ENGINEERING AND MEDICINE BY Mark H. Bechtel, M.D.

My Story No inclination into medicine originally No inclination into medicine originally Mother and wife are nurses, Wife also CRNA Mother and wife are nurses, Wife also CRNA 1 st hand experience with hospitalization 1 st hand experience with hospitalization Wanted Change Wanted Change Career Counseling Career Counseling Decided on Medicine in 1993 Decided on Medicine in 1993 Prerequisites by 1994 and started Med School. Prerequisites by 1994 and started Med School.

Introduction Moscow High School Moscow High School BSEE, University of Idaho 1989 BSEE, University of Idaho 1989 Internships at Varian and Chevron during EE training. Internships at Varian and Chevron during EE training. Test Engineering at IBM, Test Engineering at IBM, VLSI Design at AHA, VLSI Design at AHA, MD at University of Washington MD at University of Washington Internship in Spokane, Washington 1999 Internship in Spokane, Washington 1999 Radiology Residency at University of Wisconsin, Radiology Residency at University of Wisconsin, General Radiologist in Brainerd, MN General Radiologist in Brainerd, MN Musculoskeletal Fellowship at Penn State Hershey, 2004 Musculoskeletal Fellowship at Penn State Hershey, 2004 General Radiologist, MSK Specialist, Yankton, SD, General Radiologist, MSK Specialist, Yankton, SD, General Radiologist, MSK Specialist, Moscow, ID, 2006-present General Radiologist, MSK Specialist, Moscow, ID, 2006-present

Main Points Engineers as Physicians Engineers as Physicians Engineers as Information System Experts Engineers as Information System Experts Biomedical Engineering Biomedical Engineering Electrical Design in Medicine Electrical Design in Medicine

Physician Engineers Engineering is an excellent base for medicine Engineering is an excellent base for medicine High percentage of radiologists are engineers High percentage of radiologists are engineers Engineering teaches a method of thinking that is not taught in other undergrad degrees Engineering teaches a method of thinking that is not taught in other undergrad degrees

Medical School 4 Years 4 Years Easier conceptually than engineering Easier conceptually than engineering More time than engineering More time than engineering –Engineering: if understand the concept then studying is over. –Medicine: Doesn’t matter if understand the concept. Human body is dynamic and the patient is still sick. Learning is constant and there is no definite endpoint. Much more memorization Much more memorization

Internship Most Physicians have internships Most Physicians have internships One year general training One year general training Interview and selection process Interview and selection process

Residency Three to Six years Three to Six years –Radiology (4 years)

Fellowship Further specialization Further specialization 1-2 years for radiology 1-2 years for radiology …

Engineers as Information System Specialist Radiology is highly Technology Dependent Radiology is highly Technology Dependent PACS systems PACS systems –Large storage system –Single CT can have 2000 images at 500Kbyte each –Need to interface with different equipment –Need to be able to send entire studies many miles away –NightHawk

Biomedical Engineering Designing equipment for medical use Designing equipment for medical use Ie: Insulin pump and detector Ie: Insulin pump and detector –Pacemaker/defibrillator –Digital Subtraction Angiography –Stents –Intravascular work

Pacemaker Earl Bakken Earl Bakken

Pacemaker Bakken’s orignal schematic Bakken’s orignal schematic

Pacemaker Newer Devices Newer Devices

Pacemaker Chest Xray Chest Xray

Pacemaker Conduction system Conduction system

Ultrasound Images

Magnetic Resonance Imaging

MRI Images Enhancement characteristics Enhancement characteristics

MRI Images Diffusion Tensor Imaging Diffusion Tensor Imaging

MRI Images MRA MRA

MRI Images Fat saturation Fat saturation

MRI Images Spectroscopy Spectroscopy

MRI Images Cardiac Imaging Cardiac Imaging

MRI Images K-Space K-Space

MRI Physics

CT See other lecture See other lecture

Conclusion Engineering is an excellent base for medicine as a researcher, designer, information specialist, or as a physician. Engineering is an excellent base for medicine as a researcher, designer, information specialist, or as a physician.

Multidetector CT Mark Bechtel, M.D.

Education Medical School: University of Washington Medical School: University of Washington Radiology Residency: University of Wisconsin Radiology Residency: University of Wisconsin Musculoskeletal Fellowship: Penn State University, Milton S. Hershey Medical Center Musculoskeletal Fellowship: Penn State University, Milton S. Hershey Medical Center

Chronological Developments in Multisclice CT 1971 CT invented by Godfrey Hounsfeld of EMI and independently by Allan Cormack of Tufts University, Massachusetts CT invented by Godfrey Hounsfeld of EMI and independently by Allan Cormack of Tufts University, Massachusetts First Commercial CT scanners (for head CT only) First Commercial CT scanners (for head CT only) 1976 Whole body CT now available Whole body CT now available CT now widely available CT now widely available Introduction of Helical CT by Siemens, Germany 1989 Introduction of Helical CT by Siemens, Germany 1991 Launch of Dual Slice CT by Elscint, Haifa, Israel 1991 Launch of Dual Slice CT by Elscint, Haifa, Israel 1999 Launch of 4 Slice Scanners 1999 Launch of 4 Slice Scanners 2002 Launch of 16 Slice Scanners 2002 Launch of 16 Slice Scanners 2003 Prototype 32 Slicers developed 2003 Prototype 32 Slicers developed 2003 Prototype 256 Slicers developed (Toshiba) 4D CT 2003 Prototype 256 Slicers developed (Toshiba) 4D CT 2003 Research in Flat Panet Detectors 2003 Research in Flat Panet Detectors 2003 Research in Faster scanning (<0.4 s rotation time) 2003 Research in Faster scanning (<0.4 s rotation time) 2003 Research in Cone Beam CT 2003 Research in Cone Beam CT Multislice CT : A Quantum Leap in Whole Body Imaging IK indrajit, mn shreeram, jd d’souza Ind J Radiol Imag :2:

16 Slice is new standard 16 Slice is new standard 32 and 64 slice models for cardiac scanning 32 and 64 slice models for cardiac scanning New method of use is 3D evaluation versus axial imaging New method of use is 3D evaluation versus axial imaging

Evaluation of a Mandibular Lesion Left mandibular lesion was scanned in the axial and coronal planes. Left mandibular lesion was scanned in the axial and coronal planes. Sagittal, oblique Sagittal and 3D images were reformated. Sagittal, oblique Sagittal and 3D images were reformated.

Mandibular Mass/Abscess

Mandibular Mass/Abscess 3D

Comparison of Reconstructions Comparing lumbar spine reconstructions from usual abdominal CT data sets from a single slice CT scanner and from a 16 slice multidetector CT. Comparing lumbar spine reconstructions from usual abdominal CT data sets from a single slice CT scanner and from a 16 slice multidetector CT.

Comparison of L-Spine Recons

3D Reconstruction of Bones and Fractures Multiplanar reconstructions are possible Multiplanar reconstructions are possible Allows better visualization of orientation of certain types of fractures. Allows better visualization of orientation of certain types of fractures. Experienced readers often prefer 2D reconstructions Experienced readers often prefer 2D reconstructions

3D Hind/Mid Foot

Clavicle Fracture missed on plain film

CTA of the Lower Extremities Fast scanning abilities allows scanning of the lower extremities for vascular disease. Fast scanning abilities allows scanning of the lower extremities for vascular disease. Makes conventional diagnostic angiography almost obsolete. Makes conventional diagnostic angiography almost obsolete. Can be used for surgical planning. Can be used for surgical planning.

Mesenteric CTA

Carotid and Intracranial Evaluation CTA is less prone to overestimating stenosis than MRA. CTA is less prone to overestimating stenosis than MRA. CTA has replaced conventional diagnostic angiography for evaluation of carotid arteries in many locations. CTA has replaced conventional diagnostic angiography for evaluation of carotid arteries in many locations. CTA is excellent for evaluation of intracranial vessels. It may be as good as 3D conventional, diagnostic angiography. CTA is excellent for evaluation of intracranial vessels. It may be as good as 3D conventional, diagnostic angiography.

CTA Intracranial Arteries

Multidetector CT in Sinus Evaluation Only need to scan in one plane. All other planes can be reconstructed. Only need to scan in one plane. All other planes can be reconstructed.

Sinus CT Reconstruction Scanned axially

Routine Cross Sectional Imaging Tube heating is not a problem. Tube heating is not a problem. Patient can be scanned from head to toes in less than 30 seconds making trauma evaluations with contrast possible. Patient can be scanned from head to toes in less than 30 seconds making trauma evaluations with contrast possible. Multiple phases of contrast enhancement can be obtained with single contrast administration. Multiple phases of contrast enhancement can be obtained with single contrast administration. Multiplanar reconstructions of most scans is possible. Multiplanar reconstructions of most scans is possible.

Pulmonary Embolism Evaluation Standard of care for evaluation of PE. Standard of care for evaluation of PE. Much higher resolution than single slice scanners. (faster scan times, single breath-hold) Much higher resolution than single slice scanners. (faster scan times, single breath-hold) Bolus timing still very important. Bolus timing still very important.

Future Exams Coronary CT Angiograms Coronary CT Angiograms Whole Body Trauma Imaging Whole Body Trauma Imaging Brain Perfusion Imaging Brain Perfusion Imaging 3D Fracture reconstructions 3D Fracture reconstructions

Warnings Excessive Radiation from Scanning too much. Excessive Radiation from Scanning too much. CT is still not MRI for evaluation of soft tissue (ie: disk pathology) CT is still not MRI for evaluation of soft tissue (ie: disk pathology)

Conclusion 16 slice, multidector CT is very powerful and can greatly increase our diagnostic abilities. 16 slice, multidector CT is very powerful and can greatly increase our diagnostic abilities. New possibilities with CT angiography are now within reach. New possibilities with CT angiography are now within reach. There is a learning curve. There is a learning curve. Don’t overscan. Don’t overscan.