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um, for leaks. I don't want the exact way of doing things there is, but there will be a lot of generic stuff, which I'm sure will apply there a swell. All right. Uh, I think we'll make a start now, if that's okay. Okay. So, um, first of all, well done for organizing and thank you to people who have attended eso. The purpose of today is because you guys are new to, um, dealing with radiology. I wanted to let you guys know, um, what we're expecting from the clinical details that we get from your scan requests and what we'd like included in your, um, scan requests on then, you know, hopefully you'll be able to translate that into your practice so that you have a better relationship with your local radiologist. Okay, so this is the kind of stuff that we're going to be talking about, so I just, um, try to talk about the structure off radiology, new HDL. What you need to do in order to be, you know, have ah, decent relationship with the radiologist. And then we'll also talk about, um, some of the most common indications for imaging in various body systems. Um, so starting with head and then ending up with vascular stuff, which you're not not many people would have experienced, but it's just just good to know that as well. Okay, So how radiology works in us? Tell, you might have heard this word. Huh? Uh, going around whenever you called us. So the inpatient hub is basically there is one hot coordinator who is not a radiologist. They're an admin person. Usually a radio prefer by background. There'll be one senior registrar. Sometimes there's one journey registers, and they're a bunch of consultants. So what happens in the hump is whenever you guys call us about in patients, we take those calls. You firstly, talk to Uh huh. Coordinator the huh coordinator there. Purpose, basically, is to direct calls that are appropriate to us in the past. Maybe when I started 34 years ago, you didn't actually need this hump coordinated person, But, um, with radiology, what I'm sure you guys can appreciate is every year there's about a certain percentage increase in the number of scans that I requested. So at some point, we just we were doing nothing else but taking calls. So this heart coordinator roll became important on Ben. The stance I requested. We get them. We protocol them. Um, and if we get the chance, we report them on by we I mean registrars. And most of the reporting during 95 is done by consultants. So just to give you an idea at any given moment in your gel there will be 50 to 80 patients who are who have been accepted for having the scan, but they will not have a slow. So at any given time, they'll be that many number of patients waiting. Um, hopefully that kind of makes you realize that if they're 80 patients waiting when you call us and then say, Oh, can you prioritize the scan for X? Y Z said, um, it's not possible to prioritize everyone and specifically those on surgical jobs. Don't you know you're such with teams are usually quite keen for the scans to happen before the a tickle of war ground. Um, but again, you know, there are a number of patients waiting, and just because you want to impress your consultant, it's not a valid reason to prioritize the scan. Okay, Um, and in the uhl the hub is not for plain films, older sounds or any I Our stuff. The plain film reporting there is a pink been putting number, which is on the induction up. So I'm sure you know about the induction up on. You can see the phone number there. Ultrasounds. Same. We don't deal with that on intervention. Radiology as well, depending on which hospital you're up. Uh, all I requested dealt by the eye, our coordinator. So the hope is not for that. And if you do call the inpatient hub person for this, the heart coordinator will usually direct you elsewhere. Um, so this is how many registers airway working? You know, I'm not gonna talk a lot about this. What I want you to just focus on is just between one am to nine AM on a weekday, and we can't evenings or nights. There's only one registrar eso you have to call us if you want an inpatient scan overnight. Don't just requested and leave it and think that it will magically happen, particularly if you're at the general on Glen Field. Because there are no radio goobers on shift during those hours after nine PM, usually there's no radiographers. Um, and if you do want to scan it, something important happens. Then we have to call the radio cover in, wake them up in the middle of night, given to come in and then do the scan. Okay, so, um, you have to give us a ring if there's something very argent. All right. So, um, the main reason I guess you guys are here is to get your scans accepted, and there's no secret word or password that you tell us that will get your scan. Except it's just common sense. Um, so the main thing we want is a good history on day long Doesn't necessarily mean good. Well, I've already kind of given an idea about how things how busy things are at the hub, so we don't necessarily want a huge history, But so some things are important. So, for example, if you're thinking about stroke keys, tell us which side the symptoms are. Writer left. If there is any relevant history, particularly if there's any surgical history of just two or three days ago, we had a scan request for a query and ask Timoptic leak on. But the patient didn't even have an anastomosis Nintendo, You know, it was post right hemicolectomy, but they had an idea ostomy with the remaining colon not attached to anything, so they couldn't Couldn't possibly have had a nasty Martinique's. And this kind of important history is quite valuable to a stronger than the spending five minutes trying to find where on earth this anastomosis is is if you just tell us that there is on that stenosis, it's just saves everyone's time. Um, in terms of the previous a shins, particularly if you're in different specialties, then different every relations obviously can be in different things. Um, so just random examples. If you're in ophthalmology, I guess CCF could mean corrupted cabinets fistula. But generally, CCF is congestive cardiac Really? Rights of these kind of review vacations, um, can be quite difficult sometimes, particularly for consultants who have not necessarily trained in the UK. Some of the creations don't need anything to them. Um, so just be careful with what you're writing. Um, good results. So if the blood results help, um, the history, it's very useful for us. So anyone with acute abdomen, the amount of times we read guarding on rebound tenderness on the history. And, you know, there's nothing on the CT. We basically don't believe your examination findings. I'm sorry to say so. If you then say that there is guarding in tendinous. And pardon the captain of the Sierra Pee of 300 We are far more likely to believe you rather than, um, you know, if you just write, it raises 100 markets, and we do go and check the blood on the CRP is 12, which is technically raised, I suppose. Um, yeah. And then, you know, we're far less likely to prioritize that scan. So if if the white cells is 16, if you know there is a hemoglobin drop, just put that in rather than just writing it. Basically, just make it very objective. And then we We can definitely understand that this is an urgent scan and we need to prioritize this and you don't even need to call us when you do that, you know, we'll pick that up. Something is very sounds very urgent. Differential, diagnosis, air, very helpful. Sometimes we get a long history, but no differentials. It's helpful in terms of reporting, but also it's helpful in terms of protocol in the scan. So because different things, um, different contrasts phases are used for different things. A common example is if someone comes with Abdul ain't If you're thinking Roger Triple A, we have to do an arterial face can. But most of the abdomen is generally done in a portal venous base can on. I'll talk a little bit more about the contrast phases as well. And then when you do call us, it's obviously useful. If you know the patients, one of the common fungals there we get which waste everyone's time is. Oh, I'm just calling about the scan, which was 100 over to me to discuss with you. And then we start asking questions and it turns out you haven't seen the patient or read the notes on it. Just waste everyone's time. So no, the patient before you're in radiology on. You know, if you do these kind of common sense things, it's just being a good doctor. I suppose knowing your patient, giving the relevant details, documenting things correctly on it becomes are easier for us to do. You were with the virus is all, um so what not to do? Obviously, don't be in polite sometimes see when you become seniors. I guess when you are like registers and I'm guessing everyone's foundation year, but when you become registrars, you will commonly have to deal with ST One radiologist, um, who are not as experienced on you may not know a lot of things about protocol doing so sometimes dealing with them can be a little bit frustrating on we understand that. But obviously they need to learn is about justice at your stage. You're learning, so try not to be in polite. Um, another thing that that doesn't quite sit right is when when you, um, do you tell us about contrast stuff so we will get clinical history. Saying we would like a triple face can or something like that on usually doesn't make any sense because what was happening is the consultants told the 12 or two whatever to ask for a double days or a triple face scan on. Obviously, the one F two hasn't understood them properly or something lost in transition on it usually doesn't sound right, so if if they need any double face triple pace scans, we will do it ourselves. Onda. That's the important one of the reasons why you should include the differential diagnosis as well. Depending on what the differentials are, we do different bases of scan. So, for example, bowel ischemia. If the clinical suspicion about seen is high, then it's a three day scan or aortic dissection. We do it, noncontrast can burst, and then we do a contrast can later. You guys don't need to tell us about give this form of contrast stickers. To put it bluntly, we know more about contrast than you guys do. And of course, you know if if there is a reason and you understand it very clearly what you're doing, then that's fine. We only get annoyed to get it wrong, right? If you get it right, then that's fine. Um Thea other thing is to chase it stand report So again, in your gel thinks things get busy and people calling radiology to chase a scan, which is not clinically urgent on. All that does is it disrupts us and makes your scan reports even more late. Unless, of course, you know you, you open the scan yourself and there's a massive bleed and you want anergic report, then Yes, by all means, call us if the patient is very unwell. Do you need in our gyn report by all means Call us putting three out for inpatients. The turnover time is actually four hours. Right? So in those four hours obviously not going to change. So if your patients very unwell, then give us a ring and say that this patient is very your Enbrel. Can you prioritize this report and definitely will do it? But it's not. But don't call us to, you know, say that Can you do this report early because of the patient wants to go home or the patient can go home. If the scan is normal, that means that it's not clinically urgent. So we can't you know, we can't reasonably prioritize our report on top of someone else who's happy, Believe is having a stroke or whatever. Right. Um, another thing we get commonly especially at night when there's no heart coordinator to at the scans, is asking us when the scans going to happen. We have no idea. Really? Really. Ologist does not know when a scan is going to happen. The radiographers for the CT department know they start with the portrait up and things like that. So again, that's nothing to do with Radiologist. Um, and it's similar vein you know, calling but no known arginine that is calling about paying bills before you check with your own seniors. Um, those are things that someone else conducive and that does not need destruction to the radiologist, right? Um, one thing is, though, see if you if you're on FNF to, you know, confident the chest X ray on your seniors are busy. Which can happen Coke and you need advice on plain films. That's fine. That's actually fine. If you just call them explain. My seniors are in a theater or dealing with sick patient. They're not able to help. Then, obviously, we're not like, you know, stupid. We will obviously understand that kind of stuff because we have in once and after you see messages before. So then, in that case, that's fine. But when the chances they're obviously check with your own team before that. So we talked about it scans before the side you go walk around, Uh, so in us teleradiology we have, you know, certain things that don't go very well, and I guess that's the same for any department. One of the things that's impatient scanning, Uh, so he usually gets priority because the last emergency department is one of the busiest. So in the country. Um, so lots of people serving scan. And you know, we're generally trying to prioritize in patients. Um, X rays as well limited porters limited radiographers. There's a long waiting time. My wife is a medical register, and, you know, I have to hear a lot of it when her patients are waiting for two days for their hip X ray and then turns out they have, ah, neck being a fracture. Unfortunately, about sometimes sometimes happens. Um, but yeah, if you think something is urgent, just keep phoning. All right, um, especially for infections, Poor drinking, Like I've already said, It's It's very difficult. Porters are busy as well. They're they're short stuff, too. So, um, if your patient is sick and you have the ability to bring them down yourself, that is, that is actually a nice little trick. If you call CT and then say, Can we bring that we can be in this patient down ourselves? Can you can you get the men. They're more likely to say yes, rather than if you wait for porters. Okay. So, um, and one of the other reasons why the delays happen is because there is a huge, huge shortage of radiologists in the whole of UK. So in England, only we have. We're 35% short for the stimulants. That number goes up to 44%. Onda in East Midland's in 2018. I think the status from 13 million waas spent on outsourcing, uh, or insulting. Which means that people are reporting these outside of their normal working hours. Obviously, 30 million is a lot of money. It's worth one. Christiana Ronaldo. Okay. Um all right. So what will now do is we're going to talk about different parts of the body and see what the common modalities, uh, to image. This is okay, so we'll start with, See, he had So, um, don't have to, you know, write anything, but just have to think about what the first investigation is in, um, in these patients groups. So an 80 year old person who has a full 20 year old person with the same someone with what sounds like a stroke someone with what sounds like a key eye. A on someone who seems to have had a stroke but has a normal CT head. Okay, so CDL is obviously the most common CT we do. And there is. You know, nowadays you don't need a rhyme or a reason to have a CT, and literally everyone gets a CT. Had we hardly ever reject the CT head unless there very young or, um, if they're, if it's if it's being requested by mistake, that's that's the only way that we actually reject CD. It's these days. It's become first line. Obviously, it's first line patrolman stroke, but it it's kind of become a part of confusion Screen now, even before the Bloods come back on, anyone is confused. Gets a CK had these days, and that's not necessarily right. Obviously, you know, for confusion. There are lots of reasons why pretty pretty elderly patients can be confused when they're in hospital. But the reason why a CT head is done so much is it's a quick test, a relatively low radiation, particularly, you know, once that officer in aged, then you don't really think that much about radiation, and it's a very good test to rule out lots of things. Um, so I guess, uh, you know, people are trying to be safe, I suppose. And CT head is dime. Um, quite frequently on. Generally see, the hands are non contrast. So if you're ever in sure about contrast Like I said again, you know, you don't need to write about contrast stuff on, not worry. So that was the thing for me particularly. And when I was at one on, I started off with a surgical job like I needed to tell the radiologist about contrast. 1000. It's like I used to make. But Ashby, you don't just order whatever you want. I'll write clearly work. Um, the clinical indication is what your differential diagnosis is And believe the protocol into us. Um, yeah, so the and nowadays we do a mechanical from back to me for stroke patients is well, so. But then we do a CT angiogram. Um, MRI's are usually done to confirm ah, stroke that was seen on CT or if there is a diagnostic doubt for T i Z. At least before cove it. It used to be that we didn't do a CT head Onda. Um, the reason for that is by definition, you know, there is no, in fact, in a TIA it's it's it's kind of a transient thing. Um, and you you don't necessarily get any abnormalities that you see on CT 48. So therefore, we didn't We didn't used to do it and then could happen, and access to MRI became even more limited. So then people started doing CTS, and I don't know what what the right thing to do now is I was working in Darby, um, until the last change over. And they were still doing CVS for their T i Z because somehow after stand where I was still difficult, I suppose they had a lot of backlog to clear through and day in one, Um, miss anything acute? So just going back to the previous slice of will not talk through one of these investigations and what to do? So eight year old with a fall? The correct answer is it depends on the nice guidelines, right? So nice that lines with head trauma. There is clear guidelines about who needs scanning and how quickly they need scanning. Um, in truth, anyone with a full kind of now has a CD yet anyway, on D, I think, um, what I needed to emphasize to you guys is just don't be a robot and press the button. Do your clinical evaluation afternoon, If you confident that you know there is no drop in GCS. The patient doesn't have any risk factors. They're not 90 coagulation. They're fully alert. Then have the confidence to say that. You know, according to nice guidelines, this patient does not need a CT head, and that would be very helpful on the same thing it goes. The same thing goes for 20 years old. Patients. Well, so being over the age of 65 years and risk, but as long as they will fill the nice guidelines were very happy to do the CT head. Um, and sometimes, if you're worried, even if you're not like a set out here, we rarely ever rejects. It gets into a gel, um, 50 year old with the right sided weakness and slurred speech. The current answer for this is a CT head. So speaking, it is the first line for stroke. Um, the point of the city had a stroke. Is not to diagnose the stroke. It's to rule out hemorrhage. If hemorrhages rule out, then the patient can have their aspirin or they can have their, um, term on from formalizes. Or they can have their mechanical from back to me scam. But if there is hemorrhage than the obviously, there's no thrombus. It's a hemorrhagic stroke, so they don't get their aspirin or the anticoagulation. So that's the main reason why we do it on 40 Eiseley. Like I was saying, the first thing we generally generally offer is, um and I'm all right. What would use to happen was you do the AB CD to score, and then, based on that, you calculate their how likely they're t a wasp to lead to a stroke. And then, depending on that, you do the MRI scan. But just check your local guidelines for a lab. Um, if someone with suspected stroke has a normal CT head, then you go into doing MRI's. The CT is actually not that very not that much sensitive for diet using small strokes so you can have obviously different scales. Serve a huge sugar, a small stroke on when it's small. It can be quite difficult to actually say with confidence that there has been a stroke on a CT. All right, so we'll now move on to another part of the body, which is the the Thorax. So I'm a cardiothoracic trainee, so cut out the rest of radiology training. So, um, this is right mustering. Okay, So 40 year old with shortness of breath, fever and cough. 40 year old with a past history of cancer, Shortness of breath, pleuritic chest pain. Um, any year old patient with any respiratory symptoms. So, basically, for chest, chest X ray is a very good test. Okay, so that should be the first line for everything. So, you know, suspected pneumonia. Suspected pieces of suspected pneumothorax. All of these things generally require AIDS. Chest X ray first with P. Um, So you have two different schools of thoughts that personally for me, I'm very happy to your CTP a without a chest X ray before. If the history is very convincing, so patient has risk factors you've done D dimer is they're elevated on, but, um, you know, they're requiring oxygen, Sinus tachycardia. They take a lot of boxes. Um, I'm very happy to do it CTP without a chest X ray. But in certain places, it's Department of Policy to do a chest X ray before you do, Um, a CPA, uh, and you can argue both both sides of the argument just X rayed your rules out. The reason for that is you're looking to rule out you're looking to rule out the differentials, right? So if there is a big pneumonia or pneumothorax, then obviously faster diagnosis, they don't need a CPA. But sometimes they can be confounded. An area can look like consolidation, but actually it's ah long involved, and we've been caught out by that before. We have said chest X, it clearly shows consolidation. Why do you want to see GPA? And then in the end, we going to do a CT pa. And actually, those areas have been longing parks. So if the history is good, if your clinical judgment is good, then usually people don't have a problem. So if in doubt, get a senior review and, um, we can we can definitely do a CT pa before chest X ray, Um, particularly if I'm on call, so I don't think there's a clear guideline for this just just use a clinical acumen, right? I'm just going to talk about a chart of CTS because this is against something which people kind of put the capsule. Okay, on and go. Please do. HR ct age. Our CT is and old thing, right? So in the past, the CT scanners, we're not fast enough, so they have to go sliced by slice on day to get a high resolution slice took too long. So what they would do is they would scan at point a and then move 10 millimeters down and then scan at another point. Then they were 10 millimeters down as scan in another point, so it would be a noncontiguous ct. Um, and what they were doing was they were they were sacrificing, scanning the whole chest for good quality images for at one particular level. And that would help you understand that that would help. You see, you know, some sections of the lung, but interrupted sections on you see that in good quality. Now, the CT scan is a fast okay, so we can afford to scan all of the chest with good quality and literally all the chest CT's. We do are higher and higher. Resolution CT. So you don't have to ask for hatred Cities again. So it goes back to the same thing If you put your differential diagnosis on history, fine. We can particular it, however, best answers your clinical question. All right, So don't get wound up about his car. Seat is is also if you go on to do your special jobs and then your consultant ask you Yeah, order. Hate our city. And by then, we don't use the word order to regular. Just It's always a request in order. Um, so, yeah, if you're consultant, ask is you ask for a, uh, a CT. Just just ask the normal CT on. Do we'll deal with it? Okay. Right. So see GPA on CT autographs. These are the contrast in hand. Cities we can do normal contrast. Enhanced CT chest a swell. I won't go into that much detail. I'll just keep it fairly simple. So, generally speaking, see, keep pa. We have the contrast in the pulmonary arteries CT or 2 g. We have Congress in the aorta on. So sometimes we do get these and you know that's completely justified. Someone who comes in with chest pain and the differences could be why it's it can be a P. But it could also be a dissection, right? So again, we have to prioritize one over the other. So there are There are certain things called these triple rule out scans, which is eventually will have dissection pee and then Emory. But they're not widely used. Um, Andi not generally well validated. Um, so we don't we don't tend to use it. Certainly in uhl you don't have it, so we either have it as a P or we have it as a dissection on. So then we will ask you to kind of prioritize what you think is right or what you think is the most likely, and then we'll do one with the other. So for rupture Triple A's as well, um, generally, what tends to happen is because these patients come with the pain we do a noncontrast can and we just check whether or not there is a ruptured cripple a which you can kind of tell on a non contrast as well. And then if they're they're looks like they're does if it does look like there is Iraq Tripoli, we'll do the angiogram. But if there's no rupture triple, they will do a portal, venous abdomen, which is your book standard CT abdomen with contrast, and the reason for that is they have abdomen pain, and you know we might as well do the scan to find the alternative causes. So that's the reason behind it. Okay, so moving on slightly lower down into the abdomen. So just have a thing. Cough on these in these clinical situations. So we have a 50 year old with the right upper quadrant pain and during jealousies, sounds a bit cold. Bladder E um age. A role with left eye loss of pain and raising planting markers. Sounds diverticular. Disease related? Um, yeah. Most likely 60 year old with Abdul Pain after right Hemi and 50 year old with after pain raised Emily's during Jefty. Sounds a bit like paper. Titus. 70 year old nausea and vomiting. Four days bowels, not five days. So this is a bowel obstruction. Yeah. So what is the most appropriate radios the investigation for this? Um all right, let's just discuss the cases. So 50 year old with the right upper corner being deranged so usually things that are to do with the goal but our best seen on ultrasound. And the reason for that is, um, when you have goal goal, bladder, stones. Um, you can only see it on CT if they're calcified. If they're not calcified, we can actually see it. And we can kind of make a diagnosis. Of course, it's like this, But the most sensitive thing we have to diagnose call this ascites is ultrasound. So the first line should be in order sound rather than having a CT. Okay, so that, uh, older son was the percents of that. That's our friends. The crackdown sort of the last one. Second one, it's CT. CT abdomen is generally the first line for anything. Abdomen, unlike in the chest, when you know we always ask me to do a chest X ray first. Um, abdominal X ray now has very little you. So I'll talk about have done X rays in a second. So CT is generally the first line for anything Abdominal. Elated, Um, And like I said earlier, if if the blood's are terrible, just put the CRP on, put the white cells down, and that makes you it makes the scan sound bit more urgent, brother, than you know, someone just saying parenting too, Captain in. But because we everybody writes park in the Cabinet to get that gets that stand done on 80 year old patient with Abdul Pain worsening less after right Hemi Sounds like in mathematically, if they've had in estimates is, uh and that that will be investigated with a CT. Um, Andi, 50 year old with central abdomen, abdominal pain, raised amylase and during your left is that sounds that pancreatitis. So we don't actually scanned pancreatitis in thier really face. So because the reason for that is if the amylase is raised on, you know I can give you have pancreatitis that the diagnosis is made. There is no need for a CT to confirm that. Just a boost. The clinician's ego. Uh oh. You thought it was pancreatitis, I guess, where it was pancreatitis. You know, there's no point in doing see that the role of the city bank type. This comes 10 days later, Um, or 15 days later, when they're not improving or even if they're improved, everyone gets followed up with a CT as an outpatient and the reason for that is it for complications? If they're not improving, maybe they have a necrotizing pancreatitis or they they have developed collections around the pancreas, and that takes time. So you know there's no point scanning than in day to collections. Have informed because it's too quick saying with pseudo aneurysm and cirrhosis is, well, they take time to develop. So you you generally wait around 10 days for this for the initial scan, um, abdominal pain. And so the last last case is off balance. Truck shin on. If the clinical suspicion for bowel obstruction is high, you go to CT abdomen. Don't don't waste your time doing half of X rays, because I do X rays. Even if you don't see obstruction after X ray, it doesn't mean they don't have the instructions. It's sensitive. Sensitivity is quite low. The specificity is fine, the sensitivities low. So this is the summary, so generally everything for acute abdomen. We tend to do a CT, give us an accurate surgical history if you know if there's no gold bladder or there's no appendix in that. Tell us, um, acute cholecystitis is the only thing we do. Ultrasounds for in the first instance. You know, obviously over some have other rules. Student. Look for other causes of urine, jealousies or whatever. But in the acute phase, that's kind of the only thing we do ultrasound for. Except we also do it for a pen dissected on. So you, if you've done a surgical job, you might have come across the appendicitis pathway, which I'll talk about in a second and then panic attacks we already talked about. Okay, so, um, after extrate, is it still relevant? Um, depends on who you ask. All school GI consultant. Still believe in it? New school people don't really believe in it because they say that sensitivity for picking up anything on Avonex Resperidone No, um, and if they had it there way, they would actually stop doing and the X rays. But I think you know, it still has its roles for lines, tubes, foreign bodies and things like that, you know, makes sense. Don't have the X ray first for monitoring patients who have I'll ius are toxic megacolon. We tend to do a nap too extreme because it still has a lower dose compared to CT. So after x ray has about one, maybe Seibert, where a CT abdomen pelvis has 10 cc. So we're talking about 10 times the radiation on. So particularly with UC patients, if you're following checking for toxic megacolon, Um, we kind of, uh, tend to follow it up with Abdul X rays on. If they do develop a toxin, that goal and then we can diagnose that an abduction. Or at that point, they can have a CT two other complications to see, for example, that they're curved or if there is a necrotic bit of bowel in there. Um, calling calculi is really good with Abdul X ray. So urology used it quite often just to make sure whether previously seen your crack calculate is still there or not, um, after extra still has a role for that. And obviously, um, if you've done a surgical job, you I'm sure you come across someone with additional small bowel obstruction by now on. And if you haven't, you will. Um, so people use Castor happen to treat that gastrograph in as it passes truly how it kind of improves the transit time and opens up the abdomen and the bowel obstruction tense up and suddenly leaving itself. The only benefit it has is in additional small bowel obstruction. So you can use it in someone who let's say, has POSTOP. I'll yes, on. But it doesn't actually accelerate any recovery for POSTOP patients. So in addition to small bowel obstruction, it hasn't stroke. Okay, so I was talking about ultrasound earlier. So in Uhl, we haven't appendix passed away. What that is is anyone with suspected appendicitis? Initially, they have an ultrasound if they present between 95 Uh, or if this is a pediatric patient, we do know some first on. But we are. I wouldn't say we're particularly hot at diagnosing acute appendicitis on whole percent because it really depends on who's doing it. Um, but sometimes if you know, if the person is good at what they're doing, then then they will. No. Used to be able to see an appendicitis quite clearly. Um, and sometimes it's hard because, you know, it's retrosigmoid and cecum. It's full of gas. So therefore we can actually get the ultrasound to the appendix, so sometimes it's difficult. But if it's good going appendicitis, usually you can time use it on hold for sound. Um, if we don't see it on ultrasound and again, you don't need to do anything. We will automatically on a CT and the ultrasound repressed. Then if we can't see the pen, decide appendix or can't find his appendicitis, um, we will change it to a CT, and then the CT just happens straight from the departments of the patient. Doesn't even actually go back to the ward. Trade from the ultrasound will go to the CT, and that's the appendicitis pathway. But being the fantasize pathway that you actually do have to have some derangement off exam tree markers. So someone with a normal white cell and CRP can't go on depending stuff away because they've looked at the usual data and they found that, um, having a normal CRP actually has a very good negative predictive value for appendicitis. Um, colecystitis we do ultrasound, uh, achy I. This's another thing that happens quite a lot. And usually ultrasound betting is done by sonographer. Just because we don't have the time to be involved with ultrasound acting as well on they generally Well, no, I mean, doesn't apply to everyone, but some of them may be laughing clinical acumen because obviously they're not clinically clinical doctors. Um, and they accept a lot off achy I older sounds. But if you look at the look nice guideline. If if you already know what's causing the achy I they don't need ultrasound. And most of the achy eyes are prerenal. So they're elderly people, dehydrated or septic. People in there are different prerenal causes of achy I It will get better when you hydrate them. Um, but if you don't know the cause of the guy, that's when we should do you hold her sound, and the nice guideline is to perform in within 24 hours. If you don't know what's causing the, uh, the only, um, don't the, um, caveat is for someone who has an obstructed me and infected kidney because they will actually lose that kidney if we don't relieve the obstruction. So if someone on do you suspect has a really calculate, um, and there is a pilot, in fact, it's on top of it, causing a pyelonephritis, which is possibly kidney. Then we need to do an ultrasound within six hours. So if they have a key, I doing pain on their septic and you know, then that kind of sounds like an infected kidney, but they could also be obstructed. So therefore, we would prioritize that ultrasound on Do pick up the phone. Um, because, like he said, we jumped. We don't generally tend to look at ultrasound request. It's left with the sonography. So just if something is very urgent on this disappoints to everything. Something is very urgent. Pick up the phone and call radiology Okay with lft derangement as well. Um, it's kind of become normal practice where everyone with doing gel ft's to have on ultrasound of the abdomen on. There's no clear cut guidelines for that. Sometimes you do need it. But also, you know, if someone with known alcohol liver diseases now admitted to hospital because off whatever reasons on there are these deranged. And it was still doing 200 years ago. Probably doesn't need an ultrasound, but it's a new dimension of these may be the ultrasound, but then, could that be because you started a new drug? Have they been on a new active Arctic for their UTI, or community acquired pneumonia? So those are things that commonly called markers, mild dementia and allergies, which then resolves itself when you stop them, the medication and and doing an ultrasound for that probably is just wasted. Everybody's time patients yours hours on does not best used in just resources. So just be careful on in that situation, right? So, um, cities other cities that we commonly get asked for a CT hips if a senior clinicians sees the patient on day, even if there is no fracture on plain films, Um, if someone who knows what they're doing things, that there may be a fracture again. We're quite happy to do CT off the hips without because again, patients are elderly and you know it's It's a quick scan, and it's not that hard to report either, so we don't actually mind that. I think things are generally quite good, but obviously not all fractures, particularly if they're not displaced. We may not see it on the plain film, and also, you know, we make mistakes reporting plain films as well. On what the spring things. I guess everyone makes mistakes that we make the states reporting lots of things as often might not. We might have missed the fracture on a plane doing this well, So if if someone is clinically behaving as a fraction of a femur the last CT CDs we do all the time for all the fractures as well, like on gets going. It's actually becoming a lot more common now where anyone who has a little bit complicated, kind of fracture with multiple fragments or displacements. We were quite happy to do CT for orthopedic plan. Um, literally, um, angiograms. Um, so this will definitely require a senior review, because this everyone hates reporting ct angiograms because they take a lot of time to report cause you're looking at, uh, very long arteries which might have very short plaques in them. So we have to look at it very in great detail. Um, so it takes it's very time consuming S O. You know, that doesn't mean that we won't do it because it's time consuming if the patient needs to be needed. But we would probably ask you for a senior of you. Whoa, when you're requesting these. Okay, um, another thing that, um mainly the radio offers give the clinician's a lot of heat on is contrast. Nephropathy. So actually, there is not that much off evidence behind it. Um, but it's now so ingrained in our practice that it's very difficult to actually do anything about it. So generally, around 35 is Okay, um, in previous trust that I work that they were expecting accepting 30 years. Well, um, so look depends on where you're working, but I think most people would ex accept 30. Um, if it's being, you know, 30 35 for 34 years and based on the CT, we will probably just do it anyway. But if it's an achy I on again, there is another debate about whether he Jaafar is a good representation off. Um, achy I because Egypt four is actually meant for long term renal function is actually not good. Measure off achy I, but it's still we're still using it. Um, so I'll just talk about seizure far in the context of a car as well. If the patient has a key, I and you know they're your renal function is no and is the scan is not particularly urgent. Then we can always treat the achy I wait 24 48 72 or whatever hours a week for the renal function to improve and then do the CT, particularly malignancies. Cancer. This is quite common when elderly patient comes in on day have achy I because it doesn't take a lot for them to develop an achy I, um, and someone would insist that they have weight loss or change in bowel habit or whatever. And then they asked for a malignancy scan, UH, which is fine, except it doesn't need to happen quickly, because if they do develop, contrast nephropathy, then that would be unjustified, because we could have totally waited for that patient to improve before we gave them contrast. Burden on. One thing to remember is when you have patients on your ward who have poor renal function and have had contrast, it takes about 48 hours. Core it to manifest. So the most dangerous stay for them to have it is on a Thursday because they will develop it on the Saturday and no one will see them on the Saturday or Sunday and then by Monday might be a bit too late. So if anyone's having a CT scan on the Thursday I was lowering function, make sure that you get your weekend team to just do their boots to make sure that they're okay. And why did you bang on about contrast the whole time? So on the left, we have a noncontrast ct. It's a slice through the liver, and on the right is the contrast CT and those leave. But you're seeing with the big yellow arrows are invisible on the non contrast scan. Um, so, you know, we we keep telling everyone, you know if you don't need contrast, and it won't be quite sensitive. So this is this is the difference between, um, someone having, um, radical treatment versus palliative treatment. So if we miss liver metastases, um, you said, for example, we pick up a colorectal cancer, But we missed liver metastases because we haven't get compressed, which can happen. It's a totally different treatment, right? So it's actually, there's no point doing a, um, noncontrast study on this. They're allergic and they can't have anything. Um, in which case we might do an MRI, but that's a different. That's a different matter. I'm I'm sure you guys why we we bang on about contrast the whole time, another kind of, um issue, but is with pregnant people. So pregnancy's of risk factor for developing pees on. Do you see it? Very commonly. Um, I think what we will. I think there is no wrong test for this. If they can have a leaky skin, they can have a leaky scan equally if they can't, it's fine to do a CT scan. Um, but with CT scan, because you're scanning the chest. The mother's breast is, um, usually where the danger life. So the breast issue, particularly lactate in breast, is quite sensitive to radiation, so they might have a slightly increased risk of breast malignancy. Uh, with a VQ scan, there is theoretically a slightly higher risk off the baby developing a malignancy. But these are extremely low. Um, so I think we're talking about, like, one in one in 10,000 risk when you generally even if they don't have a CT or whatever, the background risk is one in 500. I think so. Anyway, over the point to bear in mind is both of them haven't don't actually have a huge risk. But what we will ask is, um, for you to discuss it with the patient, because just because there isn't that much of a high risk on, but it doesn't mean that we don't explain things to the patient. So we will ask you to have kind of a quick talk with the patient and tell them, um, obviously they're pregnant and usually avoid radiation and pregnant patients both make you scan and CT scan use ionizing radiation. Uh, there are different types of radiation is, but they're both ionizing radiation, meaning that they have the potential to cause damage. Um, you might find, um, leaflet or something like that on the Internet about this, which you can obviously used and explain this to the patient. All right, so I'm going on about 15 minutes. I think, Um, just some things I just repeat a few things. So most important thing when you're calling is no. Your patient Give us good clinical history, particularly surgical history. Don't give us things that it really you know, useful. So, for example, if someone had a CT head, we don't need to know that they have a total hip replacement. Um, but obviously, if there is a history of glaucoma blastoma, then we need to know that it's a relevant history. Long does it mean good concise and relevant. Don't worry about contrast. If you know what you're talking about, bio means write it. But if I don't kind of have our sit on, you know, don't don't. If you're not sure, just leave it with us. Same with asking for the test. So if you end up asking for a CT chest because you can't find the CT pa, as long as you write clearly pee on your request, it will get protocol as a CT pa. So don't worry about that kind of stuff. Where generally, chest, Uh, chest X ray is the first line or abdomen stuff. CT is the first line. Um, and if in doubt, call us if in doubt, just, you know, like I said, right things very clearly. And obviously we can change it from our end on. If your patient is sick, call us. And again we will prioritize those patients on device You on the best way of doing things. So four f once and after you use personally for me like my my biggest thing when I was dealing with radiology was worrying about contrast. And don't worry about contrast. Don't worry about what you write on the form. Just get the history right. Um And if you're unsure about anything on a plain film on do you can't get hold off your seniors. So try and always get hold of your seniors first. But if you can get hold middle of the night, Um, just use the I'm an F one, and I don't know what's going on, and I can't find anyone helping card on. Then. Usually it will work. Okay, So I'm happy to take any questions about, um, anything about regular getting into radios. You are. You know anything else? Um, otherwise known as any questions that you can go. Think that the question person in the chart. Yeah. Sorry, I just saw that shot. Can I confirm when requesting contrast imaging? Is it breast? Best practice for us to include peace and Egypt far unless bond you're seeing again. Then it's a really hard to decide suitability s. So you don't. You can, but you don't have to, because the radiographers at least and uhl they will usually check it and they usually check it on ice. And they they will come to us if there's a problem. If there is a problem. And you know already that there's a problem if you clearly document that. So, for example, someone has Egypt are 25 Um, and they need a CT scan. With contrast on D. If you clearly document that I discussed this with senior clinician, but the name, whatever. It doesn't matter. Even if you don't with the name, um, we've discussed it and we're happy for the patient to have contrast on. Then that's fine. That's one this phone call for us to make to check with you guys. Whether or not you're happy for the patient have contrast on D. The suitability is not decided by radiology because ideology doesn't treat if there is contrast nephropathy you guys treat it so, um, from our end, what we'll say is Egypt far as low. Normally we wouldn't get contrast. But of course the patient is sick. So if you want contrast, we can get contrast. Just be careful about, um, contrast in a property that will be our advice. And like I said, they'll happen 48 hours to 72 hours after, so just know when to expect things to go down. If it will go down most of the time. It's fine. I I don't know if anyone who has had contracts in a proper the since I've become doctor, so don't worry too much. But like I said, it's just so ingrained in in our practice. And I was very difficult to shifted, but there is not a huge amount of evidence behind it. Yeah, okay. That's brilliant. Thank you. Um, if nobody else has, um, any more questions than, uh, please take a minute to follow the link on the chat on. That's the feedback, Lincoln. It'll generate your stiff, um, on, but yeah, if if anyone has any questions, any point, um, after the session, please feel free to email us, Lester red sock at gmail dot com. Um, and we can get them answered for you. All right. Thanks for listening. Anyone? I'm going to sign off now. It doesn't look like very there are any. Um, all right. Enjoy the rest of the Sunday evening