International Radiology Outreach: Implementation of Web-based Training Modules for Teaching Imaging Features of Various Emergency Medical Conditions

Supriya Gupta, MDSung Kim, MDRaul N Uppot, MDSanjay Saini, MDKeith J Dreyer, DO, PhD, FSIIMGarry Choy, MD 

Goal of this Educational Exhibit

• Illustrate an effort at our institution to create educational modules for teaching basic radiology skills to identify acute conditions on ultrasound and plain radiographs

• Describe use of a web-based educational portal (in development) for teaching basic aspects of imaging features of acute conditions

• Target audience includes but not limited to healthcare providers in developing countries where there is lack of formal radiology training

Background

• Physicians who perform outreach work in resource-poor settings and in underdeveloped nations are frequently non-radiologists

• Many local physicians desire additional training in basic radiology skills

• Basic medical imaging such as radiography and ultrasonography are often utilized in outreach settings

• Significant need exists for proper training of basic skills in radiology interpretation, particularly skills for identifying acute conditions on ultrasound and radiographs

Background

• Efforts in development of educational material for radiology outreach have been the work of volunteers from International Radiology Exchange (iRadX.org) and MGH Imaging Global Health Programs

• iRadX.org is a non-profit outreach organization of volunteer radiologists, a multi-institutional effort

• MGH Imaging Global Health Programs are based at an academic medical center

Background

• iRadX.org is a non-profit outreach organization of volunteer radiologists, a multi-institutional effort

• iRadX (http://www.iradx.org) is focused on education/training as well as providing remote clinical consultation services (teleradiology) for physicians volunteering in international settings

• A survey of the sites and physicians served by iRadX has found that over 49 out of the 50 physicians (98%) who are currently volunteering in the field do not have formal or subspecialty radiology training

Initiatives in Global Outreach

• Multiple academic-divisions at MGH currently have initiatives in global health

• Numerous efforts based at Partners, Harvard, MGH, and BWH focused on international outreach

• Newly created MGH Center for Global Health

• Other efforts outside our institution include those notably sponsored by the ACR, RSNA, Imaging the World and RAD-AID

Pictured: Ratanakiri Provincial Hospital,

Cambodia and x-ray reading room

Images via “Operation Village Health”

Autoimmune Hepatitis

TB resulting in chronic ureteral stricture/obstruction and marked cortical atrophy

Neonatal Pulmonary TB

Cases from Rwanda via Teleradiology (iRadX.org)

Cases from Haiti via Teleradiology (iRadX.org)

TB TBVSD

Hirschsprung’s HIV CholangiopathyNeurocysticercosis

Beyond Teleradiology: Onsite @ Haiti

Beyond Teleradiology: Sanjay Saini MD (MGH Radiology) and Larry Ronan MD (MGH Internal Medicine) on delegation to Haiti to explore opportunities for medical education / institutional development

Grant Funding

RSNA R&E Foundation Funding: Supriya Gupta MBBS has received funding for development of ultrasound modules in Rwanda, Africa for the healthcare providers of Partners in Health

MGH Imaging Global Health Programs

Program in Education and Training

Program in Education and Training

• Implementation of training modules is carried out under division of education and training under MGH Imaging Global Health Programs in collaboration with iRadX.org

• Objectives of the program are as follows:

– Establishment of educational exchange programs

– Online Learning Portal

– Development of Continuing Medical Education Programs in collaboration with international medical societies

• Establishment of educational exchange programs

– Uganda/MGH Center for Global Health (Ranu Shailam, Pediatric Radiology)

– Rwanda & Haiti / Partners in Health

– China / Peking University

– Haiti via collaboration with International Medical Corps

Program in Education and Training

• Training would be provided through the Online Learning Portal developed under this program

• Online Learning Portal - Features

– Creation of website for open-source access to learning resources

– Selected mini-courses (opt-in by lecturer)

– Contributed cases, PowerPoint presentations, and other documents by trainees or faculty

Program in Education and Training

• Development of Continuing Medical Education Programs in collaboration with international medical societies

– Example: Haiti – collaboration with Medical Society of Haiti to develop standards and also CME course for radiology training

– Example: Begun discussion with Dr. Rehani of International Atomic Energy Agency (IAEA) to identify areas for collaboration – i.e. establish training programs in radiation safety in developing nations

– Example: Cambodia Medical Society has expressed strong interest in developing basic radiology skills course

Program in Education and Training

The Training Strategy

• Via implementation of an educational web portal to host training modules in PowerPoint, PDF, and other multimedia formats that will be downloadable and freely available as open source content

• Due to restriction of available internet band- width in developing countries, condensed files would be hosted by the portal

The Training Strategy

•Modules will be classified by

– Modality

– Emergency conditions in medicine

– Prevalent disease conditions in developing countries

Interpreting Chest Films| Courses

• All courses will be web-accessible

• In this presentation, sample course on basic principles of ultrasound imaging will be demonstrated

Web Portal for Open Access Courseware

Sample Module in Ultrasound

Module 1

Fundamentals of Ultrasound Imaging –

Basic Principles & Techniques

Introduction

This chapter will familiarize the reader with basic principles of ultrasound physics, instruments,

understanding the probes and images along with achieving the best image quality. Modes of scanning

and artifacts will also be discussed.

Basic Principles

• Ultrasound machine and probes create sound waves inaudible to human ear

• These waves travel through the tissues of the patient and then return to the probe as they encounter tissues of different densities

• Intensity of the returning echo determines brightness of the image on the screen.

• Strong signals produce white, or hyperechoic, images. Weak echo signals produce dark black, or hypoechoic images

• Different tissues can be shown in many shades of gray, from white to black, depending on their density.

• Frequency is the number of times per second the sound wave is repeated, and for diagnostic ultrasound it is generally between 2 to 15 MHz

• Higher frequency ultrasound waves better visualize superficial structures and create high resolution good quality images.

• Lower frequency ultrasound waves are able to penetrate structures thereby providing a better visualization of deeper tissues.

• Different ultrasound probes are used to see deeper or superficial structures in the body.

Basic Principles

In Figure 1, a linear probe can be used to see a superficial abscess of the skin with good quality images. Conversely, a curved probe of lower frequency (Figure 2) can visualize deep structures, such as

the aorta. The decision of which probe to use for a particular ultrasound exam is based which frequency is most appropriate.

Figure 1 – Linear Probe Figure 2 – Curved Transducer

• Attenuation - As the ultrasound beam travels through the body, it looses strength and returns less information to the probe as it goes deeper

• Certain tissue densities, such as bone, diaphragm, pericardium, and air, slow the ultrasound beam, reflecting the waves and producing a bright or hyperechoic image

• Other tissues allow ultrasound beams to pass and reflect at moderate speeds, creating a gray image on the screen, such as muscle, liver or kidney

• Some tissues allow ultrasound waves to pass easily and retain their strength, creating dark black or hypoechoic images , such as blood, ascites, and urine

Basic Principles

Example illustrating difference in echogenicity based on body

structures

Figure 3 – Free fluid in hepato-renal pouch appears black (arrowheads). The hyperechoic diaphragm appears bright

white (arrow), and the moderately echogenic liver appears gray.

Basic Instrumentation - Transducer Use

• Ultrasound waves are generated by electric current that travels through quartz crystals present on probe surface

• Ultrasound waves are emitted from these crystals

• Since air scatters sound waves and creates poor quality images, it is necessary to use a liquid gel or water on the probe surface to improve contact between patient’s skin and probe surface

4a- Probe with gel

4b- Probe with water bath submersion

Basic Instrumentation - Transducer Use

• Ultrasound probe should be held lightly in your hand with the probe marker facing the patient’s right or towards patient’s head.

• For all ultrasound exams, except echocardiography, probe marker is kept in this orientation.

• The probe marker is a bump or marking on the side of the ultrasound probe that corresponds to a logo or dot on the top of ultrasound screen (Figure 5). Use plenty of gel to improve your image quality and do not apply too much pressure on skin with probe.

5- The probe marker (a)

corresponds to the screen marker (b)

Improving Image Quality

• Depth should be adjusted to improve the quality of the image by placing the object of interest in the center of the screen.

• On the right side of the ultrasound screen, markings show depth in centimeters (Figure 6).

6- Depth markings on the ultrasound screen

correspond to actual tissue depth

Improving Image Quality

• Gain is the brightness of an image, and can be adjusted for each scan to ensure that dark hypoechoic objects such as urine or blood appear black on the screen, while bright hyperechoic objects such as bone appear white

• Avoid using too much or too little gain, as shown in Figure 7

In 7a, the gain is too low or hypoechoic while in 7b, the gain

is too high or hyperechoic

Modes of Scanning

• Various buttons are present on the side of the ultrasound machine labeled as B mode, M mode, Color, and Doppler

• These are the various scanning modes a sonographer can choose from

• For usual diagnostic imaging, use B mode ultrasound

• For visualizing motion, choose M-mode

Modes of Scanning

• M Mode applies a reference line on ultrasound screen that shows motion towards and away from ultrasound probe at a depth along that line.

• M mode can be used to measure the fluttering of a fetal heartbeat, as shown in Figure 8.

8- M mode allows measurement of fetal heart rate

Modes of Scanning

• Color Doppler mode applies a reference box to the ultrasound image, within which color representing motion toward or away from the probe is seen

• This helps identify motion and patency of a vessel

• The blue or red color corresponds to direction of flow, but does not differentiate between an artery or vein

9 – Color Doppler demonstrates the active blood flow in vessels

Modes of Scanning

• Spectral, or pulse wave Doppler, provides a reference point applied over a vessel of interest to hear and see changes in flow over time as shown by the Doppler waveform (Figure 10)

• This mode is useful to differentiate artery and vein, or measure velocity of flow and stenosis across an opening, such as a cardiac valve

10 – Pulse wave Doppler on a vessel shows pulsatile arterial

flow

Artifacts

• Artifacts occur due to principles of ultrasound physics and how machine processes image

• Shadowing is an artifact that occurs deep to a very dense, hyperechoic structure, such as a gallstone or a rib

• Dark line of a shadow is seen deep to bright object since ultrasound waves are reflected towards probe on reaching highly reflective surface of a stone or bone

11 – Gallstones (arrows) create shadow artifact (*)

Types of Artifacts

• Mirror Image Artifact - when an ultrasound beam is reflected multiple times creating a false representation showing two images of a single object; The mirrored object appears deeper to the real image and disappears if probe position changes

• Posterior Acoustic Enhancement - when ultrasound waves travel quickly through low density medium, such as urine, and reflect back quickly from next high density structure encountered, like posterior bladder wall. Structures deep to hypoechoic object look falsely hyperechoic

12 – Posterior acoustic enhancement causes the area deep to the bladder

(arrow) appear hyperechoic

Teaching Goals

• Comprehension of ultrasound physics and instrumentation allows the sonographer to approach specific ultrasound exams and techniques with greater confidence

• Try to develop ease with handling the ultrasound probe and machine controls

• Be aware of artifacts that may change the interpretation of images

• And, attempt to maximize image quality by adjusting depth and gain as needed

Assessment and Evaluation of Competency

• The effectiveness of these modules will be evaluated research surveys distributed to the on-site clinician and a quiz would be conducted to analyze their learning based on modules

• This exhibit will feature a live demonstration of the website and modules

• Lectures along with notes covering the basics of radiography (x-ray) and ultrasound for use in diagnosis of acute conditions are currently being developed

• Basic skills in recognizing normal structures and findings also taught in web content/curriculum

• Educational material will be available in multiple formats (web-based, hardcopy, CD-ROM)

• All content will be made available free of charge (open source license)

• Examples of electronic formats (PowerPoint presentations, HTML, Flash, Word documents, PDF)

• Both slide-based and video-based lectures will be developed and hosted on the website

• Educational material will be in English and will be translated to multiple languages (written and audio translations). Physicians would be assessed before and after training

Format of Course Materials

Future Directions

• Collaboration with professional societies such as ACR and RSNA

– Sharing of needs assessment data

– Education and training opportunities

• Assist international medical societies in developing standards for ensuring high quality education, training, and practice of radiology

– Example: Haiti

– Additional Sites: Cambodia, Rwanda

Conclusions

• Radiology forms an important pillar of diagnostic medicine in developed countries but also plays an increasingly important role in global health

• Medical global outreach can be strengthened and enhanced via educational programs in radiology

• When compared to other subspecialties of medicine, there are significantly fewer non-profit organizations managed and spearheaded by radiologists

Conclusions

• More radiologists will become more involved in education, training, and clinical service

• Opportunities exist to build upon the work of the American College of Radiology (ACR) and Radiological Society of North America (RSNA) for international radiology outreach

For more information

For a copy of this presentation or for information relating to this exhibit, please contact:

Supriya Gupta MBBS MDsgupta11@partners.org

Garry Choy, MDgchoy@partners.org

Massachusetts General Hospital55 Fruit StreetBoston, MA

For more information

International Radiology Exchange (iRadX.org)

http://www.iradx.org

MGH Imaging Global Health Programs

http://www.massgeneral.org/research/researchlab.aspx?id=1414