Giving Back: RAD-AID

Question: What do airships, 747’s, William Shatner, Radiology, and giving back have in common?

Answer: RAD-AID International!

Let me explain…

A few years ago, I decided to bail out of the rat-race of private practice. My original goal was to retire altogether, but it seemed more reasonable to ease out slowly, maintain health insurance and some shred of income, and have something to do, at least periodically. And so I started out working 26 weeks per year, and now I’m down to 22 weeks. Which leaves 30 weeks that need to be filled. I had originally thought I would ramp up my writing, but somehow that hasn’t happened; in fact, my articles and blog posts have been fewer and further apart. Part of the problem is that my wife has insisted upon “For better or worse, but not for lunch,” and so I’ve had to look for more to do outside the house.

It seemed wasteful to simply walk away from things Radiological and Nuclear, having trained extensively and practiced the trade for many, many years. But what could I do with this expertise? I wasn’t about to go academic, and I didn’t want to teach, at least not in the conventional sense.

In the midst of my musings, a pilot friend alerted me to an elaborate plan to convert a 747, then languishing in a Tucson boneyard, into a flying hospital:

I had strong opinions as to what imaging equipment absolutely had to be onboard, and I prepared to bombard the project with my recommendations. Sadly, the 747 proved to be the wrong platform for this purpose, and the idea was ultimately scrapped, along with the airliner itself. (But don’t despair, the concept will reappear in a few paragraphs.) Having absolutely no idea about how to make such things happen, still wanting to do something this meaningful, and basically wanting to reinvent myself, I actually tried to contact actor William Shatner, of Star Trek fame, who had reinvented himself as a businessman and philanthropist. I figured he might have some advice. Ha. Naturally, he never wrote back. What a Klingon.

So my search for a meaningful post-retirement existence continued. Ultimately, I wanted to do something with imaging, particularly with PACS and Nuclear Medicine. And through Merge (now an IBM company), I stumbled upon RAD-AID. Merge, the PACS I knew best at the time (still true) had just partnered with RAD-AID, and the picture snapped into focus for me. The announcement from September, 2015, tells that part of the story:

Merge Healthcare (NASDAQ: MRGE) today announced a new global collaboration with the nonprofit organization, RAD-AID International, (US Registered 501c3) to bring vital radiology and health information technologies to medically underserved and poor regions of the world. The collaboration—RAD-AID Merge International Imaging Informatics Initiative (RMI4)—leverages Merge’s leadership in radiology information technologies with RAD-AID’s global health outreach network, including 3,500 volunteers, 14 country-outreach programs, 33 university-based chapters and affiliation with the United Nations’ World Health Organization (WHO).

WHO reports that nearly half the world has little or no radiology services. Moreover, most of these low and middle-income countries have no access to health information technologies, such as Picture Archiving and Communication Systems (PACS), Electronic Health Records (EHR), Radiology Information Systems (RIS), Hospital Information Systems and other life-saving health informatics platforms for storing, retrieving and interpreting patient data. In collaboration with Merge’s charitable contributions of software, technical resources and expertise in radiology image-management, RAD-AID will implement these health information technologies at the nonprofit’s partnered international sites along with RAD-AID’s ongoing delivery of clinical education, on-site training and radiology assistance to comprehensively support poor and resource-limited countries.

“This collaboration between RAD-AID and Merge represents a major step forward in bridging charitable outreach and health technologies for the mission of improving global health,” said Dan Mollura, chief executive officer, RAD-AID International.

And there it was. I’ve since joined up with RAD-AID and I’ve been on mission trips to Ghana and Tanzania, and I hope to keep traveling on their behalf as long as I can still tolerate the required shots and flying around the world in Coach.

I’ll speak of my personal experiences shortly. First, you need to know a little more about RAD-AID. Most of my information comes from their website,, and my friends among the incredible folks in charge, particularly Dr. Mollura himself.

I don’t have to tell anyone about the vast improvements in medical care we’ve seen in the past several decades, due in no small part to the incredible power of medical imaging. But the advances we take for granted in the United States and Europe may be difficult to find in the Third World. And this is where RAD-AID comes into the picture:

RAD-AID began in 2008 to answer this need for more radiology and imaging technology in the resource-limited regions and communities of the world. The organization began as a few people at Johns Hopkins, and has grown to include more than 7800 volunteers from 100 countries, 45,000 web visitors per year, 53 university-based chapter organizations, on-site programs in 20 countries, and an annual conference on global health radiology.

RAD-AID’s mission is to increase and improve radiology resources in the developing and impoverished countries of the world. Radiology is a part of nearly every segment of health care, including pediatrics, obstetrics, medicine and surgery, making the absence of radiology a critical piece of global health disparity.

I’m quite proud to be one of those volunteers.

Bringing underdeveloped nations up to world-class imaging standards is not as easy as it sounds, and it doesn’t sound at all easy. Even if the funds exist to place a scanner on the ground in such a location, that is just the beginning. There must be infrastructure to keep the thing running, electricity, air-conditioning, service, parts, and so. And technologists need to be trained to operate it, and there must be enough radiologists around who are able to read what the machines produce. There are a hundred, a thousand, moving parts to this process. But if the magnificent technology that we take for granted is to come to the places where it is most needed, we have to start somewhere.

Image Courtesy of

RAD-AID begins this process with something called the Radiology-Readiness Assessment Tool. This is the heart of RAD-AID and dictates how advanced imaging service will be introduced or enhanced at any particular site. The name says it all, really:

Radiology-Readiness is a data collection and analysis tool developed and trademarked by RAD-AID in 2010, which has been endorsed and used by the World Health Organization since 2012. Radiology-Readiness is an instrument used by our volunteers and outreach teams for evaluating radiology infrastructure and planning an optimized radiology strategy that meets the health care needs of specific communities and facilities in resource-limited regions.

The survey asks some very hard questions, determining just how much technology a site can support and what will be done with the output. For example, is there adequate electrical power to support a CT or MRI? Are there drugs available to treat infections that might be found with a “simple” chest radiograph? These are questions we wouldn’t even consider in the United States, for example, but they help dictate what can be accommodated elsewhere.

Once the assessment is complete, RAD-AID can drill down to the most optimal ways of bringing about change:

Once we conduct the Radiology-Readiness Assessment, we plan the project based on that data. (Then), we implement the project based on the plan whether it means installing hardware, configuring workstations, organizing training, writing research, or designing a new technology. …(E)ducation is a central part of everything we do, and we hold training sessions so that RAD-AID can train our in-country partners to use and maintain the implemented program. More importantly, we also receive training and education from our in-country partners so that we can learn from them about clinical and cultural factors that will influence the success of our collaborative program.

Lastly, we work with our in-country partners to analyze the results of the program, to find what worked and what did not work. In this way, we identify new challenges to face and find new resources to strengthening the program. Then, we return to step one and repeat our Radiology-Readiness assessment so that we can see how our project had positive impact and what gaps need to be addressed. This circular iteration of data, analysis, planning, self correction and new data collection keeps RAD-AID moving forward.

Rather like iterative reconstruction of an image, isn’t it? Each pass yields better and better results.

As a “seasoned” volunteer, I can tell you this program works, quite well, in fact.

My first trip took me to Korle Bu Teaching Hospital in Ghana, where my task was to help train residents and Consultants (what we call Attendings over here!) in the use of their new PACS, donated by IBM/Merge as you read a moment ago. I’ve been using PACS for something like 25 years, and there are many aspects that are second nature to us. Think about comparing the current to prior exam. You can do it with film, if you have enough view-boxes, but with PACS, it’s trivial…IF you know how to do it. Simply demonstrating the process of bringing up the prior alongside the exam to be read led to some huge grins and aha! moments. You cannot imagine the satisfaction of seeing the promise of soft-copy reading rediscovered, and assisting in the process.

Working with PACS at Korle Bu Teaching Hospital, Accra, Ghana

I’ve just returned from my second trip, with the tremendous honor of receiving the Hyman-Ghesani RAD-AID SNMMI Global Health Scholarship (in partnership with the Society of Nuclear Medicine and Molecular Imaging) for travel to the Aga Khan Hospital in Dar es Salaam, Tanzania. RAD-AID’s focus in Tanzania is on oncologic imaging, and building diagnostic capacity in Arusha, Moshi and Mwanza to create a band of interconnected institutions in northern Tanzania. My task was to help improve Nuclear Medicine services, and frankly, I really just had to make the medical staff aware of how good their NM department really is. Given the limitations of having to have a Molybdenum/Technetium generator flown in from South Africa every two weeks, having to share the only Nuclear Medicine physician in Tanzania with the hospital down the road, and having one and only one technologist who also serves as the physicist, Radiation Safety Officer, radiopharmacist, nurse, and occasionally, the janitor, I give this little department the highest marks. I did have the privilege of supervising Tanzania’s first sentinel node procedure.
Reviewing sentinel node map with the Chief Surgeon, Aga Khan Hospital, Dar es Salaam, Tanzania

I cannot wait for my next travel opportunity! With a bit of luck, I’ll get the chance to return to Ghana and Tanzania, and perhaps to visit other sites as well. We’ll see what the future brings. I went to each nation knowing no one, but left many friends behind when I returned home. My wife probably didn’t think the “for better or worse but not for lunch” thing would evolve into me going to Africa for two weeks at a time!

Oh, yes…the flying hospital concept, with advanced imaging onboard…Well, it might fly yet!

Image courtesy RAD-AID and Straightline Aviation 

From the press release (do read it in its entirety):

Straightline Aviation today signed a memorandum of understanding with RAD-AID to launch a humanitarian and philanthropic medical assistance program using Lockheed Martin’s Hybrid Airship, uniting aircraft innovation with health technology for a new approach to global health outreach.

The RAD-AID Straightline Medical Airship Program will deliver advanced radiology health services, diagnostic medical imaging equipment, and medical assistance to populations that are medically underserved, remote, or limited by poor access to conventional transportation infrastructure.

I wish I’d thought of that! An airship does indeed make much more sense than a 747, which gobbles fuel and needs a good-sized runway to takeoff and land. I’m hoping to be on the inaugural flight, whenever that may happen. (It might not be the U.S.S. Enterprise, but then I’m not Dr. McCoy, either. Hear that, Mr. Shatner?)

We went into healthcare, and into medical imaging, to make a difference. RAD-AID offers the opportunity to do just that, and to give back in ways I could not have imagined. And so, I urge you, I beg you, I implore you…go to the RAD-AID site,, and sign up to be a volunteer. (And please consider donating to the cause as well. Bringing imaging to the world takes vast amounts of funding, and every little bit helps.)

RAD-AID has literally hundreds of opportunities for everyone in imaging from physicians to medical students and residents, as well as radiologic technologists, sonographers, nurses, physicians assistants, health physicists, as well as specialists in health information technologies and public health. If you have a radiologic skill, there’s a place where you are needed. Trust me on that. You will help others, and you will grow as a person. Likely, you will learn more than you teach, but that’s part of the process.

I mentioned the sentinel node procedure above, the first to be done in Tanzania. Think about it. Thanks to RAD-AID, an old (not that old!) Jewish radiologist from the Deep South of the United States had the opportunity to go to Africa and help its citizens. As it turns out, the sentinel node patient and her husband were Muslim followers of the Aga Khan. They were very gracious, and demurred when I thanked them for consenting to be the first to have this done in country. In fact, the husband gave me what I consider the greatest compliment I have ever received in my career: “G-d has sent you here to help her.” I cannot vouch for that, of course, but certainly RAD-AID deserves the bulk of the credit.

THIS is the promise, the incredible potential of RAD-AID. I urge you to be a part of it.

via Blogger September 18, 2017 at 03:54PM


Lions and Sentinel Nodes!Oh, My!

Eid Mubarak!

It seems surreal that two weeks have passed so quickly. As today is the holiday of Eid Al-Adha, the hospital has very little activity, and I’m taking the day to pack, catch up on correspondence, and perhaps pay one last visit to Slipway for lunch.

This was on Page 16 of the local English-language newspaper a few days ago. A coincidence with my arrival in country? I wonder…
I haven’t posted since heading out to Ngorongoro Crater, so let me briefly fill you in on that incredible experience. I’ll place some photos here, but they can all be found at THIS LINK for your leisurely perusal. 
I left Dar in the afternoon, flying to Arusha, the gateway to the Serengeti and Ngorongoro. There is a larger airport in the area, Mount Killamanjaro field, built by Israelis I’m told, which was further away from the action. So I hopped on Coastal Air’s afternoon flight to ARK:

You know you ain’t on Delta when the pre-flight briefing from the pilot consists of: “Put on your seatbelts! By the way, if we don’t get to Arusha before dark we’ll have to to to Killamanjaro instead.” 
We did make it, with only a little chop as we flew past Mount Killamjaro itself:

At least I think it was Kilimanjaro, as the pilot made no announcements. I had my phone going the whole time, since no one said we couldn’t, and I was sending pics home from the air. Without GoGo Inflight.
Once safely on the ground, I was retrieved by Ernest, my guide for the weekend. Thanks to my friend Stacey, who has travelled extensively in these parts, I was connected to Ernest via his brother Allan, who was Stacey’s guide here.

Let me stop and say right here that if I have the good fortune to return to Tanzania, I will be calling upon Ernest (and Allan.) He is the BEST, and I recommend him highly. If you are headed this way, let me give you his contact information. 
I spent Friday night in Karatu, as I arrived too late in the day to enter the Ngorongoro Crater Conservation area itself. But Allan owns a place there, the Oldeani Safari Lodge, and it was very pleasant:

And the next day…Safari! I won’t post every last little detail or photo…look at the Album if you like. The partial list of animals encountered includes lions, baboons, ostriches, Cape buffalo, wildebeest, fox, one elephant, hippos, Thompson’s gazelles, zebras, hyenas, warthogs, and a fair number of humans in Land Cruisers.

I have to laugh when I think of the folks in the States who paid $100,000 for the GX570, the Lexus version of the venerable Toyota Land Cruiser. Little do they realize that their soccer-mom grocery-and-rug-rat transporter has these tanks of the savannah as their heritage. I do have to tell you that the ride can only be described as punishing. There are far more potholes than road, and many was the time I was convinced we were either going off the road or into an oncoming Cruiser. But that didn’t happen, obviously. On trips like this, you have to put your fears aside, and trust your life to your driver or pilot, whatever the case may be. And that trust is most always justified.

Suffice it to say, this was a once-in-a-lifetime experience that I hope to experience more than once!

After a long day with the animals, we went to the Serena Ngorongoro Hotel, where each room overlooks the Crater. Here is sunrise over the far rim, as seen from my balcony:

And alas, all good things must come to an end, so Sunday morning, Ernest drove me the three hours back to Arusha. Unlike the trip out, we were only stopped once by police at a roadblock. The junior officer checked Ernest’s license, then the senior fellow wandered over, pointed to the front of the Land Cruiser, and remarked that Ernest had no winch. But fortunately, the gentleman owns a company that sells such things and perhaps Ernest might be interested. My guide had no need, but he gave out a relative’s number who might be in the market. Such is life here, it seems.

The trip back was on a much larger Precision Airlines turboprop, with colors and flight attendant uniforms apparently stolen from 1970’s Braniff. But for a small regional line, the trip was just fine, and they did make the passengers turn off their cell-phones.

This being a four-day week due to the holiday of Eid, we still managed to get a lot done. Here we are performing a MAG3 scan on a baby with renal problems. I convinced the urologist to try MAG3 instead of the more traditional DMSA, as the latter provides a much higher radiation dose to the kidneys.

I was shown a very unusual case of a neglected child:

I texted the images to my pediatric radiologist colleague back home, and we think this is a case of scurvey. We read about this entity in training, but pretty much never see it live.

Here I am with Dr. Tausi, the only Nuclear Medicine physician in Tanzania! Well, after I go home she’ll again be the only one!
This is Zara, the head CT technologist, making the Aga Khan Hospital’s Philips 128-slice CT work to its maximum potential. 

On my second-to-last-night, Raghu and I had dinner at Akemi, the only revolving restaurant in Tanzania, 21 floors above street level. It may well be the most expensive restaurant in Dar, but the view is worth it.

I think the highlight of the week, and in some ways the highlight of my entire visit, was the chance to oversee the very first Sentinel Node procedure done in Tanzania:

The tiny dot on the image shows migration of tracer to the “sentinel” node, the first node in the drainage pathway from a tumor site. By directing the surgeons to this node, using imaging and an inter-operative probe, it can be excised before any other nodes. If Pathology determines that this node has no disease, further dissection is unnecessary. I was present at the operation itself, and the surgeon handled the probe as if he had been using it his entire career. He even apologized to me for “taking so long” to find the node! (In my 36 years in the medical field, no surgeon has ever apologized to me in this manner!)

To me, this procedure illustrates the incredible potential and promise of Rad-Aid: An old Jewish radiologist from the Deep South of the United States has the opportunity to go to Africa and help its citizens, and here, the sentinel node patient and her husband were Muslim followers of the Aga Khan. They were very gracious, and demurred when I thanked them for consenting to be the first to have this done in country. In fact, the husband gave me what I consider the greatest complement I have ever received in my career: “G-d has sent you here to help her.” I cannot vouch for that, of course, but certainly Rad-Aid, and those with Hyman-Ghesani Scholarship get much credit.

The other notable events of the week included another lecture to the staff on Tuesday, this one about PET/CT, and a meeting with the CEO and COO on Wednesday. I hopefully got the staff excited about PET/CT, a modality which has tremendous potential to help the victims of many cancers, and of other diseases as well. I am informed that the Aga Khan Hospital in Nairobi may be getting a PET facility, including a cyclotron, in the near future, and the presence of the cyclotron so close to Dar es Salaam will allow the possibility of placing a scanner here as well. This would be an incredible development, placing the Aga Khan Hospital System at the forefront of Oncology in this region.

I have discussed some of my ideas with the folks here, and present them only as my opinions, for whatever they might be worth. In no particular order, here are some of my thoughts and observations:

  • I would like to set up some sort of semi-formal reading pipeline back to the US, perhaps including my group and others as suitable. The new Agfa PACS (it is what it is) will simplify the mechanics of such a conduit, but more bandwidth/faster Internet connections will be needed to make this practical. I realize this is a costly suggestion, but hopefully it can be made worthwhile.
  • While Dr. Tousi has great expertise and is doing a very good job with the Nuclear Medicine studies, as business improves, she will need help, and eventually AKH might want to have their own NM Consultant. In the meantime, PACS will enable Dr. Tausi to at least provide quick preliminary reports from her hospital, as she is “on loan” from the Ocean Road Cancer Centre down the street.
  • Similarly, Raghu is doing an incredible job as a “one-man-band” running the department all on his own. As business ramps up, he will need help for daily activities, and he will need a back-up so he can go on vacation with his family. I was very impressed with his professionalism, expertise, ability, and devotion to the department. 
  • For the more distant future, when the Radiology residency program is up and running, I would like to see cross-training the residents in Nuclear Medicine. This has been done since the ancient days when I was a resident in the U.S., but elsewhere NM remains its own separate field. Having been trained in both camps, I say with some regret that NM is at a disadvantage as a discrete entity with the advent of SPECT/CT, PET/CT, and ultimately PET/MR. Cross-sectional imaging has become the core of Nuclear Medicine AND Radiology, and the combination of the two for training seems to make sense. 
  • The promotion of Nuclear Medicine studies with the staff needs to continue. Dr. Tausi, Raghu, and I met with Marketing, and they have some thoughts on how to proceed. From my standpoint, I would suggest quickly getting an email, or even a physical letter, sent to every physician on staff. It doesn’t have to list everything we can do in NM, but simply reiterate that the capability is there, and confirm that there are many things we can do to help the patients.
  • There was apparently some question raised by an earlier visitor about CT doses. This is not my area of expertise, but to the best of my ability to evaluate, the only problem is the use of multiple sequences. A CT of the abdomen might consist of a pre-contrast, arterial phase, venous phase, and several delays. In many if not most cases, not all of these are necessary. I have provided the protocols we use at home to Zara, the CT technologist, who is quite conscientious about this situation and will be able to contribute to the solution. While volumes are still relatively low (which will certainly change when the new department is ready), there is the possibility of tailoring each individual examination. There will follow a comfort level with fewer sequences in many circumstances.
  • Having seen what happened in Ghana, where the hospital had PACS but no RIS, I am happy to see that AKHS has chosen a combined RIS/PACS package. I understand the plan is to migrate the Clear Canvas and the Nuclear Medicine examinations to the new system. It is imperative that names, Medical Record Numbers, and birthdays are entered in a consistent manner to match the patient to all of his/her examinations and records. I’m assuming Agfa will have a migration tool to facilitate this process. It can be VERY tedious, but well worth it. I know from speaking with the head of IT that the Patient ID is central to the expansion of the Aga Khan Hospital System, and he has a tremendous understanding of this critical concept.

​I came to Tanzania knowing no one, but I leave many friends behind upon my return home. I have been treated with warmth, courtesy, and the utmost kindness​ by everyone I have met here.

I hope to bring Mrs. Dalai here to see this incredible place for herself, and I would be honored to visit Aga Khan Hospital again in the future if I can be of any assistance. In the meantime, I’m expecting to hear from everyone via email or WhatsApp!
Until we meet again!

Asante Sana!!!!

via Blogger September 01, 2017 at 05:41AM

Flavors of DVI

I just completed (a rather long) Day 4 at Aga Khan Hospital, here in Dar es Salaam, Tanzania (in case you didn’t know where I was). As usual, time flies when you’re having fun, and I really am enjoying my time here.

Today was a day of many hats. In the morning, I played “real doctor” and attended an OB Gyn lecture series beamed over from the Aga Khan University Hospital in Nairobi:
The full title was “Female Sexual Dysfunction and its Effects upon Fertility” and it was quite well done. While the lecture will have little impact upon my medical practice, I’m trying to get the staff used to me hanging around, and I had high hopes of amusing the residents with my tales of the wonders of Nuclear Medicine. Which didn’t happen today. That will hopefully come tomorrow, when I give the “Introduction to Nuclear Medicine” talk. Maybe there will be a great turnout. They sometimes offer breakfast with the talks around here, and residents anywhere in the world will do anything for free food. 
The rest of the day I became everything from Nuclear Medicine junior technologist to junior Nuclear Medicine Staff to IT assistant. Raghu, the absolute genius running this department, had an onslaught of patients, as the Molybdenum/Technetium generator arrived yesterday from South Africa:

In many ways, this symbolizes the problems of Nuclear Medicine in a place like Tanzania…even something as simple (to us) as a Technetium generator must be shipped by air from South Africa, via Nairobi. And due to various regulations, it can take several days to arrive in country. This generator actually got here almost a day early. (I’m told of an incident wherein the guards at the airport wanted to disassemble a generator…the doc in charge said something like, “Go ahead, I’ll be on my way to Zanzibar as fast as I can go..” 
Because of all this, Raghu must tightly schedule his patients for the days following delivery. He can hope to have some extra activity remaining for emergencies, and it is possible to get a dose here and there from the Cancer Center down the street. (Their cameras have been out of service this week, and Aga Khan hospital has stepped up to scan some of their patients.) I am constantly reminded of just how spoiled I really am back home. We NEVER have to wait on a generator, and something like a CCK shortage is an incredibly rare pain in the backside about which we whine incessantly. 
I was able to help with some of the clinical duties as well, taking histories, and even writing notes for the patients! I signed them all, “Visiting Nuclear Medicine Physician”. I hope I don’t get in trouble with any boards here. 
The Siemens Symbia SPECT (sadly not SPECT/CT) is a battleship of a camera, and Aga Khan Hospital is incredibly fortunate to have one. I’m a reluctant fan of the eSoft computer system, however, and at several points, Raghu and I struggled a bit to force the thing to do what we wanted it to do. Scaling of one image vs. another for subtraction of a parathyroid image should be easy, for example, but Siemens hides the key to activating the Scaling feature. So I put on my Engineer cap, and started clicking buttons until I found the right one.

Soft-tissue attenuation can be a problem in cardiac Nuclear Medicine. Now, I’m somewhat removed from this as the Cardiologists have stolen/taken over now read the MIBI perfusion scans. My newly minted Chief Tech back home reminded me before I came here that prone scanning would help here, and I suggested we try this with today’s solitary MIBI patient. (There was a second, but he had to meet with government officials, and apparently my letter did not get him out of whatever it was he had to do.)

The Siemens eSoft interface is not incredibly intuitive for setting scan protocols (but the hardware is bullet-proof, so I give them a pass), and we had to resort to hand-drawn schematics to confirm to ourselves that when prone, the patient should be scanned from LPO to RAO, and that a 90-degree orbit of the two heads opposed at 90 degrees would yield 180 degrees of coverage. The things I do for my patients…

The rest of the day was consumed with monitors and their connections to Ultrasound scanners. While the Radiology Department is about to go completely digital with Agfa PACS (don’t say anything), moving off the venerable Clear Canvas (which actually works quite well here), the U/S scanners do NOT have DICOM licenses. This is a sad situation I faced in Ghana. It seems that over here, the vendors charge EXTRA for DICOM. Not nice, folks. Not nice at all. So the three U/S machines here aren’t connected to anything except printers. Now supposedly there will be funds allocated to get the DICOM running once full PACS is here, but in the meantime, there is the desire to view the images in real-time. Which means looking at the monitor. Originally, the thought was to purchase a large monitor and a KVM switch to multiplex the inputs from the three scanners into one station. But by the time I got here, the idea had gelled a bit and the Chairman realized that three small monitors cost less than one big one and a multiport, multi connection KVM. So I spent a good bit of time with one of the guys from IT, connecting a monitor to the various scanners. One scanner, fortunately in the room right next to the reading room, has only a DVI output. The other two have VGA. So it now becomes a matter of figuring out how to string cables to connect the various rooms. That one is above my pay-grade at the moment.

We did discover whilst trying various DVI cables in various sockets that there are two main (actually more) versions of DVI, DVI-I and DVI-D. (And DVI-A, but that’s beyond our scope)…

DVI-I has extra pins not found with DVI-D, and so a male DVI-I plug won’t fit in a female DVI-D socket. Sounds like some dysfunction to me after the morning lecture. But the good news is that we now know what cables we need, and the only remaining question is how to run them.

With that solved, I shall have some dinner, finish my packing for my quick trip to Ngorongoro Crater tomorrow, and turn in early to be ready for my early morning talk.


via Blogger August 24, 2017 at 12:19PM

Patient ID

Hello from the Aga Khan Hospital, Dar es Salaam, Tanzania!

Just wanted to let you know that I’m here and on the job. I’ve met so far with the head of Radiology (who is also the Chief of Staff of the Hospital), the head of IT, the Nuclear Medicine technologist/physicist, and briefly with the Regional CEO and the COO of the hospital. Everyone has gone out of their way to make me feel welcome here, and their warmth, and their pride in this amazing place is incredible.

I am quite taken with the facility as it stands, but the additions, and plans for the future, will certainly propel AKH well into the forefront of patient care in this region. I was most impressed to find that the AKH has passed the stringent Joint Commission standards, which is quite an achievement for any hospital.

The plan will be for me to talk about Nuclear Medicine with the clinical staff one-on-one as the opportunities arise. There may be a chance to give a talk to a larger grouping of the staff, and the request has been that I discuss PET/CT at that time. I plan to have a presence in the Imaging reading room as well, and hopefully IT can put me to work with some connectivity tasks.

At the end of the day I met with the Nuclear Medicine Consultant, who comes in after her regular stint at the Ocean Road Cancer down the street. She works closely with the physicist who essentially runs all of Nuclear Medicine, juggling the schedule to match the delivery of the Mo/Tc generator from South Africa, serves as RSO, and cleans up radiopharmaceutical spills. And he’s a physicist, not a technologist!

I talked a bit about PACS with the head of the department. We have had Agfa PACS at home since 2003, and apparently this will be the replacement for the venerable Clear Canvas installation here. Any of you who have read my blog know of my trials and tribulations with Agfa, and I expect our experience has been parlayed into a better product on Agfa’s part. We briefly discussed CT protocols, and I’m going to have a peek at those. AKH has a very capable Philips 128 slice scanner, (and some very capable people running it) and I’m sure it won’t take much tweaking to optimize it.

It seems the major staff CME occurs on Tuesday mornings. I’ve missed getting on the schedule for tomorrow’s session, but we ran into the pediatrician in charge of staff education, and I’m set to give a talk next Tuesday. I plan to give my introductory lecture about Nuclear Medicine. We are going to try a different idea for some of the remainder of the time; I’m going to try to approach the clinicians in one-on-one fashion, perhaps join in on rounds if that is permissible, and suggest the appropriate Nuclear Medicine studies when, well, appropriate. I’m not certain we can gather more than a handful of physicians at any other time, but if so, I’ve got other talks to give.

These are exciting times at Aga Khan Hospital. The expansion, physically, strategically, and if I can make up a term, informatically, appears very well thought-out. It is ambitious but rational, and achievable in scope. In particular, the outreach to outlying clinics seems to be quite logical, with development paced by the best connectivity available to the individual site. I can tell you, when the head of IT said the entire process is built around the Patient ID, I was hooked. This is exactly the problem we faced (and continue to face) at Korle Bu, and it is gratifying to see it addressed from the very start.

All in all, this has been a wonderful first day on the job. Again, I’m very grateful for the opportunity to be here.

More to come!

Oh, by the way, I had to miss the eclipse to be here. As seen from my backyard by my wife and friends, it might not have been all that spectacular…

via Blogger August 21, 2017 at 04:05PM

I Bless The Rains Down In Africa…

You just can’t be in Africa without thinking of Toto’s song by the same name, and I can’t resist offering both the original and a very moving chorale version:


Now that we have that accomplished, let me say Jambo to everyone from here in Dar es Salaam, United Republic of Tanzania. I got in last night, and to adjust to the time zone (7 hours ahead of Eastern Daylight Time), I’ve done my usual brief walk-about. (I have to admit that I was rather disappointed by the rain, as it made me decide not to take a boat-ride to the nearby island of Zanzibar. Oh, well.)

Dar is a large city, the capital of Tanzania. It is somewhat similar to Accra, my only other personal reference point, but there are some profound differences. You may recall my comment that Accra contained throngs of people. People everywhere! Milling about, selling things in roadside or sidewalk stands, and so on. Now I haven’t seen that much of Dar es Salaam, but what I have seen is much different. Things are much quieter, there are far fewer people on the streets and sidewalks, the traffic isn’t quite as congested. I’m not sure how much to make of this, and perhaps it will gel as time goes on. M initial thought was that Tanzania might be a wealthier nation due to tourism, but it turns out that the economy is mainly agrarian, and tourism has not yet been effectively tapped. Tell that to the vast majority of folks on my flight from Amsterdam last night who got off at the Mount Kilimanjaro airport to go on safari. Ghana has far more natural resources, according to the Wiki, so I’m probably missing something.

Unlike last time, I’m staying in a hotel rather than the hospital guest house. The Aga Khan Hospital is undergoing major construction and expansion, and no one was sure there even are any guest rooms at the moment.

So I’m staying in the Marriott Courtyard. Here’s the courtyard of the Courtyard:

I hit two of the highlights of Dar on my little trek, the National Museum and a waterfront area called Slipway. The Museum is quite near the hotel, located in an area full of government buildings. As I walked by the Prime Minister’s office, a monkey dashed across the street directly in front of me. That’s something you don’t see in Washington, D.C. No comments, please.

The small but fascinating museum had a nice display of artifacts, fossils, and replicas thereof from Oldavi Gorge, the birthplace of human-kind (which I might get to see over the weekend). I found an old relative…meet your great^1,000,000th grand-daddy, Mr. Hominid:

Do you remember hearing about David Livinstone, the great explorer (Dr. Livingstone, I presume..)? Here’s his writing desk:

Slipway is a nice waterfront area with several restaurants, shops, and a craft market. Here I am enjoying a libation, which you can’t see it but rest assured it was only bottled water:

This was my first view of the Indian Ocean from its western shore; I had the chance to stick my foot in it from the Australian side when I spoke in Perth in 2010. Dug-out canoes are ubiquitous:

The craft market featured lots of paintings and wood carvings, as well as bright fabrics and clothing:

I was quite taken with the carved birds. Might have to go back to get a few.
I did stop at the hospital to say hello on the way to the National Museum. I was able to speak with the ER physician, but apparently the Radiologists (and Nuclear Med physicians) are not in-house on the weekends, and come in on call. How often that happens, I don’t know, but I’m already wondering if they need more rads. I’m sure some of my colleagues would be interested, although I wouldn’t trust them to drive on the left side of the street. 
Tomorrow, I hit the ground running. The plan is to give lectures and see if there is anything I can do to help with workflow in the Nuclear Medicine department. But if this trip turns out to be anything like my last mission, I’ll be the one who learns the most. 
As I found in Ghana, one is greeted with “You are welcome!” which I think makes far more sense that saying it after being thanked as we do in the US. However, the word for “You are welcome” in Swahili is Karibu, and the first few times I heard it, I wondered if the speaker was directing me to look at some wildlife that had wandered into he hotel lobby. Hopefully by the end of two weeks here, I’ll catch on a bit better.
But in the meantime, I’ll bid you kwaheri.
Stay tuned!

via Blogger August 20, 2017 at 12:28PM

Life Imitates Art: Apple Listens to Doctor Dalai

I’m sure this is all my doing. Remember my April Fool’s Day post a couple of years ago about the “NEW Apple EMR”?

Well, it seems Apple has taken the hint. From Healthcare IT News:

Rumors are at a fever pitch that Apple has big plans for healthcare, including putting a medical record on the iPhone, possibly acquiring its way into the EHR market.

From its leap into healthcare in 2014 with its HealthKit application programming interface in September 2014 to the June 19 revelation of Apple’s work with the tiny start-up Health Gorilla, Apple has made a series of moves in healthcare that clearly indicate the company has plans for the space that will somehow manifest on its mega-popular iPhone and iPad products.

Here’s a look at how Apple got to where it is today in healthcare.

The article proceeds to describe recent Apple acquisitions in the healthcare space which appear to point to an eventual (huge) presence in the HIT realm:

I’m going to direct you back to the original article, titled, “Timeline: How Apple is piecing together its secret healthcare plan” for the details, but suffice it to say, they are pretty clearly targeting the healthcare market. An EMR is the next logical step.

Could Apple PACS be lurking in the wings out there in Cupertino???

via Blogger August 01, 2017 at 09:00PM

Excuses, Excuses, Excuses…Must Be The Russians’ Fault, But The AI STILL Isn’t Taking Your Job

Forgive me, loyal readers (both of you), for I have sinned. My last post was in May, months ago, and I’ve not posted since. This is unacceptable, and I humbly accept my penance of getting my writing back on track.

But there are reasons for my sloth. No, the Nuance Ransomware foolishness is not at fault. I don’t use Nuance, and I do apply security patches the moment they are released. Unlike Nuance. (I guess if you can convince the healthcare world that Speech Recognition actually works, you must feel invincible.) As you know, I’m going on another Rad-Aid trip to Tanzania in a few weeks. My task there is to aid the growth of Nuclear Medicine at the Aga Khan Hospital in Dar es Salaam. To that end, I’ve been quite busy putting together a number of lectures covering at least the basics of NM. Creating these talks is certainly a labor of love, and I’m hoping I’ve hit close to the mark on the level of complexity I’ll be presenting. I found on my previous trip to Ghana that the physicians were nothing short of brilliant; what I had to offer was not knowledge per se, but rather 28 years of experience in private practice. I suspect I’ll find the same in Tanzania. Please stay tuned for my daily (mostly) log of the trip. I do plan to make a 48 hour excursion to the Ngorongoro crater, and I’m not sure what sort of WiFi might be found there, so expect a gap. I’m hoping to spend one afternoon on the nearby island of Zanzibar as well; it is said to have some incredible beaches, and, well, it’s Zanzibar!

I’m taking a break from taking a break in writing due to a recent, rather sad post on Aunt Minnie from a fellow (I chauvinistically assume) named shouldadonerads:

Hi everyone,

I was seeking some advice on a peculiar situation I’ve gotten myself into. I graduated med school in May. I applied for rads and received 20+ interviews. However lurking these forums and others I couldn’t stop thinking about the AI scare and ended up applying to another specialty concurrently and ranking both. I ended up marching into the other specialty. I am currently in a transitional year and set to start the others soecialty in 7/2018. However I feel a deep sense of regret and realize now that rads is really where my passion lies.

Is it still possible or advisable for me to get a rads spot (I want DR not IR). If so, how should I go about this. Thank you very much.

On a side note, the amount of negativity I encountered on forums and even my interview trail was ridiculous. On more than one occasion I had a PD/faculty member question why anyone would go into radiology now. I accept sole responsibility for the predicament I’m in. But just as a side note, for those that are here in positions of interacting with medical students, please keep in mind what you say really effects prospective trainees and their view of the fields, possibly a lot more than you think.

Emphasis mine.

This makes me sad. No, this makes me angry. Really angry. You folks out there pushing the “AI will replace radiologists” meme are HURTING people. Like Dr. Shouldadonerads. And you are hurting the profession. Why are you doing this?

There are a number of possible explanations. Some truly believe that machines will someday (soon) take our jobs. Some might have invested in AI startups (or IBM). Some might think there are too many radiologists, and wish to thin the herd. And some are just jerks, trolls who want to make trouble. After all, they say, we have self-driving cars and Google can recognize a picture of a cat. Thus, robot-rads are obviously just around the corner. Right.

I cannot say with absolute certainty that machines won’t be able to read studies, render final reports, and displace rads, but I seriously doubt that this will happen. Conversely, I would take with a Mt. Everest (or shortly for me Kilimanjaro) sized grain of salt any claims that they will. I’ve had the opportunity, as I’ve reported previously, to speak with many of the principals of IBM’s Watson Health, and they insist that Watson will be a tool to be used by Radiologists, nothing more, nothing less. And I’ve even had a long chat with the person whom I most respect in this space, Dr. Eliott Siegel, who has been researching AI applications in Radiology for a very long time. Dr. Siegel is adamant that we are not going to be replaced. The key is to control the development of radiologic AI’s, he says, and I think he is absolutely correct.

While Wall Street has an imperfect record of accurate predictions, the old phrase, “Follow the money!” tends to be a safe recommendation. Hugh Harvey, a British Radiologist quite actively involved in commercial AI medical applications, writes in “Where to Invest In Radiology AI“:

Avoid companies claiming to replace humans. Not one single company has ever got FDA approval for a clinical diagnostic device that is not overseen by a human. Instead, to reduce regulatory burden, look for companies producing software that works alongside and augments humans, known as Clinical Decision Support. These may be triage systems, quantitative analysis tools, registration or segmentation systems. If you absolutely must invest in a diagnostic service, be sure to have deep pockets – FDA fees for PMAs start at $250,000. Good luck to you!

Dr. Harvey dismisses the famous Gregory Hinson’s famous dismissal of Radiologists: “We should stop training radiologists right now,” declared Google’s Hinson. Not so fast, says Dr. Harvey:

I’m a huge evangelist of AI in radiology, but also a pragmatist and a realist. I do not subscribe to the ideology that radiologists will be replaced in a mere 5 years time, but I do believe that radiologists will be incredibly well served and augmented by AI within the next decade. My respect for Geoffrey Hinton is immense; he is quite literally the godfather of image perception, after all. However, his famous quote over-eggs the pudding quite considerably (and I’m sure that if pressed he would clarify and cushion this statement!). For starters, his implication is that the only thing a radiologist does is interpret images — a huge misrepresentation of an entire profession. He also assumes hospitals will accept new technology unquestioningly. I only need point to the abysmal uptake of CADx software over the past decade to demonstrate how difficult it is to infuse new tech into the clinical frontline…

AI promises huge amounts of future reward, but total replacement of radiologists is not happening in the foreseeable future.

The nay-sayers thus have either been taken in by hype, or have some reason for spreading it.

Some hype is good; it helps drive research, bring investment, raise awareness, creates competition. But hype can also be detrimental; it can lead to over-promising, lack of investment in improving current practice, and rushed unscientific approaches to problems. . . As we start to drop over the hype apex into the trough of disillusionment, we will start to see excitement wear off rapidly as reality sets in. 


Clearly, we are still at the Peak of Inflated Expectations. As for investing, do take Dr. Harvey’s advice (again, emphasis mine):

Invest in companies that will help grow radiology AI as a sector, not just the end products. If I had a multi-million fund to invest, I wouldn’t even look for companies involved in image interpretation. What is sorely needed in the field is not the algorithms (these are the fruit) – it’s the infrastructure behind it (the trees) that’s important. Invest in the orchard!


My final piece of advice is simple: be a tortoise, not a hare. You are in for the long haul. Do not expect significant return in under a 3 year timescale. Spread your investments and plan for a 5-10 (even 15) year period of scaling. Those who invest wisely now and choose companies that can scale smartly on focused problems can lead the market infrastructure. Those who rush and over-promise will only have to play catch-up later down the line.

While there are a good number of small-fry out there, working on this piece of AI, that piece of machine-learning, the other bit of image recognition, etc., I would have thought IBM’s Watson is closer to becoming our little electronic helper than anything else out there. I’ve always had tremendous respect for IBM (although I still favor Mac over PC’s) and if any company can get there, it should be IBM. But even Big Blue is seeing a tinge of red…

While I don’t think Watson is a “joke” as per the title of this Forbes piece, I think we need to realize that even he (it?) isn’t there yet:

In February 2017, M.D. Anderson Cancer Center canceled a promising, but troubled contract with IBM for its Watson platform. “The breakup with M.D. Anderson seemed to show IBM choking on its own hype about Watson,” Freedman added. “The University of Texas, which runs M.D. Anderson, announced it had shuttered the project, leaving the medical center out $39 million in payments to IBM—for a project originally contracted at $2.4 million.”

It’s unclear, however, what the root of the problem was for M.D. Anderson. “Most of the criticism of Watson, even from M.D. Anderson, doesn’t seem rooted in any particular flaw in the technology. Instead, it’s a reaction to IBM’s overly optimistic claims of how far along Watson would be by now,” Freedman added. “After four years it had not produced a tool for use with patients that was ready to go beyond pilot tests.”

The medical community was similarly concerned about Watson’s shortcomings at M.D. Anderson. “A university audit of the project exposed many procurement problems, cost overruns, and delays. Although the audit took no position on Watson’s scientific basis or functional capabilities, it did describe challenges with assimilating Watson into the hospital setting,” said Charlie Schmidt, writing for the Journal of the National Cancer Institute. “Experts familiar with Watson’s applications in oncology describe problems with the system’s ability to digest written case reports, doctors’ notes, and other text-heavy information generated in medical care.”

One could say a radiology report is text-heavy.

Why aren’t Watson and his AI cousins, there yet?

A team of Booz Allen Hamiltonnull +0% experts and an MD blogging for Health Affairs explained this challenge. “Human intelligence outperforms machine-learning applications in complex decision making routinely required during the course of care, because machines do not yet possess mature capabilities for perceiving, reasoning, or explaining,” explained Ernest Sohn, a chief data scientist in Booz Allen’s Data Solutions and Machine Intelligence group; Joachim Roski, a principal at Booz Allen Hamilton; Steven Escaravage, vice president in Booz Allen’s Strategic Innovation Group; and Kevin Maloy, MD, assistant professor of emergency medicine at Georgetown University School of Medicine. “Moreover, despite significant progress, even state-of-the-art machine-learning algorithms often cannot deliver sufficient sensitivity, specificity, and precision (that is, positive predictive value) required for clinical decision making.”

Right now, it all comes back to hype:

As the M.D. Anderson fiasco illustrates, IBM fell into the trap of over-promising and under-delivering. “IBM claimed in 2013 that ‘a new era of computing has emerged’ and gave Forbes the impression that Watson ‘now tackles clinical trials’ and would be in use with patients in just a matter of months,” Freedman noted.

As to whether Watson will ever be useful in clinical situations? “This is hard,” opined Stephen Kraus, a partner at Bessemer Venture Partners. “It’s not happening today, and it might not be happening in five years. And it’s not going to replace doctors.”

It may be that a successful AI will come from the heart (or bowels) of Google. Or Facebook. I’m thinking Apple, personally. And don’t count Watson out. Not at all. The folks at IBM are some of the best in the world at what they do, and Watson still has great potential. He just got caught at the Peak of Inflated expectations.

But to Dr. Shouldadonerads, and all the medical students out there who are listening to the trash-talk… The announcement of the death of Radiology is incredibly premature. (And some of those bleating it are immature.) I cannot envision AI taking you job, my job, or anyone else’s job as Radiologists for the working lifetime of any of you out there. IT WILL NOT HAPPEN.

What WILL happen, eventually, is that AI will be at your side, well, on your workstation, and it will assist you. It will flag things you should see, suggest what those things might be, give you ready access to the patient’s medical record and a host of other things. Think of AI as your butler, your medical student/scut monkey, your pal, your friend. It is NOT your competition.

Look at it this way. When you plan a romantic evening, you might want your butler/ladies’ maid to prepare a nice dinner, put rose-petals on the bed, draw a nice bath. And then LEAVE. You really don’t want the butler to take care of the, ummm,  pièce de résistance, now do you?

Your patients don’t either.

via Blogger July 30, 2017 at 09:40PM