Veterinary Medical and CT: Part 3 – What is the ROI on CT?

I’d love to stick to the numbers on this one because that would be simple. But the reality is that a true look at value and ROI is more slippery than just numbers, especially when it comes to the overall value that our clients and patients receive in terms of our clinical culture.

The time and energy we spend on each relationship, client, and task are an investment in the future. We invest time and energy in relationships and tasks with goals in mind. Moving closer to those goals produces momentum that makes it easy to choose to keep investing our time and energy.

The more time & energy we invest, the more valuable those things should become. To invest in something that continually loses value is folly.

As veterinary professionals, we invest time and energy into tools & skills that produce better outcomes for our clients and patients. If our clients and patients get better outcomes, our clinics get better outcomes. If our clinics have better outcomes, we have better outcomes as veterinary professionals.

If an investment does not equally benefit both ourselves as professionals and the client-patient relationship, we fail in the long run to honor our commitment to our profession.

Most may think that a return on investment (ROI) is only about the dollars that return on an investment.  ROI is bigger than doing the math of “gains minus costs divided by costs”.

Investments are about increasing value, and ROI should explore the different kinds investments a clinic makes. This includes investment in equipment dollars, clients and patients, the people we work with, ourselves as veterinary professionals and the clinical culture we create together.

That said, this look at ROI is multifaceted and nuanced. It does take the numbers into account. It explores the client & patient side of perceived value. It takes your investment in your employees and yourself seriously as big factors in creating a positive clinical culture.

Investing in computed tomography (CT) returns in many ways on several different levels. After we get through the ROI elements, I will walk you through the specific steps you will need to take to make a CT purchase work for you, for your clinic, for your employees and for your clients & patients.

ROI #1: ELEVATED DIAGNOSTICS

OsteoSarc CBCT MPR View

Diagnostic return is the main reason we should consider purchasing a CT machine. Veterinarians can obtain more detailed information within the targeted anatomy of the animal patient when compared to typical radiographs. Cross-sectional CT images of the animal patient allow a veterinarian to evaluate the precise location and scope of an identified mass or lesion. Radiography and ultrasound are both limited in providing this high level of precision.

A veterinary hospital can raise the level of diagnostic information that can be generated on-site with an investment in CT.

ROI #2: INCREASE OF GOODWILL

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Goodwill is another form of return on an investment in CT. Goodwill has value in any business. It can be defined as perceived value. It is always considered in decisions by prospective clients, pet owners, partners, and associates. You cannot see, touch, smell, or taste goodwill. It’s more of a gut feeling generated by an overall sense of culture, customer service, and level of attentiveness that is standard practice. A familiar companion of goodwill is called trust. Trust that comes from neighbors and patrons is important in the long-term success of any business. A veterinary hospital obtains more goodwill & trust when it develops a reputation for practicing medicine at a higher level with investments in new technology and training.

ROI #3: ENHANCED CLINICAL CULTUREshutterstock_327440975

The culture in a veterinary hospital is the key to all types of returns. If a veterinary hospital does not        normally operate on the cutting edge of medicine and technology, any returns on investment cannot be maximized. A positive, upbeat culture is embodied by engaged, happy employees who have the skills, supplies and confidence to do their job well. Clients and patients leave happy. They are glad to speak highly of your clinic in the public space. The opposite is a culture where the grind is a daily frustration, requests for materials & supplies go unanswered or the lowest bidder continually wins contracts that offer sub-par supplies & equipment. Clients, patients, and employees may turn over quickly in these environments.  Without the proper culture, adding a technology like CT will fall flat and the returns will disappoint. Many general practitioner veterinarians experienced this disappointment when they purchased an ultrasound 10-15 years ago. Quality ultrasound training was not yet available, so many went unused.

The same applies for CT today. Everyone seems to want a CT. The training has not caught up to the technology on a broad scale…yet. Some of those ultrasounds became expensive door stops. A CT could have the same fate if you’re not investing in the skills of your staff to use it effectively. Investment in cutting edge medicine needs to be coupled with cutting edge training to enhance client, patient, and employee culture.

ROI #4: DOLLARS & ‘SENSE’

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This is the part you’ve all been waiting for. This section is last because the other pieces of the puzzle need to be in place as you consider making this investment. A hospital owner must be able to pay for the machine, training, operations, and maintenance while also producing profit from using the machine. Profit is healthy and fair for all business entities so as long as value is produced and received by all parties. Those who are satisfied with breaking even (or just barely exceeding the breakeven) often find themselves constantly struggling. Animal hospitals must prioritize staff training in technology tools. It pays off in all the ways outlined above in this post. The right culture plus a healthy profit will often yield growth in trustworthiness and increase the longevity of the hospital. The long-term result of this is called “creating a legacy”.

FIRST CONSIDERATION: FINANCING YOUR CT

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Choose wisely when selecting a finance plan for your equipment. Some vendors will offer their own financing plans. Sometimes, vendors are receiving a commission on the financing in addition to the profit from the equipment sale. Most of the time these vendor finance deals are leases. Leases, in my opinion, are toxic. ALWAYS read the fine print and/or have your attorney do that for you.

Simple interest loans with a fixed APR are the best option for equipment. Therefore, the cheapest financing is rarely with the vendor you are purchasing the equipment from. The best advice: Give your local banker a shot at the financing first. Another option is to consider lending entities who specialize in veterinary equipment financing. There are several experienced equipment financing entities whose representatives understand veterinarians and the veterinary business.

THE SECOND CONSIDERATION: ANALYZING THE NUMBERS

Several things factor into the purchase of CT machine. The stakes are raised on this type of purchase simply because this will be the most expensive piece of equipment a veterinarian will buy, except for an MRI.

Equipment Purchase – This should include the gantry, couch, and workstation. Sales tax and freight are also added to this number. Signing an order for this equipment is simply the beginning of all work that must be done. No other piece of equipment will require as much preparation and training as a CT will.

Training – All vendors will offer some type of training regimen with the CT or Cone Beam CT. Some vendors will offer training included with the purchase price. Others may charge an additional fee. These trainings are designed to get you started, not to help you and your staff maximize the tool. To learn more about CT training, simply send me an email / PM. I am happy to go over the particular needs that must be met by a program. (robert@vitalrads.com)

Service and Maintenance – Extended service and maintenance costs are important. Spiral CT purchases are often intimidating because of these extended service and maintenance programs. However, you will see later on that the spiral CT is very capable of paying its way in a veterinary practice. I have known some Cone Beam CT vendors who include 5 years of warranty and service with the unit at purchase. The Cone Beam is usually more simplistic in design because it is simply a DR unit on wheel. There are fewer moving parts and CBCT units turn at a significantly lower RPM than a spiral CT.

When purchasing a refurbished spiral CT, the 5 year warranty is just not offered by any vendor, to my knowledge. Spiral CT vendors can and will offer some kind of warranty at purchase. It could be 90 days or up to one year. This plan may or may not include preventive maintenance. That is why it is important to understand all aspects of the offering.

READ YOUR TERMS AND CONDITIONS ON ALL SERVICE CONTRACTS! Have your attorney read them too if that makes you feel better. Hint: CT service contracts are all written in favor of the vendor & manufacturer. Do not be surprised at that, it is the usual CYA language that all big corporations put out to keep themselves protected from litigation.

Facility Modification or New Construction? – All existing animal hospitals who wish to add a CT will be required to modify their current facility to some degree. Room size and electrical are the first factors to consider. Shielding and climate control are equally important. There are newer CT and CBCT machines that can utilize 120v power source with a dedicated circuit instead of the usual 220v – 240v. Again, read the specs of the machine and read the contract!

You also should check with your local and/or state health department on radiation shielding code regulations. If you plan on building a new addition to the current space or plan to move into a brand new building altogether; the earlier your contractor gets involved with your CT vendor, the better.

Other Costs – There are several “forgotten costs” that are often overlooked when adding a CT or CBCT. Without consideration, these costs can create shortfalls in your hospital’s operating budget and inventory.

Additional equipment may be needed: (1) Anesthesia Machine, Vaporizer, Concentrator, and Patient Monitor (2) Radiation safety accessories (gowns, gloves, collars, mobile shielding, and warning signage) (3) Foam troughs and other animal positioning aids.

Incremental Costs (per exam): These costs occur each time a CT exam is performed. (1) Radiologist Consult (2) Drugs (contrast agents, anesthesia, IV fluids) (3) Consumable Items (syringes, needles etc.) (4) Technician Labor

THIRD CONSIDERATION: Profit or Loss?

CONE BEAM CT P/L ANALYSIS

This is an example of a cash flow analysis for a Cone Beam CT. The pricing on goods and services used in this example may or may not be current (or accurate) for any given vendor or manufacturer. This is a simple learning tool for the reader.

Cost Analysis Cone Beam CT

SPIRAL CT P/L ANALYSIS

This is an example of a cash flow analysis for a Spiral CT. The pricing on goods and services used in this example may or may not be current (or accurate) for any given vendor or manufacturer. This is a simple learning tool for the reader.

Cost Analysis Spiral CT

All readers of this blog are free to discern what you will about these two analysis sheets. You should not make any decisions based on these particular cost analysis numbers because it is possible that the pricing and services from CT or CBCT vendors could be completely different than what I have shown here. Each situation is different for a particular veterinarian and his or her facility.

READ ALL CONTRACTS CAREFULLY! Use an attorney if it makes you feel better. Ask a lot of questions. These two analysis sheets are based on my own past experience as a veterinary imaging consultant, a partner in an animal hospital, and as a sales person.

FOURTH CONSIDERATION: NAVIGATING THE BUYING PROCESS

It is wise to accept bids from up to 3 different vendors. Beyond 3 vendors will be too much information to analyze and too many people will be calling and emailing you…constantly…for follow up. Too many choices will increase confusion significantly. The stakes are high in a purchase of this magnitude. Therefore, the buying process should be well-planned and made to be simple.

  1. Create YOUR OWN timeline for signing the deal and stick to it. Do not allow vendors to manipulate you into signing their deal RIGHT NOW. This is your purchase! It is the most money you will have ever spent on a single piece of equipment and you are the client. Therefore, you must be bold enough to drive the bus. Sales reps are trained in closing deals. Many are effective at closing deals and when the they control the deal, they are essentially controlling you.
  2. Meet with your CPA and any banking institutions before talking to any vendors. Know what you can be approved for and understand what your budget and tax implications will be.
  3. Schedule and complete up to 2 phone conversations with as many vendors’ reps as you please. These phone conversations will allow you to discern which 2-3 vendors to select for meetings in person. Schedule meetings at your hospital with the top 2 or 3 vendors from your phone conversations.
  4. Ask for references of veterinarians in your state or region. Call those references. Ask them a lot of questions.
  5. Make sure that all proposals from vendors can be compared as apples to apples when it comes to services and features in the equipment. Have someone help you with that if you need it. Pricing, contracts and extras can be confusing when you’re not used to looking at things this way.
  6. Always call your mentor or another 3rd party (friend, consultant, etc.) and discuss the transaction with them before signing off and committing. This outsider can assist you in being objective.

CONCLUSION

CT should enhance all the ways your animal hospital offers value to clients, patients, employees and to the bottom line. But it’s not just about the dollars. It’s really about increasing value through investment in better client / patient outcomes, a positive clinical culture, and a healthier balance sheet. However, if we stop there, we fall short. It’s about improving our standard of practice as veterinary professionals. CT can help provide that under the right circumstances.

Do your research. Be confident in your choice. Do not allow yourself to be bullied. Make an eyes-wide-open choice to invest in the value that your hospital offers to your community.

-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.

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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

 

Veterinary Medical and CT: Part 1

It is officially Spring down here in South Texas. I have seen the first bloom of our bluebonnets today on my drive to and from Houston. They are beautiful! Western Veterinary Conference will begin next week in Las Vegas. There are new CT systems on display at the WVC trade show this year and I am pumped to see them and talk with the vendors. Computed Tomography is used in virtually all veterinary specialty hospitals in North America. CT machines have made their way onto the wish lists of many general veterinary practitioners. There are a few general practitioners who already own a CT. Maybe you are one who has begun to seek information on CT. If so, you have come to the right place!

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I love veterinary technology and CT is at the top of my list. It is one of the most effective diagnostic tools in advanced veterinary imaging. I have become familiar with this modality over the last few years. Learning about CT seems easy at first but I must compare it to an iceberg. What you see on the surface is but only a small portion of what is needed for a veterinarian to make it successful. This is why I am writing a 3-part series on CT. One article cannot do this technology any justice.

This article will cover some of the basics. Part 2 will be released after WVC and will be highly detailed as I move through the different types of CT systems that are available to veterinarians. I will also outline the indications for veterinary use of the CT in more detail. Part 3 will cover the most critical nuances of CT technology such as contrast studies and the challenges that a general practice will have to meet head on when adding a technology that is advanced beyond anything purchased prior to ultrasound. Last but not least, I will share how to develop a return on investment for a CT.

The basic concept of modern computed tomography is based on x-ray technology with a spin…or shall I say…spins. Essentially, x-rays are used to acquire cross-sectional images of a specific region within a medical patient. CT machines have two halves. The couch (aka table) and the gantry (aka donut). The business end of the CT is all inside of that gantry. What makes one type of CT different from another really cannot be seen on the outside.

There are two types of CT scanners available for sale today.

SPIRAL / HELICAL CT          CONE BEAM CT (CBCT)

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The spiral CT machines are the most popular and widely used in human and veterinary medical facilities. I plan on diving into the differences between CT and CBCT in part 2.

As stated earlier, CT machines are being used in all specialty practices and vet schools but are becoming more popular with general practitioners. CT diagnostics include but are not limited to the following:

  1. Skull / Nasal / Brain
  2. C-Spine / T-Spine / Lumbar Spine
  3. Thorax / Met Checks / Masses
  4. Abdomen / Masses / GI Tract / Adrenals
  5. Hips / Pelvis / Extremities

Will CT reduce the need to use X-Ray and ultrasound?

No. It will not replace those modalities nor will it reduce your use of them. CT is often the next step in imaging diagnostics once an ultrasound and/or radiographs point to a more significant issue within the animal patient.

Clinical Scenario #1 

A two year old yellow lab presents with abdominal pain. An ultrasound is performed and the findings indicate that there is a mass in the abdomen. The size and exact location of the mass cannot be determined with accuracy. A CT will be ordered and the information it provides from the radiologist will indicate the following: 1) where the mass is 2) what it is attached to 3) exactly how large it is. From there a clinician can give the client more information about their pet and provide better options in treatment and prognosis.

Clinical Scenario #2

A 10 year old DSH feline presents for labored breathing, nasal discharge and lethargy. Radiographs of the thorax are normal. A quick view of the heart with the ultrasound reveals there is no pericardial effusion or cardiomegaly. A CT is performed on the skull of the kitty which indicates there is a mass in the nasal cavities and the mass penetrates into the bone. This is where CT provides an answer when ultrasound and x-ray could not. Could we have scoped the nasal cavities of the kitty? Certainly. However, sedation or anesthesia would have been required to do this and with a CT in the hospital, it is the easiest path to a definitive answer. Scopes are not in this case.

CT will add a new level of diagnostics to a practice. A veterinarian should not see a drop in the use of ultrasound nor will they use their x-ray system less.

Can I use CT instead of ultrasound or X-ray?

No. It is unethical, unnecessary, and expensive for our clients. CT machines are there for giving us a more complete answer when the ultrasound or the radiographs cannot give us a complete view of what is going on inside the animal. Moreover, even CT machines will have their limitations. Ultrasound is actually more suitable than CT for things like urinary tract infections and scans on other internal structures such as the heart. Furthermore, a CT scan requires anesthesia for the patient and the procedure itself will often cost two or three times as much as an ultrasound or radiographs. It is unwise to think you can replace an ultrasound or a digital x-ray with your CT. This is pure folly and certainly this should be obvious to any licensed veterinarian.

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Is there special training required for adding a CT to my practice? 

Yes. There is special training required for all doctors and technicians working in that hospital. Operating the machine is the simplest part of this training and sadly that is mostly all one will get from a vendor. If you are planning on buying a CT for your practice, training will be the most important factor in whether or not the equipment will return the investment. In the specialty hospitals and the universities, CT technicians are sent to schools for few days at a time to learn the operations and protocols associated with performing CT studies on patients. Here is the tricky part; all of these “CT schools” are taught from a human medical perspective for human patients. Shameless plug alert! Instruction Intelligence is presently developing a formalized CT training program within the Veterinary Intelligence product line specifically for veterinarians and veterinary technicians. We will have a complete team of veterinary CT technologists and veterinary radiologists who will teach our clients all that they need to know about CT procedures that should be performed in a general veterinary practice. This program will launch in the Summer or Fall of 2017.

Do general practices in veterinary medical have any business whatsoever purchasing a CT machine? 

The answer to this question depends on several factors. 1. What is the culture of your veterinary practice? If your practice normally implements the best technology in imaging, labs, surgery, and treatments; then CT may be a good option. 2. Is your veterinary practice geographically isolated from veterinary referral centers? If so, adding a CT is definitely a good investment to consider. However, there are some general veterinary practices who are not isolated geographically and they have added CT with success. 3. Does your practice have frequent turnover of technicians and DVM associates? If so, CT would not be a good investment to consider because you obviously have larger problems to address in your hospital. The success of advanced procedures in any discipline of veterinary medical greatly depends on the attrition rate of team members such as technicians and associates. If a practice spends a great deal of time and money training new team members on a regular basis, CT (among other diagnostic tools) is not forgiving.

I will release part 2 of this blog at a later date and it may not be until late March 2017. Part 1 has been aimed at the most basic questions that I get asked when speaking with veterinarians who are looking into buying a CT. Please feel free to leave any questions in the comments and I will answer them as I have time to do so. Thank you for your valuable time and attention.

-RW

 

 

 

Check yourself before your wreck yourself! A common-sense approach to data security in your veterinary hospital.

It is a day like any other in your veterinary practice. Clumsy puppies and hissy kitties are coming in for their vaccinations. Your associate is working hard in surgery. You can hear the chatter from the front desk team as they are taking calls and answering questions from clients as you are moving from exam room to exam room. Then there are some of the worst words spoken that can be heard in a veterinary hospital: “Um doctor, something is wrong with our computers…all of them.”

Interrogations ensue and not one person ever really knows “who done it” or “how it happened”. All that you know is that your team can no longer access your software or your most important files to help you serve your patients and clients. All of the PDF docs, Word docs, and photos have been locked down and encrypted. When you try to open any of them a message reads that you must pay $10,000.00 in bitcoin to get your files back and then it gives you payment instructions. What a great day! These types of viruses are called RANSOMWARE and they are a plague upon veterinary hospitals all over Texas and North America.

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Most of the time this invasion is done with subtlety through an email. The email appears to be from either a co-worker or someone who is likely to email the hospital. The subject line may read: “Please help me open this” or “Please look at this” or some other subtle but firm command to help with opening or looking at something. The unsuspecting user opens the attachment. It is an executable file (these end in .exe) and now every computer in your entire network is infected and every file is encrypted. You have a choice. Pay the ransom and hope they are kind enough to remove the encryptions…or…you tear down your entire network and start over. Oh and there is a third choice, all of your data was backed up and secure…your IT consultant shows up and has your hospital back up and running within a few hours. That last one represents the vast minority of practices who are hit by these techno bandits.

This is a nightmare that I have witnessed several animal hospitals suffer through over the last few months. I am writing this to save all who read it a great deal of heartache, downtime, and money. This is America and you are free to ignore my advice, but I suggest you do what I am about to tell you if you haven’t done so already.

STOP! Do not open email attachments without VERIFICATION

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Read the subject line. If the subject is not a common subject line that you see regularly, STOP. Do not open the email. Contact the person who is sending it in person (if possible). Delete it otherwise. I know many veterinary hospitals have a publicized email address for clients and vendors, this brings me to the next order of protection.

Overhaul and Change your email system…immediately.

Stop using any email addresses with your clinic’s domain name. Yeah I know you paid for it but your email addresses are not private if you did not select the privacy option when establishing your website and email hosting. Remove all email addresses from your web pages. These butthole hackers can also find your email addresses on your website and mimic it. So please, remove email addresses from your website pages. Now, you need to create two brand new email addresses. I suggest you only use Gmail because they have great filters.

  • Create an email address for client communication only. Give this out in your ON HOLD message, give it out on your business cards. DO NOT PUT IT OUT ON YOUR WEBSITE. Your website should be equipped with a “contact us form” that is filled out by the client and then it automatically emails to your client communication email address.
  • Create an email address for vendor communications only. Give this out to your lab services, your pharma suppliers, and other vendors you purchase services and products from.
  • Forbid the staff from utilizing any personal email and all social media other than these two email addresses on your hospital’s network.
  • Designate only 2 or 3 people on your team to handle emails and the practice social media pages.

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Backup Your Data

Veterinary hospitals are data heavy businesses and this is why they are targeted more often than other businesses by ransomware pirates. There are patient medical records, inventory records, accounting records, HR records, and diagnostic imaging records. Often, these software systems that operate these records exist on the same network and server. There are some hospitals who do a great job of backing EVERYTHING up. There are others who only backup the patient medical records but they do not backup anything else…these are the ones who suffer the most in these virus attacks.

These are applications you should use to backup your data:

For all PDF docs, Word Docs, Excel Docs, and Photos

Dropbox – my favorite

Carbonite

Google Drive – my least favorite

For all Diagnostic Imaging Records (.DCM .TIF .JPG .PNG)

All of your images for x-ray, ultrasound, CT and MRI should be archived offsite. These are critical medical records for your patients that you are required to keep by law. Dropbox and carbonite are not a wise option for diagnostic images because they do not allow you to retrieve and review them easily. The most effective backup of your medical images is with a DICOM PACS (picture archival communication system). The old school PACS were a server that was setup in your hospital and they would cost anywhere from $50k to $100k. The new PACS are now cloud based and they much more affordable. Usually these services are based on a flat monthly fee or a per exam stored fee.

My Favorite PACS:

VitalPACS.com (by VitalRads.com) yes…shameless plug for me.

AccuVue (by Radmedix.com)

Keystone (by Asteris.com)

For Patient Medical Records

There are many Veterinary Patient Management systems, each will have their own way to backup your records. Some older versions of systems like Avimark or Cornerstone will ask you to backup to a server tape or to a separate hard drive that you must execute and take home each night. The modern cloud based records systems connect you to a cloud server where your records are always protected and backed up two and three times. My favorite way to backup our patient records is via the cloud. It is automatic and yes it costs less, much less. None of us are responsible for backing up the system and taking a hard drive home each evening. The system backs up on its own and we have peace of mind.

My Favorite Cloud Based Patient Records:

www.ezyvet.com

www.evetpractice.com

www.vettersoftware.com

Accounting and HR Records

I believe that accounting and HR can be as complicated as patient management systems. They come in all shapes and sizes. I really like Quickbooks online for accounting. As far as HR is concerned, you can now hire a freelance HR consultant to help you with OSHA, State, and Federal employment compliance. Most of these folks will ask you to use their forms which are usually stored in Excel, PDF, and Word. These should be backed up on your Dropbox, Carbonite or Google Drive.

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Hire a professional IT consultant  – aka propeller head or computer nerd

If there is anything that you need to do, other than everything else I have written about…it is this. Please hire an IT Professional and keep him or her on retainer with your practice. Do not hire your technician’s husband or your associate’s cousin. Hire a real IT professional who has experience in working with law offices, health care clinics and other professional offices which are data heavy. A good IT consultant is often a quirky person and will demand that you do everything a certain way. Follow their instructions without argument, it could save your practice someday.

So, there you have it! You now know what it takes to protect yourself at a basic level from these a-hole ransomware invaders. There are some victims of this crime that have paid the ransom and luckily they got their data released back to them. There are others who paid and then nothing happened. They were double screwed. Do not take any chances with this serious threat. Act now to protect your hospital and your clients.

-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!