Downloaded from www.ajronline.org by 116.29.253.81 on 11/03/15 from IP address 116.29.253.81. Copyright ARRS. For personal use only; all rights reserved
871
Technical
Note
.
Autoradiology: Spencer
Patient
B. Gay,1 J. Bayne
Selby,
Heal Thyself
Jr.,1 and Henry
G. SeIby2
In this age of cost-reduction schemes, technologist shortages, and consumer advocacy, we considered it important to study the efficacy of patient-performed procedures (PPP) for reducing radiology costs. This approach reduces medical
thanked us for the opportunity to witness barium refluxing into their esophagus at the same time they experience their
nagging “heartburn.” Interpretation of the radiograph
has not been
costs
Many
day
by decreasing
support Patients
the amount
of physician
required for a variety of radiologic also benefit by playing a more active
care. Physical
self-examination
(breast,
and technical examinations. role in their own
testes,
skin) is cur-
rently in vogue, and we see no reason that this approach cannot be applied to internal organs as well. Our preliminary investigations confirm that several procedures are amenable to greater patient participation.
nonradiologists
do it every
Gastrointestinal
Autoradiology
A disturbing
trend away from the barium meal and toward endoscopy for examination of the upper gastrointestinal (GI) tract has encouraged us to rejuvenate the radiologic approach. We trained patients in the art of BS (barium swallowing) in order to evaluate their own GI tract. Patients are eager to drink the “pink shake” (Fig. 1) and actually look forward to ingesting gas crystals as long as eructations don’t ensue. Patient positioning is greatly improved by self-cooperation. It is gratifying to see the extra time patients are willing to spend themselves.
patients
Interesting
abnormalities
are often
Chesapeake
AJR 154:871-873,
discovered
during
auto-
GI examinations, and occasionally an academically oriented patient wants to publish the findings. These patients usually
A further
of their
benefit
diseases.
is a better
More
than
understanding
one
person
has
are often
captivated
stomach
and tend
to having
Academy,
© American
Roentgen
more views
The self-administered
the attending
ra-
Ray Society
of a well-distended
than the standard
compression accomplished
spot films of quickly and
barium enema has also proved
ular. Patient pride in a meticulous enhanced by use of a common may discuss and compare their able where the scout film of the colon distension on double-contrast poor, presumably because of overdistend their own colon.
lrvington, VA 22480.
AprIl 1990 0361 -803X/90/1544-0871
by the appearance
to take
examination requires. Conversely, the gastric antrum are usually without repeated attempts.
Received November 1 5, 1 989; accepted after revision December 1 9, 1989. I Department of Radiology, Box 170, University of Virginia Health Sciences Center, Charlottesville, 2
a problem. experience
There are some differences in the quality of the PPP cornpared with conventional procedures. For instance, patients
Procedures
by
little
and no training. We initially attempted a comparison study of auto-GI series and autoendoscopy; however, this idea was abandoned at the patient’s request after the first autoendoscopy attempt.
will agree (after some coercion) diologist be the first author.
with
with
popcolon preparation has been waiting room where patients methods. A viewbox is availweek is mounted. However, barium enemas has been
the patients’
reluctance
VA 22908. Address reprint requests to S. B. Gay.
to
Downloaded from www.ajronline.org by 116.29.253.81 on 11/03/15 from IP address 116.29.253.81. Copyright ARRS. For personal use only; all rights reserved
872
GAY
Fig. 1.-Gastrointestinal (GI) autoradiology. Patient performing upper GI examination on himself. Good eyehand coordination is necessary for obtaming optimal spot radiographs of dietended stomach and pesky duodenal bulb.
Cervical
should perform
Once the general concept is accepted, the applicability of PPP to other examinations becomes obvious. We are currently investigating the technical feasibility of having patients their
own
C1-C2
puncture
for cervical
automyelog-
raphy. The spirit of adventure and stick-to-itiveness make the procedure attractive to many patients. We developed a simple three-step
AJR:154,
Fig. 2.-Cervical automyelography. A, Patient performing lateral C1-C2 puncture. Note calm demeanor. B, Anteroposterior spot film shows suboptimal needle placement. was recommended.
Automyelography
perform
ET AL.
approach:
Step 1 : Patient lies supine and is instructed to hold a 22-gauge needle in the right hand and a mirror in the left hand. The right hand directs the needle under lateral fluoroscopic guidance (Fig.
In this case,
come as no surprise, surgery on themselves
repositioning
of the needle
as the ability of patients to has been well documented.
Kahn [1 ] reported a case of atternpted autoadrenalectorny a patient who had previously completed an autocastration.
witness
the signature,
and most patients
are willing to sign.
We have found that leaving a baby monitor (Fisher-Price, Mountain View, CA) in the room allows the technologist to perform other duties simultaneously. Caveats Although
we encourage
the use of autoradiology
procedures,
tion
easily. Cervical rnyelography, knee arthrography, graphically guided liver biopsies are all possible,
be
a problern
in these
do-it-yourself
procedures.
The
some guidelines
patient
should
rnyelography
Step 2: The needle is advanced anteroposterior is obtained.
moval
fluoroscopic Copious return
of the stylet
carefully
guidance of blood
indicates
that
under
until CSF upon re-
the needle
should
be repositioned. (Cerebral autoangiography by direct vertebral artery stick is another procedure of potential merit.) Numbness and arm tingling are also indications of overaggressive needle placement (Fig. 2B). Step dard
3: Contrast material cervical rnyelograrns
is injected, and stanare obtained by the
technologist.
In our experience, the self-performed calmly accepted and adroitly handled
Cl -C2 puncture is by the patient. This
by
To provide continuity of care, we ask the patient to obtain informed consent. The technologist should be available to
2A). A technologist moves the fluoroscopy tower as needed. Sedation is beneficial, but oversedacan
April 1990
for patients
and
difficulty. 1 930
hysterosalpingography is possible,
literature
The first vascular
provides
the area
have preferably
punctures examples
catheterization
Forssrnann [2, 3], who for angiography, producing
by
atrium
to reach
Axillary and translurnbar The
zation.
be able
of interest
and sonobut lumbar
proved
difficult
to master.
Autoangiography
approach.
for other
are in order:
from
the
fernoral
are fraught
with
of self-catheteri-
was performed
in
catheterized his own right images of the pulmonary
arteries. In highly motivated patients, more advanced procedures such as ernbolization of carotid-cavernous fistulas and intracranial arteriovenous malformations are possible. As nonradiologists have been trained in these techniques, training of nonphysicians is the next logical step. When performing interventional neuroradiologic procedures, we instruct patients to talk to themselves continuously and to notify the technologist irnmediately if they don’t get a response.
AJR:154,
AUTORADIOLOGY
April 1990
ment lunch, golf swing.
Downloaded from www.ajronline.org by 116.29.253.81 on 11/03/15 from IP address 116.29.253.81. Copyright ARRS. For personal use only; all rights reserved
Discussion
There has been little to motivate physicians or hospitals to participate willingly in cost-reduction measures other than the threat of GMR (Government Moolah Reduction) sanctions against costs perceived to be high for given procedures. The potential savings from PPP in terms of money, technologist time, and physician time are obvious. Do-it-yourself surgical procedures have been described before [1 ,4], but similar radiologic innovations have not been reported. This represents a missed opportunity to optirnize many radiologic procedures. Other cost-saving measures that have
been
873
introduced
are to be lauded,
but they
have
ad-
dressed only efficient use of equipment [5-7]. Manpower efficiency measures should not be overlooked. Self-performed procedures should decrease litigation against the physician. Our legal staff has advised us that having the patient perform the examination allows us to use the legal argument of doctore immunem in any subsequent lawsuit.
All in all, our program has been a great success, endorsed by everyone from patients to health care providers and hospital administrators. The PPP will revolutionize diagnostic and interventional radiologic procedures and will free the radiologist to perform more critical maneuvers-the out-of-depart-
afternoon
off, and perfection
of the
REFERENCES 1 . Kahn NH. Genital and abdominal self-surgery. JAMA 1979;241 :2188-2189 2. Forssmann W. Die Sondierung des re#{231}hten Herzens. Kim Wochenschr 1929;8:2085-2087 3. Forssmann W. Ureber kontrastdarstellung der HOhIen des lebenden rechten Herzens und der Lungenschlagader. MUnch Med Wochenschr 1931; 78:489-492 4. Wilkins M. How to perform hemifacial spasm surgery on yourself. National Lampoon, June 1982:36-39 5. Reid MH, Dublin AB. QUAC: a modest proposal for optimal use of CT scanning equipment. AJR 1984;142:845-846 6. Reid MH, Dublin AB. Simultaneous anthropomorphic projections. AJR 1986;144:861 -862 7. Edwards DK Ill. X-ray gogs: preliminary evaluation of a “new” imaging modality. AJR 1988;150:731-734
Editor’s
Summary
the extended
note.
Day
eloquently
Fools’
Day,
April
practicaljokes
paid
M. M. Figley
1, it is considered
almost
is thought to friends
explained
issue
on the unwary.
is observed custom
Dr.
in a previous
on the
first
day,
also
throughout
begun day
the
origin
which
lies
was
and
as AllFools’
Western
where
formal 1 week
world. visits after
Year’s Day (March 25 under the Old Style Gregorian calendar). New Year’s Day was moved to January 1 in 1 752, mock continued
to be paid on April
1 as a joke.”
Fools’
“On April to tell
known the
in France, of April,
of April
1984;142:845):
appropriate
This
universally to have
(AJR
play Day, The were New
When calls
871
Technical
Note
.
Autoradiology: Spencer
Patient
B. Gay,1 J. Bayne
Selby,
Heal Thyself
Jr.,1 and Henry
G. SeIby2
In this age of cost-reduction schemes, technologist shortages, and consumer advocacy, we considered it important to study the efficacy of patient-performed procedures (PPP) for reducing radiology costs. This approach reduces medical
thanked us for the opportunity to witness barium refluxing into their esophagus at the same time they experience their
nagging “heartburn.” Interpretation of the radiograph
has not been
costs
Many
day
by decreasing
support Patients
the amount
of physician
required for a variety of radiologic also benefit by playing a more active
care. Physical
self-examination
(breast,
and technical examinations. role in their own
testes,
skin) is cur-
rently in vogue, and we see no reason that this approach cannot be applied to internal organs as well. Our preliminary investigations confirm that several procedures are amenable to greater patient participation.
nonradiologists
do it every
Gastrointestinal
Autoradiology
A disturbing
trend away from the barium meal and toward endoscopy for examination of the upper gastrointestinal (GI) tract has encouraged us to rejuvenate the radiologic approach. We trained patients in the art of BS (barium swallowing) in order to evaluate their own GI tract. Patients are eager to drink the “pink shake” (Fig. 1) and actually look forward to ingesting gas crystals as long as eructations don’t ensue. Patient positioning is greatly improved by self-cooperation. It is gratifying to see the extra time patients are willing to spend themselves.
patients
Interesting
abnormalities
are often
Chesapeake
AJR 154:871-873,
discovered
during
auto-
GI examinations, and occasionally an academically oriented patient wants to publish the findings. These patients usually
A further
of their
benefit
diseases.
is a better
More
than
understanding
one
person
has
are often
captivated
stomach
and tend
to having
Academy,
© American
Roentgen
more views
The self-administered
the attending
ra-
Ray Society
of a well-distended
than the standard
compression accomplished
spot films of quickly and
barium enema has also proved
ular. Patient pride in a meticulous enhanced by use of a common may discuss and compare their able where the scout film of the colon distension on double-contrast poor, presumably because of overdistend their own colon.
lrvington, VA 22480.
AprIl 1990 0361 -803X/90/1544-0871
by the appearance
to take
examination requires. Conversely, the gastric antrum are usually without repeated attempts.
Received November 1 5, 1 989; accepted after revision December 1 9, 1989. I Department of Radiology, Box 170, University of Virginia Health Sciences Center, Charlottesville, 2
a problem. experience
There are some differences in the quality of the PPP cornpared with conventional procedures. For instance, patients
Procedures
by
little
and no training. We initially attempted a comparison study of auto-GI series and autoendoscopy; however, this idea was abandoned at the patient’s request after the first autoendoscopy attempt.
will agree (after some coercion) diologist be the first author.
with
with
popcolon preparation has been waiting room where patients methods. A viewbox is availweek is mounted. However, barium enemas has been
the patients’
reluctance
VA 22908. Address reprint requests to S. B. Gay.
to
Downloaded from www.ajronline.org by 116.29.253.81 on 11/03/15 from IP address 116.29.253.81. Copyright ARRS. For personal use only; all rights reserved
872
GAY
Fig. 1.-Gastrointestinal (GI) autoradiology. Patient performing upper GI examination on himself. Good eyehand coordination is necessary for obtaming optimal spot radiographs of dietended stomach and pesky duodenal bulb.
Cervical
should perform
Once the general concept is accepted, the applicability of PPP to other examinations becomes obvious. We are currently investigating the technical feasibility of having patients their
own
C1-C2
puncture
for cervical
automyelog-
raphy. The spirit of adventure and stick-to-itiveness make the procedure attractive to many patients. We developed a simple three-step
AJR:154,
Fig. 2.-Cervical automyelography. A, Patient performing lateral C1-C2 puncture. Note calm demeanor. B, Anteroposterior spot film shows suboptimal needle placement. was recommended.
Automyelography
perform
ET AL.
approach:
Step 1 : Patient lies supine and is instructed to hold a 22-gauge needle in the right hand and a mirror in the left hand. The right hand directs the needle under lateral fluoroscopic guidance (Fig.
In this case,
come as no surprise, surgery on themselves
repositioning
of the needle
as the ability of patients to has been well documented.
Kahn [1 ] reported a case of atternpted autoadrenalectorny a patient who had previously completed an autocastration.
witness
the signature,
and most patients
are willing to sign.
We have found that leaving a baby monitor (Fisher-Price, Mountain View, CA) in the room allows the technologist to perform other duties simultaneously. Caveats Although
we encourage
the use of autoradiology
procedures,
tion
easily. Cervical rnyelography, knee arthrography, graphically guided liver biopsies are all possible,
be
a problern
in these
do-it-yourself
procedures.
The
some guidelines
patient
should
rnyelography
Step 2: The needle is advanced anteroposterior is obtained.
moval
fluoroscopic Copious return
of the stylet
carefully
guidance of blood
indicates
that
under
until CSF upon re-
the needle
should
be repositioned. (Cerebral autoangiography by direct vertebral artery stick is another procedure of potential merit.) Numbness and arm tingling are also indications of overaggressive needle placement (Fig. 2B). Step dard
3: Contrast material cervical rnyelograrns
is injected, and stanare obtained by the
technologist.
In our experience, the self-performed calmly accepted and adroitly handled
Cl -C2 puncture is by the patient. This
by
To provide continuity of care, we ask the patient to obtain informed consent. The technologist should be available to
2A). A technologist moves the fluoroscopy tower as needed. Sedation is beneficial, but oversedacan
April 1990
for patients
and
difficulty. 1 930
hysterosalpingography is possible,
literature
The first vascular
provides
the area
have preferably
punctures examples
catheterization
Forssrnann [2, 3], who for angiography, producing
by
atrium
to reach
Axillary and translurnbar The
zation.
be able
of interest
and sonobut lumbar
proved
difficult
to master.
Autoangiography
approach.
for other
are in order:
from
the
fernoral
are fraught
with
of self-catheteri-
was performed
in
catheterized his own right images of the pulmonary
arteries. In highly motivated patients, more advanced procedures such as ernbolization of carotid-cavernous fistulas and intracranial arteriovenous malformations are possible. As nonradiologists have been trained in these techniques, training of nonphysicians is the next logical step. When performing interventional neuroradiologic procedures, we instruct patients to talk to themselves continuously and to notify the technologist irnmediately if they don’t get a response.
AJR:154,
AUTORADIOLOGY
April 1990
ment lunch, golf swing.
Downloaded from www.ajronline.org by 116.29.253.81 on 11/03/15 from IP address 116.29.253.81. Copyright ARRS. For personal use only; all rights reserved
Discussion
There has been little to motivate physicians or hospitals to participate willingly in cost-reduction measures other than the threat of GMR (Government Moolah Reduction) sanctions against costs perceived to be high for given procedures. The potential savings from PPP in terms of money, technologist time, and physician time are obvious. Do-it-yourself surgical procedures have been described before [1 ,4], but similar radiologic innovations have not been reported. This represents a missed opportunity to optirnize many radiologic procedures. Other cost-saving measures that have
been
873
introduced
are to be lauded,
but they
have
ad-
dressed only efficient use of equipment [5-7]. Manpower efficiency measures should not be overlooked. Self-performed procedures should decrease litigation against the physician. Our legal staff has advised us that having the patient perform the examination allows us to use the legal argument of doctore immunem in any subsequent lawsuit.
All in all, our program has been a great success, endorsed by everyone from patients to health care providers and hospital administrators. The PPP will revolutionize diagnostic and interventional radiologic procedures and will free the radiologist to perform more critical maneuvers-the out-of-depart-
afternoon
off, and perfection
of the
REFERENCES 1 . Kahn NH. Genital and abdominal self-surgery. JAMA 1979;241 :2188-2189 2. Forssmann W. Die Sondierung des re#{231}hten Herzens. Kim Wochenschr 1929;8:2085-2087 3. Forssmann W. Ureber kontrastdarstellung der HOhIen des lebenden rechten Herzens und der Lungenschlagader. MUnch Med Wochenschr 1931; 78:489-492 4. Wilkins M. How to perform hemifacial spasm surgery on yourself. National Lampoon, June 1982:36-39 5. Reid MH, Dublin AB. QUAC: a modest proposal for optimal use of CT scanning equipment. AJR 1984;142:845-846 6. Reid MH, Dublin AB. Simultaneous anthropomorphic projections. AJR 1986;144:861 -862 7. Edwards DK Ill. X-ray gogs: preliminary evaluation of a “new” imaging modality. AJR 1988;150:731-734
Editor’s
Summary
the extended
note.
Day
eloquently
Fools’
Day,
April
practicaljokes
paid
M. M. Figley
1, it is considered
almost
is thought to friends
explained
issue
on the unwary.
is observed custom
Dr.
in a previous
on the
first
day,
also
throughout
begun day
the
origin
which
lies
was
and
as AllFools’
Western
where
formal 1 week
world. visits after
Year’s Day (March 25 under the Old Style Gregorian calendar). New Year’s Day was moved to January 1 in 1 752, mock continued
to be paid on April
1 as a joke.”
Fools’
“On April to tell
known the
in France, of April,
of April
1984;142:845):
appropriate
This
universally to have
(AJR
play Day, The were New
When calls
