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.

shutterstock_211047973

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.

shutterstock_531887029

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.

shutterstock_327440975

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

 

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.

shutterstock_402401725

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

shutterstock_60552715

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.

shutterstock_543837406

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.

shutterstock_211047973

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