Welcome to Mammo-Land:
An R2 Guide to the Mammography Service
Introduction
As you will quickly discover, Mammo at LAC-USC is a busy, high energy, procedure-heavy service. Not to fear, though—the rotation is also a common favorite among residents, and this guide is designed to help you hit the ground running on Day One.
As an R2, you are the most junior on service and will typically be joined by a senior resident (R3 or R4) and fellow. Your primary role on the service is handling procedures. This means vetting procedure requests, consenting patients, coordinating with technologists, and actually doing a majority of the procedures. More details on procedures to follow.
When you’re not handling procedures, you will be an active participant in the readout of both screening mammograms and diagnostic imaging (including mammogram and ultrasound). The screening is done “offline”; this means the images are reviewed after the study is completed and the patient has gone home, so if further imaging is needed, the patient will need to return for more studies on another day. Diagnostic imaging is “online”—as soon as technologists and sonographers perform the exams, they are reviewed with us in the reading room, so that the patient doesn’t leave until they have a final result/plan.
More advanced imaging (breast MRI) is handled primarily by the fellow on service. However, this doesn’t mean you will be deprived of exposure to this modality during your first rotation on service. In fact, our fellows help ensure you gain familiarity with this modality by hosting case review sessions on Friday mornings. In addition, you will also gain insight into MRI during the frequent Rad-Path review sessions, in which pathology results are compared with imaging findings to determine further management. Since this is LA County, cases are frequently complex, and it’s not surprising to have numerous imaging modalities employed for any single case being reviewed.
Lastly, you will be critical in helping to prepare case presentation for the weekly Monday morning interdisciplinary conferences. You will help the senior resident/fellow to present imaging for cases to be reviewed with our colleagues in surgery, oncology, radiation oncology, and pathology.
“Life moves pretty fast.
If you don’t stop and look around once in a while, you could miss it.”
The Workflow
The first thing you should do when you arrive at 8AM is review the printout of the scheduled procedures for the day. You will be primarily responsible for ultrasound biopsies and ultrasound cyst/abscess aspirations. Usually the fellow will review the imaging with you early in the morning, and together you should decide which biopsy device to use for each procedure. Needle localizations and stereotactic biopsies will typically be performed by the senior resident or fellows; you should review these cases with the fellow as well, as you will often be obtaining consent for these cases.
After you establish your plan for the scheduled patients, you should check for any inpatient procedure requests and for orders from the ED. It is not unusual for patients to be kept in the ED from overnight/early morning in anticipation of a prompt evaluation during the subsequent business day. On Mondays, also check for any breast cases that were done over the weekend; these patients typically require a complete workup in our department. Review these cases with the senior resident/fellow and attending as time and schedule allows, as these can potentially be “Add-on” cases for you.
Next, check the whiteboard for patient status updates. Patients are tracked regarding arrival time, consent status, procedure completion, and if there are any other “Add-ons” that need to be addressed. When an outpatient arrives for a procedure, the consent should already be printed for you.
When you’re ready to consent, you can take the patient to the consenting room, where you’ll have a phone (for translator service), computer (to re-review patient chart, if needed), and copies of Spanish/English post-procedure instructions for the patient to take home. For biopsies, you should consent them for both the biopsy itself, and for biopsy marker placement. There are examples of the biopsy markers in the room for the patient to see; you should also inform them that they will get a mammogram before going home as well. It is understandable for the consenting procedure to feel tedious at times, but, since patients come from various backgrounds and have various levels of anxiety about procedures, consenting can be an invaluable asset to you by helping you develop rapport with the patient before ever setting foot inside the procedure room.
Once the patient has been consented, touch base with the sonographer/technologist to let him/her know that the patient is consented; this will alert them to not get tied up with another diagnostic case, and to prep the room and patient. In addition, you should tell them which device you want to use. Then, head back to the reading room to see if other patients have arrived, or to begin participating in read-outs. You will get a call from the technologist when the patient is ready. On busy days, your co-resident will help with consenting, and you may end up running two procedure rooms simultaneously.
Readouts usually address three different situations: 1) Screeners; 2) Diagnostics; and 3) Rad-Path. At first, diagnostic and Rad-Path can feel overwhelming; this is fine, and you will get up to speed sooner than you think. Early on, you should devote your focus on really understanding the screening cases, and how, in detail, to further workup the call-backs.
Odds and Ends
· A product representative should be on site at the beginning of your rotation to help you get familiar with all the biopsy instruments. The representative will typically prepare a specimen (think: raw chicken meat stuffed with olives) on which you can practice ultrasound-guided biopsies using multiple different devices. If interested in learning about biopsy devices we use, we currently use the following: the Bard® EnCore® vacuum-assisted device, and the Bard® Mission® and Bard® Marquee® core needle instruments.
· At the beginning of the rotation, an attending should also give you orientation/training in handling and deploying the biopsy markers.
· Regarding patients with implants: Fellows perform procedures on patients with implants. If you are consenting these patients, please ensure the consent includes risks regarding possible damage to the implant, and that you discuss these additional risks with the patient.
· Patients with multiple biopsy sites will need a separate order for each site biopsied; a single consent indicating the multiple sites to be biopsied is adequate. Be careful with these patients’ samples and labeling!
· Patients under 30 years of age typically will not get post-biopsy mammograms in order to spare them the extra radiation.
· Don’t forget to log all of your procedures in the Mammo log book in the reading room. Also keep your own procedure log up to date!
· Dictations are done in MagView software. Don’t hesitate to ask for help in creating reports.
· Monday morning interdisciplinary conference is at 7AM. Ask your senior/fellow for location and how to help prepare your presentation.
· Although there is some variability in terms case load, and which staff is on service, you should be able to get your feet wet with needle localizations and stereotactic biopsies by the end of your rotation. I think a good way to get a couple stereos/needle-localizations under your belt is to be proactive in consenting for these procedures throughout the block whenever possible; it shows you’re a team player, and your seniors will be more inclined to return the favor if you’re interested in these procedures.
-t. iafe 02.2018