Extending Advanced Visualization Across Multiple Departments
Among the virtues of thin-client 3D advanced visualization are ease and economy of deployment across an enterprise. Above both, however, lies the ability to improve the quality of care. At Beebe Medical Center in Lewes, Delaware, which has extended access to its advanced visualization platform from the radiology department to the emergency department, critical care unit, and operating suite, thin-client advanced visualization is making a big difference. 
Michael Ramjattansingh, MD Diagnostic radiologist Michael Ramjattansingh, MD, says that the technology played a decisive role recently in saving the life of a woman admitted to the emergency department with a complaint of chest pain that turned out to be caused by a rare, potentially fatal condition that no one expected to encounter. “She was bleeding into her chest; that much, the emergency-department team could determine in triage,” Ramjattansingh recalls. Accordingly, a CT scan was performed, and it ruled out the possibility of pulmonary embolism. The test showed, however, that some sort of penetration of the thoracic aorta had occurred. Ramjattansingh says, “There was no sign of trauma, so this penetration was peculiar, since spontaneous rupture of the thoracic aorta is rare. There wasn’t any indication of aneurysm or significant chronic pathologic distension of a blood vessel, similar to what’s seen with abdominal aneurysm. In any event, our most worrisome issue here was that the source of the bleeding was not immediately apparent.” A closer inspection of the CT image in 3D revealed that the patient had significant atherosclerosis and arterial plaque. “Using our thin-client advanced visualization system, we were able to focus down on that original CT dataset not only to locate the origin of the bleeding, but also to show us the morphology and shape of that point of origination,” Ramjattansingh says. “It turned out that one of the plaques on the vessel wall had become ulcerated. It eventually became so deeply ulcerated that it broke through the vessel wall. We were able to identify on the spot, and with great clarity, what was actually wrong,” he says, and the patient’s life was saved. A Click Away Beebe Medical Center is a 210-bed, not-for-profit seaside community hospital, founded in 1916 by two physician brothers. Its specialized service lines include cardiovascular, oncology, women's health, and orthopedic care. The radiology department is made up of seven radiologists: Two (including Ramjattansingh) are cross-sectional body imagers, two are nuclear-medicine specialists, one is a neuroradiologist, and two are generalists. All are supported by approximately 80 technologists and other personnel. Their equipment includes PET/CT, CT, MRI, ultrasound, gamma-camera, fluoroscopy, radiography, mammography, and bone-densitometry systems. Image interpretations are performed at six workstations, located either in a reading center in the hospital or at an outpatient imaging center across town. Each workstation is configured with three monitors (two black and white and one color). In addition, deployed throughout the hospital are a number of dedicated diagnostic-quality monitors for use by clinicians. These are found in the emergency department, the critical-care unit, and the surgery suites; plans call for eventually making online access to images available to the broader clinician community throughout the hospital and beyond its walls. At Beebe Medical Center, using advanced visualization software at a workstation is as simple as clicking on a CT or MRI study. A drop-down menu then gives the user a choice of two advanced visualization software programs, one a thick-client package and the other a thin client. The thick-client package was Beebe’s first. Installed in 2003, it permitted volume-rendered and 3D reconstructions of vascular work, such as CT angiograms (CTAs) and MR angiograms (MRAs). About a year ago, the thin-client enterprise visualization system from Visage Imaging, Carlsbad, California, was installed alongside the original. “We make both systems available because doing so has been very helpful in transitioning from old to new,” Ramjattansingh explains. “The new system is far superior, but we’ve also got the familiar old one to fall back on during the learning process.” The main difference between the two packages is that the new one is vastly quicker on the draw, he says. “With the old system, if you used it on a large dataset—anything above 700 to 1,000 images—you’d have maybe a three- to five-minute wait after launching until it finished loading. Worse, there was a real risk of crashing the system,” he notes. “With the new package, there’s only a minimal wait, even on the largest datasets, and virtually zero wait if the sets aren’t quite so large. You can start rendering and viewing the images almost immediately. The risk of crashing the system is also negligible.” As other hospitals and imaging centers have discovered, larger volumes of data from 3D CT and MRI multiphase, contrast-enhanced, and functional studies push the limits of existing IT infrastructures like PACS. The result is a grueling strain on the operation of older and slower servers that ends up clogging and interrupting the flow of data across low-bandwidth networks and surpassing the capacity of workstation memory and graphics (not to mention diagnostic software). The solution, for many, is to shift their advanced visualization image viewing and postprocessing activities from PACS and loosely linked 3D workstations to thin-client systems that centralize 3D processing and incorporate streaming technology. This approach eliminates the need to send data back and forth from imaging modalities to PACS and workstations. Moreover, the thin-client approach ensures full data integrity by establishing a centralized exam database with all of its content accessible from a single point. Growing Interest Advanced visualization at Beebe Medical Center is causing quite a buzz. The neurology department is among those expressing keen interest in the application. “Our neurologists and vascular surgeons send us a significant volume of MRA and CTA scans intended to detect signs of abdominal aortic aneurysm, lower-extremity vascular disease, carotid-artery stenosis, circle of Willis arterial aneurysm, and other conditions,” Ramjattansingh says. “Advanced visualization is now an integral tool, and a very powerful one at that, to help us see and understand the pathology of these problems better. For instance, if I’m measuring a renal or carotid artery for a blockage, I’m able, with a high level of accuracy, to tell my referring physician just how severe that blockage is, and to be more confident in recommending that patient as either an appropriate candidate for surgery or as someone who would be better served by continued surveillance,” he adds. Thin-client advanced visualization technology can minimize the need to acquire expensive new workstations and additional hardware in any bid at achieving enterprise-wide, universal access—reasonably up-to-date computers and monitors already in use fill the bill perfectly. “Our thin-client advanced visualization system is not, at this time, configured to allow access to the package’s elements anywhere but at the workstations at the hospital and outpatient center,” Ramjattansingh says. “That is very likely to change later. Often, at night and on weekends, I read emergency-department cases at home on my computer. I’m looking forward to being able to view and process 3D images there, and anywhere else I happen to be when image interpretation is needed.”Rich Smith is a contributing writer for ImagingBiz.com.
Michael Ramjattansingh, MD Diagnostic radiologist Michael Ramjattansingh, MD, says that the technology played a decisive role recently in saving the life of a woman admitted to the emergency department with a complaint of chest pain that turned out to be caused by a rare, potentially fatal condition that no one expected to encounter. “She was bleeding into her chest; that much, the emergency-department team could determine in triage,” Ramjattansingh recalls. Accordingly, a CT scan was performed, and it ruled out the possibility of pulmonary embolism. The test showed, however, that some sort of penetration of the thoracic aorta had occurred. Ramjattansingh says, “There was no sign of trauma, so this penetration was peculiar, since spontaneous rupture of the thoracic aorta is rare. There wasn’t any indication of aneurysm or significant chronic pathologic distension of a blood vessel, similar to what’s seen with abdominal aneurysm. In any event, our most worrisome issue here was that the source of the bleeding was not immediately apparent.” A closer inspection of the CT image in 3D revealed that the patient had significant atherosclerosis and arterial plaque. “Using our thin-client advanced visualization system, we were able to focus down on that original CT dataset not only to locate the origin of the bleeding, but also to show us the morphology and shape of that point of origination,” Ramjattansingh says. “It turned out that one of the plaques on the vessel wall had become ulcerated. It eventually became so deeply ulcerated that it broke through the vessel wall. We were able to identify on the spot, and with great clarity, what was actually wrong,” he says, and the patient’s life was saved. A Click Away Beebe Medical Center is a 210-bed, not-for-profit seaside community hospital, founded in 1916 by two physician brothers. Its specialized service lines include cardiovascular, oncology, women's health, and orthopedic care. The radiology department is made up of seven radiologists: Two (including Ramjattansingh) are cross-sectional body imagers, two are nuclear-medicine specialists, one is a neuroradiologist, and two are generalists. All are supported by approximately 80 technologists and other personnel. Their equipment includes PET/CT, CT, MRI, ultrasound, gamma-camera, fluoroscopy, radiography, mammography, and bone-densitometry systems. Image interpretations are performed at six workstations, located either in a reading center in the hospital or at an outpatient imaging center across town. Each workstation is configured with three monitors (two black and white and one color). In addition, deployed throughout the hospital are a number of dedicated diagnostic-quality monitors for use by clinicians. These are found in the emergency department, the critical-care unit, and the surgery suites; plans call for eventually making online access to images available to the broader clinician community throughout the hospital and beyond its walls. At Beebe Medical Center, using advanced visualization software at a workstation is as simple as clicking on a CT or MRI study. A drop-down menu then gives the user a choice of two advanced visualization software programs, one a thick-client package and the other a thin client. The thick-client package was Beebe’s first. Installed in 2003, it permitted volume-rendered and 3D reconstructions of vascular work, such as CT angiograms (CTAs) and MR angiograms (MRAs). About a year ago, the thin-client enterprise visualization system from Visage Imaging, Carlsbad, California, was installed alongside the original. “We make both systems available because doing so has been very helpful in transitioning from old to new,” Ramjattansingh explains. “The new system is far superior, but we’ve also got the familiar old one to fall back on during the learning process.” The main difference between the two packages is that the new one is vastly quicker on the draw, he says. “With the old system, if you used it on a large dataset—anything above 700 to 1,000 images—you’d have maybe a three- to five-minute wait after launching until it finished loading. Worse, there was a real risk of crashing the system,” he notes. “With the new package, there’s only a minimal wait, even on the largest datasets, and virtually zero wait if the sets aren’t quite so large. You can start rendering and viewing the images almost immediately. The risk of crashing the system is also negligible.” As other hospitals and imaging centers have discovered, larger volumes of data from 3D CT and MRI multiphase, contrast-enhanced, and functional studies push the limits of existing IT infrastructures like PACS. The result is a grueling strain on the operation of older and slower servers that ends up clogging and interrupting the flow of data across low-bandwidth networks and surpassing the capacity of workstation memory and graphics (not to mention diagnostic software). The solution, for many, is to shift their advanced visualization image viewing and postprocessing activities from PACS and loosely linked 3D workstations to thin-client systems that centralize 3D processing and incorporate streaming technology. This approach eliminates the need to send data back and forth from imaging modalities to PACS and workstations. Moreover, the thin-client approach ensures full data integrity by establishing a centralized exam database with all of its content accessible from a single point. Growing Interest Advanced visualization at Beebe Medical Center is causing quite a buzz. The neurology department is among those expressing keen interest in the application. “Our neurologists and vascular surgeons send us a significant volume of MRA and CTA scans intended to detect signs of abdominal aortic aneurysm, lower-extremity vascular disease, carotid-artery stenosis, circle of Willis arterial aneurysm, and other conditions,” Ramjattansingh says. “Advanced visualization is now an integral tool, and a very powerful one at that, to help us see and understand the pathology of these problems better. For instance, if I’m measuring a renal or carotid artery for a blockage, I’m able, with a high level of accuracy, to tell my referring physician just how severe that blockage is, and to be more confident in recommending that patient as either an appropriate candidate for surgery or as someone who would be better served by continued surveillance,” he adds. Thin-client advanced visualization technology can minimize the need to acquire expensive new workstations and additional hardware in any bid at achieving enterprise-wide, universal access—reasonably up-to-date computers and monitors already in use fill the bill perfectly. “Our thin-client advanced visualization system is not, at this time, configured to allow access to the package’s elements anywhere but at the workstations at the hospital and outpatient center,” Ramjattansingh says. “That is very likely to change later. Often, at night and on weekends, I read emergency-department cases at home on my computer. I’m looking forward to being able to view and process 3D images there, and anywhere else I happen to be when image interpretation is needed.”Rich Smith is a contributing writer for ImagingBiz.com.