CT scanners in the Emergency Department are life-savers

VANCOUVER – Too often, trauma patients brought to hospitals wait hours to receive the diagnostic images needed to confirm a diagnosis. Vancouver General, however, has reduced the wait to just minutes by installing high-powered CT scanners right in the Emergency Department.

Top-tier CT scanners, like the Siemens Somatom Force, also provide high-resolution pictures of tiny structures in the body – enabling trauma radiologists to increase the accuracy of their diagnoses. The combination of speed and quality in imaging has meant the difference between life and death for many patients.

“Every single day, we see people with blocked arteries, with strokes, with damage from trauma, and we’re quickly able to tell surgeons and ED specialists whether operations are needed,” says Dr. Savvas Nicolaou, Director of Emergency/Trauma Imaging at the Vancouver General.

Dr. Nicolaou tells of a recent case in which a 23-year-old was brought to the department and scanned after a nasty fall while skiing at Whistler, the resort close to Vancouver.

“We were able to see the vessels of the heart, and that there was a tiny tear,” said Dr. Nicolaou. “The patient had started to develop clots, and was close to having a heart attack.”

Within minutes, the patient was transferred to the cardiac cath lab, where the clots and dissection were repaired with medication and stents.

“We saved his life,” says Dr. Nicolaou.

The patient benefited from a highly skilled team of radiologists, technologists, nurses and ER physicians, along with the cath lab team. Another crucial component was the newly installed Siemens Somatom Force CT – a top of the line scanner that is so fast that there’s no need for breath-holds when imaging the heart.

The machine also takes crystal-clear images of tiny structures – giving radiologists more certainty about clinical decisions.

Radiologists at the VGH were so impressed with the higher speed and clarity of the Siemens Somatom Force that they pitched in $250,000 to help buy it.

The high-end machine is the first in Canada to be installed in an emergency department. For its part, Vancouver General pioneered the phenomenon of using CT scanners in the ED – Dr. Nicolaou led the effort in 2005, and the department now has four CT scanners.

Two of them are dual-energy Siemens Flash CTs, while the latest generation Force was installed just last December. Dual energy CTs make use of two X-ray tubes and two detectors, for very fast and detailed imaging. As well, X-ray dose can be reduced considerably to achieve these results.

Seeing the impact that ED-based CT scanning has had, other hospitals across Canada are starting to follow VGH’s lead.

“This is now the model, and everybody wants to do it,” says Dr. Nicolaou. “It’s the way things are going.”

So if VGH has been doing CT scans in the emergency department since 2005, and has proven its worth, why haven’t others followed suit more quickly?

Dr. Nicolaou explains that when he and his colleagues started their campaign, it was difficult to get the ball rolling. “Now we’re seen as pioneers and trail-blazers, but at the time, we were seen as madmen.”

Not only does it take committed radiologists, ED physicians and other clinicians, but hospital brass, board members and foundations must also be persuaded. And of course, the funds must be raised and the technology acquired.

It’s a process that can take years.

What really galvanized Dr. Nicolaou in the late 1990s and early 2000s was seeing young people brought to the emergency department after suffering car crashes, only to die of blood loss while waiting for imaging studies to be done.

“We lost five or six people, aged 18 to 23, because by the time they were transferred upstairs, it was too late,” he said.

He spearheaded the drive to bring CT imaging into the emergency rooms, to speed up the imaging process.

And there is no lack of need for this service. Trauma is the number one cause of death in Canada for people under the age of 44, with the majority of them suffering car crashes and subsequent blood loss.

Diagnosing them correctly is imperative – and that’s where CT comes in. “Time is brain, and time is heart,” notes Dr. Nicolaou.

Dr. Nicolaou mentions another recent trauma patient who benefited from having a powerful CT in the ED.

The patient was brought in with gunshot wounds, with bullet fragments in his chest. It was difficult for the ED physicians to tell if the fragments had penetrated the heart muscle, or whether they were on the surface of the heart.

“If they were inside the heart, you’d have to open up the chest to do the surgery,” explains Dr. Nicolaou. “But that means you have to stop the heart, and the danger is that it might not start again.”

Using the Force CT, Dr. Nicolaou was able to image the beating heart, and determine definitively that the fragments were on the surface of the heart.

“They didn’t have to open the chest, and we may have saved his life,” he said. “We could do it all in minutes. It was amazing.”

It’s important, too, says Dr. Nicolaou to have trauma radiologists on-site at all times. “Emergencies are unpredictable and sudden,” he notes. When they happen, you want to have an imaging expert on hand, to make fast decisions and advise the ED physicians and other specialists.

Tele-radiology is not an option, he says, because most tele-radiologists are generalists and not trauma imaging experts.

As well, it would take them too long to download images and advise the ED doctors.

“Speed is of the essence,” he says. “You can’t wait for a tele-radiologist to download 6,000 CT images, read them and get back to you.”

Dr. Nicolaou is now campaigning to acquire an MRI scanner for the Vancouver General Hospital’s emergency department – something that would be another first for a Canadian ED.

MRI, he notes, is excellent for soft tissue imaging, such as the brain and heart, and it also has the benefit of using magnetic waves rather than X-rays. As a result, it is safer for patients.

“For stroke imaging, MRI is the gold standard,” says Dr. Nicolaou.

“It would also mean that the ED is a one-stop imaging centre,” he said. “That’s my vision.”