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  • Imaging in the ER: From Terrorist Incidents to Daily Traumas, Emergency Radiology Plays Vital Role

    The Manchester bombing is one example of the growing need for emergency radiology across the globe. By Richard Dargan

    November 1, 2017

    Shortly after 10:30 p.m. on Monday, May 22, 2017, a suicide bomber detonated an improvised explosive device outside Manchester Arena in the city of Manchester, England, as fans were leaving a concert by American pop star Ariana Grande. Scores were injured, many of them children or teenagers.

    Pediatric radiologist Rui Santos, MD, of Royal Manchester Children’s Hospital, got the call to come in just as he was getting ready for bed. He hurried to the hospital and, as is his habit, visited the resuscitation area next to the radiology department to check on the injured. The first victim he saw was a child.

    Pediatric radiologists are sometimes reluctant to order full-body CTs due to concerns about radiation dose, but after seeing the desperate condition of the victims and consulting with his colleague, Rachel Jenner, MD, Emergency Department (ED) clinical lead, Dr. Santos knew what had to be done.

    “When there are mass casualties, with patients coming through every 15 minutes, the ‘As Low as Reasonably Achievable’ dose principle has to be carefully balanced with the need for crucial and immediate information regarding life-threatening injuries,” Dr. Santos said. “Any delay in making a decision puts radiology at risk of becoming a bottleneck for patient flow. Dr. Jenner and I agreed that with the number of mass casualties expected, including unconscious victims and unknown injuries, we should proceed to obtain the best information and full-body CT would be the main form of imaging for most of the severely injured children.”

    Pediatric Radiology Team Relies on One CT Scanner

    With that, the pediatric radiology team began a long night of work based around the department’s sole CT scanner. One after another, the victims arrived with secondary blast injuries or injuries related to flying objects from the explosion. The bomber had packed the explosive device with nuts, bolts and screws, transforming the small pieces of metal into deadly projectiles that punctured flesh and lacerated organs.

    With so many shrapnel injuries, Dr. Santos and his team used a low-dose full-body scan known as a scout CT to refine their imaging approach.

    “On the scout CT, we might see shrapnel in the neck that would cause us to change the subsequent head CT to a head-and-neck CT,” he said. “Or a patient would come in for an abdominal CT, and the scout CT would show shrapnel in the chest, so we’d change the abdominal CT to an abdominal-and-chest scan.”

    Dr. Santos worked nonstop until 4 a.m., took a 20-minute nap and then continued his shift as a total of 29 victims (24 children and five adults) came through the children’s hospital ED. He finally left at 9 a.m. By then, the news was everywhere: 23 people, including the bomber, had died in the attack, and 250 were injured.

    During the night, eight children underwent full-body CT’s, six had CT’s of multiple anatomic regions and all required x-rays of multiple areas of concern for shrapnel injuries.

    “I was overwhelmed by the images going through my mind,” Dr. Santos said. “There was no anger — just sadness about what I had seen and concerns about what was going to happen with the injured.”

    New MRI Guidelines for Shrapnel Injuries

    In the following days, Dr. Santos and his colleagues worked closely to ensure that each patient received proper care. The teams, including nursing, surgery, pediatrics, anesthetic, microbiology and radiology staff, held debriefing sessions twice daily to discuss patient management and surgical needs. Psychological support for families and staff members was also offered, beginning the day after the bombing.

    The tragedy inspired Dr. Santos to develop guidelines for better record keeping of shrapnel injuries in the event that MRIs are ordered for patients anesthetic at a later date. Shrapnel retained in the body can heat up and dislodge during an MRI, creating a potentially dangerous situation.

    “There hasn’t been much published on the risks of doing MRI in patients with retained shrapnel,” Dr. Santos said. “Information about shrapnel should go in the patient’s record, just like information on allergies.”

    Emergency Radiology Central to Patient Care

    Manchester Children’s Hospital is just one example of the increasingly crucial role emergency radiology is playing in healthcare facilities around the world. Emergency radiology — the focus of the sixth annual International Day of Radiology (IDoR) on Nov. 8 (see sidebar) — is a unique discipline in which radiologists must adapt their work to the high-intensity environment of the ED.

    Along with being prepared to handle mass casualty incidents, emergency radiologists play a central role on the clinical teams facing serious incidents in the ED every day.

    “The time pressure incentivizes you to be extremely focused,” said Edward J. Zaragoza, MD, a diagnostic radiologist and chief of acute care imaging at the University of California in Los Angeles. “Emergency radiologists must walk in the shoes of emergency physicians and do the work as quickly and carefully as possible.”

    At UCLA, Dr. Zaragoza has seen emergency radiology grow from the minimally-staffed graveyard shifts of the 1990s to a critical component of healthcare. Information technology has helped drive the expansion through the development of tools to integrate different PACS and improve computerized decision-making.

    Key to the growth has been UCLA’s aggressive expansion of imaging services in the community — an expansion that has paid dividends in revenue to the hospital system and in healthcare, including emergency services, for the people of greater Los Angeles, said Dr. Zaragoza, a member of RSNA’s Public Information Advisory Network.

    Nowhere is the need for emergency services more evident than at Martin Luther King (MLK) Jr. Community Hospital in southern Los Angeles, near the city of Compton. The Los Angeles County Department of Health Services closed the hospital in 2007, leaving a void in terms of emergency services for residents.

    “A mother with an asthmatic son would have to make five bus transfers to get from Compton to Children’s Hospital in Los Angeles,” Dr. Zaragoza said. “Meanwhile, her kid is coughing the whole way and she doesn’t know if they’re going to make it in time.”

    UCLA collaborated with MLK Hospital on the facility’s reopening in 2015 and offered to provide physician services for the area’s underserved population. The partnership has been so successful that hospital officials expect to see 75,000 patients this year, up from 35,000 in 2016.

    Many of those patients are in dire health, Dr. Zaragoza said, like the 25-year-old woman who recently came to the MLK Hospital ED with abdominal bloating and pain. Upon further examination, physicians discovered that she had advanced ovarian cancer.

    “Because the hospital was open, because the ED team was there, and because that team had the backing of a radiology department committed to giving care 24/7, the patient was able to get diagnosed and get the treatment she needed,” Dr. Zaragoza said.

    These kind of opportunities make the pressure-packed job immensely satisfying, he said.

    “I never finish a shift feeling that I didn’t matter,” he said.

    International Day of Radiology (IDoR) Focuses on Emergency Radiology

    On Nov. 8, the sixth annual International Day of Radiology (IDOR) will be dedicated to emergency radiology and the essential role that radiologists play in the emergency room, increasing the quality of care and treatment of patients.

    IDoR joint sponsors — RSNA, the European Society of Radiology and the American College of Radiology — will host international activities to mark the event, together with more than 100 medical societies in 57 countries. Visit IDoR2017.com for information and social media activities.

    Visit RSNA.org/IDoR for promotional materials you can customize for your practice or organization.



    Manchester Children’s Hospital (above), was one of the hospitals where victims of the terrorist bombing were treated. Image courtesy of Manchester Children’s Hospital.

    CT Machine
    When victims in the Manchester bombing poured into Manchester Children’s Hospital, Rui Santos, MD, and his team used a low-dose full-body scan known as a scout CT to refine their imaging approach. Image courtesy of Manchester Children’s Hospital.

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