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The Evolving Role of the Radiologist Assistant

The Evolving Role of the Radiologist Assistant. Richard Danieli. Outline. Introduction Radiology journey R.R.T. to R.A. Education as a Radiologist Assistant student Registered Radiologist Assistant (R.R.A.) Handbook ARRT RA education requirements Procedure List

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The Evolving Role of the Radiologist Assistant

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  1. The Evolving Role of the Radiologist Assistant Richard Danieli

  2. Outline • Introduction • Radiology journey R.R.T. to R.A. • Education as a Radiologist Assistant student • Registered Radiologist Assistant (R.R.A.) Handbook ARRT • RA education requirements • Procedure List • Mandatory procedures • Elective procedures • Competency requirements • CR1 Forms • CR2 Forms • Summative Evaluations • Board license eligibility • Exam outline • Career outlook • Current legislation • HR 3032 Medicare Access to Radiology Care Act • Society of Radiology Physician Extenders • Interesting Case studies • Fibrin sheath port injection study • Hiatal Hernia on UGI • Loopogram obstruction • TFC tear wrist arthrogram • Questions and Answers

  3. Introduction • Clark F. Miller School of Radiologic Technology at Central Maine Medical Center • Central Maine Community College • Florida Hospital College of Health Science • Currently at Quinnipiac University Masters in Health Science Radiologist Assistant • 24 Month Full time: first year classroom, second year clinicals. Clinical placement: • Yale New Haven Hospital, CT. • Fallon Clinic Worcester, MA. • Baystate Medical Center Springfield , MA. • Cooper Univerisity Hospital Camden, NJ. • Uconn Medical Center Farmington, CT

  4. R.R.T. to R.A. • R.R.T. license in every state for clinicals • Advance Cardiac Life Support (ACLS) • Moderate/Conscious sedation • Response to a code/anaphylaxis/allergic reaction • Cardiac rhythyms • Educational structure differences and the importance of good educators • The bridge between Radiologist and Technologist • Technician difficulties and interpretation difficulties • logistics (PACS,RIS, proper orders etc…) • Responsibilities- need to recognize pathology • RT’s have Merrills. RA’s have….. Pathology, experience, Radiologist preferences. • IR-Coagulation factors • If you don’t know about it, you don’t look for it • Radiologist-4 years undergrad, 4 years medical school, 1 year surgery/ internal medicine internship, 4 years residency, 1 year fellowship= 14 years education • RA’s- 4 years undergrad, 2 years graduate school= 6 years education

  5. Q.U. Education Courses • Clinical Pharmacology I • Human Anatomy • Human Anatomy Lab • Imaging Pathophysiology • Radiation Safety and Health Physics • Image Critique & Pathologic Pattern Recognition I • Image Critique & Pathologic Pattern Recognition II • Interventional Procedures I • Interventional Procedures II • Patient Assessment, Management and Education • Research Methods and Design • Clinical Seminar I • Clinical Seminar II • Clinical Seminar III • Radiologist Assistant Clinical I • Radiologist Assistant Clinical II • Radiologist Assistant Clinical III • Radiologist Assistant Clinical IV • Thesis I • Thesis II

  6. GastroIntestinal and Chest • Esophageal study must fluoro and image the esophagus, may be with UGI • Swallow Function Study (participate in procedure and provide initial observations to radiologist • Upper GI Study • Small Bowel study- direct the study and spot TI • Small bowel study via enteroclysis tube • Enema with barium, air, or water soluble contrast • Nasogastric/enteric and orogastric/enteric tube placement-may not require image guidance • T-tube cholangiogram • Defecography • Perform chest fluoroscopy for diaphragmatic motion • Genitourinary • Antegrade urography through existing tube (e.g. pyelostography, nephrostography) • Cystography or voiding cystourethrography, with minimum of 10 bladder catheterizations • Retrograde urethrography or urethrocystography • Loopography through existing tube • Hysterosalpinography- imaging only • Hysterosalpinography- procedure and image (physian participation required) • Invasive Nonvascular • Arthrogram (radiography, CT, MR joint injection and aspirations) • Lumbar Puncture • Cervical, thoracic, or lumbar myelography- imaging only • Lumbar Puncture with contrast • Thoracentesis with or without catheter • Placement of catheter for pneumothorax • Paracentesis • Abscess, fistula, sinus tract study • Injection sentinel node localization • Breast needle localization • Change of percutaneous tube or drainage catheter • Thyroid biopsy • Liver biopsy • Invasive Vascular • Peripheral insertions of central venous catheter placement • Insertion of non-tunneled central venous catheter • Insertion of tunneled central venous catheter • Port injection • Extremity Venography • Post processing • Perform CT post processing • Perform MR post processing

  7. Clinical Portfolio • The Clinical Portfolio consists of the following components: • (1) Clinical Experience Documentation and Clinical Competence Assessments • (2) Professional Activities and Accomplishments Record • (3) Case Studies • (4) Summative Evaluation Rating Scales.

  8. Form CR-1: Summary of Clinical Experience and Competence Assessments • 1. This form is completed by the student as he or she: (a) completes the requisite number of cases for the mandatory and elective procedures; and (b) is evaluated by a radiologist on the mandatory and elective procedures. • 2. The student records the number of cases completed for each mandatory and elective procedure he or she performs. • 3. The student records only the date that the competency assessment was completed. Note that the actual competence assessments are completed by a radiologist using Form CR-2 • 4. The preceptor and program director must verify and sign the bottom of Form CR-1. This form is submitted to ARRT at the time of application.

  9. Form CR-2: Clinical Competence Assessments (Forms CR-2A through CR-2E) • 1. These forms are completed by the radiologist at the time he or she evaluates the student. There are separate evaluation forms for each class of radiologic procedures: • Form CR-2A: GI/Chest Form CR-2C: invasive nonvascular • Form CR-2B: GU Form CR-2D: invasive vascular • Form CR-2E: post-processing activities • 2. The radiologist and student are required to sign the bottom of Form CR-2 for each assessment, which is subsequently reviewed and signed by the program director. • 3. The student must submit a minimum total of 15 assessment forms to ARRT (12 mandatory and 3 elective procedures).

  10. Summative Evaluation • The Summative Evaluation Rating Scales address five skill areas: • (1) evaluation of medical information • (2) patient communication • (3) radiation safety • (4) professionalism • (5) specific procedural skills

  11. R.R.A. Exam Board Eligibility • 1. ARRT Certified and Registered in Radiography • 2. One year of Acceptable Clinical Experience • 3. Educational Program Completion • 4. Didactic Competence Requirement

  12. R.R.A. Licensing Exam Board Eligibility • 5. Clinical Education Requirements • 5A. Component 1: Clinical Experience Documentation and Competence Assessments • 5B. Component 2: Professional Activities and AccomplishmentsRecord • 5C. Component 3: Case Studies • 5D. Component 4: Summative Evaluation Rating Scales

  13. R.R.A. Licensing Exam Board Eligibility • 6. Baccalaureate Degree • 7. ARRT Ethics Requirements • 8. Application for Certification

  14. Registered Radiologist Assistant Examination Content Categories • Multiple Choice: • A.Patient Communication, Assessment, and Management- 45 points • B. Drugs and Contrast Materials -30 points • C. Anatomy, Physiology, and Pathophysiology- 55 points • D. Radiologic Procedures- 40 points • E. Radiation Safety, Radiation Biology, and Fluoroscopic Operation- 15 points • F. Medical-Legal, Professional, and Governmental Standards -15 points • Total Number- 200 points • Testing Time Allowed 3.5 hours • 2 Case Studies • Each case is followed by four to six essay questions worth 3 or 6 points each. • Testing Time Allowed 2.5 hours

  15. Career Outlook • Momentarily Difficult • New Profession, Myths, and Fears (lack of support) • Reimbursement issues (CMS Guidelines and supervision requirements) • R.R.A. roles beyond ARRT • Image interpretation ( think radiology residence) • Radiology Procedures not listed (bone marrow biopsy, IVC filter placement, drainage tube insertion, port removal, radiologist comfort etc…) • Liability • United kingdom • Advanced radiographer Practitioner • Quality of service provided • Clinical training of RA vs resident, PA, NP

  16. HR 1148 Medicare Access to Radiology Care Act of 2013 • To amend title XVIII of the Social Security Act to provide for payment for services of qualified radiologist assistants under the Medicare program. • More senator Co-sponsorship needed.

  17. Society of Radiology Physician Extenders • “The Society of Radiology Physician Extenders (SRPE) is a non-profit organization for the RPA and RRA sharing a common bond within the global mid-level radiology profession and medical community in general. The society holds an annual conference conducting seminars and presentations. The SRPE is an active participant with other health care professionals and organizations to educate and promote the role of the mid-level radiology extender. Our organization is committed to fostering the highest values and promoting superior lifelong success both personally and professionally.” • Conferences with Continuing Education Credits • Legislative involvement • http://www.srpeweb.org/DesktopDefault.aspx

  18. References • A.R.R.T (2013). Registered Radiologist Assistant (R.R.A.) | ARRT - The American Registry of Radiologic Technologists. Retrieved January 12, 2013, from https://www.arrt.org/Certification/Registered-Radiologist-Assistant • S.R.P.E. (2013). Society of Radiology Physician Extenders Inc. Society of Radiology Physician Extenders Inc. Retrieved January 12, 2013, from http://www.srpeweb.org/DesktopDefault.aspx

  19. Port Injection Richard Danieli

  20. PatientInformation • 55 year old female • Right breast grade 3 infiltrating ductal carcinoma

  21. Mammogram of Right Breast Breast Cancer

  22. Ultrasound of Right Breast Breast Cancer

  23. Patient History • Left sided portacatheter placed 5/23/12 in good location and functional • Portacatheter needed for chemothereapy treatment for cancer of the right breast

  24. Initial post port chest x-ray on 5/23/12

  25. Reason for the Examination • No blood return from port when accessed two days ago

  26. Relevant Information • Left sided portacatheter placed to keep right side open for surgical and radiation options

  27. Radiographic Procedure • Portacatheter was accessed using sterile technique • Patient was positioned supine on fluoroscopy table • Scout spot x-ray obtained • Patient was positioned in right anterior oblique • 10 cc non ionic iodinated contrast was injected in the port • Live fluoroscopy and rapid sequence imaging was obtained

  28. Scout fluoroscopy image 1 month post port placement Note: Loop in catheter Note: Distal location of catheter

  29. Examination Results • Malposition of the distal end of the portacatheter • Loop in middle portion of portacatheter • Fibrin sheath formation of distal portacatheter lumen

  30. Port Injection Image Note: contrast jetting superiorly and laterally from catheter.

  31. Differential Diagnosis • Extravasation of contrast through fracture or hole of catheter

  32. Discussion • Migration of the catheter tip superiorly with a mid-portion loop is known complication especially with left sided ports due to the vessel pathway • Fibrin sheath formation of the distal catheter lumen another known complication of portacatheters allowed a limited forward flush, but no blood aspiration

  33. Suggestions • Removal of current portacatheter • Replace with a new portacatheter

  34. Discussion Questions • John: • 1. What are the indications for a central venous port? • 2. What are the indications for a left chest port placement? • Stacy: • 1. If a large symptomatic venous air embolism is caused, in what position do you place your patient? • 2. What is the treatment for a large symptomatic venous air embolism? • Tina: • 1. What are the post op port placement instructions for patients? • 2. Describe the details involved with using tissue plasminogen activator to treat fibrin sheaths or clots at the catheter tip.

  35. References • Kandarpa, K., & Machan, L. (2011). Handbook of interventional radiologic procedures (4th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. • Kessel, D., Robertson, I., & Sabharwal, T. (2011). Interventional radiology: A survival guide (3rd ed.). Edinburgh: Churchill Libingstone/Elsevier. • Kim, F. M., Burrows, P. E., Hoffer, F. A., & Chung, T. (1996). Interpreting the results of pediatric central venous catheter studies. Radiographics, 16, 747-754. Retrieved from http://radiographics.rsna.org/content/16/4/747.full.pdf+html. • Mauro, M. (1998). Delayed complications of venous access. Techniques in Vascular and Interventional Radiology, 1(3), 158-167. doi:10.1016/S1089-2516(98)80145-5 . • Slaby, J., & Navuluri, R. (2011). Chest Port Fracture Caused by Power Injection. Seminars in Interventional Radiology, 28(3), 357-358. doi:10.1055/s-0031-1284463.

  36. Esophagram Pathology Richard Danieli

  37. PatientInformation • 77 year old female • No known surgery to gastrointestinal tract • No weight loss

  38. Patient History • Dysphagia • Pharyngeal perforation, aspiration, and fistula were not clinically indicated therefore thick and thin barium contrast was used and not water soluble contrast.

  39. Reason for the Examination • The patient stated “food gets stuck in my throat” • Other clinical reasons for performing an esophagram include: • Dysphagia (difficulty swallowing) • Odynophagia (painful swallowing) • Globus (sensation of a lump in the throat) • Suspected aspiration • Postoperative assessment of laryngectomy • Penetrating Trauma

  40. Relevant Information • Endoscopy showed antraldeformity follow up with GI study recommended

  41. Radiographic Procedure • Esophagram performed • Thick and thin barium used in vertical and horizontal positions • Patient positioned upright in right lateral, AP, and LPO • Patient positioned supine in RAO, AP and RPO • Images obtained of esophagus collapsed and dilated with barium • Modifications of routine exam to image visualized pathology

  42. HH on CXR • The chest x-ray shows the Hiatal Hernia. Notice the circumscribed lucency behind the heart.

  43. ZenckersDiverliculem • Notice the small Zenker’sdiverticulm.

  44. Diverticulum • Notice the distal esophageal diverticulum with barium distending distal esophagus • Image obtained in upright position

  45. Distal Esophageal diverticulum • Notice distal esophageal diverticulum has barium pooling. In comparison to previous image there are tertiary contractions of the distal tortuous esophagus • Image obtained in upright position stomach

  46. Distal Esophageal diverticulum • Notice the location of the diaphragm, clearly showing a Type IV complex paraesophagealhiatal hernia. • Image obtained supine notice difference in appearance from prior images done upright showing or movement of the hernia

  47. Examination Results of Radiology Report • Results:Multiple tertiary contractions of the esophagus are seen associated with prominence of the cricopharyngeus sphincter. 5mm in diameter Zenkers diverticulum is noted. No aspiration or penetration is seen. Large Hiatal hernia is seen with the majority of the stomach herniated into the chest cavity. There is considerable gastroesophageal reflux. A 2cm diameter outpouching is noted of the distal aspect of the esophagus compatible with distal esophageal diverticulum. • Impression: Prominence of the cricopharyngeal sphincter associated with small Zenkers diverticulum. Significant motility dysfunction of the esophagus. Diverticulum of the distal esophagus as described. Large hiatal hernia. See above

  48. Differential Diagnosis • The differentials for the hiatal hernia on the frontal chest x-ray are: • retrocardiac lung abscess • retrocardiac empyema • epiphrenicesophageal diverticulum • There are no differentials for the esophagram images. They could potentially be wrongly diagnosed. • The stomach could be wrongly diagnosed as a volvulus or malrotation if the interpreter did not notice the level of the diaphragm, but these diagnosis should be done on an UGI where the duodenum is visualized • The zenckers diverticulum could be wrongly diagnosed as an ulcer • The distal esophageal diverticulum could be wrongly diagnosed as a large ulcer

  49. Discussion • Zenker’s diverticulum correlates with the sensation of food getting stuck in the upper esophagus • Motility dysfunction which contributes to the patient’s dysphagia. • Considerable gastroesophageal reflux (suspected treatment or forgot to mention symptoms) • Asymptomatic distal esophageal diverticulum • Asymptomatic type IV complex paraesophageal hiatal hernia

  50. Suggestions • Treatment for the reflux would be recommended such as Prilosec (an antacid). • Surgery of hiatal hernia only necessary if hernia causes strangulation which cuts off the blood supply or causes an obstruction • No treatment for asymptomatic type IV complex paraesophageal hiatal hernia • No treatment for 77 year old asymptomatic distal esophageal diverticulum • No treatment for the Zencker’sdiverticulum • No treatment for dysmotility

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