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Zone 3 is a podcast that discusses everything MRI. Tune in to hear about the latest advances, optimization techniques, and more! Hosted by Robert and Reggie who are both MRI Technologists. They have an entertaining rapport as they tackle topics like MR safety, imaging protocols, upcoming technology, and so much more.
You can tune into Zone 3 Podcast on YouTube or listen to it on your Podcast RSS Feed! Thanks for Stopping by Zone 3.
00:06:57:17 - 00:06:59:09
Speaker 1
It's been a while as all three podcasts. I am.
00:06:59:09 - 00:06:59:20
Speaker 2
Robert.
00:06:59:20 - 00:07:01:20
Speaker 3
Yes, and I am ready.
00:07:01:20 - 00:07:08:17
Speaker 1
And back by popular demand probably are one of our most requested guest. How many? What does this make for you?
00:07:08:18 - 00:07:09:04
Speaker 2
Three.
00:07:09:07 - 00:07:20:17
Speaker 1
Three. Rob Cloutier, thanks for joining us, Rob. Appreciate you. Yeah, Rob's here to discuss. Well, first of all, he he named. Yeah. What do you said? You said what? It was a fast gains. Beautiful images.
00:07:20:19 - 00:07:25:17
Speaker 2
I didn't say that. I think that's what you heard. I feel like you said that well.
00:07:25:19 - 00:07:44:00
Speaker 3
And I feel like the real reason why Rob is here, honestly, is there's a lot of green, green texts that are entering the field. And we actually just hired a few where we work at that came from Rob's program. And they're not like the traditional green techs that we have also hired that wasn't a part of his program.
00:07:44:02 - 00:07:58:04
Speaker 3
So we just want to kind of figure out like your perspective on where the field is at with how, you know, people coming in green and education status. But really, what are you doing differently? Like why why all the people who go to your program come out more successful.
00:07:58:06 - 00:08:23:09
Speaker 2
Pretty pictures in the shortest time? Mr. JANSEN Yeah, I think I think tomato, tomato, you've got. I do things differently, and I always have in more in when I was younger, it used to get me in the trouble because I didn't always follow the rules because I had a zoomed out perspective of how we were going to use the MRI machine to image patients.
00:08:23:11 - 00:08:50:05
Speaker 2
And I think that that's important. So when you guys brought this to me a couple of weeks ago, it had been something that's been with me for really my entire career, but more so the last few months because my phone is blowing up again and the demand for Mars going out like it's the Mars demand is rapidly growing, but the talent can't support it.
00:08:50:07 - 00:09:14:02
Speaker 2
So I'm being asked, how do you address this? And I said, Well, if you want my involvement, I'm going to kind of take AT&T to your current structure because I see technologists getting lost in protocols. They're in the weeds and there's 200 something protocols and they're trying to memorize them all. And it's the wrong approach. I have a different approach in it's a looser approach.
00:09:14:04 - 00:09:38:10
Speaker 2
I watched your episode with Frank Sherlock. He has been doing MRI safety so long that he's the guy, right? He's the expert. I'm not big into clichés. I like to come up with my own ideas. Right? But the one that fits with Frank is he's forgotten more than anybody will ever know. And because of that, he's able to zoom out and speak about things on a macro level.
00:09:38:10 - 00:10:06:00
Speaker 2
I watched him show you these implants and come at it from almost a philosophical angle, like show it to you. Reggie what could happen to this? No, we're not worried about a change in gradient field. We're worried about. RF No, we're not worried about. RF We're worried about a change in gradient field. I think when you've done something long enough, you come at it from a different, more zoomed out level where you make it easier to the layperson.
00:10:06:02 - 00:10:24:10
Speaker 2
And that's what I do in my program. I do not go in and tell them to memorize what's in the house. I do not do that. I start with the Y and say, listen, we look at the body with MRI because we're able to see soft tissue better than the other cameras that we use in radiology. Start there.
00:10:24:12 - 00:10:40:17
Speaker 2
Right. Why is it that we're able to do that in from there? I go I think being in the weeds for a long, long, long time affords you the ability to zoom out and make things simple for for new people.
00:10:40:17 - 00:10:47:14
Speaker 3
You kind of understand the goal of why we're there, right? A little bit better, Right. So you just pretty much taking that goal and just simplifying it.
00:10:47:16 - 00:11:10:22
Speaker 2
To the point, Reg, where I've been involved with an outpatient imaging center that's doing a ton of whole body imaging now because you're seeing this fad, right? And the new systems that are out there, you can plug in all these coils in, you can scan somebody from breathing down to the knees rapidly, and patients are paying cash for these preventative scans because they want to know what's wrong with them.
00:11:10:22 - 00:11:28:15
Speaker 2
They want to get ahead of it. And I get why. Right, right, right, right. They're coming into MRI suites and they're discounting the fact that they still get to go into an MRI machine. And some of these people are claustrophobic. And I've been asked to come in and make these things more efficient in they in they and they say to the technologist, well, I'm claustrophobic.
00:11:28:19 - 00:11:47:15
Speaker 2
I come into the room and I say, well, then don't do it. And they're like, What do you mean? I paid for this? I'm like, What you pay for is there is there something wrong with you? You came in here today on your own volition for a preventative scan. If we're going to move you into the bore and it's going to cause more trauma than you currently have year in your life.
00:11:47:15 - 00:12:02:14
Speaker 2
But what are we doing? We don't have to do this. All we do is take pictures. We do not cure anything. I've been in the weeds so long that I'm able to zoom out to the point where I tell patients, Don't do it. You know, I think that that's healthy, Right?
00:12:02:16 - 00:12:03:13
Speaker 3
Okay. Nice.
00:12:03:19 - 00:12:05:13
Speaker 1
So we're talking about the Kardashians, right?
00:12:05:15 - 00:12:08:20
Speaker 2
Yeah. What does that mean, Robert? Normally, I'm really general.
00:12:08:20 - 00:12:09:23
Speaker 1
I don't know if they're the ones that make the.
00:12:09:23 - 00:12:13:18
Speaker 3
News what they call it. Does his body starts sort a P.
00:12:13:20 - 00:12:19:06
Speaker 2
Yeah. The company that's out there doing it all for you. Yeah. Yeah. They got a trendy name. Well, there's a couple of them.
00:12:19:09 - 00:12:19:21
Speaker 3
There's a couple.
00:12:20:00 - 00:12:22:00
Speaker 1
I try to relate everything to the Kardashians.
00:12:22:00 - 00:12:22:14
Speaker 2
Yeah, that's.
00:12:22:14 - 00:12:23:08
Speaker 3
How I run my life too.
00:12:23:11 - 00:12:24:22
Speaker 1
Yeah.
00:12:25:00 - 00:12:29:14
Speaker 2
They still. Yeah, they've done so well that it was cardiac. Well I think actually you.
00:12:29:16 - 00:12:55:11
Speaker 1
Yeah. You said something that kind of resonated with me and I'm using that word intentionally, but a lot of times when you're first you're new to MRI, you're learning what? What are these buttons? But you're, you're approaching it from the ego y first and with that becomes the jumpstart in their competency and their skill level as a technologist, because I'm seeing some of these tech that you've trained and I've seen compared to some of the tech.
00:12:55:11 - 00:13:09:23
Speaker 1
So you have and they come from other facilities and education places and, and there's a lot of green techs out there and I don't want to call them but pushers because that's offensive. It's a four letter word here. Right. But at the end of the day, if you don't know TR ranges or T.
00:13:10:01 - 00:13:12:02
Speaker 2
Then I think.
00:13:12:02 - 00:13:13:17
Speaker 1
You're just learning what you're not learning.
00:13:13:17 - 00:13:45:04
Speaker 2
Why we are here is part of the solution. I think it's appropriate to call them button pushers because button Pusher is not an offensive term unless you are a button pusher and you don't believe that you are and then you'll get, you know, annoyed at that, right? They are button pushers in MRI. Technologist is not opening a protocol that somebody else built spinning slices hitting go hoping it comes out well and if it doesn't saying why use the protocol because that is prevalent in our field, right?
00:13:45:06 - 00:13:45:12
Speaker 1
yeah.
00:13:45:12 - 00:13:48:17
Speaker 2
It's rampant in our field. Right. And that's one of the reasons why we're.
00:13:48:17 - 00:13:50:19
Speaker 1
Here is how the system is designed.
00:13:50:21 - 00:14:13:17
Speaker 2
To tell the system's designed. I've always gone the other way. You know, the first time I was on, you made a comment about how MRI technologists are artists. I had never really looked at it like that before right. But I agree with you. We're producing art. How better or quicker to kill the spirit of the artist, of the MRI technologist?
00:14:13:22 - 00:14:17:03
Speaker 2
If you tell them, do it this way and don't you dare do it a different way.
00:14:17:03 - 00:14:18:09
Speaker 1
See line does all you're doing.
00:14:18:10 - 00:14:34:18
Speaker 2
That's all you're doing. I've always thought, teach them why leave the Watson house up to them? Because then they can have meaning and purpose at their job and they can say, Hey, that looks really good, right? Can I show you how I did it? You know, I know we're trained to do it this way, but I decided to try it this way in.
00:14:34:18 - 00:14:52:15
Speaker 2
Look at what happens. I mean, that's how innovation, that's how innovation happens. The leaders in our business, whether it be Tobi or Frank or Manny or any one of those guys, do you think those guys sat there and said, they told me how to do it this way, right? All of those guys said, This is how we do it.
00:14:52:15 - 00:15:03:07
Speaker 2
It's not enough. Let me go in here on my own time, on my own volition, and figure out a different way. And then let me come back and tell you what I learned. And that's what I've done on the technologist side.
00:15:03:07 - 00:15:08:16
Speaker 1
So do you think that takes initiative on the tech's part, or do you think that they're just a product of their education?
00:15:08:18 - 00:15:30:10
Speaker 2
I think it takes initiative. I think that let's call it what it is. The leaders in any industry are always the top 5%. The other 95% kind of fall in somewhere. That's not to pick on those people. It's probably just not their passion. The 95% button pusher we don't know anything about their personal lives. Maybe they go home and garden for 16 hours on the weekend, Right?
00:15:30:10 - 00:15:46:14
Speaker 2
That's where they that's where they want to make their contribution. Work is work for them. But I've always viewed it as I look at these technologies and I see how scared they are throughout the day. They're scared for the phone to ring. I always want to help them. Why sit here and be scared all day waiting for the phone to ring?
00:15:46:14 - 00:15:54:05
Speaker 2
Why don't you learn what they need and then you can give it to them and then you can chill at work. I guess I always write well.
00:15:54:05 - 00:16:10:14
Speaker 1
Ironically, it's like the more competent you are, the less anxiety you have, but the more anxious you are as less and competent you are. So it's kind of like inversely proportional. It's it's interesting because you're right, like teach somebody to be confident and learn why that why they do the things that they do and not just what.
00:16:10:14 - 00:16:28:09
Speaker 3
Well, on the issue with some of the green techs that have been coming in is they're not always trained. So this is some of the biggest questions that we have about you, because I've even seen this situation happen with Robert as he's trying to train somebody new. He could pick out a story, but they're not always receptive because what we really want to do is get them up to speed.
00:16:28:09 - 00:16:40:02
Speaker 3
The button pushers want to get up to speed, you know, try to align them with how they should kind of be looking at the scenarios. But sometimes there's pushback there, which kind of makes it hard right.
00:16:40:04 - 00:16:42:04
Speaker 2
Before you tell that story.
00:16:42:06 - 00:16:43:09
Speaker 1
So I've got a couple stories.
00:16:43:09 - 00:17:15:00
Speaker 2
Before you get to any of them. It's important to understand where we are in the cycle. This is this is a little bit of a goofy example, but I think it helps that I won't even do that. Let's just say we're reactive in the MRI business. We have the patients on the schedule, we have the huge fixed cost MRI machine burning a hole in the organization's pocket and we need a tech.
00:17:15:02 - 00:17:31:17
Speaker 2
There's a staffing shortage. We need somebody there. We've got to close down these shifts. So got to close down Saturdays because we don't have the people. So it's not realistic to think, Let's go find this person, bring them in and groom them for three months with the wives. They get thrown to the whatever the metaphor is. We've all been there.
00:17:31:17 - 00:17:35:02
Speaker 2
So that's part of the problem. Right. But they have to.
00:17:35:02 - 00:18:03:22
Speaker 1
Also show initiative because they want to. All people should always strive to be better and not just become complacent with what the status quo is, whatever that as far as peers go and like expectations of their facility, I don't know. Like so the the story that he's alluding to and I've got a couple is that it's frustrating because we work at a place that some a well according to different resources they consider the number one hospital in the world.
00:18:03:22 - 00:18:04:19
Speaker 3
We're held to a high standard.
00:18:04:19 - 00:18:28:04
Speaker 1
We can't say names, but it's a prestigious place. And when I first went there, they required at least five years minimum, the experience. And and I like that. And I put in my time before I went there and and I went into it surrounded by a lot of a lot of smart people. And now with its current climate, the short staffing there, they're hiring people that are straight out of school.
00:18:28:04 - 00:18:48:20
Speaker 1
They're hiring people from from other facilities that aren't very credible. And I'm finding a lot of incompetency with that in the learning curve. It's much different. And so that's frustrating. So, for example, we have one tech who I and I train a lot of these people when we all do, we they're you know, we're all kind of a team effort.
00:18:48:20 - 00:19:13:14
Speaker 1
There's so much to like. I'm the only one that trains, but so I train them and there is this one tech that I'm training and on the exact same patient I see him make the exact same mistake. Three times. And so I talk to him with some sensitivity, but I'm a straight shooter as well. People think that I'm a New York kind of a guy and I'm not from New York, but I have that personality of like very straight shooter.
00:19:13:15 - 00:19:35:16
Speaker 1
Blunt. I'm honest with my opinion, you know, where you stand with me. But and so I was straight with him and I talked to him the same as I would talk to my kids and I talked to my kids extremely, like considerate and but direct to, you know, I'm very sensitive to them. But so I said I said, hey, you know, you just made the exact same mistake three times on the same patient.
00:19:35:16 - 00:19:47:15
Speaker 1
That's not okay. And I said, That's not okay. And I said to my kids, That's not okay. This is it. You're not a waiter working at IHOP and you forgot this customer's refill.
00:19:47:15 - 00:19:48:06
Speaker 3
But shout out to.
00:19:48:06 - 00:19:53:22
Speaker 2
I said, Yeah, this is no, you know, if you are a server at IHOP, Robert holds you at the same level.
00:19:54:00 - 00:19:54:21
Speaker 1
Well, no, I know.
00:19:54:23 - 00:19:56:10
Speaker 2
Yeah, yeah, yeah.
00:19:56:12 - 00:19:57:01
Speaker 1
But this is.
00:19:57:07 - 00:20:00:23
Speaker 2
A mistake that IHOP is not as big of a deal as a mistake at your hosp.
00:20:00:23 - 00:20:16:18
Speaker 1
Absolutely not. Because, like, if you look at your refill, if you see the bottom of your glass before you want to, that's whatever. But if your work, if you go to a health care facility that has a reputation to be one of the top in the world, not just the country, you have a certain level of expectations.
00:20:16:18 - 00:20:41:00
Speaker 1
And if you're there, by the way, every patient has a threshold. And I think that that's something that techs don't appreciate. So as far as fast scans go, it's important because there should never be downtime. I hate hearing silence. You should always have the next sequence prescribed before the previous one finishes. And when you see that there's downtime in between, as I've been, that that patient that's on the panel, by the way, I'm just there for protocol development.
00:20:41:00 - 00:20:58:10
Speaker 1
I'm not even like a pain patient, but just sit there thinking, What are these guys doing? Why am I listen to silence right now? And then if from a facility like admin perspective, it's like they say silence is money. Like that's just wasted money, right? So you wasted money. Wasted patients tired. By the way, that patient has a threshold of time.
00:20:58:12 - 00:21:18:17
Speaker 1
How many times have you had a patient squeeze the ball with literally one minute left. Right. I can't do this anymore. Well, did you make that exam? 3 minutes longer than they had to be. If you did, then that patient would have never squeezed a bomb. And that's something that people don't really think about. So like when you're doing repeats and you made the same mistake three times on the same patient, that's not okay.
00:21:18:17 - 00:21:22:07
Speaker 1
These people come here with certain level of expectations. They're going through a lot.
00:21:22:13 - 00:21:23:00
Speaker 2
They are.
00:21:23:06 - 00:21:41:06
Speaker 1
They're going through a lot and they've got a lot on their plate. And if if they could just rely on one thing, they should rely on you being able to do your job correctly and get them in and out with a certain level of quality and no order that it has to be. And so that was frustrating.
00:21:41:07 - 00:21:54:00
Speaker 3
When you were trying to kind of get them up to speed. After that. He was just kind of he was put off by your you being so direct that he did not want to kind of be trained by you again, like he would literally try to avoid you.
00:21:54:02 - 00:22:04:20
Speaker 1
Yeah, that's unfortunate because now keeps the distance for me. And I maybe I was too maybe I wasn't sensitive enough.
00:22:04:22 - 00:22:05:13
Speaker 2
Yeah, I don't think.
00:22:05:13 - 00:22:08:23
Speaker 1
But this is this is the professional world.
00:22:09:00 - 00:22:09:16
Speaker 2
You're right.
00:22:09:18 - 00:22:11:13
Speaker 1
This is a.
00:22:11:15 - 00:22:27:05
Speaker 2
Yeah, this ain't a pre-season game. Yes. And we talked about this in the first episode. If you're going to come with just a tech mentality and your what you do for a living defines who you are as a person and you're going to take the all away.
00:22:27:05 - 00:22:27:20
Speaker 1
Tables.
00:22:27:20 - 00:22:43:00
Speaker 2
Then then you know, that's for you, that's for your own development. You've got to figure that out on your own, right? You're always going to have somebody like you who's upstream from you in the process, who's going to tell you when you're not making the grade. That's capitalism. And Wheatley's in full disclosure.
00:22:43:00 - 00:22:51:17
Speaker 1
I want to be clear, because I make mistakes, too. We all make mistakes. Come to me. If I make a mistake, tell me what mistake that I made and you will see that I will not repeat that mistake.
00:22:51:19 - 00:23:08:23
Speaker 2
Not only not repeat it, but you'll be open to the feedback because you I understand it's not a it's not a slight towards you when you say what you just did three times in a row is not enough. You're not saying you're a worthless person. What you're saying is it's not enough. So we got to get it to be enough.
00:23:09:05 - 00:23:26:17
Speaker 2
And if they're not able to be, you know, stable enough as a human being to accept that feedback, then you got two problems. Not only do they not have the knowledge and they don't make the grade, they're not open. They're not open to ever getting it right. Right. That kind of person probably, you know, And sometimes.
00:23:26:18 - 00:23:45:05
Speaker 3
I feel like you just have to this is one thing I think you're amazing at is you just have to water it down enough so that they understand the mistake. And I think one of his biggest issues is that even though Robert called him out and told him what he was doing wrong, he was like, okay, but he did not understand what Robert was trying to tell him.
00:23:45:10 - 00:23:50:00
Speaker 3
But he didn't he didn't say that. So he just said, okay. And he made the mistake again.
00:23:50:01 - 00:23:59:14
Speaker 2
Well, let's empathize with him for a moment. Think about what a defensive, helpless position that is. When you come from the memorizing in Watson house.
00:23:59:16 - 00:24:00:18
Speaker 1
It's intimidating for.
00:24:00:18 - 00:24:13:12
Speaker 2
Sure. In somebody coming at you with that one. How you just did is not correct in they have no ability to get into the why and actually critically thinking that that's a pretty helpless feeling.
00:24:13:14 - 00:24:30:21
Speaker 1
Well and then the the one thing that I found and I guess it's unfortunate the thing about it that's unfortunate is that he knew Reggie and I for the podcast before he even started working there. And he thought that was the coolest thing in the world that could work with Reggie. And I like, my God, I've been watching your podcast.
00:24:30:23 - 00:24:45:11
Speaker 1
And then here I am criticizing him. Said he went from thinking, I would love to work with you. Now he's keeping his distance for me, and it's because I called him out on it and it's I guess it is what it is. And the mistake that he.
00:24:45:11 - 00:24:46:21
Speaker 2
Made.
00:24:46:23 - 00:25:07:12
Speaker 1
Was he scanned in the wrong plane three different times. Mind you, before he even did it, the first time, I said, Hey, because what I did is I pulled a savage over from a different protocol and I said, Hey, you're going to run this as an axial. But I pulled it over as a sage. I just relabeled it so it might come up as a sedative.
00:25:07:12 - 00:25:13:21
Speaker 1
Just make sure that you scan it as an axial. I, I leave for 10 minutes, I come back. He scanned it. As I said.
00:25:14:03 - 00:25:42:08
Speaker 2
In that's alarming on so many levels. But the greatest one to me is again, zoom out the people who come through my program, if they don't come see their exam, they literally are. That's not one I'm very patient with. I tell them, you know, lovingly as kindly as I can, but I'm like, listen, we can get anybody in here to hit the button and not look it what it came up as.
00:25:42:10 - 00:26:03:15
Speaker 2
I don't care that you ran three sagittal. I do not as much is the fact that they didn't notice. They ran three sagittal because that means I issue you. You're not Q seeing the images and it ain't like X-ray tech when it goes to a QC department. You are the QC technologist and if you're not. Q seeing the images, what you're really telling me is you have no issue.
00:26:03:20 - 00:26:07:18
Speaker 2
If that person leaves the facility and has to come back in a couple of days and take more time off work.
00:26:07:18 - 00:26:25:18
Speaker 1
A lack of empathy, but actually I would take it one step further. The way you're saying talk about cutscene images, you're talking about a reactive thing. I'm saying you need to be proactive. You need to be checking your prescriptions to make sure that what you're doing is what is intended to be. But when you're choosing images that's more reactive.
00:26:25:18 - 00:26:30:15
Speaker 1
You're like, crap, I scan this in the round protocol or in the road plate. That should have never.
00:26:30:15 - 00:26:51:18
Speaker 2
Happened without question. But it's a safety net. I don't love the I don't love the react. I don't love the word reactive because it catches you. Now, what the safety net does is it catches you and then you're like, okay, I'm not dead now. shit, I forgot to look at. Right? So gives you the chance to go back and learn that.
00:26:51:20 - 00:27:07:18
Speaker 2
But without the safety net then I agree completely with you. But there's still a component of that's part of the learning process. So if you tell them, Hey listen, QC is mandatory, then that means that the exam might have been 15 minutes longer than that.
00:27:07:20 - 00:27:15:20
Speaker 1
But what you say is part of the learning process, in my opinion, there should be a fundamental understanding like you should have the 1 to 1 stuff down.
00:27:15:22 - 00:27:35:17
Speaker 3
I think they agree with this is the whole reason pretty much why the people in your program come out so much more ready for success in Meri is because he was just ready the scan how the however the thing popped out how were those slices popped up? He was just ready to place it over the anatomy and scan it.
00:27:35:19 - 00:27:51:06
Speaker 3
Even though you told him, Hey, this is going to pop up wrong, He's been trained to be just be a button pusher. You've been trained to, Hey, it's going to come up like this. You just cover this. And without even looking at sequence name, without looking at anything, he's just been trained to be a button pusher. And I think that's the problem with the industry right now.
00:27:51:08 - 00:28:01:01
Speaker 2
It's a thing. The sagittal T1 is a thing called a widget, right? And we're not going to go into it today because we don't have time. But I briefly describe the bucket system on episode two that we did.
00:28:01:01 - 00:28:02:08
Speaker 3
Rank in the description.
00:28:02:10 - 00:28:21:21
Speaker 2
Write bucket. You know, the bucket system was for different, for different buckets, slice plane, right? So it would be a sagittal and then it would be the weighting or the contrast, then the pulse sequence and then the mode 2D versus 3D. So the students to go through my program, they they don't say sagittal one or I'll wait for them to correct themselves.
00:28:22:02 - 00:28:39:11
Speaker 2
They say Sagittal one fast spin Echo 2D. Now, what's the advantage of that? The advantage of that is letting them know that a fast spin echo doesn't always work. Sometimes you need to run just a regular spin echo. Not very much anymore, but right, right, right. Sometimes you don't have time to run a fast spin echo or SA won't allow it.
00:28:39:11 - 00:29:00:13
Speaker 2
So now you run a gradient echo, right? Or sometimes you need to do at1 mic. I want them to understand that the pulse sequence is separate from the contrast. Bucket two and bucket three are different. So if somebody comes in with metal susceptibility artifact issues, I'll say, Well, we still need a T1, right? But what you don't need is a gradient echo because it's going to be worse.
00:29:00:13 - 00:29:20:18
Speaker 2
So go to a fast burn echo. So when you can understand the four individual buckets and you can sub things in, I still want a T1, but I have to use a different pulse sequence. So I still want a fast burn echo, but I want a different contrast for I needed to run a coronal T1. I imported a sagittal T1 and it was bucket one that had to be changed.
00:29:20:22 - 00:29:37:21
Speaker 2
No big deal. I train my technologist that way once you build a sagittal T1 in the femur, the last thing you'd ever want to do is import a brand new crawl, T1 copy and paste this agile T1 rename it. Now the field of view matches the size. This matches everything matches. And now you spin it in. Now you get your coronal in.
00:29:37:21 - 00:29:57:11
Speaker 2
The advantage of that is whatever the region of interest was that you showed the rad on the sagittal, you're showing them the same region of interest on the coronal. So they're without these fundamental understandings of imaging. I even dumbed down Roberts to the point. Now imagine being a radiologist in quick thinking that they hung the moon, okay? They went to school longer than you did.
00:29:57:11 - 00:30:12:02
Speaker 2
We take the pictures, They interpret the images. Do you all know how they interpret the images? They look at it from here and then they look at it from here. They step up on a ladder and they look at it from here. That's what they do, Right. And if you run three sagittal, is they going to go like this?
00:30:12:02 - 00:30:30:02
Speaker 2
One, two, three? They can't go like this and see the same deal. from the side I break it down like that. I'm like, stop promoting them to be the supreme being. They went to school for what they do. Help them do what they do. It don't don't be so inferior to them. Back to episode one, right?
00:30:30:02 - 00:30:33:08
Speaker 2
I go all the way back to that.
00:30:33:10 - 00:30:35:13
Speaker 1
Yeah, that's awesome. So what is the solution?
00:30:35:18 - 00:30:55:16
Speaker 3
Yeah, like, because we asked, like our community are, you know, people who I saw on Deepika's last time are either new techs. So it might be some of those green people who are out there. But also, yes, there's always those people who go above and beyond. Right. That are like high speed techs, too. So like, how can we help them train some of these new text and what can new tags kind of do to help get up to speed is.
00:30:55:18 - 00:31:17:05
Speaker 2
Okay, so let's do it. So I thought about how we could do this in a condensed way and we're going to zoom out. All right. Let's call it the MRI expert. Okay. The MRI expert. Not the tech, not the button pusher, not whatever the MRI expert in. That makes sense, right? There's 40,000 of us in the in the country right now.
00:31:17:05 - 00:31:17:18
Speaker 1
I think so.
00:31:17:18 - 00:31:36:13
Speaker 2
40,000. That's a very, very small profession. Right. Okay. We should be experts. We don't do CAT scan, we don't do X-ray, we don't do mammal. I know some people do, but for the most part, MRI techs are running the MRI machine. If you don't know how to run the MRI machine, well, that's kind of a problem, because if we don't know how to do it, who would?
00:31:36:15 - 00:32:00:13
Speaker 2
Ooh, yeah. So the MRI expert, we have two customers, the patient in the radiologist. We're a liaison. And that's why I pretty pictures in the shortest time has been my moniker for as long as I can remember, Robert because the pretty pictures are for the radiologist. We satisfy customer number one with the pretty pictures, we satisfy customer number two in the shortest time, and that's the patient.
00:32:00:15 - 00:32:10:08
Speaker 2
Now, in the shortest time is not as narrow as that might sound. It's be comfortable, give them instructions so they know what to expect and we'll get into that quality.
00:32:10:12 - 00:32:10:18
Speaker 1
Yeah.
00:32:10:20 - 00:32:19:03
Speaker 2
Let's talk about pretty pictures. What is a pretty picture? What do you guys consider a pretty picture? Because I define it three different ways. How would you guys define.
00:32:19:05 - 00:32:21:00
Speaker 1
Diagnostic integrity.
00:32:21:02 - 00:32:21:09
Speaker 3
Yet.
00:32:21:15 - 00:32:43:06
Speaker 2
Locally shall solution? Yeah. Okay. Diagnostic competence, right. Yes. You have to be able to make an accurate read. Right. You guys said resolution resolution is one of the three ways that I define a pretty picture in that is zoomed out isn't it. Because it's the same way I take a, you know, picture a YouTube right now with my iPhone four.
00:32:43:10 - 00:33:10:23
Speaker 2
Right? The first thing I do is zoom it up. How good do we look? Right. That's resolution that allows for that. Okay. So how do you determine resolution in MRI? Because our primary customer I shouldn't say primary one of our customers, the radiologists, a lot of them think that the only way you define resolution is through the field of view, so much so that on offer, oftentimes you'll see on protocols, they'll say, use this field of view on this exam.
00:33:11:00 - 00:33:15:16
Speaker 2
I've always thought that because they're only looking at half of it.
00:33:15:18 - 00:33:33:17
Speaker 1
And I think it lacks critical thinking skills, especially when you do like EMC's case studies. And they every patient is different, you know, And there's a lot of similarities, don't get me wrong. But a lot of times you come to our our facility, a lot of new hires. Right. And they're told right away, don't change field of use, don't cheat, especially on MSC.
00:33:33:19 - 00:33:38:20
Speaker 1
And I say, you know what? Just so you know, I change field of use all the time.
00:33:38:22 - 00:33:40:20
Speaker 2
What I yeah I think.
00:33:40:22 - 00:33:57:11
Speaker 1
But every single time that I care I do I could justify it if ever question and I'm and I'm happy to make that I had that conversation so don't be afraid to change field of use but if you're going to change field of use but there be a purpose and just know that there you might have to justify it in.
00:33:57:13 - 00:34:01:02
Speaker 1
But if there's a purpose and you can justify it, then absolutely.
00:34:01:04 - 00:34:23:06
Speaker 2
And I pole radiologists had I always use the language that's not productive. It's not productive to mandate a fixed field of view that can't change. Let's talk about pixel size instead. Now you want to talk about pixel size. We can sit in here and we can we can work together. Pixel size allows technologists and rads to work together.
00:34:23:08 - 00:34:44:06
Speaker 2
So it's not field of view, it's field of view divided by the matrix, right in that gives you your pixel size. Now, it's not just per patient, which it is, right? You get a gigantic shoulder and the dude's breathing heavy and you got to go quick. How about the equipment that you're working on? Because prior to 23, well, the whatever she is, half of the MRI machines out there.
00:34:44:08 - 00:34:47:04
Speaker 1
Field of view on every body with every coil. Yeah.
00:34:47:07 - 00:35:06:22
Speaker 2
You can't do that small field of view because you have to turn on, know, phase wrap. And if you understand imaging parameters, when you turn on no phase wrap, it cuts your Nixon half, although this system doesn't show you. That's why when you work on an inflexible G with no phase wrap, which they have moved away from right right now it's oversampling just like Siemens does.
00:35:07:00 - 00:35:28:00
Speaker 2
But when you use 16 X in lower, you're using no phase wrap and there's a lot of machines out there that use no phase wrap. It's all it's fixed on or off. Well, when it's on, the reason why the time stays the same is because they cut the necks in half. It's just doesn't show it to you. And that's when you get the fine line artifact, which they've since created a CV for to compensate for.
00:35:28:02 - 00:35:51:15
Speaker 2
But the point is which way you're going to run your phase on an axial shoulder. There's only one way to run your phase on axial shoulder, and that's a to P Well, if they're saying 12 field of view for all professional baseball players, no, because they have muscles that go beyond the 12 field of view. And now if I want a 16 X or lower now I have to turn on no phase wrap, which I need to double the next four if I want a seam image quality picture.
00:35:51:15 - 00:36:21:18
Speaker 2
And now you've just doubled my scan time. But out you don't get the tell me what the field of view is. Those are techniques and those are up to me. What you're more than qualified for is to tell me what pixel size you want when you're looking at a shoulder. And I'll be happy to give you a point five pixel size all day long, because when I make my field of view bigger so I don't have any wrap, I know I lost resolution, I'm going to increase the matrix and now I only have to use two necks without no face wrap in my imaging.
00:36:21:19 - 00:36:23:08
Speaker 2
Time is half as much.
00:36:23:10 - 00:36:29:13
Speaker 1
Do you find that there are certain vendors that make it easier to do? Like, for example, I think Phillips kind of caters to that.
00:36:29:18 - 00:36:48:00
Speaker 2
I think that in the old days Simmons made it easiest because Oversampling Anti-Aliasing was a percentage and you could turn on as much as you needed in it, contributed to your signal and it showed it to you, but it also contributed to your time because Simmons did it, cut the next and half like she did with their no face wrap.
00:36:48:02 - 00:37:17:01
Speaker 2
In the old days, Philips had something called fold over suppression, right? So I think in the olden days Simmons was the most flexible, but nowadays it's a percentage anti-aliasing it directly impacts your time. And I think that that's always been the best because you use as much as you want and sometimes you can use it even even when you're not concerned about wrap, but you need just a little bit more signal when you guys know that you can turn on a little bit of oversampling to increase your signal when you're worried about signal.
00:37:17:03 - 00:37:30:07
Speaker 2
But resolution is the most important thing on an MRI image. But you got to understand it's field of view divided by matrix, and you probably have a rectangular matrix. So you have to do two different calculations in that gives you your pixel size.
00:37:30:07 - 00:37:33:18
Speaker 1
Do you have anything else to define image quality.
00:37:33:23 - 00:37:47:05
Speaker 2
To other things? One is phase smearing motion. Okay. If the person's moving or if you're running your phase through something that's moving, whether it be breathing or a vessel.
00:37:47:06 - 00:37:48:02
Speaker 1
Property on.
00:37:48:02 - 00:38:10:04
Speaker 2
Any anything, you're going to have a crappy image. You're damn right. That contributes to a pretty picture. Again, I'm zoomed out, right? I'm not talking to MRI techs right now. I'm trying to talk to the layman. Right. You need to have a pixel size that is small enough to be considered high resolution. You need to not have a motion picture, which is to say you need to not have any phase smearing.
00:38:10:06 - 00:38:35:14
Speaker 2
Right. Right. And you need to eliminate fat. And I use the word eliminate deliberately because we have fat suppression, we have fat saturation, we have fat separation. Forget it, zoom out. Fat makes the radiologist job harder. So I tell students on day one, if we have tons of fat in our body, if you're going after yourself, you have less of it.
00:38:35:14 - 00:38:35:21
Speaker 2
Yes.
00:38:35:23 - 00:38:38:12
Speaker 1
Number 140 on my shoulder, you say, you know.
00:38:38:13 - 00:38:39:03
Speaker 2
What is it.
00:38:39:03 - 00:38:39:19
Speaker 1
140.
00:38:40:00 - 00:38:40:16
Speaker 2
140 what?
00:38:40:17 - 00:38:41:17
Speaker 1
14 field of view?
00:38:41:21 - 00:38:44:01
Speaker 2
Yeah. Yeah. That's cool.
00:38:44:03 - 00:38:46:05
Speaker 1
Yeah. I just want to be clear about that.
00:38:46:06 - 00:39:12:15
Speaker 2
We have tons of we want them distract me. Right. So we have a ton of fat in our body. If it's bright, it's going to make it harder to see what we really care is bright. And that's pathology. That's fluid. Okay, So I tell MRI techs on day one that the fat is usually going to be dark. I have a little joke with the students that you now have employed.
00:39:12:17 - 00:39:43:09
Speaker 2
Ask them whose responsibility fat fat elimination is. They'll say mine. Yeah, that's right. So if the protocol is built with chemical fat saturation and they have an ACL screw in their knee, okay? Or if you're using a field of view over 30 centimeters in, it's built with chemical fat saturation or if you're way off ISO center because you're doing a shoulder on somebody who's £350 and you're trying to run chemical fats, that you're not going to give the radiologist what they need.
00:39:43:09 - 00:39:56:00
Speaker 2
It's your responsibility to eliminate fat. You should have done a stir. You should have done a Dixon Technique. You should have moved off of chemical fat saturation. Right. It's your responsibility to make fat dark.
00:39:56:03 - 00:40:01:13
Speaker 3
But but, but there's no metal protocol supposed to do. If there's no metal protocol.
00:40:01:15 - 00:40:22:17
Speaker 2
They have to understand that they need to remove the fat saturated sequence, chemical fat, saturated, and in they have to replace it with an air or a Dixon technique. But they also have to understand, well, they have to have buy in that fat elimination is their responsibility. The radiologists can't do it right. You have to make fat dark, right.
00:40:22:17 - 00:40:44:04
Speaker 2
Okay. And that's not just with T2 weighted imaging. In my case, that's also every time you give gab, because I like to I like to say it like this fluid is bright, gadolinium is bright. Well, if fat's bright with fluid and gadolinium also bright, you're not going to see it as well. So any time you're looking for bright fluid, you have to turn the fat dark.
00:40:44:07 - 00:41:07:08
Speaker 2
In. Any time you inject gadolinium, you have to make the fat dark. Now we have times when we don't do that, we'll image the central nervous system. Fats, you know, looking at the cord, things like that. Fat suppression sometimes obscures the image. And when we're doing gadolinium, sometimes if you try to fat set areas with air interfaces, you won't get proper fat saturation or uniform fat saturation.
00:41:07:08 - 00:41:22:21
Speaker 2
And we bail on it. Of course, in Dickson, techniques allow for us to come back. I'm talking about the soft tissue neck or in and around the sinuses or the bony foot fat. Fat elimination works just fine when you use a Dickson technique. So that's what I do on day one.
00:41:22:21 - 00:41:33:20
Speaker 3
Robert So take it back. So take it back. So pretty much what you're saying is that you make sure that Day one, they recognize what their goal is like. You want to quality image, pretty picture.
00:41:33:20 - 00:41:35:16
Speaker 2
So did the reading.
00:41:35:16 - 00:41:38:11
Speaker 1
And quality image is pixel size.
00:41:38:11 - 00:42:00:02
Speaker 2
Right? Fat saturation fat elimination in my language, no motion In no motion. And by the way, I don't say image quality because to me that's moving towards a in the weeds perspective. I see pretty pictures. I'm using layman's terms on purpose. They come in, my gosh, I'm in the MRI space. Relax.
00:42:00:02 - 00:42:01:17
Speaker 3
You took three, baby. You have all three.
00:42:01:17 - 00:42:21:21
Speaker 2
Zone three. I'm like, relax. You took 15 selfies this morning. It's the same concepts. You wanted a pretty picture when you took a selfie. You want a pretty picture when you do an MRI. And yes, what builds a pretty picture? An MRI pixel size, a.k.a. resolution, not just the field of view. Right. Making sure it's not motion is a word we've created in MRI.
00:42:21:23 - 00:42:31:01
Speaker 2
Right. Space smearing and of course, making sure that fat does not distract to the radiologist from what they're looking at it inherently.
00:42:31:01 - 00:42:40:19
Speaker 1
We're taught that to achieve all three things, that it comes with a price. And that price being time. So like, how are you able to keep the time down by still achieving those three things?
00:42:41:01 - 00:42:42:22
Speaker 2
Yeah, that's the second half of it.
00:42:43:00 - 00:42:45:05
Speaker 1
So perfect segue way.
00:42:45:07 - 00:43:12:03
Speaker 2
They say I'm going to do so. Reggie, can you pull up the axial shoulder picture? yeah, for sure. It's a nice looking image. Right? Right. Young person. Right. Can still see the growth plate. Really nice labrum, blah, blah, blah, blah. Nice uniform, fat suppression, bright fluid, no motion. We can all tell that. That's a nice pixel size.
00:43:12:05 - 00:43:25:23
Speaker 2
Right? Right. That would be the definition of a pretty picture. Robert Pixel size is appropriate. There's no motion and fat is not bothering us. It all there. It's eliminated.
00:43:26:01 - 00:43:29:17
Speaker 1
Right? So if that was a bumble date, you would get asked for a second date?
00:43:29:18 - 00:43:55:10
Speaker 2
Yes. Yeah. Yeah. Even if I was on Bumble and I thought girls cared about axial intermediate images of the shoulder that would be my profile picture. They do have it. Yeah, of course. It's stupid. I'm just trying to roll with them. Yeah, I love that. Yeah, I love Mr. Janssen. He exists for many reasons. His. We're not just one thing, but one of the things you love is doing is putting speed bumps in front of me when I'm cruising down the road.
00:43:55:12 - 00:44:09:11
Speaker 2
And he wants to see whether or not it's going to knock me off course suspension is negative. No, I've good suspension. Yeah. Keep them coming. Yeah. Luckily he told me about Bumble in our before the episode, so I knew what it was. Yes.
00:44:09:13 - 00:44:12:03
Speaker 1
He's a connoisseur.
00:44:12:05 - 00:44:19:20
Speaker 2
So I have something called caps. Okay. Love it. Something I created.
00:44:20:01 - 00:44:21:00
Speaker 3
There.
00:44:21:02 - 00:44:33:10
Speaker 2
Because it's simple caps a.S.A.P, you know, a little less like the ASP belongs to about it. I'll tell you all about Robert. You'll turn into it. All about it. You'll tell you'll. He'll turn it into a rap song.
00:44:33:12 - 00:44:40:07
Speaker 3
Better caps on caps on caps like the C.
00:44:40:09 - 00:45:02:22
Speaker 2
The C and a R, something that the button pushes will recognize because that's how they're trained, coverage and angles. That's how they're trained in the MRI school. Now, they are trained to go to the open lab and this is we scan a shoulder you cover from here to here and you angle here. Then you hit go, okay, now coverage.
00:45:03:00 - 00:45:11:05
Speaker 2
Let's consider an axial shoulder. I've been trained to scan from above the AC joint.
00:45:11:07 - 00:45:12:15
Speaker 1
Through the glenoid.
00:45:12:17 - 00:45:29:17
Speaker 2
Through the glenoid, usually five, six, seven slices below the inferior labrum that gets you through the shoulder. Okay. Right. So when my students sit down to scan a shoulder, they have to have their caps in front of them. Caps is in a three ring binder, and they will open it to shoulder. And then within their shoulder caps, they'll have axial sagittal coronal in.
00:45:29:17 - 00:45:55:12
Speaker 2
When they're planning an axial, they have to be open to the axial pitch coverage you scan from here to those parameters. Doc. No deal. Don't jump ahead to this breathes. Maybe we did this episode in our positioning either you both relax, but first coverage. Okay, don't jump ahead. I tell all these students I try not to see my students because they don't belong to me.
00:45:55:12 - 00:46:15:19
Speaker 2
They're just students, and I'm privileged enough to be helping them. Go see any coverage you scan from here to there. Again, layman's terms, you scan from here to there, and they write it in their book from above the AC joint to approximately six slices below the inferior label. And it's a written in their book. It's not arbitrary. They never have to learn a different coverage.
00:46:15:19 - 00:46:35:11
Speaker 2
It's there for the rest of their career. Angle orthogonal. There is no angle on the axial shoulder. All right. If their arm is down the side, if they're overweight in their humerus is offered an angle, it will say perpendicular to the shaft of the humerus. Okay, Coverage an angle are permanent. They're never going to change. I tell them all this all the time.
00:46:35:11 - 00:46:47:08
Speaker 2
I What is so hard about MRI? I just told you everything you need to know about axial shoulder. It doesn't change on Tuesdays. Come on, learn the shoulder so we can move on to the humerus and the elbow and the wrist. Come on, What are we doing? So I tell him. I know.
00:46:47:09 - 00:46:48:07
Speaker 3
The P is before you say.
00:46:48:07 - 00:46:50:03
Speaker 2
It. Yes. Can I? Yes.
00:46:50:07 - 00:46:53:12
Speaker 1
It's not what you think of face.
00:46:53:13 - 00:47:00:06
Speaker 2
Face considerations. Now this is where you separate the button pushes to the next level. Right now there's a level after that.
00:47:00:06 - 00:47:01:06
Speaker 1
Critical thinking skills.
00:47:01:06 - 00:47:17:05
Speaker 2
Yeah. Yep. Because you have to start thinking now. So now that you have your coverage an angle and this is a little corny, but sometimes I'm corny, right? Right. See, A is the state abbreviation for California. I lived there for a little while. And in California, the most important thing in California, I'm generalizing.
00:47:17:10 - 00:47:20:01
Speaker 1
no cat here.
00:47:20:03 - 00:47:26:20
Speaker 2
So I'm from Massachusetts, so obviously I'm going to goof on California, right? No, cat. That's good. I even get it.
00:47:27:02 - 00:47:30:05
Speaker 3
I think there's an in school thing these kids are saying, Cat.
00:47:30:07 - 00:47:30:21
Speaker 2
What does it mean?
00:47:31:02 - 00:47:33:10
Speaker 1
Ask my kid. My kids are outside the room right now waiting but.
00:47:33:10 - 00:47:34:20
Speaker 2
So we want to back that.
00:47:34:22 - 00:47:39:21
Speaker 1
Up because it means like, it means like for real.
00:47:39:23 - 00:47:41:03
Speaker 2
Cap.
00:47:41:05 - 00:47:42:00
Speaker 3
No cartilage.
00:47:42:00 - 00:47:47:04
Speaker 1
It like cap is like fake. Like it's not real. And then no cap means it is for.
00:47:47:04 - 00:47:56:21
Speaker 2
Real, right? Cool. Right? Yeah. Although the words change, the important things continue to remain the same. Right? You need to know when someone will show up, when they're not.
00:47:56:22 - 00:47:58:23
Speaker 3
Right? Right. This is a real talk.
00:47:59:01 - 00:47:59:17
Speaker 2
Real talk.
00:47:59:23 - 00:48:00:08
Speaker 3
Today.
00:48:00:08 - 00:48:04:18
Speaker 2
And I used to just say no show. If you say it afterwards, say.
00:48:04:19 - 00:48:06:20
Speaker 3
You're really old now.
00:48:06:22 - 00:48:12:15
Speaker 2
Yeah. Like you go on and on and on and you say, No shit, right? But you know, there's different ones.
00:48:12:17 - 00:48:14:03
Speaker 1
I think of all of them right now.
00:48:14:03 - 00:48:16:02
Speaker 2
But yeah.
00:48:16:04 - 00:48:17:01
Speaker 1
They keep it to myself.
00:48:17:03 - 00:48:19:17
Speaker 3
If you got a good one, please leave it in the car.
00:48:19:21 - 00:48:20:14
Speaker 2
Do it.
00:48:20:16 - 00:48:21:20
Speaker 3
It's nice.
00:48:21:22 - 00:48:44:10
Speaker 2
So what's really important in California is appearance. Yes. Right, Right. So whenever I would stand behind the student on the console and, they set up their slices and they do their coverage and their angle. Right. I would say just to be corny, I like your style because that seems like a California thing to say. And what that would mean is you can move on the face considerations.
00:48:44:15 - 00:48:48:00
Speaker 2
Now, this is where you got to think now, phase considerations.
00:48:48:06 - 00:48:49:20
Speaker 1
Okay, you know what I say?
00:48:49:22 - 00:48:51:00
Speaker 2
What do you say?
00:48:51:02 - 00:48:54:06
Speaker 1
If you like it, then you should have put a shame on it.
00:48:54:08 - 00:49:06:11
Speaker 2
Because he's a rapper. If you like it, you should put a shame on it. That's a take out batteries. You should put a ring on it. You know? Yeah. I don't listen to Beyonce, you know, neither. Okay, either. Yeah it's.
00:49:06:11 - 00:49:07:10
Speaker 1
Cool. I Jay-Z fan.
00:49:07:11 - 00:49:13:20
Speaker 2
I like some Rihanna stuff. Just because it's a female doesn't mean I won't listen. But Beyonce, I don't know would be like you said what about.
00:49:13:23 - 00:49:16:10
Speaker 3
This new country song that breaking records.
00:49:16:10 - 00:49:17:10
Speaker 2
I guess.
00:49:17:12 - 00:49:20:17
Speaker 3
I'm sorry. I know we're kind of detouring here.
00:49:20:18 - 00:49:30:07
Speaker 1
To get you back on track. If you're in California and you like their coverage, you like their angles and you say, I like your style. And then that's their way of saying, what's the final step exactly right.
00:49:30:12 - 00:49:42:16
Speaker 2
When I say I like your style, they transition to phase considerations. The thought that word would get you the base considerations. But I'm.
00:49:42:18 - 00:49:45:00
Speaker 1
You can phase me See, when.
00:49:45:00 - 00:50:16:20
Speaker 2
I did that that's the class. Now that you're on phase considerations, they assess for three things. Let me back up for a minute. When they get the phase considerations, I say, Which way are you going? Now look at that axial shoulder. Jeff Post talented MRI technologist, good guy, and somebody that I am, somebody who came through my program.
00:50:16:22 - 00:50:46:06
Speaker 2
He saw me trying to explain phase direction. And Jeff has been like, you know, Jeff has stood at number like 9 million for me. And he looks at me, he goes, Why don't you just say this way or that way? I said, What do you mean? He said, Well, when you're doing an axial shoulder, rather than solving the riddle of GE, showing the frequency, direction and having to unwind that whole big discussion you've been doing for all these years, why don't you just say on it axial, you can go this way or that way as well?
00:50:46:06 - 00:50:58:21
Speaker 2
What do you mean? He goes, Well, look at an axial. He took his finger and he goes, You can go this way or that way. He goes, The only two ways you can go with your phase on an axial are this way or that way, he said On a sagittal. It's this way or that way on a chronos, this way or that way.
00:50:59:01 - 00:51:24:12
Speaker 2
Look at that axial picture. You guys know we can go eight appear left to right with our phase because the size selection gradient is as two eyes. So that's not an option, right? Well, just draw your finger both directions that's left the right and that's a to P. Now it's not quite moving the needle with you guys the way it did with me because I've had to tell technologists what is the optimal phase direction when you're doing an axial shoulder.
00:51:24:18 - 00:51:44:10
Speaker 2
And Jeff realized it was easiest to actually look at the axial picture with just the field of view boxes because I used to tell students, quit looking at the axial. When you're setting up an axial, all you care about is the corona on the sagittal to get your coverage mangled. Right? But Jeff's like, no, but now when you get the phase considerations, look at the image that you're actually acquiring and just do this with your finger.
00:51:44:10 - 00:52:03:07
Speaker 2
Would you rather go like this way? Would you rather do this or this? Now, if you did that there, you'd realize that if you went left to right, you have the rest of the body to contend with. You Can't go left or right. You have to go in the short axis, which is A2 PE. So I would tell students what's the optimal phase direction and they would have to say a two PE.
00:52:03:12 - 00:52:24:13
Speaker 2
And I'd say Good. Now assess for motion rapid time. That was the process. So let me review coverage and angles. I like your style. Move on the phase considerations. Which way you going this way or that way? They would base their decision on whether or not they were going this way or that way upon motion, rapid time.
00:52:24:18 - 00:52:25:14
Speaker 1
If they're a speed bump in.
00:52:25:14 - 00:52:26:00
Speaker 2
The sure.
00:52:26:04 - 00:52:27:02
Speaker 1
Rock your world.
00:52:27:03 - 00:52:29:06
Speaker 2
Do it.
00:52:29:08 - 00:52:38:08
Speaker 1
I would say is not just a PE, it's also a left, right, right, left. So there's actually four options and there is a tie that you should pick over.
00:52:38:08 - 00:52:41:17
Speaker 2
AP When.
00:52:41:19 - 00:52:45:00
Speaker 1
Will you I think you would get less motion if you did PA versus AP.
00:52:45:00 - 00:52:46:01
Speaker 2
Y.
00:52:46:03 - 00:52:47:21
Speaker 1
Just because the breathing.
00:52:47:23 - 00:52:49:01
Speaker 2
Y.
00:52:49:03 - 00:52:51:14
Speaker 3
Motion comes in the phase direction right?
00:52:51:16 - 00:52:53:06
Speaker 2
Motion is only in the phase direction.
00:52:53:06 - 00:53:11:00
Speaker 1
The motion mostly from the anterior portion of that image. So if you're coming from P.A., like, for example, if you're going right to left lip versus left or right, well, if you go from here, if you go left to right, you're going into the lung versus out of the lung, into the area of interest.
00:53:11:00 - 00:53:12:11
Speaker 2
I don't know that it has a difference.
00:53:12:16 - 00:53:13:22
Speaker 1
I think it does Keyword.
00:53:13:22 - 00:53:23:22
Speaker 2
I don't know. I don't know. And by the way, other than only certain vendors will you pay and AP writers and Siemens think that's true?
00:53:23:22 - 00:53:25:11
Speaker 3
Well, inverting the gradient.
00:53:25:11 - 00:53:30:12
Speaker 1
Those Siemens you can actually changing 180 degrees to make it the right.
00:53:30:16 - 00:53:34:12
Speaker 2
But if you're on a DJ and you're looking for apnea, you won't find it, right?
00:53:34:14 - 00:53:39:17
Speaker 1
So did I just rock your world?
00:53:39:19 - 00:53:46:16
Speaker 2
I'm not convinced. I'm open to the fact that there is a difference in image quality between PA and AP. I'm open to it right?
00:53:46:16 - 00:53:47:18
Speaker 1
Right to left on the shoulder.
00:53:47:18 - 00:53:54:10
Speaker 2
I'm open to it. I would like to be shown it and then understand it.
00:53:54:12 - 00:54:07:04
Speaker 3
Because the the most of the concern would be motion, right? Move. So to come down to how we're filling case base, right, if we're flip, if we're in Bergen, the gradient in the starting point, there's going to be a different starting point. It's going to be perhaps right.
00:54:07:04 - 00:54:25:07
Speaker 2
Contrast goes in the middle, detail goes in the periphery. You gather most of the contrast earlier in the sequence. Right? Right. And you know that because if you stop a pulse sequence where they've got like 30 seconds left, it will still reconstruct sometimes, but you'll see a really hazy image. So, you know, the resolution is filled last. So your point probably has some merit, right?
00:54:25:09 - 00:54:36:21
Speaker 2
Depending on direction you go in which area is moving. More to your point with the chest, the chest is moving more than the back. That may very well have a have a.
00:54:36:23 - 00:54:37:12
Speaker 1
Should we wrap.
00:54:37:12 - 00:54:56:07
Speaker 2
It up in back over? Yeah, that's going to go home if this is good. Listen. Yeah. When you become the teacher right, you realize that what that means is you're forever a student. Because the only way I can keep teaching is by keep on learning. The is the only way. I love that I learn more from my students.
00:54:56:09 - 00:55:13:22
Speaker 2
Yeah. I've gathered all this knowledge at this point in the game because I've been teaching, right? And when you teach, you have to know things. And you all you have two of those shit moments per lecture where you're like, I don't know that that's the case. And then you go back later and so, So thank you for that.
00:55:14:00 - 00:55:43:02
Speaker 2
Yeah. So phase considerations, motion wrap time. So look at the shoulder. They say ATP is the optimal direction and I say it is in. My students have to say to me before they hit go less motion going ATP not worried about rap because there is no is none And then they see time and they look down and they tell me whether or not that's an appropriate time or not for the field strength magnet.
00:55:43:02 - 00:56:02:05
Speaker 2
They're on for the antenna they're using for the parallel imaging factor that they've chosen. And TR .2.2.., dot. That's how my students do it. They don't hit go until they go through coverage angle phase considerations, optimal direction, assess for motion wrap and time.
00:56:02:07 - 00:56:06:13
Speaker 1
It's almost like canals, like pilot checklist, right? Like you've got a checklist.
00:56:06:15 - 00:56:26:13
Speaker 3
I think that in that think the power in you know this type of stuff is just simplifying it into steps. Right. Like if you if you do it the same way every time, then it really takes away that margin of error that creates, you know, you winging it every time you get a shoulder and you're like, what? And I do What did I do last time when I had this similar issue, you know, type of thing.
00:56:26:13 - 00:56:44:23
Speaker 2
So and you see that fear in new technologist eyes when they sit down in there is no methodical nature to their process, right? It is it is different every time. And you see them, they'll look at this and they'll click on that and then they'll go back and change the angle of to CVI at five different times during it.
00:56:44:23 - 00:57:03:10
Speaker 2
Right. They'll go over here. I don't let the students that work with me do that. They go methodical after their coverage, an angle is set and I say, I like your style. You better not touch your slices again. If I don't say I like your style, you better add a slice. You'd better change your angle. You'd better do something before you ever talk about phase direction.
00:57:03:12 - 00:57:35:03
Speaker 2
It's worked for me my entire career, and that's what the set method was. Same every time, right? I do it the same way every time. That's what pilots do. We talked about that before. Yeah, You have a checklist and it simplifies their lives, you know, totally. Robert Excuse me. Reggie That's satisfying your radiologist customer. That whole process. Pretty pictures.
00:57:35:03 - 00:57:37:23
Speaker 1
So as you said before, you have to customers as in MarTech.
00:57:38:03 - 00:58:03:07
Speaker 2
I do. And before I get to the second customer, the patient, the client, the customer, the person who's sick or injured, you can notice I didn't talk about t, r, r t or echo train or receiver bandwidth with their parallel imaging factors. I flipping any of this stuff yet? All of that stuff comes after this in the program.
00:58:03:09 - 00:58:31:12
Speaker 2
Okay. Because you know whose protocols they're running at the beginning mind. Right. And then after they can fluidly move through this process and not have a bunch of dead time in between sequences, then what they do is I say, okay, you're doing a shoulder now, but the only thing that's in the protocol is a scout hour, and then they copy and paste the scout and they turn it into the axial intermediate fat suppressed image, turn it into Curl two that that comes later.
00:58:31:14 - 00:58:50:10
Speaker 2
And that's not for sport. That's not because I think I'm cool. That's not because I want me to, you know, say, my students the best. That's because when you go from a Phillips to a DJ and there isn't a protocol on that, I don't want you to say, well, I'm just a Phillips Tech. That's such horseshit. If you're an ma technologist, you're an ma technologist, right?
00:58:50:14 - 00:59:06:07
Speaker 2
Just like a mechanic doesn't, you know, look for the engine in the front of a Porsche and say, I can't fix this thing. Right? Right. You might go and open up the front and say, they put it in the back, but when you get back there, it's still a carburetor. It's still a motor. Okay? And that's how I've always viewed M.R. for sure.
00:59:06:10 - 00:59:13:22
Speaker 2
So we'll get to that stuff later. But a great analogy, right? Yeah, it is great. Thanks for noticing. I know.
00:59:14:00 - 00:59:14:13
Speaker 1
You're great.
00:59:14:19 - 00:59:15:20
Speaker 2
Thanks, Robert. You too.
00:59:15:23 - 00:59:18:08
Speaker 1
And you look great today, by the way.
00:59:18:10 - 00:59:25:00
Speaker 2
China throws speed bumps in the air. Can you look grow up and itself?
00:59:25:00 - 00:59:29:08
Speaker 1
Speed humps. Speed humps so people can still see the signs?
00:59:29:10 - 00:59:40:03
Speaker 2
Yeah. yeah, you would? Yeah. You'd love to have a sign. This said hump in your bedroom with your neon light. I could just picture it. Lava lamp. Neon might help stop room.
00:59:40:05 - 00:59:44:10
Speaker 1
it's if it's a red light that your eyes don't have to dilate in the middle of the night.
00:59:44:10 - 00:59:45:23
Speaker 2
Is perhaps only.
00:59:46:01 - 00:59:48:06
Speaker 1
Smart, especially if you have a hypersensitivity.
00:59:48:10 - 01:00:06:21
Speaker 2
When somebody gives you a compliment. One of the hardest things to do in the whole wide world is to breathe and smile and say thank you. All right. Thanks, Robert. You. Customer to other customer by no means a priority above or below. The radiologist. The way I look at it is you go do right by the rad. You go do right by the patient.
01:00:06:21 - 01:00:33:10
Speaker 2
Right, right. And if you do, you're an MA expert. So now let's talk about how to get that pretty picture in the shortest time. Okay. Now let me say this. Shortest time benefits everybody involved with the venture. The person paying the rent on the building and paying the note on the machine wants you to do it quickly. We want to do it quickly because we have other people to do the piece.
01:00:33:10 - 01:00:55:02
Speaker 2
It wants to do it quickly because they don't want to be in there. There has been this feeling in our business for as long as I can remember, that if you're going fast, you're half assing something. Somebody very smart in my life told me time is not an indicator of image quality. So stop looking at the time and saying, it's not going to look good enough.
01:00:55:07 - 01:01:00:10
Speaker 2
It's got nothing to do with it. Doing 2223 second pulse sequences. Now on the brand new a.
01:01:00:10 - 01:01:02:21
Speaker 1
Call, you got a RDL, a deep resolve.
01:01:02:21 - 01:01:28:01
Speaker 2
And so the air, the recoil has it's a holiday, right? Is wild. Is wild. All right. So how do you do right by the patient. You get them in and out of there and you get the pretty picture so they can get accurate diagnosis, but you get them in and out of there. In the less time you have them in the board, the more time you create to make them comfortable in the more time you create to give them instruction.
01:01:28:01 - 01:01:49:14
Speaker 2
When I was scanning the number of five star reviews, I would get that would say, Rob told me exactly what to expect, surprised me. I wanted to get the five star review because of all the stuff I knew. Parameter wise, they're giving me a five star review because I told them the next picture was 2 minutes. They gave me a five star review because I told them it'd be 8 minutes.
01:01:49:19 - 01:02:10:03
Speaker 2
We'll do an injection, they'll be 3 minutes more. And I was thinking myself, doesn't everybody do that? Very few people do that, especially the button pushers. Now, again, let's empathize with the button pusher. Why would a button pusher not be giving clear instructions online? Not only do they not know, but they are overwhelmed, right? With everything else. It's like the person on the register for the first day.
01:02:10:03 - 01:02:32:11
Speaker 2
You know, it's their first day because they haven't even said hello to you. How to open this thing? I can't find a guacamole. Yeah, you need to be competent before your personality comes out. Right? Right. So why do we need to go so fast beyond the fact that they just don't want to be in the noisy bore and you decrease to lift the risk of thermal injury?
01:02:32:11 - 01:02:55:21
Speaker 2
The less time you have them in there. I know thermal injuries can happen acutely, but the less time they're in there, the less likely it is to happen. Right. You can give them clear instruction on what's going to happen and you can do a wrist down by the side. You don't have to force them into the Superman position if you're in a wide bore and you know that they can't do that, you can go put an extra pillow underneath their knees.
01:02:55:21 - 01:03:17:10
Speaker 2
You can use an alternate coil. You brought up these air coils, these blanket type coils. Well, the number of chaotic patients that come in nowadays that you can now scan with a blanket coil wrapped around their head. And you can't tell that they were done in that they weren't done in the head. Coil. It's remarkable. But you only have time to do these things if you're decreasing your pulse sequence types.
01:03:17:12 - 01:03:18:07
Speaker 2
Right? Right.
01:03:18:12 - 01:03:22:22
Speaker 1
Because you still have an appointment time slot. You got to stay within that window of opportunities.
01:03:22:22 - 01:03:23:09
Speaker 2
That's right.
01:03:23:09 - 01:03:24:11
Speaker 3
Every patient has a threat.
01:03:24:17 - 01:03:36:21
Speaker 1
So if it's a 45 minute appointment time, but the scan itself is only 25 minutes, so that means you have 20 minutes to spend extra time with the patient explaining the exam and getting them comfortable.
01:03:36:23 - 01:03:56:16
Speaker 2
And if you're in a high throughput environment where the exam times are now 15 minutes and you have inefficiencies everywhere around you and your 215 patient, and by the way, you have a two and you have a 230 in the 215 patient is arriving at 218 filling out paperwork till 226, getting dressed and using the restroom till 233.
01:03:56:18 - 01:03:58:07
Speaker 3
In I.V..
01:03:58:09 - 01:04:19:14
Speaker 2
And that is real life for a lot of people being able to do a wrist exam or an elbow in under four and a half minutes on this new technology is not just helpful. It's a requirement or you will get run over. And so there are people that are simply surviving with short imaging times two. And that's a whole different thing.
01:04:19:14 - 01:04:32:22
Speaker 2
And we've talked a little bit about that. Yeah, but getting the patient in and out of there as quickly as you can is how you do right by that patient. So how do you middle it? You get a middle it, you get a bit of what with the rads in the patient.
01:04:32:22 - 01:04:38:12
Speaker 3
So sometimes you can conflict, right? The resolution adds time, you know, things like that. Right. So how do you know?
01:04:38:14 - 01:04:51:09
Speaker 1
Well, there's a disconnect for sure. Like the patients don't realize what what the required of their exam for the RAAS to be happy. And the rads don't understand what's required of the exam for the patients to be happy.
01:04:51:11 - 01:05:15:23
Speaker 3
I think one thing that Robert does a really good job in PI, he gets a lot of kudos where we work at this. He's a great communicator with the patients. On what they should expect for the exam is huge and I think once because they once they understand what what their role is to actually make a successful, I think that it instead of them having this expectation of it, just a lot of times they come in, they think it's a CT, they're going to be in and out 10 minutes.
01:05:16:01 - 01:05:31:03
Speaker 3
And Robert breaks down like, Hey, this is what I need from you. This how long it's going to take if this is going to be a good study. You know, we have to be consistent in this by whatever Robert's bill is. I think that really helps out with just the outcome of the study. Is expectations giving them realistic expectations.
01:05:31:05 - 01:05:32:19
Speaker 2
It's so huge and.
01:05:32:19 - 01:05:55:04
Speaker 1
Well, and I think with that. Thank you, Reggie, because I get that Q2 was a lot to do. You said you get a lot of patients who appreciate you just communicating what the expectations are and I think with that because you know, I think the there's itself in the room inside right. Yes. Every patient has a sort of 0 to 10 low of anxiety.
01:05:55:04 - 01:06:11:22
Speaker 1
Usually it's 1 to 10, I would say nobody to zero. But, you know, if you could just communicate with the expectations are, then you'll see that anxiety go way down because at the end of the day, they just don't know what to expect. So if you really lay it out and they can picture it, you'll see that subside a little bit.
01:06:11:22 - 01:06:36:08
Speaker 1
And I see that all the time. I think it's super important because I think, you know, if it's the example that I use with anxiety and like what to expect, we we we were one of the outpatient sites. It's in the lower levels, two floors below the lot, the floor level patients literally get into an elevator. She come down MRI.
01:06:36:08 - 01:06:46:16
Speaker 1
They say that they're too claustrophobic for the MRI. And so how do you even get that elevator? Well, was because you knew you've been on an elevator before. You know what to expect, but you haven't been in the MRI before. So I telling you, that's.
01:06:46:22 - 01:07:09:00
Speaker 2
That's such a powerful example in story to tell. Right. And that's zooming out for sure. That's zooming out on claustrophobia. Yeah. To be able to bring the patient to the elevator. And I you know, you'll hear from techs that they don't have time. They don't have time to explain the procedure. And I say, well, make the time, because that's home.
01:07:09:01 - 01:07:15:12
Speaker 1
We all have our script. It can be become a part of your script and you can position a patient as you're explaining the. I.
01:07:15:12 - 01:07:15:22
Speaker 2
Hope you.
01:07:15:22 - 01:07:31:15
Speaker 1
Are. Absolutely. It does it it's not mutually exclusive, right? You know, so like to say that you don't have enough time. Well, first of all, you're spending the time positioning why you're spending their time. Use it productively. Yep.
01:07:31:17 - 01:07:59:22
Speaker 2
And this you know, this is a again, being empathetic to the people who scared for their lives, who are pushing buttons and hoping things turn out well. I mean, let's all sit in that energy for a minute, okay? We've all been we've all been in this spot where you're hitting go on something. And when there's 11 seconds left in the pulse sequence, your eyes are glued to the little imagery constructor window, hoping that it that it looks good.
01:08:00:00 - 01:08:19:02
Speaker 2
You know, I was so cocky as I, you know, just for fun, because I try to make students laugh, right? I would build a protocol organically. Every parameter from the scout up. Right? And I knew it would be good because I knew what I was doing and there'd be 12 seconds left in. I would say, I'm going to go walk to the door right now so I can save some time.
01:08:19:02 - 01:08:44:08
Speaker 2
And they would say, No, but you need to see your images. I said, I don't keep the images, you know, is this kind of my, you know, UCB, you guys need the QC images. I r know what it's going to look like because I built the thing right. But if what we all remember when we didn't feel that way, right, you know, it's a terrifying thing and you're, you feel behold in you feel like you're you're hoping it comes out well because you need it to, but you have no impact on it.
01:08:44:08 - 01:08:57:14
Speaker 2
And that's a really bad feeling. I figured you guys would ask me for an example, a real life example. So if you want to bring up the tib fib images, Reggie, because I tried to come up with an image or an exam here.
01:08:57:16 - 01:09:00:08
Speaker 1
Yeah, a bit raster. You guys have got.
01:09:00:10 - 01:09:24:16
Speaker 2
That image right there. Robert, I can't wait for you to come back in a quick note. If there's got one more trick. This is what podcasts keep going. Okay, we'll keep going. Robert says This is what podcasts are. Real life, right, Robert? You don't just show them the best part. You show them everything that does no, no cap because we're cool.
01:09:24:18 - 01:09:47:05
Speaker 2
So I don't know that. You can truly appreciate it on the screen, but on the left is a stir. And on the right is a stir. Okay? And did do my little trick where I built the kernel first and then I just turned it into a sagittal. And that's why the coverage is the exact same meaning I showed you just as high north as I did south.
01:09:47:07 - 01:10:23:00
Speaker 2
Right. Right. So what you see on the left is a stir. By the way, this so is a3t magnet. And On the left is a stir with a tie of 170. And on the right is a stir with a tie of 195. Now, the protocol called for PD fat sats in T to fat SATs, but I'm not going to try to use a fat saturation technique with a field of view this large because I know once I get over a 28, 32 centimeter field of view, you're going to have a lack of uniform fat saturation, chemical fat saturation.
01:10:23:02 - 01:10:46:13
Speaker 2
So I immediately pivot, use a stir sequence, but to satisfy what the radiologist wants to see, which is a greater fat on the PD, fat sat in a darker, more high contrast fat saturation on the T two. I changed the tie. No big deal, right? The 170 T gives you that PD fat sat look on the left, the 195 T gives you that more t to fat sat on the right.
01:10:46:15 - 01:10:57:00
Speaker 2
If you are on a15 magnet instead of 170 and 195, you might use 130 and 155 to show that difference. The higher you go up in field strength, the the longer it takes.
01:10:57:00 - 01:10:59:08
Speaker 3
For sure trying to find that no point.
01:10:59:10 - 01:11:24:03
Speaker 2
Trying to. Yeah the longer it takes you to get to the no point higher field strengths because things don't relax quick right so this is an example Reg of don't just bring over a fat switch or a chemical fat saturation technique on a field of view that's this big because it will be white if the edges. Right. And if that's the area of pathology, you're going to have a problem and not.
01:11:24:03 - 01:11:26:14
Speaker 3
Pleasing one of those customers.
01:11:26:14 - 01:11:52:07
Speaker 2
Right? That's right. This is the pretty picture. Yeah. And I love that you just said that this is satisfying radiologist. They need uniform fat, saturation, fat elimination, as I like to call it. Now, I could have also used a Dixon Technique on this scanner, but the Dixon technique takes a little bit longer than the stir pressure. Okay. Now, if this was a with and without contrast study in, I had to get fat.
01:11:52:09 - 01:12:16:23
Speaker 2
Eliminate the fat post gadolinium. I absolutely would have used a Dixon technique because now stir is not an option. All right. Right. But it wasn't. So this was without study. Now, if you go to the next picture, the next one after that. Ridge So these are videos and I wanted to just kind of show you. So obviously you're looking at the femoral condyles on picture on the left.
01:12:16:23 - 01:12:43:15
Speaker 2
So that was the superior stack and the inferior stack is on the right. I look at what CP3 said recently. Nope, just sick. Yeah. Lots of t. I didn't wear it. You have lots of TPS resets when you have neglected chillers on the roof that cause high head pressure and cause everything to screw up. Mary Right there. Total in there.
01:12:43:17 - 01:12:58:01
Speaker 2
Actually, now that I think about to go back to previous picture, if you would, please. Reggie Yeah. Now you might ask the question, if I can. Let me see why separate this one. Now, why separate? The axial is in the two stacks.
01:12:58:01 - 01:12:58:23
Speaker 1
Homogenous.
01:12:58:23 - 01:13:04:20
Speaker 2
Homogenous uniform, whose job is the elimination of fat.
01:13:04:22 - 01:13:07:08
Speaker 1
It's one of those three things that make up.
01:13:07:12 - 01:13:12:15
Speaker 2
A pretty picture. Ian tell Robert didn't. Robert was not a student in my program.
01:13:12:17 - 01:13:14:01
Speaker 1
What? I just passed.
01:13:14:03 - 01:13:18:22
Speaker 2
Derek. Whose job? Whose job is it? Mine. Mine is the answer.
01:13:19:01 - 01:13:20:03
Speaker 1
Proud of myself for coming up.
01:13:20:03 - 01:13:21:06
Speaker 2
With your own interest.
01:13:21:06 - 01:13:22:09
Speaker 1
Instead of quality.
01:13:22:11 - 01:13:35:05
Speaker 3
Well, the funny thing about separating the stacks is I've. I've seen where people won't separated on the actual T ones I don't have FARZAD But then separate it on the the actual. But you want it to match.
01:13:35:06 - 01:13:36:10
Speaker 2
You want to match, right?
01:13:36:15 - 01:13:37:19
Speaker 3
So That's.
01:13:37:21 - 01:13:58:02
Speaker 2
Right. You want to match it. I understand, you know why you keep it in one main stack and a t, but if you really, really, really understand imaging that many slices, you're going to be doing a couple of concatenation anyway or acquisitions. So you'll make two stacks will be the exact same time as one step. Then ask if you're really paying attention to really say so.
01:13:58:04 - 01:14:14:12
Speaker 2
Absolutely. Mr. Jansen, fresh off your bathroom break with a clear mind. Yeah. Uniform fat elimination. So now you can go to the next slide. And I put a couple of videos here just so you could click on them and thumb through the images, the image. The left is the superior stack.
01:14:14:12 - 01:14:16:02
Speaker 3
Do I start with this? Yeah. Looks like it's.
01:14:16:04 - 01:14:36:00
Speaker 2
Gonna start with either one of them. The only thing I want to show you guys is that you have uniform fat elimination throughout the entire lower leg. And that's what the radiologist needs now to get to that. If either one of you are looking at the fat and saying my gosh, is that uniform? Why I a couple other things.
01:14:36:02 - 01:14:48:09
Speaker 2
I put the leg in the damn center of the machine because ISO center is critical when you're trying to chemically saturate fat. That leg is in the middle of the table.
01:14:48:11 - 01:14:58:12
Speaker 1
Right? It's crazy how many techs that I see the do I help with the head coil? So on the table it's like, well, if you got the head, go on the table. How you going to school them over right. ISO Center We have a rap song.
01:14:58:14 - 01:14:59:06
Speaker 2
A rap song.
01:14:59:11 - 01:15:01:01
Speaker 1
Called ISO Center Baby Scoots.
01:15:01:01 - 01:15:36:22
Speaker 2
Skip Yeah, I saw that. I actually saw that one. And it's incredible, actually. It's very good. Very good. It's ISO Center. It's two stacks. It's also Spectral I.R.. This is a hybrid technique On the MRI scanner. You have three different fat saturation options. Under the chemical fat saturation, it's fat, it's classic, and then it's special. I think Siemens calls it starts with that letter a idea, Bartok or something.
01:15:36:22 - 01:15:38:15
Speaker 2
You see it on Siemens scanners.
01:15:38:21 - 01:15:41:04
Speaker 1
And their Durata rock chair. What is it?
01:15:41:06 - 01:15:49:20
Speaker 2
No, it's like a debate. I see that somebody watching this, Matt Hayes or Letterer or told me those would know. Right?
01:15:49:22 - 01:15:51:00
Speaker 1
That was that question.
01:15:51:05 - 01:16:17:11
Speaker 2
But hold on. What it is, is special is a chemical fat saturation technique with an air that helps you. That's why that is so dark in uniform. So whenever I'm doing a region of interest, there is a ton of slices because even though I separate this in the two, it's still covering a large area. I prefer the special fat saturation because it gives me more uniform.
01:16:17:11 - 01:16:41:08
Speaker 2
So what am I doing here? Right on. The pretty pictures are making sure the leg is an ISO center, are making sure I did two different stacks. I'm using a fat elimination that is best for this exam and I used ires instead of chem. SAT on the long plane sequences because those field of views are too big to have uniform fat elimination.
01:16:41:13 - 01:16:57:00
Speaker 3
And that and this. Another story from Robert. But how important is your coil right? Because the coil still plays a big role at whether you think so or not. The coil placement for how well you're going to have fat saturation plays a huge role.
01:16:57:05 - 01:17:18:04
Speaker 2
We talked about an episode, the second episode I did when we talked about the part has to if the body part from the coil, the distance, and I showed you a side that showed one centimeter away from the coil results in 40% less signal, right? Or an X or.
01:17:18:06 - 01:17:19:23
Speaker 3
Yeah, it's like.
01:17:20:01 - 01:17:26:15
Speaker 2
Losing an X when you move the coil from here to there. Like it's sort of wild. Yes.
01:17:26:17 - 01:17:42:00
Speaker 1
Actually the analogy of that and not like that. Yeah, for sure, because that kind of gets more mathematical. But visually speaking to somebody, let's say it was Jonathan, you said think of the coils like a stethoscope. The further away from the had to be that you're looking at, the less you're going to hear. See?
01:17:42:02 - 01:17:51:20
Speaker 2
Yep. It's perfect. Jonathan is good at zooming out. yeah he he's good at zooming out Right.
01:17:51:22 - 01:17:55:15
Speaker 1
Let's go rather able to say one thing we love about Jonathan Think.
01:17:55:17 - 01:18:01:04
Speaker 2
That was mine, right? His beard. His beard? Yeah. Yeah.
01:18:01:06 - 01:18:07:02
Speaker 3
He's. He's genuine. I just like because he's a genuine guy. Super nice standup guy.
01:18:07:04 - 01:18:19:01
Speaker 2
you know what's great about that? We didn't realize we did it, but I complimented his professional expertise. You complimented to his core. All right. And you talked about his vanity. This is great.
01:18:19:03 - 01:18:20:06
Speaker 1
So we we cover it all.
01:18:20:06 - 01:18:22:21
Speaker 2
We cover Reed. Yeah. If he ain't satisfied with that, then he can.
01:18:23:01 - 01:18:25:03
Speaker 3
Yeah. Genuine. Yeah, you better like us. That's great.
01:18:25:06 - 01:18:28:08
Speaker 1
So is that like, the caps of Jonathan? And what were those caps?
01:18:28:08 - 01:18:30:18
Speaker 2
And for this, those to be. I don't know.
01:18:30:18 - 01:18:32:05
Speaker 1
Can we, can we think of something.
01:18:32:07 - 01:18:36:08
Speaker 2
Yeah, we could. But in what context.
01:18:36:10 - 01:18:40:05
Speaker 1
Who he is as a person. So P would be.
01:18:40:07 - 01:18:46:14
Speaker 2
the P is the personality. Now this is, this is going down a rabbit hole that's uninteresting to people who don't know either.
01:18:46:14 - 01:18:49:14
Speaker 3
Charity Is it out of the U2 is attractive.
01:18:49:16 - 01:19:08:03
Speaker 2
Yeah, yeah, yeah I don't blame a C is no C is copy. I got it. I got it. You guys, this is what happens when you let fame go to your head, Put aside, right? And you don't remember that the shit that you think is interesting and interesting to everybody. It's like Corey Feldman, right? Hey, listen. So he's putting all this He you that's that's a cheap shot.
01:19:08:03 - 01:19:15:20
Speaker 2
But, you know, he's very serious about what he's doing. But when other people see it, they're like, what is that right? You know, you got to be aware of what your audience I'm playing.
01:19:15:20 - 01:19:23:09
Speaker 1
To the back of the room, them a comedian. That's what they do. So see is competency A is attractiveness and P is personality. You're welcome. Moving on.
01:19:23:14 - 01:19:28:05
Speaker 2
Very good. Yeah, yeah, yeah, yeah, yeah. But you didn't assess for motion wrapping time under personnel at.
01:19:28:06 - 01:19:30:08
Speaker 1
Time stamp on this because I want to send it the.
01:19:30:09 - 01:20:03:12
Speaker 2
Theater. Here's where I'll leave you guys. Okay. In this is no filter. If you're a button pusher, you're a button pusher. It's okay. It has to do with your training. It has to do with how the market forces needed you in here so rapidly. It's philosophy from radiologists and administrators before you who thought that don't touch the protocols, just run them.
01:20:03:12 - 01:20:06:03
Speaker 2
It was a short sighted.
01:20:06:05 - 01:20:07:01
Speaker 3
Product of the system.
01:20:07:01 - 01:20:32:15
Speaker 2
But you're here, right? Your task is to recognize that that's what you are and to be honest about how uncomfortable you are at work day to day and be open to changing in. If you can do that. There are systems, not just the ones that I presented here today, but other systems that you've had other guests come on and this is how you can learn.
01:20:32:15 - 01:20:57:01
Speaker 2
This is how you can grow in, get busy growing. You don't need to be scared at your job because you work 40, 50, 60 hours a week. You want to be calm and relaxed at your job. If your nervous system is stressed out 40, 50, 60 hours a week, you're going to start to look old. You go, It's life gets.
01:20:57:03 - 01:21:13:08
Speaker 2
You have all this hate. You don't want it. You want to feel free, competent and part of something bigger than yourselves. When you're at work. And these are the answers you have to understand the whys. The memorizing, the what's in the house will only get you so far. That's what I want you to create your own. What's it?
01:21:13:08 - 01:21:34:19
Speaker 2
House? Because then you can take you know, an interest in what you're doing. You can consider yourself an artist and you can say, Hey, Reggie, let me show you how I did this. Right. Subclavian MRA. Have you ever done one before? No. Who cares. Who cares? You got to inject contrast at a specific time in You have to do a T1 weighted spoils gradient that go with a large field of view in the coronal plane.
01:21:35:00 - 01:21:45:03
Speaker 2
Then it's the same way you do a renal, it's the same way you do a runoff, it's the same way you do every contrast enhanced artery.
01:21:45:05 - 01:22:05:18
Speaker 3
Do you have any like for some of the green people out there, like, do you have any recommended resources that they can like cause a lot of, especially if they're watching this episode right now? We already know that you are going home and you're kind of doing your due diligence because you want to improve, right? You want to understand the bill, but what are some of the resources you would recommend to kind of, you know, kind of help them navigate some of those questions they might have?
01:22:05:22 - 01:22:41:15
Speaker 2
There are a lot of them. So just because I don't say a particular one doesn't mean I don't believe in it probably means I haven't spent a lot of time with it. I think the most robust website that's ever been put together is MRI questions dot com great. That radiologist, he's over there in Chattanooga somewhere or Easter hour Easter or something like that MRI questions dot com is the most comprehensive quality explanation of MRI concepts topics and if in if you want to go into the real weeds he has something that says advanced discussion here.
01:22:41:15 - 01:23:08:20
Speaker 2
You can click and you can go even deeper right the amount of time that that person put into that site is here. So that's if you're looking for information, that's where I would go. Other than that, you need to remember that MRI is non-ionizing radiation and you can put your friends in there and practice on them right. So when you have when your schedule allows talk to your administrators, put people in there, you still have to read them.
01:23:08:20 - 01:23:28:02
Speaker 2
There's a process to it, right? You can't just take images in that show them to Arad. But there's a there's a way to be able to use the MRI scanner to hone your skills in, scan your friends and scan your coworkers and change the echo trains and the bandwidths and change the acceleration factors. Use different antennas, change your phase directions.
01:23:28:04 - 01:23:34:16
Speaker 2
Start learning what happens when you make this change or when you make that change. Those are those. Those are the.
01:23:34:18 - 01:23:36:05
Speaker 3
I think you're 100% right.
01:23:36:05 - 01:23:37:12
Speaker 2
And one of the things. Reg, I'm sorry. yeah.
01:23:37:12 - 01:23:37:18
Speaker 3
No, you're.
01:23:37:23 - 01:23:56:01
Speaker 2
One of the thing. Read the reports. That's a good one two days later. Log on. Take a guess. Was it a meniscal tear? Was it an MCL sprain? Is it bursitis in the shoulder? What kind of lesion was that? Was that MMS or was it just Terri? Ventricular, white matter, disease. Learn what you're looking at.
01:23:56:01 - 01:24:05:18
Speaker 3
So, yeah, they will literally mention the sequence that that pathology is highlighted on the mouse right? They try to understand how important that sequence is. I think that's best.
01:24:05:20 - 01:24:21:23
Speaker 2
That's right. You get a claustrophobic person in there for a shoulder. Start with the coronal intermediate fat, suppressed image because they're going to do all they're diagnosing from that for the most part. Read the reports. Right. But the last thing you want to do is do a sagittal t one hour call to you on and then have the patient wave the white flag and they have no right right, right.
01:24:21:23 - 01:24:26:00
Speaker 2
Call back. What were you going to say? I jump in front of you because I wanted to.
01:24:26:00 - 01:24:44:12
Speaker 3
From now I was just going to say, like even if if even if your facility won't let you scan and things like that there are so many resources out there that are popping out with these virtual scanning technologies, right. Where you can actually scan like practice with, you know, out having to a scanner and stuff like that. I know Matt Hayes went to Matt.
01:24:44:14 - 01:24:48:02
Speaker 3
We love that dude with scanned laughed and laughed.
01:24:48:02 - 01:24:50:16
Speaker 2
Yes I haven't used it, but I hear great thanks.
01:24:50:16 - 01:25:10:00
Speaker 3
Powerful that thing. It gets better and better every year. And then of course there's cause med that has something to as well. So I don't know how the individual licenses work for either one of those companies, but you're right, really, I'm a very tactile person. I need to get my hands on it and see, like, if I do this, then this a happened type of thing.
01:25:10:01 - 01:25:21:10
Speaker 3
So having access to those type of tools I could see be a super beneficial or just being able to do that. When you have downtime, you just you just you're going to accelerate the amount of learning that you have. So nice. Well Thanks, Rob.
01:25:21:10 - 01:25:22:20
Speaker 2
You got anything over there? You're welcome.
01:25:23:01 - 01:25:25:12
Speaker 1
you thinking him play player?
01:25:25:15 - 01:25:28:15
Speaker 3
The real reason why we're here. That's why I'm paid. Yeah.
01:25:28:17 - 01:25:42:13
Speaker 1
Just this might be off topic, but you mentioned, like, making sure you do run certain sequences first. I try to tell patients or text this and. And correct me if I'm wrong, but I always do my repeats last. And the reason why.
01:25:42:15 - 01:25:43:20
Speaker 2
Yeah, without question.
01:25:43:22 - 01:26:01:09
Speaker 1
Is I saw patient tech the other day doing a prostate and they really wanted to make sure they got a good axial to TSC. Right? And so they did it a little bit of motion. So then they ran, another one did so then they ran a third one. did it? And then the patient tapped out.
01:26:01:11 - 01:26:05:18
Speaker 3
Like, what are they changing when they're running it or are they just doing a communication computation?
01:26:05:18 - 01:26:25:22
Speaker 1
Yeah, it's really important they don't move the sandbag on their legs, whatever these sort of things know, right? So I would say, do your repeats last like so you had they got to do a diffusion that would have been super beneficial. But that kind of that goes back to the critical thinking skills. Why not.
01:26:25:22 - 01:26:27:07
Speaker 2
What do I.
01:26:27:07 - 01:26:31:00
Speaker 1
Understanding the bigger picture zooming out and so.
01:26:31:01 - 01:26:41:14
Speaker 3
And most of us had to learn this from experience so the people who are watching, who doesn't who didn't know this and are getting it like firsthand right now, it's extremely valuable, like to, you know.
01:26:41:18 - 01:26:59:13
Speaker 1
Yeah, if you get see quality images on at2 axes or that diffuse, it's better than constantly trying to get that on that T to axial and never getting the diffusion. So things to think about like you said zooming out seen the bigger picture.
01:26:59:17 - 01:27:03:07
Speaker 3
I'm always surprised by what the rats can too on some of those motion.
01:27:03:09 - 01:27:28:12
Speaker 1
Absolutely. Absolutely. I mean how many times have I reached out to Rad and say, hey, look, is this worth proceeding right? I mean, it could be artifact from a susceptibility artifact like a pacemaker or it might be so much motion. Is this worth repeating or proceeding? And they'll say, yeah, keep going. And then you're like, But really, was it that when you go back, like you said, and you read the report and it turns out it was diagnostic.
01:27:28:12 - 01:27:47:22
Speaker 2
So I would like to answer your question in a multifaceted way and I would say, yes, your repeats should be last, right? Because you wind up with three axial tattoos and nothing else, and that's not productive. And then there's a part two to that, which is through your experience, you recognize the order of importance for those sequences. And you nailed it, right?
01:27:47:22 - 01:28:09:08
Speaker 2
The axial t two and the axial diffusion in. The prostate is 99% of the prostate, right? So that comes later and you can reprioritize those ones earlier if you think a patient can't get through it. You know, I showed you one example in this lower leg. I leave you with this, really leave you with this breast patient came in.
01:28:09:10 - 01:28:38:02
Speaker 2
They had a loop recorder. Well, if you listen to the mid-level managers out there who are not MRI experts, many of them and, they say do the protocol, don't change the feel of you. Run it just as it is. Right. Your button, push buttons and stop making a big deal about it. Right. Well, if you do a most breast protocol, still use chemical fat saturation.
01:28:38:04 - 01:29:02:04
Speaker 2
Right? Right. Because Dixon techniques mess with the cad. Yeah. Although we need to get in front of that sooner rather than later and talk to the CAD providers because Dixon is the most robust fat elimination technique. You know, in this breast exam. I absolutely used a Dixon technique because they had a loop recorder, and that loop recorder with the susceptibility artifact would have caused a lack of uniform spat elimination right on the breast, which is where they're looking.
01:29:02:04 - 01:29:20:19
Speaker 2
And the radiologist called and said, Why did you use a Dixon technique? And I told them why. And they said, Yeah, but this mixes message with the cat. And I said, Well, figure it out. Call the cat bravado, Do something. See, there's a there's something that happens to technologists when when they're not allowed to flourish and understand the white.
01:29:20:20 - 01:29:21:16
Speaker 2
Right.
01:29:21:18 - 01:29:29:13
Speaker 3
Well, and on the other hand of that, the rat would have been upset and asked like, okay, why didn't you use another sequence? Like, why is the fat saturation so poor? Honesty?
01:29:29:15 - 01:29:47:11
Speaker 2
Yes. Well, oftentimes reds want to see the bad before they say, I see what you did. Right. Well, I don't play that game right. I already know what it's going to do and I don't need you to sign off on. I don't need to show you a bad image to be allowed to run the one I should have run to begin with.
01:29:47:11 - 01:30:02:22
Speaker 2
All right, So that's how that whole thing run a stir. If the two fats that doesn't look good in button push world, they'll say, no, but you have to run the two fats out and show them the bad fats. Had them run the stir. Yeah. Let's see. Two fats out is a stir. It's a different technique. It's exact same theory.
01:30:03:00 - 01:30:26:01
Speaker 2
Yeah. And that's why the ACR says dark, fat, bright fluid. Right. They understand. So, again, I sound so boxy right now, but I'm really trying to unlock the technologist to understand the whys and the critical thing, be the artist, have fulfillment at their job, not live in fear and actually love what they do. Because when you really get into more hell, you realize it's never ending, right?
01:30:26:01 - 01:30:29:12
Speaker 2
And you show up to work every day excited to learn. That's been my experience. Yep.
01:30:29:12 - 01:30:31:09
Speaker 3
Say so. Yeah. Same here. Well, it's.
01:30:31:09 - 01:30:35:11
Speaker 1
Why we're here. Sitting here on Sunday Drive. Right My day off. Yeah, for sure.
01:30:35:16 - 01:30:36:16
Speaker 2
Exactly right.
01:30:36:18 - 01:30:39:02
Speaker 1
Well, as always, Rob, you're also there.
01:30:39:02 - 01:30:40:21
Speaker 3
Thank you. Thank you. Thank you.
01:30:40:23 - 01:30:42:22
Speaker 2
Thank you, fellas. Is the best. Yeah, Yeah.
01:30:43:04 - 01:30:45:10
Speaker 3
Anything you're working IP, you want to give a shout.
01:30:45:10 - 01:30:55:04
Speaker 2
Out to? No, no, no. Shout out to you to keep on going. Like I always tell you and you guys are making me cool.
01:30:55:06 - 01:30:57:04
Speaker 3
I appreciate that. Thank you.
01:30:57:05 - 01:30:58:23
Speaker 1
At the check out Cash Report.
01:30:59:00 - 01:30:59:15
Speaker 3
Sorry, I.
01:30:59:17 - 01:31:04:08
Speaker 1
Totally shout out. Well, Zo three podcast Reggie, are we missing anything?
01:31:04:09 - 01:31:17:06
Speaker 3
And now you know, thank you guys for your patience. I know we haven't really released anything in a while, but you know, it comes in spurts for us. So we just want to make sure that content is good that we're providing. So, you know, you're never going to catch any you're not going to catch us slipping. Long story short.
01:31:17:08 - 01:31:20:04
Speaker 1
And it's based on the our guests of availability.
01:31:20:06 - 01:31:21:14
Speaker 2
Right?
01:31:21:16 - 01:31:24:07
Speaker 1
And yeah like we like you said, we we.
01:31:24:10 - 01:31:33:17
Speaker 3
Still got a lot of good things come in so do you guys just keep being patient. We appreciate all our subscribers, our supporters, you know, Hey, it's only three podcasts. We are out.