more traditional stack of 2D images.

3D modeling from CBCT machines is useful in reconstructive surgery for dentists and surgeons in both human and veterinary medical applications. However, 3D images are of little diagnostic value to board certified veterinary radiologists. Radiologists always rely on the 2D image stack in cross-sectional imaging modalities to report their findings.

So manufacturers of CBCT took a technology originally developed for human dentistry and adapted it for the veterinary market.

Veterinary Medical Indications for Use of Cone Beam CT Technology:

Bone: skull fractures / nasal masses / dentistry / distal extremities / spine IVDD (requires contrast)

Soft Tissue: NO RECOMMENDED INDICATIONS ON MOST ANIMAL PATIENTS

The Science behind CBCT

CBCT emits a cone-shaped pattern of radiation, earning it the name “cone beam”. Essentially, a CBCT is a digital radiography system fitted onto a wheel inside of a gantry. It contains a small flat panel detector (usually about 18cm x 16cm) and it is positioned perpendicular to a cone beam x-ray tube (like the tube in a conventional x-ray system). As the wheel with the components is moved 1 degree a radiograph is taken, and then it advances another 1 degree and takes another and so on until it completes a full circuit around the animal patient.

Cone beam tubes produce a wide cone shaped signal pattern, originating at the tube (the point of the cone) and scattering outward toward the panel. This typically produces more scatter and less detail in the images when compared to spiral / helical CT modalities.

This is especially problematic in animals over 20 lbs., or in animals that are much larger than a human skull.

Can CBCT be a good tool for a veterinary hospital?

The hardware and software of CBCT units were optimized to acquire high resolution images of the human skull and particularly, the human mandible and maxillary portions of the skull. This means that it can definitely be a good tool for veterinarians who are passionate about canine and feline dentistry. Some veterinarians would be very interested in acquiring high resolution images of the patient’s skull which is crucial for quality performance of veterinary dental procedures such as extractions and reconstructive surgery.

The CBCT can also be used successfully for studies in the spine (IVDD with the use of proper positioning, collimation, and contrast). CBCT is also good when evaluating the integrity of joints and extremities (ex. canine elbow disease and osteosarcomas).

If the CBCT user can be trained to operate the technology within these limited indications, it can be diagnostically useful to a veterinary hospital, yet it will remain limited as compared to the spiral CT technology.

Some shortcomings of CBCT

CBCT units were not designed to perform scans of the thorax or abdomen on human or animal patients. The CBCT emits a cone shaped pattern which is cast upon the targeted anatomy. This results in more scatter radiation and less detail in the resulting images. This makes diagnosis more difficult because the images are not as clear.

Most CBCT manufacturers’ machines do not allow cranial to caudal movement of the patient. The table or couch does not move automatically. This means that operators need to move the table or move the patient if the targeted anatomy does not fit within the finite field of view.

Essentially, the CBCT unit remains stationary over the targeted anatomy and the field of view is limited to the finite dimensions of the selected capture area (L x W x D) in the acquisition software. This results in more than one series of images which will need to be either stitched together into a single stack of images or organized separately as individual image stacks with 1/3 or 1/2 of the targeted anatomy in one stack and the remaining anatomy in the subsequent stack(s). This can often frustrate a veterinary radiologist when reading a Cone Beam CT case that does not utilize automated and precise movement of the patient on the couch during the scanning process. When attempting to image the spine with CBCT, this can be a challenge for the operator to perform and for the radiologist to read.

CBCT scans can also take more time to complete. If the thorax / lung fields were to be the targeted anatomy; as animals breathe and the heart beats distortions are produced from the motion within the chest cavity during the scan. A manually induced breath-hold (while under full anesthesia), can reduce the effects of “motion artifact” from the lungs but the heart continues to beat so motion artifact remains problematic if the heart is what is targeted. In the animal patient, the most precise evaluation of the heart should be performed with ultrasound (i.e. an echocardiogram) and thoracic chest radiographs.

                 4 Slice CT Lungs                  CBCT Lungs

Note: the entire lung field is captured by the CT. The CBCT leaves out some of the lung field due to its confined field of view. Lung views in the CT image stack are much higher in resolution. In the CBCT image, there are too many artifacts, and in this case an incomplete field of view for a radiologist to read it successfully.

                  CBCT Abdomen      4 Slice CT Abdomen

Veterinary Radiologists and CBCT

In general, all boarded veterinary radiologists are familiar with spiral CT as it has been around in veterinary specialty clinics for a couple of decades. However, most, but not all veterinary radiologists have done no research on the cone beam CT technology. Therefore, most veterinary radiologists will have a negative opinion about cone beam CT simply because they know very little about it and how it’s meant to be properly used.

Radiation Safety

The CBCT folks claim their technology produces less exposure to radiation for patients and operators. They argue that lead-lined walls are not required. Depending on various state regulations, this claim may be true. The accuracy of such statements are at the mercy of the local regulations of the end user. In addition to that, we are simply comparing apples to oranges when comparing CBCT to CT. Remember, the core design of CBCT technology is limited in application to the skull or extremities. These anatomy indeed require less radiation for acquisition of diagnostic images. However, in reality, it is not much less radiation than what a spiral CT uses to acquire diagnostic images on the same anatomy.

In my opinion, it is always better to err on the side of safety. Go ahead and design your CT room with lead-lined sheetrock and place the acquisition workstation outside of the CT room behind a lead-infused glass barrier where your technologist can see the patient and the attending technician. Yes, this costs more money up front but it can save a practice from safety citations and lower the potential for employee / client litigation in the long run.

Can a veterinary hospital be successful with either technology?

The short answer is yes. The CBCT can be applied successfully in animal hospitals that perform a high volume of dentistry cases, and can be used effectively with imaging extremities as well as IVDD.

Conventional spiral CT technology can be even more successful because this technology can address more indications than their cone beam counter parts.

No matter which way you go, SUCCESS will hinge on whether or not the doctors and techs have the proper amount of comprehensive veterinary training for CT or CBCT.

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Computed Tomography Training for Veterinary Teams

CBCT and CT are not easy modalities to add in a veterinary hospital environment. Floor plan and power are not the only challenges we face either. The proper amount of training and the proper types of training are what make CT the greatest challenge of all imaging modalities. Even ultrasound (which requires copious amounts of personnel training) is actually easier to integrate into a vet practice than CT is. The bummer is that most vendors who are selling CBCT and CT to veterinarians are doing minimal training with their buyers.

It is not a simple plug-and-play scenario. More than 60 hours of physics, safety, software / hardware operations, and veterinary applications training is required of veterinarians and their teams to make this technology successful.

Very few CT or CBCT vendors will offer a fully comprehensive program of computed tomography training for veterinarians or veterinary technicians. Many will only offer a “safety talk” and a few hours of software and machine operations training. So be advised that you are entering a venture where there veterinary CT training by most vendors is minimal and weak at best.

ANNOUNCEMENT: Dr. Holly Jarvis-Whitaker and the Instruction Intelligence adult education team will be launching a specialized CT and CBCT training for veterinary hospitals who own or plan to purchase a CBCT or CT. Please stay tuned to LinkedIn and the Veterinary Intelligence website  for updates on the launch of this highly advanced Veterinary CT training.

CBCT Summary:

PRO: Quality. Good image quality in canine and feline skulls as well as distal extremities.

PRO: Always sold brand new. Cost $175k – $250k depending on the vendor. 5-year warranty and service programs are offered with the purchase of CBCT from most vendors.

CON: Indications. Soft tissue image detail in the abdomen and thorax of animal patients is inferior to those generated by spiral CT. Some CBCT vendors advise the veterinarian to use ultrasound in lieu of their CBCT for abdominal soft tissue imaging. This is not bad advice, however, it is much easier to evaluate the size and precise location of masses / tumors with spiral CT.

CON: Field of View. A finite field of view on most CBCT machines can cause increased operator errors during acquisition. Most CBCT units do not move the patient or move through the patient cranial to caudal (automatically) which requires the manual movement of the patient by the operator and this produces multiple image stacks which each stack may only contain 1/3 or 1/2 of the targeted anatomy in larger canine patients.

CON: Training. Most vendors do not offer a comprehensive training program for vet techs and veterinarians. Most invest a few hours to teach the client basic operation with safety training after installation. This is problematic because the client is left to learn more valuable lessons by trial and error.

CON: Radiologist review and reporting. Most boarded veterinary radiologists will refuse to read and report on CBCT cases from veterinary hospitals. Only a select few are willing to read CBCT cases. VitalRads.com is one of the few veterinary teleradiology services that read veterinary Cone Beam CT exams.

What you need to know about Spiral CT (CT)

Spiral or helical computed tomography equipment is specifically designed for cross-sectional scans of soft tissue and bone in human patients. The CT couch or table slowly moves the patient through the spiraling signal. One newer CT design has a mobilized gantry that uses a motorized wheel system underneath to “crawl” over the table or couch where the patient is positioned.

An acquisition workstation and software render the acquired dataset and organize the data into one or more readable exams based on selected anatomy and protocol.

So this is also a technology that was adapted for veterinary from human medicine.

Veterinary Medical Indications for CT Scans

Soft Tissue: met checks / mass ID / lungs / liver / spleen / GI tract / urinary tract

Bone: skull fractures / nasal masses / dentistry / distal extremities / complete spine / hips / pelvis

The fundamental technology consists of a specially designed x-ray tube that emits a confined linear beam of photons which pass through the patient that is received by a linear array of sensors as the scanning unit it continuously spins around the patient at high speed.

What’s the deal with CT and the number of “slices”?

You may have overheard a conversation about CT where someone refers to the number of “slices” their particular CT has. This is because the higher the number of “slices”, the better the image quality. Ultimately, image quality in a CT is determined by the number of channels (aka slices) available in the sensor array. Please note that “slices” is a misnomer, because the number of slices really refers to the number of channels in the CT’s sensor array.

The more channels a CT sensor array has, the faster it can scan a patient, raw data acquisition also increases and then is processed into higher resolution images. The more raw data that acquired, the clearer the image quality. A 40 slice CT system can perform a full body scan on a 90 pound Labrador retriever in less than 15 seconds and still produce impeccable image quality. This occurs when the operator (aka technologist) is experienced and well-trained in applications and protocols for small animal veterinary medicine.

CT Software

Just like all software based technology, CT acquisition software applications have improved immensely over the last ten years. Most modern CT units (manufactured after 2010) will have highly-advanced acquisition software which allows a fully trained technologist to set up customized protocols which is great for applications in animal patients. CT units come from the factory with human presets (scanning protocols) in the software which means that it is up to the veterinarian and the CT technologist to adjust those protocols and customize their own presets for animal patients of various sizes and anatomy.

Some shortcomings of CT

They can cost a lot. Brand new CT units can easily cost a veterinary clinic well over $600k which is often more expensive than the real estate the vet hospital sits on. Purchasing a new or refurbished CT scanner can reduce the investment to below $250k for the equipment purchase. Then you need to add the extended service and warranty contracts after the first year is over.

There are older refurbished single slice CT machines available for sale that cost less than $80k (before you add facility modification, training costs, and extended service agreements). This is because a single slice CT is the slowest and lowest resolution model available. Single slice CT’s do a decent job imaging a patient, but they take longer (up to 20 minutes on that same 90 pound Labrador retriever which I mentioned earlier).

With lower resolution and slower scanning time comes a lower price tag, and vice versa.

Spiral CT machines are almost always purchased used or refurbished by veterinary hospitals. A brand new 64 slice CT will set you back at least $1 million. So, there is a delicate balance to be sought when looking to purchase CT. I intend to discuss pricing and ROI in part III of this blog which is forthcoming.

A good rule of thumb is to buy refurbished, buy a well-known brand (GE, Philips, Siemens, Toshiba), and stay between 4 and 16 slices. Another rule to live by; always purchase the preventive maintenance package with an extended warranty on the CT x-ray tube.

They are big. Most of the refurbished spiral CT units are huge by comparison to the brand new CBCT units. Spiral CT rooms need to be at least 16’x20’ when developing the room’s floor plan. All of the CBCT units I know of can exist in a 12’ x 12’ sized room.

Veterinary Radiologists and CT

In general, all boarded veterinary radiologists are familiar with spiral CT as they each were trained on how to read CT images from spiral CT units. You should have no problem finding a boarded radiologist to read your CT scans from a spiral CT.

If a vet hospital can maximize the use of a CT, it is a good investment to go with a spiral CT because it’s simply more versatile. Radiologists are more open to reading CT scans. They do take up more room but a spiral CT makes more sense for most general veterinary practices.

Can a veterinary hospital successfully use CT?

Absolutely yes. CT can be used successfully in animal hospitals who are looking to up their game on imaging and who want to raise the level of practice inside their clinic walls.

The long answer is a bit more complicated. Again, CT is not an easy technology to add to a veterinary hospital. It requires a different way of thinking on when and how imaging is ordered for animal patients. It requires much more training for veterinarians and technicians as compared to acquiring radiographs and/or performing an abdominal ultrasound.  This training differs among the spiral CT vendors but most training from these vendors is not veterinary focused which can be problematic.

CT Summary

PRO: Versatility. Spiral CT has a broader set of applications than CBCT.

PRO: Reads. All veterinary radiologists are trained and prepared to read CT studies.

PRO: Clarity: Spiral CT is faster, so the “motion artifact” problem is greatly reduced vs. CBCT

PRO: Easy: Spiral CTs come with pre-programmed protocols and can be manually programmed with protocols that your hospital uses frequently. This makes image capture faster and more consistent.

CON: Cost. Higher resolution means better, more diagnostic images, but it also means a higher price tag.

CON: Space. The room size for a spiral CT is greater than the space required for CBCT.

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How does this information help my decision?

Decide what’s important to you! You want to improve your vet hospital’s ability to get great images. CT is a good way to go if you already have an active ultrasound modality and use your DR system to its fullest capacity.

If cost is a major consideration, you will want to consider how to start making your investment back as quickly as possible. That may mean getting some great training with experts in veterinary CT. Look for a full discussion about ROI on CT in an upcoming blog.

If space is a major consideration, that will play into your decision. If you are landlocked in a strip center or your imaging suite simply cannot expand beyond its current footprint, look carefully at the space required for each.

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What is the culture in your veterinary practice?

Look at your culture and how you practice vet medicine. Maybe you don’t need a CT. You may not know if it will fit into your culture (i.e. your team’s collective philosophy of how you practice vet medicine). That is okay. It is imperative that you know your practice culture. There are two major cultures of thought in vet medicine and all others may vary minimally from one of these two.

1) There are veterinarians who enjoy the opportunity and ability to perform more specialty type levels of service such as CT and advanced orthopedic surgeries. This is in addition to doing basic wellness / internal medicine, and sterilization.

2) Veterinarians who prefer to be limited only to wellness, basic internal medicine, and sterilization surgeries. All of the advanced and more difficult cases are quickly referred down the road to a specialty hospital.

Do not kid yourself…if you are buying a CT to keep up with Dr. Jones down the road…maybe you should check if your clinical culture is prepared for such an advanced modality.

You are more than welcome to contact me privately or leave questions in the comments section. Please do not forget to check out these important resources on the web at VitalRadsInstruction Intelligence, and Veterinary Intelligence.

Thank you and have a great week! -RW

 

Gravity Applies

There are many who believe our new president will bring about good changes and there are equally as many (or maybe more) who think our new president will destroy America as we know it. I have lived through seven U.S. presidents since my birth. Four of which were Republican and three which were Democrat. As I grew older and began to follow American politics, I discovered that most Americans seem to think that the President of the USA has all of the power to either make or break this great country of ours. As each election year has come and gone, political rhetoric has become more fearful, angry, and hateful between candidates and that simply carries over into the voters.

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Let’s come back down to Earth, shall we? My life has stretched from President Ford to now President Trump. Not a single POTUS has caused me to gain or lose a job that I have worked. Each time I changed what I did for a living, the POTUS had nothing to do with it. Not a single US President in my lifetime has produced a policy that determined whether or not I had a hot meal to eat each night. My Grandfather survived the Great Depression in the Texas Panhandle. He had very little money and few resources but he kept on working and got through it without government assistance.

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We Americans tend to give the POTUS too much credit for the power they supposedly have over us as individuals. Yes, taxes can be raised or lowered and interest rates can be made to be high or low under certain regimes. However, we as individuals possess the power to work, earn money, own property, access water, grow food and defend our family from harm. The US Constitution allows us the freedom to succeed and to fail as individuals based on the decisions we make in our daily lives. This is miles ahead of many other countries on the Earth whose citizens do not have the freedoms, rights, and responsibilities that we Americans have been granted. We Americans should all be on our knees daily and thanking our creator for the US Constitution and what it means to each of us. We each have the ability to chose our own destiny in life and then we must work hard in order to achieve it.

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All it takes to live a wholesome and good life is a few resources such as land, tools, a pickup truck, a rifle, some common sense, and good bit of ambition. There are many who would disagree with me on this which brings me to my next point. Those who do not believe they have the power within themselves to carve out their own destiny are the reason we have too much government. These are people who think that all forms of life must depend upon a body of elite politicians to keep them safe and place food on their table. Ultimately this represents the sharp divide that exists in our country these days. One group makes life happen as they move forward in their daily work. The other group believes that life (good or bad) is what happens to them as a result of the action or inaction of others.

pendulum

The pendulum swings left and swings back right and then back left again. Gravity applies as interest rates and taxes go up and then come down and then go up again. I have seen and experienced the regime changes in Washington DC and Austin many different times now. Here is what remains. Those who are determined to make their own way and seize upon the opportunities to improve their lives will live a full and good life. They have bad days and good days, good years and bad years…no matter what. Gravity always applies. Those who are determined to depend on a government made up of elected officials to make their lives good and full will always be disappointed and found to always be wanting more.

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So we all have a choice.

1) We can boot strap it like the Americans of old have always done. Which means we just keep our head down, work hard, and enjoy the breaks we get with our families and friends. I must do this.

2) We can choose to exists in a constant state of fear and anger. Allow cynicism to consume us and find ourselves never being happy with anything because someone else is in charge and we do not like him or her.

So choose. Enjoy your life or lose it.

-RW

 

 

There Ain’t No Strings On Me! Wireless Digital Radiography in Veterinary Medicine

There are still many veterinarians today who do not have the benefit of digital radiography in their hospitals. The majority have indeed made the move into digital over the last 10 years but there remains a remnant of veterinarians who still use film. Most of these film users claim that they are waiting for the price of DR to come down. This excuse is preposterous in my opinion.

Veterinary Digital Radiography at Basic User Level (Tethered DR Panel + New X-ray Table):

Any veterinarian practicing small animal medicine exclusively can add a digital radiography system (and a brand-new x-ray table) to their hospital for a little less than $60.00 per day.

 

Total Equipment Cost (includes tax and freight)

$66,000.00 US

5 Year Equipment Loan with Interest at 6.0%

$1,276.00 US – Monthly Payment

X-ray Fee

$125.00 / 3 Views

Minimum Monthly Caseload (3 view studies)

11 Cases / Month – Break Even Point

If your veterinary hospital is open for business 7am to 6pm for 6 days each week this calculates into the DR system costing you $53.17 US, each day that you are open for business. Not bad!!!

 

New Technology: Wireless Digital Radiography for Veterinarians

Wireless DR technology is a perfect investment for all veterinarians. It works very well for those who work in zoos, wildlife preserves, and mixed animal veterinary hospitals. Typically, these “forgotten veterinarians” have been required to purchase at least two different flat panel systems (one portable and one stationery) if they wanted to truly be digital throughout all species. The other choices would include purchasing a CR unit (cassette based) or just buying digital for small animals and using film for everything else. These complicated scenarios, I am happy to report, no longer hold true.

Wireless digital radiography is market ready and a few hundred of these wireless systems have already been sold and installed. One portable wireless DR panel can now be used to take instant radiographs on horses, cattle, goats, sheep, dogs, cats, birds, reptiles and many more species. The first wireless DR panels were launched around 2011 or 2012, and they have vastly improved in design and reliability since then. The first generation of wireless panels had some trouble with interference from outside signals such as cell phones and electrical grids. An abbreviated battery life was another challenge with the first-generation wireless panels. The highly-paid propeller heads in Asia and Silicon Valley have eliminated most (if not virtually all) of the bugs from wireless technologies and this includes digital flat panels. Most buyers are now purchasing their second digital system and leaving technologies like Film, CR, and CCD in the past which is exactly where they belong. Wireless digital flat panels are no longer the future, they are here!

 

Advantages of Wireless vs. Tethered

NO MORE WIRES – Wireless panels do not need to be wired into and timed (synced) with x-ray tubes and generators. All wireless DR panels now have what is called Auto-Timing. The panel senses the x-ray photons and automatically opens to receive them to produce an image. Furthermore, if a veterinarian is seeing many equine or food animal patients, this unit will not have wires that have the potential to become tangled or in the way.

PORTABILITY – Unlike some of the tethered systems, wireless panels can be connected (paired) to both a laptop PC and a desktop acquisition stations. This makes the wireless digital solution much more compact and portable within a hospital and away from the hospital. Another advantage to this portability is intraoperative imaging in the surgery suite. Veterinarians who perform orthopedic surgeries can now bring the wireless panel into surgery, utilize a sterile panel sleeve, and snap radiographs to ensure the proper placement of hardware. Never again will a surgeon need to move the patient into radiology during surgery. Many surgeons are using CR in surgery, which means there is a delay in snapping the radiograph and then seeing it due to the digitizing process. A wireless DR panel produces an image almost instantly, no waiting.

IMAGE QUALITY – This is a draw at minimum but I still consider that an advantage. I would challenge any veterinarian or veterinary radiologist to determine whether a set of radiographic images were created from a wireless DR panel or a traditional tethered DR panel. The wireless DR panels produce high quality, diagnostically crisp images just like many of their tethered counterparts.       

Question: Which images came from Wireless DR panels?

 

Answer: Both of them were taken by a wireless DR panel. 

Disadvantages of Wireless vs. Tethered

PURCHASE PRICE – Wireless DR technology is indeed more expensive than the tethered DR systems. On the low end, we see a wireless system selling for about $60,000.00 US and the higher end they can cost up to $80,000.00 US. This may scare some of the film users but it is not as likely to scare those practitioners who are buying their second or third DR system.

CYCLE TIME – Some of the wireless systems will take a little longer to cycle and reset between shots versus the tethered systems. This slower cycle time seems to only be problematic with selenium based panels during an equine pre-purchase exam. Many equine veterinarians will push DR systems to their limit in cycle time when taking up to 40 images during a pre-purchase exam at a big event such as the Keenland Sale. However, a slower cycle time is really of no consequence when taking only a 3-5 views on a single patient.

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Making the Wireless DR Purchase

What does it take to remove the fear and anxiety from this purchase? Let’s start with simple math.

Scenario #1 – Purchasing a high-end wireless DR system with a laptop & desktop station

Equipment Cost (includes tax and freight)

$80,000.00 US

5 Year Equipment Loan with Interest at 6.0%

$1,550.00 US – Monthly Payment

X-ray Fee

$125.00 / 3 Views

Minimum Monthly Case Load (3 view studies)

13 Cases / Month – Break Even Point

$64.59 US per day of operation

Scenario #2 – Purchasing the lower-end wireless DR system with only a laptop station.

Equipment Cost (includes tax and freight)

$65,000.00 US

5 Year Equipment Loan with Interest at 6.0%

$1,260.00 US – Monthly Payment

X-ray Fee

$125.00 / 3 Views

Minimum Monthly Case Load (3 view studies)

10 Cases / Month – Break Even Point

$52.50 US per day of operation

Most 2 doctor hospitals will take 20-30 x-ray case studies per month with digital. With that said, there are some veterinarians who rely heavily on radiographic studies to get answers and there are others who do not use x-ray to its fullest potential. I plan to address this tale of two veterinarians in a future blog, so please stay tuned.

Purchasing a wireless DR system is not out of the realm of possibility simply because of the cost. If your hospital is already seeing over 10 patients each month through the x-ray suite and you are charging the proper fees, adding a wireless system is not a difficult decision.

Which of these are from a wireless DR system?

Answer: The one on the left, with the two screws in the hoof block. The one one the right is taken by a tethered DR system. 

Who Makes Them?

There are several wireless DR systems for sale in the veterinary market place today. I am pleased to report that those I have experience with are good systems hailing from good manufacturers who all have track records of sales and support dating back over 10 years.

I can only speak about these certain manufacturers so please understand I am leaving a few others off this list simply because I know very little about their systems.

Canon (multiple dealers in veterinary)

RadmediX (1 exclusive dealer in veterinary)

 

These manufacturers make a good wireless DR panel and they do a good job supporting their panels after the sale.

 Which of these are from a wireless DR system?

Answer: The one on the right is from a wireless DR system. 

Decision Time

Yes! You can own a wireless DR system and you won’t be finding yourself broke and living under a bridge! Be fearless and embrace this wonderful technology. I always say that veterinarians can get a nice bunch of “new friends” any time they begin wondering the trade shows and asking dealers about equipment. Please understand that not all equipment sales reps are used car salesmen…even though many act like it. Understand that the vast majority of these sales people know very little about the technical application of what they are selling. They are all highly trained to do one thing…getting you to sign their proposal. Please know that you do not have make your decision alone. I have many years of experience in buying, selling, and using imaging technology in veterinary hospitals. Contact me when you are ready and I will be your wingman. Please leave a comment and visit our website at www.vitalrads.com. I appreciate the fact that you took precious time from your day to read this blog.

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What’s Next?

In March, I will showcase computed tomography (CT) in the general vet practice. Heads up! CT units are being carpet bombed into general veterinary hospitals all over the USA. I will outline the technology and teach you what to look out for from vendors. Stay tuned.

-RW

Spes et fides sans peur! 

 

 

 

Understaffed? Keep Going.

Keep playing Whitaker! There is no one available to be your backup! I don’t care how much it hurts, we are counting on each of you to stay in the game and give it all you have. Full speed. No time to look back and consider the previous play. We won some and lost some but we always kept playing the game the best we knew how.

They called us the dirty dozen. There were only 12 of us on my 8th grade football team. In the sparsely populated Texas Panhandle, we often traveled over 2 hours [one way] to play a game. Each of us played offense, defense, and special teams. Most teams we played were bigger, faster and had greater numbers. Only one player stayed on the sideline. It was usually the guy who had the most severe injury from the last game.

I was taught early in life that you cannot just take a break. You cannot even slow down. Does it feel like this in your work life somedays? I can recall several instances in my working career that my team was understaffed. I was being prepared for this in 8th grade and I appreciate that experience.

There is no replacement for you. Keep going. There is no one here to lighten your workload. Keep going. If you quit, you lose. Full speed. Keep going and know that someday, this season will be over.

-RW

The Black 40

According to a Google search, the average lifespan in the USA is presently calculated at 78 years. Today, I turned 40 years old so that means I am already beyond halfway through my expected life according to Google. When I was 18 and graduating from high school, I pictured my life to be a certain way when I turned 40. My expectations were met and I can honestly say that life has been good. I took an inventory of my life and this is what I came up with.

I pictured that I would be married to a woman that I love very much and she loved me back. CHECK!

I pictured that I would be the dad of some really awesome kids. Yep! CHECK!

I did not picture that I would be living in South Texas. I thought I would still be farming and ranching  in the Texas Panhandle instead of working in the veterinary medical industry.

I do hope that there is still some time to catch up with that farming and ranching aspiration. To somehow make that happen would be an awesome accomplishment over the next 40 years. Well, the ranching and farming part anyway. I am not so sure I would leave the paradise that exists down here below the 30th parallel. We have two seasons, hot and no so hot.

Here are some things that I consider a bonus that I never thought would happen to me:

I have built a fun and rewarding career in veterinary medicine that has provided well for my family for a few years now. BONUS!

I have traveled all over North America, Europe, Hawaii, and the Caribbean for recreational purposes. BONUS!

 I was able to enjoy learning and playing the sport of all sports in the Texas Rugby Union with an awesome group of mates at the San Antonio Rugby Football Club. BONUS!

 I was able to forge strong friendships with a few awesome people. BONUS!

 All of this I count, as blessings. I thank God for carrying my family and me through the good and bad. My first forty years have been one heck of a ride and I am excited about the next forty. Thank you to all of my friends and family who are always there for me and always support me…even when I am being a horse’s ass.

-RW