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Nope. Hello, Onda. Welcome to the first in the F Y one. Radiology tutorial from IR juniors and mind Oblique. Hopefully everyone can hear us. Okay, um I'm just going to turn off this in case is a bit of an echo I'm gonna hand over to Satun. Hopefully, people are able to join in. I think there's a few numbers popping up on the on the YouTube that I can see here and now. So, such if you want to take it away and we let people filter into the room, such as? I can't hear you there. So maybe just try your mike and see if it's how is that better than you have, you know? Yeah. Yeah, We'll get to just start again. Thank you very much. Hi, guys. Start about that. My name is Satun, and I'm currently one of the members of IR Genius on this is the first part of our series radiology for if y ones where we're aiming to give you a bit more information about what is expected when you start working as an f y of one and our liaising with the radiology department just to give you a bit of background about who we are and what we're trying to achieve is a group. So, as I said where called ir genius, we started up about two years ago. Now, with the aim of raising awareness of interventional radiology A Z, we found his medical students. The exposure to IR was very minimal. So what we've been trying to do is just raise awareness or applying into radiology and also applying for interventional radiology and how you go along into that career path we've been hosting different webinars about IR, and the types of procedures that I are due on have also created research opportunities for people to get involved in and students to get involved in a swell alongside that, we've also tried to raise awareness or various global opportunities to get involved in. I are such a selective opportunities as well. So please, do you check out our website which has more information on all of these aspects that I just discussed on desire. Just a few examples of some of the things that we've hosted over the last couple years and some of the things that we're looking to also get into in the next few months and years. Eso One of the big things we've done is radiology applications. Last year we held applications eso discussing portfolios, the MSR a interviews and choosing a training scheme so that if you're looking to apply for radiology, that might be something um, worthwhile checking into will be hosting that again over the over the coming months. Um, we've also been hosting on interventional Radiology journal club on day, as this is the event that we're going to be discussing today on gonna website, they'll be linked, Teo various, but taste they are sessions which were basically more in depth. I our discussions about the procedures that I ask perform. So that's just a summary of some of the things we've been doing on. Of course today. This is what will be discussing on. We've got two great speakers, Doctor Nile Burke, who's an F one in London at the moment. And we've also got a doctor, Matt Brackey, who is a radiology registrar up in Edinburgh. So we've got to really interested in keeping speakers. Um, on the main thing that will be discussing is liaising with the radiology department. I'm kind of what you'll need to know in the first few months and years left one on. This is the first part of the Siris. Um, so the main things will be covering in this session are communicating with the radiology department How to protocol scans, transferring images, different scan modalities and types and CT imaging on these are the two speakers that I just mentioned here on. The second session will be in a couple of weeks, which will be an introduction toe i r. On how I our feature is Aziz. You are left by one and kind of three areas that crop up in on then they used to be a section on common radiology cases. On this is the collaboration that this serious have taken place with. So I'm for my are genius. The other side of things is with mine a bleep. I'm sure you guys have all heard of mind a bleep. It's ah really useful on growing society. On this is the website where you can find lots of information which has loads of F y one related content and other advice. Virginia doctors are definitely worth checking out as you start off one and get involved on just a little bit more information about our recent upcoming events. We've got the next part of our journal club, which will be on the 26th of July. So, please, do you check them out on our website on. Then the second part of this Siris will be on the second of August out about 7 p.m. a swell. So that's pretty much everything from me at the end of the session. If you can fill out some feedback, that would be amazing. Thanks very much on your hand over to know now. Thanks very much such. And I'm just going to lay a lot of my states. Just let me know if you can see everything. Okay, once these pop up. Yeah. Yeah. From what I can see, they're they're pumped up there. And so I'm going to firstly apologize for a little bit of a mix up with the streams. They're the one that was initially on a YouTube channel under IR juniors YouTube channel, and it didn't seem to link the stream to that. But we are alive, obviously, on the YouTube channel. Anyone who's watching us now is found us. And I've put the link in the in the other extreme as well. So if you know anyone who's who's trying to attend this, just send them on the the link for the current stream that you're watching on. We're forced on a social media as well. So thank you very much for asking myself to to speak today. I've asked Matt Record who's He's an ST one radiology training as well in in Edinburgh to come along. And he, uh, he'll obviously gives some useful in put as we move through these different sections and towards the end of anyone has any questions, have to be very useful to toe answer doors questions as well. So I'll let Matt pop on and just see it quicker. Lord, everyone as well. Hello, everyone. Yet thanks very much and touch it. And I know for having me. And yeah, as I say, I can't take too much credit for the the effort and work that's got into it and gets action, and I'll have done a great job but, um, computer to support in any way and answer any questions I can being a year into into the older training, so you're looking forward to it. perfect. So I might as as we go through if this if you want to kind of put in our making eight points of comments or I might defer to you as we go through the same thing out. So here we go. Right, Um, try and actually make this work perfect. So the idea behind this talk and this talks syriza's essentially to give incoming F Y one doctor's eso first your doctors in the UK a bit of an insight into what's involved with dealing with the radiology department in those first few months. Once you start. So this talk is going, this is going to be a bit of a radiology review just some of the real basics of the different types of modalities that you may come across and and refer patients for a little bit about kind of considerations. When you're for indications for different scans, gonna have a chaperone CT because I think that's it's obviously a very common mortality, and when you would be referring patients for quite a bit. But there's a little bit of confusion, often and even myself. I I found, you know, it was only after a few months of everyone that you actually start to figure out, you know, the different protocols and that as well. Not that you necessarily need to have an in depth understanding, but it is useful as you kind of have discussions with radiology. We're going to talk about making radiology requests a swell and and how to conduct yourself when you're doing those doing those discussions gonna as such and said, there is a second part of this talk, which will focus more interventional radiology. But there is at some cases that I worked through as they go through this talk and one of them is related. I are so it's just left that in. And there's some interactive cases and activities as we go through a swell. And so the slider which feel free, I'm going to keep an eye on it on the other screen here, if anyone has any questions as we go along, um, the QR code is there to have a look at on scan. And then there's also the, uh, I'll put up a few polls as we go along to keep it a little bit interactive, hopefully, and that's the cortisone. Well, perfect. So just to let you know what isn't in this talk, and things that might be useful as you go through the next year would be things like chest X ray interpretation, MSK, extra interpretation, basic CT stuff on TV building for anyone who's particularly interested, radiology and I are. And that's you know, particularly on the last point. That's, you know, there's a I Our junior is itself has a lot of resources from that point if you want those. But there will be opportunities. I'm sure in a lot of you're just pulls final. So actually, your chest and MSG interpretation is probably better than a lot of hours at the moment on. As I said, there are in or stupid questions here. This is, you know, for your benefit to make you feel more comfortable as you start your new job. So please do ask those in the slider. So a rapid radiology review is just kind of to run through some of the modalities that you may come across quite area. I know you will come across. So you know, this is a centrally a plain film X ray of wrist showing a greenstick fracture. Usually if this was like Get a little bit of interaction for us to be is also quite common one that you referred patients for quite a bit. When you're on surgical attachments, different types of barium swallow those or water soluble contrast swallows order sound, obviously is well, is quite common at CT. So this is going to be our first point of interaction. So hopefully we'll actually make this one works. So do try and give this a go. So if you're on your slide over there, um, which the details should pop up here, No eso If you want to get on to decide, I'm gonna release the first full. So essentially, just have a look at the scan And don't cheat by looking up the radio PDI d, which will give you all the answers, but just to see what what you think is going on here with the CT scan CT CT brain got so we've got a few people interacting, which is good. Maybe more than one right answer. Hopefully, you can select more than one answer. I'm just going to give it another 10 or 15 seconds and we'll leave it at that. So we've got Ah, good range of answers there. Essentially, what's going on here is on the patient's left side. There is a dense artery sign, which it should be able to highlight with my cursor. Here you've got this whole area off Hypoattenuating in their MCAT Eritrea on. Then there's this thing called the incident Ribbon signs. That's the last of the white and green matter of differentiation. These are things that you know you don't need to get to bug down about know knowing. And but if you are referring a patient with with stroke signs and symptoms for a CT scan, it's it's useful to go back and not just over the report, but have a look at the imaging to this is an MRV in a gram, a pet CT here showing a renal mass. These, I guess, are all types of examinations that I've referred patients for over my first year as an F one. And this is a D. S S o. A digital subtraction and geography and image, and that enough anyone wants to have a quick think about what that might be. But it is a fibroid. Embolization is that's a large fibroid there. This is the catheter working its way up on around so unopen over technique, and the contrast dye has been injected into the into the fibroid to implies it on take aways, blood supply a century. So I think the main point from having a quick run through a lot of doors is that when you look at different types of imaging, you can often be quite intimidated by them. But there's, you know, if you kind of stick with some basic principles, it's quite easy to figure out both. You know what it what Anatomy relates to order anatomy in the area. Um, when you're looking at different, we talk about CT scans in a moment as well. When you're looking, at contrast, enhance scan's looking at what? What actual organs are enhanced and what what vessels are highlighted can help you figure out what kind of a protocol was used. So it's just just useful as you go go through the next few months just to have a look at some of the imaging and try and figure that out. So an important point to be aware of, and often if you're probably all doing your pre hospital restarting hospital and mandatory online learning. Some most places will make you do summer as well, so radiation protection is quite important, particularly when you're referring patients for ionizing radiation scans our scans and bother nine icing radiation on this, ERM er is the is the legislation and regulations, which kind of scared the the exposure to organizing radiation in this In this setting, the main things are it's It's just when you're ordering a scan on occasion, you have to make sure that it's the right patient. Obviously, um, it pregnancy status, particularly because you know the fetus is at a higher risk of DNA damage through from exposure to the ionizing radiation and breastfeeding status particularly important for nuclear medicine scans. You also want to reduce any accidental or unintended door sense to patients as it says there. So your job as the F I want referring patients of these scans is to give enough information to the to the people who are betting the scans in order to justify the exposure. And so it can be, you know, war drowns of busy and often times through the day. You're you have a massive jobs is it could be very tempting to just put two or three words in a in a referral. Um, but actually, you know, you're less like that. Let's scan is less likely to be done, and then that will impact potentially on patient care. If it is an actual, you know, scan, that needs to be done because the the practitioner can't actually justified the scan based on the information you've given. I think something else, which I perhaps didn't completely father couldn't fathom was how could you order a scan on the wrong patient? Um, and it's amazing when you particularly, I guess over the winter months there, when you know we had a lot toward full of patients would call it. And a lot of there was a lot of similarities between your patient, Um, a graphics and a lot of them need a different type. Scans, for example, CT pas, and when you're in a rush in you, you know, got got a lot of jobs to do. It can can happen and has happened to people. So it's just important to always make sure that when you're finally clicking through that and order that requested the end, that there is Ah, you're assured that is the right patient. It's being carried out. So these are the important radiology risk assessments that I go through. When I'm when I'm referring to, a patient just gets off the ionizing radiation. So X rays, CT's I, interventional radiology procedures, pet CT scans, nuclear medicine, all of that. You want to make sure that it's the right patient and the pit and the patient is and pregnant. The stochastic effects of particularly important if you have a younger patient so trying to avoid CT scans were possible and younger patients and and thinking about older or danity, such as ultrasound and MRI, which may be used for that. And if you're not sure, ask your team and that's that's That's one of the main points I want you to take away from this evening with memory, and obviously it's a I'm a big magnet. So the brain previous brain surgery interventions, if they have any cardiac device, is particularly pacemakers, you want to be aware of that. So if you're on a war drowned in the consultants is kind of says the way we could do it. Getting this patient an Emery, Could you order that today or request that today it's worth taking that few seconds, and it'll speed you up later to be too quickly. Run through these things to be like, you know, any previous brain surgery, or any pacemakers of predict voices or any metal implants or foreign bodies in your new and and just run through that, and it could save your time down down the line. Contrast also, so contrast used in commonly and ct fluoroscopy and intervention radiology procedures on. It's an important role that you place well, if you're referring patients for the scans to make sure that you have a look at their kidney function. And you know if if, if it's if there's any issues with that, you know, or if you're not sure again, ask your team you want to decrease the risk of contracting properly, and that's often doing with, you know, pre and post hydration. Also Energy's toe contrast media. If patient disclose that to you are sometimes there's a bit of a cross over with shellfish allergies as well. And so there is just some points, Um, so just going to come on the case one, um, which is I've tried to make this as real life. It's possible, I guess, in the There's a hand over at the top of the slide here, which tells you about this 34 year old patient who's come in with some abdominal pain, vomiting, and they have, ah, tender mass at the right iliac fossa. So the team's working diagnosis of the moment is appendicitis. Patient was sent for another sound, which couldn't see an appendix, but they did see some sort of a mass. It was lateral to the to the uterus, and there was some fluid as well. And quick look at the bloods. I think the important thing here is that to realize as an F one, you're going to be faced with a lot of information on some of it's relevant. Some of it's not so much, but it's always going to be there in front of you. So it's about extracting the most important points. So we've done an ultrasound abdomen here, and this is it a relatively young patient start 34 years old. I'm gonna throw up the next one now and see if you think what is the next? In your opinion, what is The next best imaging option for this patient is obviously a few options. But just just see what you think here, So and that's lighter there again, if anyone needs to rejoin it, Yeah, there is a slight delay here on going to show the correct answer. From my point of view year there is Obviously, this American went about. There could be some arrogant with this one. And it's the patient is we don't have all the information here. Essentially, the patient is stable and and would be able to kind of get to the ultrasound department for a transvaginal scan. So that was the TV ultrasound scan, and that could be quite useful here in the sense that we haven't completely ruled out a gynecological. Cause for this on doing a trans vaginal scan will get you better results in and visualization off the the, uh, uterus and ovaries. So that is a potential here, and the other one has a lot of people went for the CT scan there, which is potentially very appropriate and potentially something that you know could happen in this in this setting. And I think there's way don't have the full picture here on other parts of the history, investigations will be useful. Hopefully you've been thinking about that. Along the way would be obviously a full of guy, any history from this patient. And I'm going to tell you now that that may not have been clear. But this was if it is a female, you want to get a tiny history on the history rebounds, opening any past surgical history. I know it says no past medical history, but asking patients if they had any of intraabdominal surgery before ruling out any cardinal features of any obstruction. Because in that, in that sense, in that case, if you were suspecting that there may be an obstruction, then, as as some people voted for their an abdominal film, a weather be useful if there's a consideration around obstruction. But other ways in these settings, I think not not very useful. So just going to come back to radiology workflow for a few moments and radiologist versus a radiographers, which is something that surprisingly still, you know, even a few months, you know, 68 months into everyone people didn't understand, and I guess it's you know it's a department in and of itself operates quite independently, and it's understandable. Obviously, the people don't know the difference. The radiologist is essentially a doctor who's got on to do further training and radiology, and obviously, math phrenic for as an example is now 61. Radiology training? Um, a radiographers. It's also a degree course, but you can kind of go into it straight out of school. And and it's more about image acquisition on Do all those things I mentioned before. So just if I just just defying scans, optimizing the scans and obviously the patient care and contact site is is a very important role for the radio. For a swell. There are extended roles for radiographers soul Sinaga for Is, and also some reporting. Radiographers Will will report on on scans as well. So just the next point is, this is something that will often happen at hand over. You'll be told that we order a CT scan over night for this patient. Can you make sure it gets done? The scan is kind of ordered, but not urgently and trying to figure out, I guess the logistics of how do you didn't bring that scan forward and and get it done. I guess that the important thing is you want to make sure that the scan it was ordered in the right patient and clarify that with the cardiac who's handed this over. And there's just two pictures of the radio for an a radiologist who is the heart reporting radiologist who's the hot seat radio, radio, your registration, these air too important to important people to know. And it may very slightly, obviously, depending on what hospital that you get into the hot seat. Radiology registrar is the person that you're going to have most of your discussions with with regard to referring patients for imaging eso they will 50. You put through the scan request and have a have a discussion with the radiology registrar, a boat You know, whether that's the most appropriate scan and way it's needed and obviously prioritizing around the list. And so, in this case, the scan was ordered overnight. You want to talk to the hot seat radiology registered? Who can help me out with that? Thus, the hot reporting radiologist. So this can be the same person or be a completely different radiology register or consultants who will be hot reporting scans as they're done in any D s. So if you have any questions or queries as you go through, um, What, you're dealing with patients and you want to kind of get get. You know, advice are on opinion on the scan. It will be the hot reporting. Really honest. You'll have a chat with it. So, as I said, the scans there are vetted by the hot seat radiology registrar usually, um on. Then, once they're vetted, that often isn't the last point in the process. You don't need to talk to the CT radiographers as well in your in your hospital to make sure that that patients put on the porters list to be brought down. Or usually these patients will need to go on a better a chair to get two different. There's a little bit different for general X rays like chest, chest X rays, abdominal films and M S K stuff. Usually you can talk straight to the radiographers on the general store who you can call directly and and again provided you've given enough information to justify the scan. They can do that for you and ultrasound scans s that this is kind of, uh, very little bit, depending on what department urine and might pop over to Matinee manages to get his his taught on on this side of things. So it's usually the sonographer is. Are the the radiology register who's who's working an ultrasound for that day? You will. Vectra scans and MRI scans are usually by consultant radiologist to If you kind of will contact the hot seat radiology register, they will be able to put you in contact with them. Are are they can kind of these with that consultant for you so mad. I don't know if there's if there's anything in that that you want to add to or whether you're thinking exactly as you said Now that is going very independent on which hospital you're at, and I think it's a good idea. I mean, during your foundation, your rotations, you will probably do a job in a District general hospital. You'll probably do a job but one of the major hospitals in the city that you work again and and you know, if in doubt, ask either ask the war stuff worked there for a long time, or the rid or don't be shocked to get in touch with the radiology department about how this works. Because yes, overall, I think that that's a very good summary of how, how, how it will work in my hospital, for example, that at at the moment in In the Infirmary in Edinburgh, which is a major center there, there are four inpatient radiologist to consultants to read Registrars who are vetting reporting all in one go on were self next door to the radiographers. So all works is one big ship. And but that's a That's a very busy hospital, you know, with recovering the large area where, as in a smaller hospital, for example, of a district general Hospital, that might be one radiologist calling all of the shots and on, you know, it's it's really just a case of Don't be shy to get in touch with radiology department to find out how about works? If you are in doubt, if you're worried about a patient callers Oscars. If this is particular, you know if you're in a big hospital in your older scan, that's really urgent, and a radiologist might not see that report straight away and request straightaway, particularly if they are very busy, so don't be shy. Teo, have a discussion with the radiologist toe. Alert them to that on balsa the radiographers as well. Yes, yes, for ultrasound. Um, again, my experience only working in two hospitals so far in one area. And yeah, between the registrar's and the consultants will get a get the pile of requests for ultrasound and and sort of that them per day. And obviously we have out patients to invest a well, so it depends. But if you are very worried about a patient, I wouldn't hesitate it to get in touch or only speak to the senior members of your team on the water to find out how it how it normally works. And, yeah, MRI scans. Exactly. This is a tends to be a consultant radiologist. I think in most places that's in charge of MRI for that morning or afternoon, See, And you know, sometimes if we get a call, if I'm on inpatient ct on asking to discuss the memory, I can speak to the memory consultant who is probably, you know, a few doors down from me. And so, um, again, it's it's hard to put a heart answer on this because it's gonna be very so much between between hospitals, but that that's a gen. That's basically how it works as a general rule. And you don't don't be shy to to find out when you move to a new hospital. What, um, you know, speak to the radiology department to find out how these things work. That's great. Thanks. That s so I think the the points obviously that were met. They're very useful. I've just noticed that there were too questions that I was looking at the pores rather than a Q and A pregnancy test. In that case, which added about earlier on would have been very useful. And I guess, you know, purposely didn't give a lot of information there. How would previous brain surgeries effective or I use, particularly if there was, uh, previous coiling, so kind of intervention, a neuroradiology treatment or clipping, I guess off aneurysms, there's, you know, often a little bit of metal left in there. That's just a discussion that will have to be had with the Emory Radiographers. And the consultants were necessary. That's that. That was that point. And I'm sorry, I I guess at the start of this introduction. I didn't mention that I waas previously a radiographers eso that. That is why I guess the logistical side of the radiology department was something that I had a bit of an insight into it before, uh, before starting medicine. So image transfer. This is something that we're just asked to pop in a swell, another logistical point that you may not be aware of our think that much about before you're actually on the job. So it's not uncommon to have a patient transferred from one hospital to another, particularly if you're working at a territory center, which you may be in the next two years. And so when these patients come across, uh, you know, unless you're in Scotland where they've got the whole of Scotland connected up together in a pack system, which is which is great and their imaging may not come automatically with, um So there is, um, this system called Paxil sensually the picture archiving communication system, which is used to a local store images and make them available for viewing. So transferring images are kind of liaising with the radiology department to transfer images is an important job because it can avoid patients having multiple scans, which which can involve ionizing radiation on double dose. So that obviously, is something. If you can avoid, you'd want to do that on. Also, it provides the teams looking after the patient and the radiology department with these important reference images, if they're been getting further scans so that they have some sort of a baseline or previous imaging to review. So there's usually a pack specialist radiographers who works in in these departments who they usually have a fairly accessible email. Or you can call them as well to organize the's packs, transfer transfers and the important things to have to hand it in. If you were asked to do these things, is the hospital that you want, the images transferred from the specific dates, if available. And also, if there's any individual scans that you know, we're particularly important and you want to get transferred across a swell, they be the things that recommend having to have more, well X rays. So you may have seen as why, why the medical students are, you know, on your shadowing blocks that it does happen sometimes that we need to get the radio first come up to the department are up to the war to do more by chest X rays, in particular for patients. Um, and there can be a little bit of a battle, and I've been on the other side of these telephone calls quite of this, chatting with junior doctors who want, ah, chest X rays done on the ward's um, and it can seem like the radiographers of being quite difficult. But essentially their job is to make sure that they're not unnecessarily going up to a ward and using X rays in a non protected environment and potentially exposing other people in in that wars, too, that I radiation. It can also be quite difficult in those external environments on award to actually get the best imaging that you know that is required. So in order to optimize the scans, these air, if at all possible, better done in the department. So if you wear a question, um, or bile X ray do ask yourself is if if this needs to be done now, and if it's going to change patient. But if if it does and that, um, that the answer to that question is. Yes. Then absolutely. Go ahead on it. You know, ask yourself, Is this patient clearly too unstable to go down or, you know, But they go down with the nurse s court to the radiology department to have their X ray done, for example. And if there's that, if you're not sure about the answers to those questions, senior nurses or obviously other members of your team are great people to talk to about that. And there's obviously very clear examples of when would be doing port with chest X rays. I see you resource patients. If you have somebody really deteriorate on the ward and they're not stable enough to go down recovery on theater chest X rays of it, patients getting lines put in and they want to obviously get imaging on the spot in case is any need for repositioning. And beyond Chest X rays, it's It's quite rare to get other mobile exams done on the word very rarely, depending on a very specific circumstances where it left and have to go through the radiologists on call, it may be possible to get other scans. Don't look that that's obviously on a case by case uh, situation or scenario. So some final insider tips on this section before we move on is that, you know, radiology potentially does have a reputation. Radiologists, that, you know, there can be some difficulty in having these conversations. And that may be something that you have seen. You know, you're therefore ones that you've been shadowing talk about. But I think it's important that although there are some personality traits that persist, I think there is a you know, a new generation of radiologist Now. We're very clinical and very approachable, and that's definitely that the parent focus on. I've said it myself. And I make this mistake all the time. When you're, you know, requesting a scan rather than ordering a scan. I mean, it's it's just to turn a phrase, but you, the radiology department and radiographers don't want to be ordered to do anything. It's more, you know, just just try and get into the habit of using that that terminology and, you know, at the start of your discussion, you know, when you're on the phone to the radiology register on call, start with would be okay to discuss the scan request with you. If if there's something that they don't agree with and you can't understand phrases like for my learning for my learning is, you know, an excellent phrase that you know you use many times over the next year is that for one. So don't be afraid to do that. If if you're ordering on online system is often, you know you will be have multiple windows open with blood results. Previous scans be able to flick through those because even though you can prepare yourself, you know pretty well I think sometimes having that information to hand. If they want a specific data point, it's it's used with have it there on the morning wardrobes. If there's multiple F ones around and there's a lot of scans to be done, just kind of raised the point of would it be used for for one of us to go off and say, you know, requesting some of these scans and really, this is the one that really bothers me? Is is that when you start to converse, a our Strattera discussion about a scan with my consultant wants a chest CT scan or whatever. Um, you're no perative dependent you and I'll be perfectly clinical team, obviously. And you know, the best interest of the patient is you know your priority as well. So you need to understand why the CT is required on, you know, you have to kind of get behind the request is Well, so you know, on it will help you if if you kind of, you know, take take a little bit of ownership off these requests and discussions rather than off, you know, putting it off to one side or kind of putting it on to your consultant, our senior member stuff. And it does get easier. The more the more of these that you do, the better it easier to get. So, gonna with through this section on CT scans, um, just again, because I think it's an important area that you'll come across quite a bit and you can get away with not no one off a lot about it. But it's, um you know, some key foundation points are important. So first of all, we're going to look at these three different types of CT scans off the chest. So we've got a CTPE a ct two or extend a CT chest contrast and just for a moment, take a look at those three scans and try and figure out which is which they're not an order at all. Um, just try and figure out if there's any kind of characteristic things on any of these scans which would make you think one way or the other. And if you're watching this back, obviously you can feel free to pause. And we're going to start with this one here, which is the CT p A. And you can see the pulmonary drunk and pulmonary arteries bilaterally or enhanced with contrast. And actually, this this one in particular shows that quite a large pulmonary embolism there and moving down to this one s so you can see that there is some enhancements off the liver. There's also a chance mint off the the rims here, off the the pleural cavity is does is this is, um, a empyema on. You also concede there is a little bit of contrast. There is well in the aorta showing, you know, that there has been some contrast. Use this a contrast enhanced CT scan, and this one is a high resolution CT of the tour, actually, in bronchiectasis is. There's a lot of kind of breakdown of the the long tissue here towards the bottom. You can see that kind of train track in appearance. They're of this on. This is, you know, beyond appreciating that which you know what type of scans these air. You don't need to get bogged down with the pathology itself. But the important thing to say is that there were several cases over the winter where we were ordering CT pas for patients with cold it who also needed high resolution chests. Chest scans are, and the important thing to say is that the main thing that's different about this high resolution chest scan is our. You know, the tour extent is that there's different wind doing used, and we've just kind of focused on it, a certain level of the data and and certain kind of how narrow down the house three of the units to look at particular densities. So if you look at the CT pa, which we've just changed over there, you can get a good you know, representation of the long tissue from that as well. I'm going to defer back to Matt after we go through these three to CVS. Anything to add? But they're the's different type of CT scans. So the other one that is quite a common one that you come across in again in surgeries the different seen a CT abdomen, ct colonography and a CT Tripathi is Abdul so again? Have a look at these three scans and see if there's any kind of characteristics on those scans that you think could play. You could place, um, under, I guess, any or all of these, uh, criteria. And again, feel free to pause. Have a look at these if you're watching it back, so we'll start on the left this time, eh? So this is a non con, um, CT abdomen s so that you can see essentially a lot, lots of graze. Very difficult to differentiate different types of tissues here. Often for these scans, they may give a little bit of oral contrast in order to differenciate the bowel a little bit from the other organs around. But there is none that we can see here, definitely, so you can see the aorta and the renal arteries, and there's, you know, the renal vessels there. There's no enhancement at all moving up to this one. The aorta is enhanced here with contrast. So this is an arterial phase off the abdomen. You can see their blood vessels that the arteries here heading out to the arenas. Well, and see the rest of the bloods place that the organs as you go along. So that's an arterial phase one. And then finally, off up on the top, Right. Um, there is, you know, again, start where I tend to start when I'm looking at these is look at the vessels and see what they look like. So that there is some enhancement of the of the aorta here, but definitely less than the arterial phase. And you can see the liver tissue there is kind of enhanced. And as have the kidneys and spleen there. So this is a port a venous phase scan on all these three together. So a non con on arterial phase on the portal venous is a triple phase, Abdul. So this's an important thing to bear in mind if you're ordering these scans because this will necessitate the patient having three separate CT scans, one dose of contra one dose of contrast, But three exposures to ionizing radiation. So, um, you know, you can you can kind of often way up the risks and benefits of sending a patient for a scan on, not necessarily realize that it's it's gonna have 33 export straight a shin. The last one was ct colonography, which wasn't there on this shores. I don't know. Hopefully you can see this. Okay, so there's, um, dilated call on there. So there's been some air insufflated into the colon and then there's, ah three D reconstruction of that as well. And finally, on the CT scan side of things. Oh, um, so ct urogram CTK you be in a CT renal protocol Onda again. Have a quick look at these. See if there's anything that really stands out about, you know, the scans that would make you think about how they have been taken that maybe some delay after the contrast was given, um, which I guess is maybe, uh, maybe a giveaway here and again. Pause if you want. So ct urogram, um, with what I'll do is I'll start with the non Conway. So essentially, this is that the noncancer that's a C T k U B, and you can see that this is a reconstruction off the CT. You can see that there's a renal calculus here, and this is commonly used in the setting off renal colic, Really in color compressions. Use a lot more often now than playing for the abdomen's for the detection off off these off renal calculi. So nor contrast, use could be done quite a low dose protocol, because the contrast that you want is, you know, but not not that much. So you can essentially just have a look at the, uh um, you know, if there's any stones in the tract moving on here, So this one on the left so we can see the aorta enhanced again and the renal arteries coming off. So this is an arterial phase. Next one on again, less enhancement of the order. But you can see that there is a definite definite change in the appearance of the kidneys. This is the nephrogram pick phase off the off renal protocol scan on Finally, you can see here that there's the contrast now draining out of the the renal pelvis and down into the ureters, and this would be the the you're a graphic. These are a CT urogram. Essentially. But all of these three together is is usually what constitutes a CT renal protocol and matter balance over to you there before we move on. I think you probably agree. It's quite a quite a knees e area to get mixed up between these different scans. Absolutely. And, you know, I think this this slide is really useful I didn't have a clue about this is is an f. Y. And you know, not not so much to be able to actually interpret the scans and report the scans. But although those who are interested in in really old years, I assume quite a few of you are, it's probably a good idea to get a good head start. That's, you know, looking What? What do these things look like when we're looking at the scans? But not just for a general doctor, too? Teo, understand why we do certain scans, you know, to understand that certain scans will give more dose of the patient than others on why we do the phases that we do. Because ultimately this is all going to lead to the question of, you know, What question can this answer? Why am I ordering this scan on that issue? I think as as a junior doctor think about, you know. Well, what? What questions answering here is this guy. I'm going to be useful. Do you justify? Yeah. The dose that we're going to give to the patient on that get probably lead you away from us now mentioned before the problem of saying like, my consultant wants this scan. So, you know, we're not expecting you to be able to interpret the scans yet, but But just to have this basic understanding of the different phases on by we do them in certain situations is a really useful too, um, to get in your mind. And especially if you're putting Radiologist, it'll set you in good stead for when you when you do start your training. Not a question. And they're just about the triple face CT abdomen. So I know myself that a common indication for those would be Pancrecarb. Yeah. Thick kind of pathology. Order indications for a triple phase. Abdul having those three scans don't. Yes, I suppose it depends when you're looking for arterial phase, which it would be the early phase it that could be for for two reasons. I suppose they're very early arterial phase would be looking for on just the blood vessels to be able to follow them down, and then later on you can. It was later arterial phase. It can sometimes see on do blood going into certain. For example, tumors are good examples of practice. Eliud carcinoma. Where you get, um, you'll get a contrast going into the actual tumor itself, and then it'll wash out in a lazy in later phase. So you look at the arterial face on you see contrast and in and around the tumor, and then later phase on deport of Venus. And then sometimes you do delay phase. You will see that on disappear on that. But that's a good going bit of evidence for a while that probably it's a participatory acosta noma. I mean, that is not don't take that as a zero read that there are different routes. That, and obviously the examinations, for example, Emory and to characterize lesions. But But that's an example off propose. Yeah, and it can give us no, no, only does it help us with contrast between different structures on but also can help us. It gives us almost like a space in time concept of what's going on and for cancer staging. So so that that would be an example. Thanks for we will move on now to the next section. So these are just some common presentations. Essentially, I know we're kind of running a little bit later than anticipated. So for PE's, um, there are a few scan options chest X rays. CTP is we've discussed a VQ scan and really an emery with an M r a m are off the pulmonary hanging. And you, uh, for Maria vasculature. And so a CTPE is generally indicated and well, score, which I do have here essentially and most the final medicine. We'll kind of have reviewed this again more recently than I have. But if the weather score is hide in a CTPE may well be indicators without doing a d dimer. But, you know, do a d don't ever comes back positive on the CT be and may be useful with regard to just discerning between, you know, doing a VQ scan NMR mrp that that will be discussions with the radiology and obviously you've consultant and not something to become bug down with, particularly in pregnant patients, for example, that may be where you need to think about not doing a CTPE, depending on you know what? What? Just a shin there, the pregnancies at all of that kind of stuff, and it wouldn't go to a chest X ray. Often these patients will have a chest X ray if they've got any respiratory symptoms, as an initial investigation anyway, just outgrew any other sinister causes for their short shortness of breath. Such is a new, mature X or, you know, a pneumonia. And so often a baseline chest. X ray will be required before patients go on have a CTPE if they haven't had one already. The acute abdomen one of the cases that we've chatted about already had had a little bit of a discussion around this and your scan options. Obviously, our ultrasound and erect chest X ray, which can be quite important on the patient, would want to be kind of sitting up for at least 10 if not 15 minutes in order to allow any intraperitoneal repair to rise underneath the diaphragm. The plain film Abdominal phylum is still potentially useful if most likely in cases where this obstruction suspected and what kind of wider use of the abdominal film I think Matt will agree has has kind of petered off. Maybe because cross X ray imaging and order some become that much better. CT Abdulle and a Sweet chatted an MRI AM um so in these cases, these patients were very likely go for a CT scan. Um, if you know, another diagnosis can't be reached with less invasive imaging, and it's, you know, obviously very sensitive for intraabdominal pathology. But the radiation dose is important. And obviously, if you have a younger patient, you might want to avoid sending them for a CT scan or just sounds good, particularly in, you know, the right upper quadrant for any Billary issues renal system as well. Although we've kind of chatted about the fact that CT K U B can be more useful if renal colic is is suspected on. We talked about that case we're gonna collagenase use. And don't obviously forget that sometimes trans abdominal will not give you the visualization that you would get from a transvaginal scan. So that's just something to bear in mind, Um matter just pop over to you one more time there on the your abdomen, just on on the point around. Abdominal films just maybe give people who have an insight about maybe how they're not used as much anymore. Yeah, I think again, this will very depending on where you work in each in the institution. But I suppose the idea is whether you're going to get a CT scan anyway, for a lot of the problems that you will find on an abdominal X ray. So if you get an abdominal X ray and it's normal, sorry if, if it's abnormal, um, the surgeon may want to, Then you get a better picture of him to find before the before they go in on on and operate, you know, So you might go down the road root of the CT scan there on, then, if you get an abdominal X ray, that that's normal, it doesn't rule out that there's anything wrong there, you know, in a CT scan, may end of being useful anyway. So So for a lot of situations, yeah, and I've done the electric on. Is it? Isn't that a lot that helpful with management plants. I mean, it has its role. It certainly does, for example, looking for lines from memory, it sometimes looking for fecal impaction or the thing that didn't expect it depends. Um, you know, I suppose it varies between different institutions, but yeah, with with CT taking over now that that's often the case of would be get a CT scan anyway on Yeah, thanks, but I'm just a question there about what is a VQ scan. If you haven't come across a VQ scan before, it's essentially a ventilation profusion scan on nuclear medicine scan. That's that's used sometimes in the detection of pulmonary emboli. And that's you know, that's essentially as much as you need to know. Sometimes it may be indicated to do this in in patients who perhaps cannot have contrast or in pregnant patients in the setting off suspected pulmonary embolism. Renal colic Again, we've we've kind of mentioned this when we went through the CT k u B, but CT K U B is the most accurate investigation owners off after news First Line A Z, I said the ultrasounds and adult films are less sensitive. Um, and this is some really or text books you do IV use. And I remember seeing one when I was a radiography student. The's kind of abdominal films, with contrast in the contrast, injected and do a plane for them when the patient is lying on a on extra table, not not doing anymore. And all that information for those three was taken from the Royal College of Radiology. I refer resource, which should be available no matter what hospital that you're working in the UK there's usually an access to it. If you go by the hospital network, one of the hospital computers, and you can essentially type in the type of presentation that the patient has or what suspected, it'll give you some guidance around the best imaging again the radiology register. So you chapter well, you know, also have this information to hand, and we'll become adept at at knowing what scans too to suggest. But I think having a bit of if you want to kind of prepare yourself really well for a discussion. Having a look at this before you have a chat with the radio radiation can be quite useful, and you had the final thing on this would be before you submit that request is just have that consideration in your own head about the information that you put in the request versus, you know, the patient's condition, the risks of having the scan itself. So the ionizing radiation, if involved, and actually put yourself in the seat off. You ever done that the hot seat, radiology registration and think like would would I approve this if I was them? And that can be helpful on Daz. I say all of these things the way that you think about putting in scans come scan, request. And you know you can lead to a more success, you know, rate with them being vetted on that. I think the worst thing that happens and it happens quite frequently is either ill prepared for the discussion are you know that the information provided in their quest wasn't there. But actually, there's a patient on the ward's who needs a scandal, And just because it wasn't kind of got across the line properly or discuss properly, it didn't get rejected. The request and then another member of the team has a lot that time. That's time that the patient eventually is not getting that scandal. And that's, you know, these are all obvious points, but I just think it's important to think about it in the wider sense. Oh, and another case just going to quickly run through. So, essentially, this is a patient who I was called to see over night, and it was just a patient was vomiting on a surgical ward? Could you prescribe some anti medics on? The temptation in these situations is often Teo. Just do what the nurses ask you to do. Um, but I I talked that, you know, I'll answer and say that that would not be what you do. Thankfully, kind of got my hand over a sheet and had a quick look down through it on realize this patient was actually in for neural observation because it had fall on a chronic subdural and essentially that that was where he was there. So he's having these new relapse. He had been vomiting, didn't speaking with his first language was very difficult to get. Um, you know, at proper history from the patient saw, I felt like I would have had a chat with the surgical team. The surgical essential one overnight and we ended up referring this patient for a CT scan because of this kind of change in his condition, particularly devising in that, and it ended up that it has. This isn't really related this, but there was an extension of the believe they didn't have previously, so we then had to rediscuss with the neurosurgical team. So that's just a learning point that I hope you'll take away from. That is some requests that you can get when you're holding award cover. Bleep er on overnight can seem very simple, but actually just think about the the implications of not kind of reactive. Cannula and kidney function is something important for CT scans as well. Um, particularly CT scans, I guess, and IV contrasts commonly used for the So it's important to know if you're patient and you'll be asked multiple times when you're talking to the particularly the Radiographers and CT. If asking if you're patient has a cannula in particular for C. T. P s, because you need quite a big bolus of contrast to get up in the pulmonary artery to give you good visualization. There a pink cannulas usually required, um for that s so That's just important thing to be aware of and and, as I said earlier on oral contrast, can be useful is well, particularly in CT Abdomen's abdomen, uh, investigations, in order to have differentiate some of the the opposite that large amounts of foul odor down there and try and see, you know, help the report on radio Radiologists kind of figure out what's going on. And so just pictures. Cannulas Kidney functions are also important in these patients, and this is kind of as as we refer to the steroids. So having recent using these and creatinine and Egypt far available when you're requesting the scan often if you're requesting online, um, on a p r similar, you will need to have them in the request of Well, there is a contrast, in fact, the risk with a contrast which, you know it does exist. But I think the fear around that has kind of reduced recent years so that a lot of things with regard to kind of pre and post hydration can be considered on. Actually, is the risk of contrast in front of the outweighed by the chance that you know this scan is going to detect something that will hopefully help the patients management in a wider sense on. But this is just one mean that came from the radiologist page, essentially, and the important things that they're the team want to know is if there is a cannula and each year for. But obviously you do have to be prepared for the school, the consideration. But when you're when they're very busy, I imagine the radiology restaurants just want to kind of make sure that things can kind of keep moving through the department as well. So have that information eso Finally, I think we're going to come on to this point about putting the actual requests and discussions together. So matter of again come back to you as we move through this piece. And this is one of the most common things is you're going to be faced with this having a discussion with the radiology register on call about getting a scan requested. So there's a lot of different formats in different acronyms that you can use with regard to, You know, the information that you need to include in a discussion with a radiologist or whoever your front. If it's another specialty, the one that I commonly used. And we should all be familiar with that. This stage is just a nest there because trying to remember another acronym for you know, one discussion or another is only just end up having to Google that the the different acronym for remembering these things. So I think if you stick with an s there and do it well, I don't think you'll run into too much problem. So essentially stacked when you you pick up the phone and you call the radiology registers the hot seat radios register and tell them who you were, where you are, what your team is and very basic background on the patient and why they're in weather in the hospital. So this is just a sample of off something that I might have said. So one of the admit next one's just wanted to open to discuss the scan request, and then you kind of thing that opens up obviously there the dialogue for further information so patient to have come in with multiple episodes of democracies and open to get a CT torques. So in the background section, then do you want to give you know if there's other major diagnosis that might be relevant to this presentation. For example, if the patient is a long term smoker and has COPD, you might want to mention this year Energy's if they're important, particularly if contrast allergy. You know, you might want to mention that now on what you've done so far for the patient. So we've brought them in to stabilize them, giving him some fluids. And and, you know, if if it's not relevant to the case that we're kind of covering as we go through, this S s better. But do they have recent surgery? Has their condition changed since their last had a scan? Why do we need the scan now? So this lady had a COPD. She's long production at home, and she is a 40 year Pakistan, and the assessment that is moving on to you know the examination one other imaging and what blood to come back. So fair. So they have abdominal pain or the parent in it. If it's for a CT abdomen observations. How unstable are they? Are the unstable blood's looking at the white cell count and inflammatory markers are there's a bleed suspect to talk about the hemoglobin and then the kidney function, as I mentioned on several occasions, Now have that toe imaging. So if they've recently had any other imaging that might be relevant, do have a quick look at that on the reports before you have these discussions as possible. So the in this case it would have been on examination. There's reduce right sided air entry and shows that there's new right middle of collapse on go her hemoglobin a stable, despite the fact that she's had the smartest. The recommendation, you know, took kind of make this, too. But I think what needs to sit and this is the clinical questions a lot. Do the team want to know or what do you want to know? More importantly about, you know, why does the scan need to be done? So is there an intraabdominal cause for the symptoms? Is there any acute intraabdominal abnormality Are intracranial abnormalities on how you know in the context of that, how is it going to change? Management of this scan is there isn't gone. Um, if you're not sure that may be a CT is the best. The best scan to do where the best modality used and be clear about that and be open and just we're not really sure what the best thing to do. We're hoping to get some advice from radiology, and they'll be more than happy to get you. From that point of view on, if you're unsure about what the clinical question is, why the scan is being donor, how it's going to change management, then ask your team and there's no there's no shame it all. And in doing that because, you know, the likelihood is if you're going to get some, you know, key information that's going to make sure that that scan is completed if it's justified. And that's that parents. So you were concerned about a long malignancy, and we thought CT for X would help characterize the course from not come up. This is in the eight electricity on her chest X ray. I think what I've come across is well in the last year is the importance of putting the right clinical question because these scans would be reported in the context off that clinical question and, uh, you know, rarely there may be things that the team, the wider team wants to know that errand then, you know, commented on in the report. So, you know, asking the question in the in the request and making sure that you're here about what you want to know Well, again the same time. Because asking somebody to go back and re look at the scan because another member of the team wanted to know the specific detail and is obviously not great for the patient on this is just a kind of I guess I can look back and say there's a funny example of memory that I try to get that area in the year. So I said I was one of the effort ones of the medical team. We'd an outlier patient who was on Outlier Ward, and she's a diabetic foot infection. And she's on IV on. Before I could say anything else, the radiologist just stopped me essentially said that, you know, telling me that this patient is, you know, an outlier is completely redundant information for me, and you're wasting my time. Tell me that. So, like, I was there ready to kind of go into my aspirin, and I was completely cut off. So, um, you know there's you can prepare yourself really well on, but you know, in the heat of the moment, maybe includes of information that isn't necessarily required. But I think it was a little bit of an overreaction of the radiologist half If if I do say so myself, a quick joint into sorry, I'll go back actually matter on that any any point. Teo, under getting you know, discussions that you would have had with you and your doctor is about getting scans done. No, I think you summarized that perfectly. Now just reiterate the same. The main points there absolutely is. You know, what's the question we want to ask on Answer. And then if we do get an answer, What What are we going to do about it? And you just ask yourself that before you type in a request every single time your actual and what you what you type in the request will become a lot more straightforward and easier. And then you ask, ask your clinical team will ask and was, Don't don't be afraid to give us a call and ask if you're not sure what the right things to do. We are nice and promise Thanks. That so going to move on briefly again? As I said, the second section is going to focus more on interventional radiology, but we are a little bit biased. Obviously, in being involved with the I r. Junior is that, you know, intervention radiology is one of the most interesting areas of modern medicine. So if you haven't considered, you know, finding out more about it, please do. There's interventions now possible across multiple body systems, and the basis of most these procedures is ascending or techniques. So, actually, you know if you're sending a patient for an IR procedure, having an awareness of how the procedure is doing is obviously quite useful as well. So usually use a needle to get access to a vessel or a hollow Oregon. Put a needle through that, and then you can kind of put your sheet up through the needle through the over the wire and then remove your wiring issue. Then you have access to that organ on. This just gives a bit of an overview off all the different systems. This is from the Intervention initiative on unorganised, a sh in the U. S. And kind of talk about all the different examinations. So the main tips and this will, you know, come back to the second part of the series is the main tip here. But it's, you know, go down to the Iron Department because in particular, I guess in being much more clinically involved And, um, wait a modern and, you know, four thinking department. They're happy to see juniors come down and have have a chat with them. Put in your request first of your signature patient for the scan for and I our procedure so that you've been have a basis to have a discussion around on. Don't be afraid to ask questions because most people are happy to teach in this round on dry and come down and see some, uh, some procedures. Want to get a chance. So this is another case. Uh, but I'll have a chat about so again, bleep goes off while you're on call. Emergency surgery F one war cover Got a lady. Was that a hematoma? Been dropped. Dropped to 50 after another p. R. Bleed and again, observations generally quite stable. But what to do next? So again, I had to refer to the hand over these These, you know, as long as they're updated and kept up to date there, they're very useful piece of information. So we've got a a lady in her nineties who's come in with PR bleeding and forth admission. The last month you've got ckd four. Just got a CBC. Um, diverticular bleeds is what they think is going on ultrasound yesterday. Nothing CT angio it free bleeds. So this kind of I guess case is to highlight the fact that we've got a lady here who's who's got a CKD or four. And so you know, ETF are extremely low, but in this case, obviously she's She's had some massive bleeding and will probably require a CT, and George will necessitate contrast. So the the decision on whether to send this patient for that scan will have to be made in in conjunction with, Obviously, your seniors, your consultant, the radiology department of potential, even the renal team. If they're aware of this patient, so you know it's not. It's not a clear cut yes or no. On the patient is in stage renal failure that they won't go for a CT scan. With contrast, it's all about the clinical picture in the context there. So again, the answer, as as I'm sure you're all the question to from medical school is to do an 81st of all and ask for see your help. And so we got got a CT scan, Um, as I said shit out of the radiology register and then called the CT's radiographers to get the patient down and there was active bleeding. And then what next? So we've got no good active bleeding at the terminal ileum, and we're obviously in there the ir section of this talk. But the next step was, you know, to transfuse the patient, but have a chat with the i R fellow to see if the patient could go for a, um, Bill is Asian of this active bleeding site, which again would necessitate more contrast but could potentially save the patient's life because, you know, was it was bleeding. So this is of the images taken from on online case reports completely separate. But this shows the angiogram with some contrast, leak here out of the vessels on do again, another one with some coiling in that area, which is kind of used to control bleeding. That's one of one of the cases that you may are similar case you may find yourself referring to. I are in the future as we come to the end and I apologize. We're running over slightly, but hopefully almost getting there, I think another thing that I would have found quite useful before I started if one was to kind of think about the jobs that are ahead of you for the day after award around and this is just, you know, you can often have a ward round of, you know, 2030 patients and and then have a list of jobs like this for every single one of the worst patients. And I'm trying to figure out, like how to negotiate. Where to start is kind of a Portland, and I put a I've put another pool here, so I'm just going to start that, um, you should have a link to it as well. So just, uh, have a look at this one and just think about where you drank these jobs in which which ones need to go towards the top of page on first. I think it's just going to have a Have a little think about this, and I'll give you, uh, 20 seconds or 30 seconds to just try and do that. And with regards to, um, I just while we're getting people to rank the was a bit I might just get, uh, you back on for for a minute. Um, with regard to vetting those scans, is there any any other tips apart from the ones that we've just had a chat about? About like where? Ah, you know, where you kind of noticed people go wrong. Are you could do with a little bit advice or what? You wish you knew when you're starting is that one? Yeah. So I suppose it's so situation dependent that, um, not probably not any simple, straightforward advice regarding that, I think. Yeah, you have that feeling that you're worried about a patient. It's always good to escalate to a senior on whether it's in your own water or the radiology department. But, um, yeah, because there's always gonna be people are on the ward who, you know, decided to go into that specialty. And they won't be the first time that they've seen a patient with this particular presentation. So you know when you get to. If I won, I would just be have a very low threshold for seeking senior advice. I don't know if there's any specific What What I wish I knew during if I won regarding regarding get the vetting scan. I think most of the time I was just requesting This happens. Yeah, on That's a good start, but yeah, Grant, I've got a roll back over. Feel free to keep prioritizing the jobs there is. You see that there's no right answer to this part of the session. It's essentially just to make you think a little bit more about it. But I think there's a few jobs here, particularly there on again if you're shadowing. If one's in the next few weeks before you start, you know they they'll be able to give you a little bit. Help around this. But scan, you know, scans requesting scans and getting stands better. This kind of a job you want to get done, Azarias possible in the day, um also refers to other specialties. So there's a few here about speaking to urology, and, uM, referring to psyche is on, depending on the urgency of those referrals. They also may need to be one of the first jobs that you do after the war drowned. And, as I said, one of those tips that I think if you're in a team often times and surgical teams, that would be maybe two or three F ones, depending on where you are, I guess, and on a war drowned. And if it's appropriate for one of you to be the way in and start to do some of these jobs, that may be something you want to do. And I think people are kind of going along with that to see, you know, CT at putting the CT pee and the CT abdomen quite high opened a prioritization there chasing bloods Generally. If they're morning bloods that have been done before, you go on more ground, they won't be back anyway until you know later in the afternoon. Unless they're urgent. One's pre our group and Save is there is, well, something that patient is going to go into theater in the morning. That might be something you need to, you know, try and prioritize, and but there are there will be jobs that you can kind of, you know, it can be overwhelming, but you get used to the fact that the jobs that you can easily kind of put off until the afternoon and focus on the ones that we want to actually help get things done today, like a cannula in a patient. To Who needs that CTP that that's going to be a, you know, a a point of call back there. If the patient is called for their CT pa but doesn't have a cannula, they kind of go together on that's That's essentially what I just wanted people to have a little think about this. But you know, you you get the hang of it. No problem. Once, once you start Matt, any any points on that, thinking back to your foundation days just in complete agreement, I think Absolutely yeah, grand. This is the one of the final activities, and there's no real Um, there's no interaction point for this, but it's just as I go down through these and report conclusions that often times you might be faced with us again. Wart cover in the evenings are at the weekends. You might get handed over to chase the scan chasing scan and chasing blood results. You know, very, very common job that you get handed over is a F Y one, and it's just think about you know, it's not just a simple as a yes, no chasing the scan, often times you want to know. Like what is the team's plan? If this report comes back with this result or a different results, or even if the scan is completely normal, does that mean that you know, that's all I need to do? Or is there is there more that needs to be done and so just get so just have a read through these as we go down through So ultrasound said scan shows right sided dilate attract with obstructing stone in the proximal you is your ultrasound shows multiple large cystic lesion struck deliver parent comma MRCB revealed normal biliary tree but multilevel retroperitoneal lymph. A dinner party, possibly in keeping with the informer CTPE shops, shows subsegmental pee with evidence of right hard strain CT brain shows right side of dense artery sign suggested of the name. See it promise kind of throws back to something for me. Earlier CT tour extra meals from body conclusion of the superior vena cava likely related to compression from Jason Neoplasm north on the previous pet ct CT venogram shores Extensive DVT, which extends approximately a spirit the left common in the AC mean there appears to be compression of the left common iliac seen by the overlying right common iliac artery. I think that's the more so essentially just to think about If you if you were you know what the f I went on call and these reports to come back, what would you do? So look, we'll just run down through them again to finish it out. Ultrasound shows right side to dilate, attracted, obstructing stone approximately. Or if this this sounds like hydronephrosis is on depending on the patient's condition. You know, if they're quite septic, they may need, you know, this definitely will need to be escalated to more senior member of the team to see if they needed a frost. Me, for example, um or other surgical intervention. Um, ultrasound shows multiple areas, cystic lesions throughout the liver, parent timer. So on ultrasound showing multiple cysts like this very likely the patient will lead at least an emery. Whether that's needed you know, very likely will be next day. But escalating to senior about this and let them know that is an abnormal report would would be useful as well. And the next one here, normal biliary tree, but a lot of lymphadenopathy potentially limb. Former. So this is, um, again, quite quite a drastic report on, but I don't expected when I would say as well. So sometimes you might be waiting for an MRI CT to come back on. Do you think you know if there is dilatation of the biliary tree or whatever? But this is like, you know, would would throw you off a little bit. So, you know, this would be one you might want to have a chat with the senior about, but very likely, you know, further scans and biopsies, and that would be organized again in hours. See, TV shows a subsequent appeal with evidence of right hard strain. So obviously this this is Ah, you know, some massive p here. And you know, patient will very likely already be on on Requip gration. But it's important to ask those questions when you're chasing a CTPE. Are they already anticoagulated? What's the plan? If there's a big P, what are we going to do? An extent? A result like this, I think, would be one that you want to talk to a senior about whether they need kind of direct thrombin. Lies is our, you know, that's that's going to be a more senior decision. CT brain shows a M T A thrombus. So if you're not a strokes into yourself, you may need to get this patient to a stroke center, particularly with the dense actually signed. If it's a large occlusion of across from a vessel, they may benefit from something like stroke thrombectomy. So again, bearing in mind that, you know, trying to get appreciation for the patient context when when you're being asked a scan is important, we've got an SPCA or next, so that again you don't have a chat with maybe accused oncology or at least a consultant. You know, looking after them to see if you want to start steroids before they get a stent put in to to relieve your symptoms on a CT venogram. This is quite a specific one. If anyone got it at home, well, doing this is Ah May Turner syndrome which can cause quite a next incivek quiggle. Okay, I got a pretty off the lower limit on the left because of compression by the artery. So that's that. So I'll just have a quick look and see if there's any questions list on those. Nothing in the moment and no acute abnormalities dissected. So that's another one you might think is important. But if the patient is on well and the scan that's been done hasn't given a cause for that, then there may be need to escalate. And actually, you know, think about what else needs to be done for this patient. So if you're chasing radiology reports, it's not just as I say, a simple yes. Nor you have to kind of consider about what's next. So the conclusions here it is hard to go wrong with your discussions with radiology if you to set an experiment, which I think Matt has kind of said that, too. It's really worth putting some time and to write in your requests, because that could be the fruit framework off which you then kind of have your discussions. And if you don't have a clinical question, mind for your your scan request, then, obviously, you know, ask your team for CT. The things there that are important are obviously thing I d. So make sure it's the right patient. You know how true pregnancy where appropriate and have looked at kidney function. Think about pre and post hydrate and, if needed, Emory Previous brain are cardiac intervention, and particularly if there's any metal work in there on implants of foreign bodies, as we talked about, Um, I know a lot of you will be starting or have started your shadowing period now with their phone. So do you use this time to start making those discussions and actually, if you if you particularly if you start your discussion with, say, and I'm one of the income and if one's, I'm just on my shadow on black. I just wanted to discuss the scan with you. Then I'm sure that will agree that you know when when he's when he's back vetting scans and having these discussions that they'll all be very kind and, you know, support you in helping get along getting these scans. Yeah, and that pretty much is so questions and answers. This is just the QR code again back to this to this. This later of anyone has fallen out of us. Um, on, I guess to say that we've all been in the position that you're now in, and it is a little bit, you know, there's a bit of stress associated with starting out and all these different things just remember. But I think there's there's some really sensible kind of basic things that you can hopefully take from this. And we'll help you as you as you start off on your foot one year matter. You know, if you have any, any comments, whether we wait for no question, Yeah, I we've all bean at the stage that you are now on boast. People just want to help on Day three. Experience is easiest cross full and certainly myself. And I know my colleagues that I know it would be more more than happy to help. And if you do have a particular interest in radiology and do you come down to the department constantly every really older department in the UK But I'm sure you know, if you take interest in our work and thinking about a career in radiology, then get down to the department early ask, ask the questions and then get some experience. And I'm sure most people would be more than happy to help you out. It's a great career. Um, yeah, and best of luck, you'll be fine. Absolutely. There's no specific radiology questions. Pop it up in the queue. And eight, the moment somebody asking about dealing with 11 really are kind of difficult. Other staff members, like you know, as an F one of the words it's very rarely happens, I think, dealing with, like, you know, other health professionals such a Z you know, nurses and that, you know, I I've worked in multiple different capacities in the hospital, both as a radio friend on the junior doctor. No, I don't think that it's necessarily, you know, been an issue for me along the way. But I think, um, trying to solve these issues always at the source is if there is any kind of, uh, aggravation of that trying, go and speak to the nurse subsides. And obviously, you know you have the support network is well between your, your clinical supervisor and education supervisor to have a chat with. If there is any issues like that? Absolutely. And the vast majority of people most people are good on day, As you mentioned there, I found during my my one years and nursing stuff could be really, really helpful. And they know how they award works. They know what's going on and off. Then they'll be the best person, actually, if even just little questions about how things happen on the ward day to day and something that you might have not have been taught in in induction in the nursing staff are often brilliant. And so yeah, ask the nurses. I think that's about it. We will leave it. There s o The email that was sent out from your registration has a link to the feedback. But again, I just don't Another few are called here for you. Alter Teo work on there. So thank you very much. And thanks very much to matter who's on any relief. But as come to join us and have this chapters evening, hopefully was useful for Ah, for you all. Um I think search is not online, so I'm just going to stop sharing this for the moment and I'll just close out with the other slide. Thanks for having me. Thanks. Nori's We got there in the end, so yeah, again. I are juniors and mind a bleep. Very delighted to be working with them on this thing. Siris there to pretty recent. The second one will be coming up a session said, And I are juniors dot com is the website for lots more information about career in intervention. Radiology. If you want to get bumped in research or any projects we're doing, um, plenty of other things as well. Your particular interest and I are did, um, did a webinar series last year called Star Videos are still available in the the the IR, the website there, so kind of different areas of irons you might want to find out about. And we've got also got the applications masterclass that will obviously be relevant to the FBI ones in about two years time. But if you want to get a head start and do to do it into those on, we've got a journal club every month as well with the British side of interventional radiology eso. Yet the second session will focus more on ir and getting patients don't fry our procedures and what needs to be done before that on this is mine to bleed on D. It's the second of August is the second session. So do put that down in your calendar. See? Come along. And also, the next journal club is on next Monday the 26th. And it's looking at selective internal radiation therapy for a sec. So thank you very much again. And thanks to mass. And we'll leave it there. Uh, have a good evening, everybody. Thank you.