Pure Imagination: A Brief Intro to Nuclear Medicine

Nuclear medicine is a unique, perhaps eccentric, branch of radiology. To illustrate, for the vast majority of conventional diagnostic imaging, the patient is exposed to a source of radiation, and static, anatomic images, of high spatial and tissue resolution, are obtained. In contrast, during a nuclear medicine exam, a carrier molecule labeled with a radioactive tracer is injected into the patient, thus becoming the source of radiation, and then relatively low resolution, dynamic and/or physiologic imaging data is acquired. Couple these principles with the sheer volume of material to learn—radiotracers, half-lives, dosages, energies, exam protocols, etc.—and a resident’s initial experience on their first nuclear medicine rotation might feel a bit like touring Willy Wonka’s Chocolate Factory.

In hopes of mitigating the borderline fanciful nature of initial exposure to nuclear medicine, the following is a brief, practical guide for junior residents beginning their first rotation on this service. Specifically, this site includes responsibilities, expectations, and step-by-step guides to the nuclear medicine software used at both County and The PET Center.

County Nucs

As a junior resident on nucs at County, your main responsibilities include managing the service and reading general nuclear medicine studies (i.e., non-PET studies).

Your first task of the day should be to vet inpatient order requests, so that the appropriate radiotracers can be prepared/ordered for administration. It is important to also review inpatient orders prior to noon conference, as there is a cut-off in the early afternoon after which additional radiotracers cannot be obtained same-day. When you have approved orders early in the morning or immediately before lunch, it is a good idea to timely communicate this fact to the techs.

Throughout the day, techs will come into the reading room to show you exams they are about to complete. You should promptly review the images to determine if the images are satisfactory, and if there are any issues that need to be addressed before the patient leaves the department (for example: getting additional views, interrogating possible artifacts, or identifying contamination, for example) . If you are uncertain, feel free to ask your senior resident/fellow, or attending. It is also important to stay on top of studies coming from the E.D.; it is recommended to read out the cardiac studies during read-out first. Also, try to keep tabs on the number of pending cardiac studies in the afternoon so you're not surprised by a bolus in the late PM. 

Another important responsibility of the junior resident on service is administering radiotracers for lymphoscintigraphy, which is done at both County and Norris. For sentinel lymph node detection in breast cancer patients, the radiopharmaceutical is administered in four quadrants around the areola; in patients with lymphedema, the tracer is administered in the interdigital webspaces. Although painful for patients, research has shown better outcomes with intradermal injections, so this is generally preferred to subcutaneous delivery.  

PETs are typically the main responsibility of senior residents/fellow. However, once a junior resident has learned the ropes of running the service and gained comfort with general nucs, he/she should be able to have the opportunity to interpret at least a handful of PETs by the end of the block. Finally, it's important to regularly read-out DEXAs (which can be found on a separate worklist).

Tips for the PET Center

• Location: The PET Center is located in HCC1, through the double doors immediately off the 3rd floor elevators. Go to the right, and the reading room is at the bend in the hallway.
• A schedule is printed daily. If there are exams prior to 8AM the next day, confirm with the techs what time you need to arrive in the morning.
• In addition to regular clinical studies (PET and general nucs), residents are required to dictate brief reports for PET research studies indicating the study protocol, dose of radiotracer, and any acute abnormalities (use PET Research template).
• More comprehensive information about PET Center responsibilities can be found here.

MIM Workflow and Dictation Tips

The Nuclear Medicine Department uses the MIM software package for image processing and analysis.  

• An introductory step-by-step guide for loading exams and launching the appropriate workflow is available in the PET Center file linked above.
• Information on templates and dictation tips are available here.

t. iafe 06.2018