Welcome to Peds!

Dr. Handly, Smith & Fordham Cathy, Crystal and Cherita

Peds

• We have a team approach to the care and imaging

of all our pediatric patients

• Day starts in the Children’s reading Room at 8 am

• Main Reading Room 4-8847

– Plain films & Fluoro

• Peds Imaging 4-8810

– CT/MR/US

• Peds Techs and front desk 4-8808

• Faculty assignments are in Qgenda

Reference materials

• Peds Fluoro Manual for residents

• Ped fluoro manual for radiographers

• RadPrimer

• Peds books on UNC HSL website

– http://guides.lib.unc.edu/radiology/books

• Pediatric Imaging: The Fundamentals 2nd ed by

Lane Donnelly is recommended for first rotation

• Additional books in reading room and

online

Lower level duties

• Fluoroscopy

• Plain films

• End of block resident case conference

with faculty mentor

Upper level duties

• Fluoro with first year for at least first week

as well as when needed as backup

• Imaging (US, CT, MR)

• Plain films

• End of block resident case conference

with faculty mentor

PACS worklists

Plain films• Lower level:

– 1st week start with inpatient then move to

outpatients (after preparing for fluoro cases)

– Lower level 2nd-4th week start with PICU then

do inpatients and then outpatients and NICU

in afternoon

• Upper level

– start with NICU in morning then move to

imaging studies

– help with plain films throughout day as

needed

Dictations

• Concise

• Relevant

• Grammatically correct

• Review macros for

accuracy

• If you don’t know what

they are asking you to

rule out, quickly look it

up!r/o ellis van creveld

no because prexial polydactyly(thumb) not post axial

Fluoro

• See fluoro manuals for details of individual

procedures

• Consider preparing cases in afternoon day

before exam

• Create worklist in PACs or EPIC for easy

case retrieval

Peds fluoro preparing for exam• Review request

– Does it make sense?

• Check clinic and inpatient notes

• Check surgical notes

• Check path results

• Review prior imaging (look at images and read report)

• Decide type of contrast and route of administration

• Page requesting physician as needed

• Review list of scheduled cases with attending and for 1st

week, upper level resident early in day

Peds fluoro

• Be ready to go when tech is ready

– Know history; medical, surgical and imaging

– Keep track of schedule

• Write in add ons on your copy of schedule

–Updates noted on white board by Peds techs

– Be aware of crying kids

• May indicate your patient almost ready

– Keep lead apron handy

• Check for and review scout film

• Check for US or other imaging studies same day

Peds fluoro • Fluoro baby trainer for practice until comfortable

• Added aluminum and copper filtration in pedsfluoro system

• Pulsed fluoro set at 7.5 f/s

• Collimate

• Keep Image intensifier close to patient

• Limit magnification

• Check position before fluoro

– Line up center of image intensifier with area of interest

• Save last image hold vs shooting spot film

• Review video rather than repeating fluoro

• Limit fluoro time and spot films

• Review case with attending prior to discharge

Fluoro baby

Peds fluoro• Introduce yourself to family

– Hi I’m Dr Jones, I am one of the radiology residents.

• Briefly review history with family– What brings you in today? – you should already know

answer

• Briefly review what you will be doing for study– Tech has already gone over

• Ask if patient or family has any questions

• Be friendly, courteous, efficient and age appropriate

• Talk to patient and family

• Be cheerleader as necessary

Peds fluoro add ons

• Tech or receptionist give you paperwork as

requests printed out or will leave for you at PACs

station

• Review request & prior imaging

– Automatic add on r/o malrotation or bilious emesis

– Discretionary add ons

• Review day’s schedule

• Discuss with attending

• Discuss with tech running schedule

• Discuss with team as needed

Add on requested for feeding

intolerance• Modified

swallow study?

• UGI?

– Bottle

– Enteric tube

• Enema per

rectum?

• Enema per

ostomy?

• These may all

be appropriate

Kids can be challenging!

Age matters

• Sensorimotor Stage (Birth - Age 2)

• Preoperational Stage (Ages 2 - 7)

• Concrete Operational Stage (Ages 7 - 11)

• Formal Operational Stage (Ages 11+)

Sensorimotor Stage (Birth - Age 2)

• Respond to the world around them

through reflexes and random behaviors

• May be helpful to allow the child to

examine and explore instruments that will

be used in the imaging study, as this

provides the child with sensory stimulation

• Stranger anxiety begins to develop at

approximately 9 months

Preoperational Stage (Ages 2 - 7)

• Can use a symbol, object, gesture, or

word to represent something and can

begin to think about past and future events

• Concrete thinking

• Egocentric

• May believe that a medical procedure is

punishment for the child having been

"bad"

Concrete Operational Stage (Ages 7 - 11)

• Can now apply logic

• More able to classify information in sophisticated

ways, understand the concepts of time and

space, and distinguish fantasy from reality

• Can not yet think in abstract, hypothetical terms.

• Cooperate best with an exam if the child feels

that she is a part of decisions about the exam:

allow the child to pick between two acceptable

options

Formal Operational Stage (Ages 11+)

• Able to think abstractly, relativistically, and

hypothetically

• During adolescence, there may be some

renewed egocentrism, characterized by

self-consciousness, self-criticism, and self-

admiration

• Respect privacy

• Include patient in all conversations

RADPED

• Rapport

• Ask

• Discuss exam

• Perform the procedure

• Exam distraction techniques

• Discuss results when appropriate

Pediatr Radiol. 2005 Apr;35(4):381-6.

https://www.cchs.net/onlinelearning/trnmnu.asp?roleid=152&caseid=109&presid=1302

Peds Radiology this is Dr. _______ may I help you?

Consults

• Phone or in person

• Listen to history and question

• Know your limits

• Ask upper level or attending as needed

• Always be professional and courteous

• If they don’t know you, don’t ask your opinion & don’t care what you think then you can easily be replaced by the lowest bidder or AI

Peds US

• Scan, scan scan!!

• Review other imaging studies

• Answer question– Protocols vs problem solving

– Pediatric abdomen is abdomen and limited pelvis

– r/o appendicitis limited to bowel

• Review with attending

• Scan, scan scan!!

CT

protocols

• Review request & history-add pelvis? Eliminate pelvis? CTA or routine? Extra recons needed?

• Review prior imaging– Decrease dose?

• kV, mAs

• Extent of imaging

– Omit iv contrast?

– Exact scanning protocol will depend on scanner

• Protocols should be done 2 weeks in advance to allow time for preauthorization and any necessary changes

• Dictate amount and type of iv contrast and specific technique in the technique section of your report

MR protocols

• Review request, hx & prior imaging– add dedicated pelvis to the abdomen?

– Gyn vs MSK pelvis vs AVN vs tumor

– Discuss/Dictate with peds attending-Protocols should be done 2 weeks in advance to allow time for preauthorization and any necessary changes

– Dictate amount and type of contrast (Dotarem unless very good reason) and scanner 1.5 vs 3T

– Dictate sedation or goggles if any, if known

PTF

• Use liberally to mark

interesting peds cases

through the department

• Review PTF in your spare

time

• Great source of material for

conference

Peds noon conferences• Twice a month

• Review peds curriculum topics in rotating fashion

• Try to avoid repeating cases or recent topics

• First conference faculty conference

– Didactic following curriculum

• Second conference- resident conference with

faculty mentor (see Peds schedule)

– Didactic or case based

Our Goals for your rotation

• High quality patient imaging

• Solid and comprehensive education for

medical students, radiology residents and

other trainees

• Research and QI opportunities

• Lots of material

• Lots of potential

Hopefully all with leave Pediatric

radiology and go on to grow up

happy and healthy