Sunnybrook's Radiologists 21 - Department of Medical Imaging

Table of Contents
If this is your first time here .............................................................................................................. 2
1. Go to Postgraduate Medical Education .......................................................................................... 2
2. Get PACS training .......................................................................................................................... 2
3. Get Vocera training ........................................................................................................................ 2
4. Get a TLD badge ............................................................................................................................ 3
General information ......................................................................................................................... 3
1. Leave (vacation, academic time, sick leave, etc.) .......................................................................... 3
2. Resident workstations .................................................................................................................... 3
3. PACSportal .................................................................................................................................... 3
4. Rounds ........................................................................................................................................... 4
5. Lunches ......................................................................................................................................... 4
6. Mail slots ........................................................................................................................................ 4
7. Important phone numbers .............................................................................................................. 4
8. Paging system................................................................................................................................ 4
9. Call room ........................................................................................................................................ 5
10. Shuttle ............................................................................................................................................ 5
11. Privacy and Personal Health Information ....................................................................................... 5
12. Reporting cases in IMPAX ............................................................................................................. 6
Call ................................................................................................................................................... 7
1. General information ........................................................................................................................ 7
2. Resident responsibilities on call ..................................................................................................... 7
3. How call works ............................................................................................................................... 8
a) Home base when on call .....................................................................................................................8
b) Our technologists ................................................................................................................................8
c) CT protocols ........................................................................................................................................9
d) Emergency Department ......................................................................................................................9
e) Emergency Department pre-approved CT indications .........................................................................9
f) Traumas ............................................................................................................................................ 10
g) Renal function and contrast ............................................................................................................... 10
h) Body intervention .............................................................................................................................. 11
i) Ultrasound......................................................................................................................................... 11
j) GI/GU studies ................................................................................................................................... 12
k) Chest ................................................................................................................................................ 12
l) Plain films ......................................................................................................................................... 12
m) Joint aspirations ................................................................................................................................ 12
n) Spine imaging (CT, MR) and interventions ........................................................................................ 12
o) MRI ................................................................................................................................................... 12
p) Neuroimaging .................................................................................................................................... 13
q) Interventional Neuroradiology ............................................................................................................ 13
r) VIR CT .............................................................................................................................................. 14
s) VIR procedures ................................................................................................................................. 14
t) Nuclear Medicine .............................................................................................................................. 14
u) Handling disagreements with referring services................................................................................. 15
v) Requests for second opinions ........................................................................................................... 15
w) Problems on call................................................................................................................................ 15
x) Call feedback and follow up ............................................................................................................... 16
4. Preliminary reports on call ............................................................................................................ 17
5. Staff radiologist coverage on call ................................................................................................. 20
Sunnybrook’s radiologists .............................................................................................................. 21

Department of Medical Imaging
Resident Site Manual
Welcome to Sunnybrook’s Department of Medical Imaging. Please take the time to review this
manual carefully; it contains a information that can help make life here a lot easier for you.
Sunnybrook’s residency site coordinator is Dr. Robyn Pugash, room MG189, ext. 6197,
robyn.pugash@sunnybrook.ca.
If this is your first time here
There are four things you need to do before starting work – go to Postgrad, get PACS trained, get
Vocera trained and get a TLD badge:
1. Go to Postgraduate Medical Education
The first thing you need to do is register with the hospital’s Postgrad department, located on the
3 rd floor of E wing. Postgrad will help you get your:
• Hospital orientation.
• Hospital ID badge. Please note that you must wear your ID badge at all times while in the
hospital.
• Laundry (lab coat, scrubs).
• Parking if needed (you must pay for this yourself).
• EPR training (Electronic Patient Record): You’ll need EPR training and an EPR log-on in
order to be able to review blood work, pathology reports, OR notes and discharge
summaries.
Our contact in Postgrad is:
• Sinthujah Santhirasiri, ext. 85044, sinthujah.santhirasiri@sunnybrook.ca.
2. Get PACS training
The PACS office is in room AB14. Contact Lorraine Torrenueva (ext. 7139,
lorraine.torrenueva@sunnybrook.ca) for training. You must have this training before you can use
our PACS.
3. Get Vocera training
Vocera training takes just a few minutes but must be completed by everyone who works in the
department. Contact Reggie Quinn for training (ext. 4374, reggie.quinn@sunnybrook.ca).
Vocera replaces an overhead paging system. It is a hands free wearable device that we use in
Medical Imaging to communicate with each other. Everyone who works in Medical Imaging must
wear a Vocera badge and be appropriately logged on to the system throughout the work day (and
when on call). The badges are shared. We keep then in each area of the department. Please pick
one up when you arrive in the morning then return it to the same place when you leave.
During the day all residents must be logged on to Vocera.
After hours: The on call resident must be logged on to Vocera for the duration of the call
period. At the beginning of the call period (5:00 PM) the on call resident must add themselves to
the Resident on Call group. This is done by tapping the Vocera button and saying “Add me to
Resident on Call”. When call ends, tap the button and say “Remove me from Resident on Call.
2

A dedicated Resident Call Vocera badge is used after hours. When not in use, this badge is to be
kept in its charger in the resident call room. Do not use this badge during the day so as to ensure
that there is a fully charged badge available that will last through the night.
4. Get a TLD badge
Please get one as soon as possible and wear it at all times. Contact Cindy Matheson (ext. 3851,
cindy.matheson@sunnybrook.ca).
General information
1. Leave (vacation, academic time, sick leave, etc.)
All leave (vacation, academic time, lieu days, sick leave) must be arranged using the Residency
Program’s online Leave Requests system (www.uoftradiology.ca/vacation).
In addition to recording your sick leave online, we ask that when sick you also send an e-mail first
thing in the morning to the:
• Site Administrative Assistant (Ellen Tyson, ellen.tyson@sunnybrook.ca)
• Site Coordinator (Dr. Robyn Pugash, robyn.pugash@sunnybrook.ca)
• Rotation supervisor (firstname.lastname@sunnybrook.ca)
If you do not have access to e-mail, please call Ellen Tyson at 416-480-4339 and she will contact
the relevant people.
2. Resident workstations
Each rotation has assigned workstations – instead of grabbing your favourite you should use one
of the workstations that has been assigned to your service (see list below). If all of your service’s
workstations are filled up, then see if one of the other services has an empty one but don’t bump
another resident (regardless of seniority) so you can use the workstation. If there are no empty
workstations anywhere else speak to Ellen Tyson (ext. 4339) about using a radiologist’s office.
We have enough workstations to go around so you should not need to use staff offices very often
if ever. (Also, if one of your service's workstations isn’t working, please don’t just move elsewhere
and leave it for someone else to find – call PACS support at 4334.)
Workstation assignments are:
• Chest, GI/GU, MSK and Gen/Emerg residents: Workstations in AG270.
• Ultrasound: There are three workstations in the US work room, for use by staff, fellow and
resident.
• CT (Body): There are four workstations in the room next to CT 1, for use by two fellows and
two residents.
• VIR: There are two workstations in the Angio area just outside Dr. Pugash’s office. These are
for use by one fellow and one resident.
• Neuro has three workstations for use by two fellows and one resident.
• Nukes has two workstations for use by one staff and one resident.
• Call: Reporting room attached to CT4.
3. PACSportal
We keep a great deal of useful information on the intranet (including the most current version of
this manual, work schedules, call schedules, CT protocols, a creatinine clearance calculator,
guidelines for contrast administration in patients with poor renal function, etc.). If you’re using a
3

computer in the hospital, enter “pacsportal” into the address bar of Internet Explorer. If you want
to get into PACSportal from home, go to https://vpn.sunnybrook.ca then log in using the same
user name and password that you use for Impax, then follow the directions on the screen. Once
you are in, open a new browser window (or tab) and go to http://pacsportal.sw.ca.
4. Rounds
The resident rounds schedule is posted on PACSportal and is also circulated each week by e-
mail. Attendance at all rounds listed on the schedule is mandatory (unless post-call, etc.).
Morning rounds start on time. Everyone should be present and seated in the seminar room (AG
255) by 8:00 AM. Rounds end at 9:00 AM. You should be on service by 9:10 AM.
Lunch does not happen after mid-day rounds – it happens during them. Please bring your lunch
to these sessions then return to your service after they end. You are expected to be back on
service by 12:40.
There are many other rounds every week including an assortment of multidisciplinary rounds,
tumour board rounds, etc. Residents may attend these rounds if they are relevant to their current
rotation provided they are invited to do so by their rotation supervisor. Please return to your
service as soon as possible after rounds.
5. Lunches
The radiologists host a lunch for the fellows and residents in AG 255 on the 3rd Friday of the
month starting around noon.
6. Mail slots
Resident mail slots are located on the wall in AG270b.
7. Important phone numbers
• Cardiac arrest team (code blue): 5555
• Fire: 5555
• Security: 4589 or page id. no. 1502
• Locating: 4244
• Resident pager id. no. is 1190
• PACS support: Our PACS group doesn’t use pagers. If you need PACS day or night, call
extension 4334 (or if you’re outside the hospital 416-480-4334). If it’s after hours, your call will
be forwarded to the on call person’s BlackBerry. If nobody answers the phone, leave a voice
message and they’ll call you back.
8. Paging system
There are several ways to page people at Sunnybrook:
• Intranet (the “Smart” system): Open Internet Explorer and enter the word “smart” into the
address bar. The first screen you see allows you to search by name, department, etc. If you
want to page using the four digit id. no., click on “Paging” in the left margin. This will bring up a
window that allows you to enter the id. no.
• Phone: If you know the 4 digit pager id. number, from inside the hospital call ext. 744 and
follow the instructions (from outside the hospital call 416-480-5744).
• Locating: Extension 4244 (from outside the hospital call 416-480-4244).
4

9. Call room
AG281 (A wing, Ground floor, room 281). The key for the call room should be kept with the call
pager.
10. Shuttle
Sunnybrook operates a free shuttle bus service for use by staff. You must show your ID badge in
order to board the bus. The shuttle bus stop is outside H wing. There are two service routes:
• Between Sunnybrook, the Holland Centre and Women’s College Hospitals.
• Between Sunnybrook and Lawrence/Yonge (SE corner) during the morning and evening rush
hours only.
You’ll find a link to shuttle bus schedule in the Intranet section of PACSportal.
11. Privacy and Personal Health Information
The Personal Health Information Protection Act (PHIPA) outlines privacy policies and practices
for health information custodians in the province of Ontario. A main purpose of PHIPA is to
establish regulations for the collection, use and disclosure of personal health information in a
manner that protects the confidentiality of the information and the privacy of the individuals in
question.
Under PHIPA, personal health information is defined as identifying information about an
individual, whether it is recorded or unrecorded, including (this is a shortened list):
• Physical or mental health records of the individual
• An individual’s health number, social insurance number or any other personally identifying
information
PHIPA primarily applies to the management and safeguarding of personal health information
under the responsibility of health information custodians. Health care practitioners, including
residents, are considered to be health information custodians. Under PHIPA, all health
information custodians are held responsible for protecting personal health information under their
control. This means that custodians may only collect, use, disclose, retain or dispose of personal
health information as it is permitted under PHIPA. The health information custodian must take
reasonable precautions to ensure that the personal health information is protected against theft,
loss, unauthorized use or unintended disclosure. The information must also be protected against
unauthorized copying, modification or disposal. In the case of such events, the health information
custodian must take steps to inform the individual of the occurrence at the first reasonable
opportunity.
This means that while you may collect personal health information, you may not store this
information in an insecure fashion – including in any cloud based system. You may not keep
lists of interesting cases or procedure logs that contain personal health information in
Google Docs, Dropbox, Evernote, etc. Use an encrypted USB key for these purposes.
5

12. Reporting cases in IMPAX
Click the “Worklists” button near the top left corner of the text screen. Select the correct
worklist(s) from the “Standard Worklists” section. If you can’t see the correct worklist, click the
“View” button in the top right corner and open up the section you need.
After you’ve picked the worklist(s) you need, make sure the “Relevance” button is highlighted (just
to the right of the “Worklists” button) in order to bring up relevant priors.
IMPORTANT: You must “reserve” every case you are going to report so that others will know not
to report it. The way to do this is simple:
Open the study you are going to report. Left-click once on the microphone button in the top left
corner of the screen. This will change the exam’s status from “New” to “Trainee Dictation
Started”, as shown.
Then, using Talk, dictate the report heading
(or insert a macro). Finally, click “Save
Report” in Talk.
This system has been carefully created to
ensure that you have ready access to
“your” cases and that cases don’t fall through
the cracks for reporting. Please do not
improvise or change this process in any way.
Personal worklists:
Each resident has three personal worklists. In addition to any other worklists you may need for
your rotations, you should keep all three of your personal worklists open in Impax at all
times.
One worklist just has your name on it. It will contain cases whose status is “Trainee Dictation
Started” – this is a list of cases you have reserved for reporting using the process noted above.
Another worklist has your name followed by the word “Reported” in brackets. This worklist
contains cases whose status is “Reported” (meaning you have signed off the reports but they are
pending staff approval). If you need to revise one of your reports before it gets signed off by staff,
you can use this worklist to find the case. Once the case has been signed off by staff, it will
disappear from the worklist.
The last worklist has your name followed by the words “Needs Review”. This worklist will contain
exams that have been flagged by staff for you to look at – the main purpose of this list is to give
you an opportunity to go over cases where you may have missed a finding on call. Don’t take this
personally! – We are required by the Royal College of Physicians and Surgeons of Canada to
give you this kind of feedback about the work you do on call. This worklist may also be used for
other purposes, for example to draw your attention to certain reporting styles or sometimes to
show you interesting cases.
Rather than just reading the final reports for these
cases, you should make every effort to go over each
“Needs Review” case with the radiologist who brought
it to your attention. Once you’ve done that, go to the
text box and click on the “Favorite Study Comments”
tab. Highlight “Report Reviewed” using a left click.
6

Then right click over “Report Reviewed”. This will bring up “Add to study comments”. Select this
option with a left click.
Call
1. General information
The resident call schedule is kept in a Google calendar on PACSportal (the U of T web site is
also linked to this calendar). It is the responsibility of the site chief resident to post the schedule
and to update it in a timely fashion if changes are made.
Call period:
• Weekdays: 5:00 PM to 9:00 AM (but must carry pager from 9:00 AM to 9:00 AM – see below)
• Weekends: 9:00 AM to 9:00 AM or 12 hour shifts from 9:00 AM to 9:00 PM and 9:00 PM to
9:00 AM
Pick up the pager at 9:00 AM on weekends and at morning rounds on weekdays. The resident on
call is rarely paged before 5:00 PM on weekdays but should be available by pager throughout the
day. Clinical services will likely not be aware that your call “officially” starts in the evening so if
you are paged before 5:00 PM, please courteously direct the caller to the appropriate department
or radiologist.
The on call resident must be logged on to Vocera for the duration of the call period. At the
beginning of the call period (5:00 PM) the on call resident must add themselves to the Resident
on Call group. This is done by tapping the Vocera button and saying “Add me to Resident on
Call”. When call ends, tap the button and say “Remove me from Resident on Call.
The on call resident is based in the reporting room attached to CT4 (ext. 88041). Do not work
anywhere else except if the CT4 workstation isn’t working (and if it’s not, please let both Dr.
Pugash and PACS support know about it). Once you’ve gone to bed it’s OK to check cases from
one of the workstations closer to the call room.
You are entitled to go home at 9:00 AM on your post-call days. If you wish to stay later for the
purpose of getting in-person feedback for your call cases you are welcome to do so. This,
however, is not mandatory. If you do not review cases in the morning, please be sure to go over
the cases in your “Needs Review” worklist (see earlier section “Reporting cases in IMPAX 6”).
2. Resident responsibilities on call
The on call resident is first call for all Medical Imaging services except Interventional
Neuroradiology, Body intervention and Vascular/Interventional Radiology procedures after hours.
See page 20 for details about division of duties among the staff call groups.
The on call resident is responsible for:
• Returning all pages in a timely manner. Residents are expected to answer pages within 5
minutes of having received them unless there are other more important medical matters to deal
with such as reviewing acute trauma studies at the scanner with the Trauma Team.
• Arranging and supervising all appropriately indicated after-hours Ultrasound (see page 11),
Nuclear Medicine (page 11), CT and MRI (page 12) exams.
• Providing timely preliminary reports (see page 17) for all after-hours Ultrasound, Nuclear
Medicine, CT and MRI exams as well as any other exams for which preliminary reports are
7

needed or requested after hours (such as plain films). This includes providing preliminary
reports for exams on the Resident Call worklist during daytime hours on weekends (unless
specifically instructed by on call staff to do otherwise).
• Arranging, coordinating and performing lumbar punctures (see page 13), joint aspirations
(page 12), spine procedures (page 12), GI and GU exams (page 12).
• Starting IVs on inpatients or Emergency patients (if no suitably trained Medical Imaging staff
are available) and connecting central lines to injectors when necessary. Before starting IVs on
CT patients, check the CT protocol being used to see if it specifies IV side, size or location
(see CT protocol section on page 8).
• Most PIC lines that are inserted at Sunnybrook are power-injectable which means they can be
used for all types of CT. These lines can be injected at rates of up to 5 cc/sec. Our CT
technologists have been trained in the use of power-injectable PIC lines.
• Power injection may be done through some (but not all) central venous catheters. The policy
and procedure for this are on PACSportal.
• Providing any medical assistance/care within the Department of Medical Imaging that may be
needed after hours.
• Supervising contrast injections after 5:00 PM and dealing with any adverse reactions that may
crop up. All residents are expected to be well versed in the management of contrast reactions.
CAR guidelines are posted in the Department–Contrast section of PACSportal
• A physician must always be available in the department when contrast is being administered. If
you are going to leave the department please inform the CT technologist beforehand and let
them know when you return. You should not be away from the department for extended
periods.
• Communicating findings to the responsible clinical services for all Ultrasound, Nuclear
Medicine, CT and MRI studies (plus any plain films for which an opinion is requested) done
during the call period. In all cases this means entering a preliminary report into the comment
box in Impax (details follow) but in some cases this will also mean calling the service directly to
discuss a case. [We occasionally do a list of elective CTs on the weekends; residents are not
responsible for providing preliminary reports for these exams.]
• Arranging next working day studies and procedures in instances where they do not need to be
done on an urgent, after-hours basis.
3. How call works
a) Home base when on call
The on call resident is based in the reporting room attached to CT4 (ext. 88041). Do not work
anywhere else except if the CT4 workstation isn’t working (and if it’s not, please let both Dr.
Pugash and PACS support know about it). Once you’ve gone to bed it’s OK to check cases from
one of the workstations closer to the call room.
b) Our technologists
Our technologists are highly trained professionals who deserve your respect and courtesy. Not
only that, if suitably motivated they can ease your burden on call and help you problem-solve. It is
in your best interests to have congenial and collegial relationships with them… meaning that it’s
not a good idea to adopt an “I’m a doctor, you’re only a technologist” attitude.
8

CT technologists are in house 24/7.
c) CT protocols
When you approve after-hours CT exams, you must “code” the requests, which means indicating
which CT protocols the tech should use. Use Protocol Viewer to code studies; do not code exams
verbally.
CT protocols are kept in binders in the scan rooms. You may wish to refer to these when coding
exams.
d) Emergency Department
Emerg is one of our main concerns at all times but especially on call. It is very important to make
every effort to work with Emerg to prevent interruptions in their patient flow.
CT is a main impediment to patient flow from the Medical Imaging side of things, so we need to
ensure that CT scans get done as soon as possible after having been approved by the resident.
This means that when you approve an Emerg study you must call the CT tech immediately and
arrange to have the scan done as soon as possible. Do not wait to notify the CT tech after you
have approved Emerg studies and do not ask the Emerg physician to notify the tech for
you.
CT exams on Emerg patients must not be left for the morning. To put this another way: If a
patient is in Emerg and with a valid (does not have to be emergent) indication for CT, then the
study must be done promptly and not left until the morning. As an example: A patient is in Emerg
with painless jaundice. Emerg orders a CT to r/o pancreatic carcinoma. This is a valid indication
for CT, but it is not an emergency. This scan should be done at the earliest opportunity even if the
request comes in the middle of the night. The same is true for MR exams on Emerg patients with
the qualifier that MR requests are accommodated during (but not outside) MR hours of operation
(listed on page 12). So if Emerg asks for an MR for a valid but not emergent indication and an MR
tech is in-house, the scan should be done promptly and not left for another time.
If you run across urgent or unexpected yet important findings on Emerg studies you must call
your report directly to the referring MD. Do not rely on the preliminary comment box report for
this purpose.
Occasionally, Emerg needs to arrange next working day procedures for semi-urgent problems.
Under these circumstances, please jot down the necessary information and pass it along to the
VIR service in the morning.
e) Emergency Department pre-approved CT indications
Weekdays after 5:00 PM until 8:00 AM plus all weekend long, Emerg is pre-approved to order CT
scans for the following indications:
• Noncontrast abdo/pelvis for renal colic.
• Noncontrast head for intracerebral bleeds (SAH, SDH, ICB), trauma, delirium, headache,
vertigo, altered LOC, seizure, stroke over 6 hours.
The process for arranging pre-approved scans does not include the resident – Emerg calls or
pages the CT tech who then does the scan. You will not hear about these scans in advance.
Once the scan has been done and sent to Impax, the tech will page or Vocera you to let you
know that you have a study to report. Please do not ask techs to not page you for these exams –
like all others, they must be reported in a timely manner.
9

CT scans on Emerg patients for all other indications must be discussed with the on call radiology
resident for approval and coding.
Pre-approval only applies to Emerg and not inpatients.
The pre-approved CT policy (for both regular hours and after hours) is posted on PACSportal.
The same document covers issues around after-hours US.
f) Traumas
Sunnybrook’s Trauma program is the largest in Canada; in other words trauma on call is very
busy. When a trauma patient arrives in the scanner, the on call resident is notified and must
attend immediately, before the scan is started (be sure to let Dr. Pugash know if trauma scans
are done without the resident being notified). Remember that scanning protocol is determined by
Medical Imaging (you, the resident), and not by the TTL. The TTL should tell you the body parts
and injury type they are concerned about. With that information in hand, you should then
prescribe the appropriate scanning protocol. To say it another way – the Trauma Team does not
determine scanning protocol, you do. As an example, CTA is not routinely done in the abdomen
and pelvis for blunt multi-trauma and should not be done simply because a TTL requests it – it
should be done only if there is a specific indication for it.
You must review all trauma scans with the trauma team at the console in CT4.
g) Renal function and contrast
Our department has a comprehensive process for screening patients for possible renal
dysfunction and imaging patients with renal dysfunction.
Screening: The nurses and technologists go through a contrast checklist with every CT and MR
patient. One section of this checklist is used to identify renal risk factors. If there are no risk
factors, creatinine levels do not need to be checked. If a patient has any risk factors, creatinine
levels should be checked and estimated creatinine clearance calculated (see calculator in
Department section of PACSportal at http://142.76.62.85/eccr.html). NB If risk factors are present
but the indication for the study is urgent (e.g. trauma patient with clinical signs of active bleeding)
creatinine measurements can be skipped – proceed using Visipaque instead of Omnipaque and
ensure adequate hydration.
Imaging & renal dysfunction: Once renal dysfunction has been identified (meaning low eCCr –
do not use elevated creatinine levels to make a determination of renal dysfunction), follow the
processes outlined in the “Contrast Guidelines” document in the Department–Contrast section of
PACSportal. This document deals with both iodinated contrast and gadolinium.
For iodinated contrast material we’ve identified three levels of renal dysfunction based on eCCr:
• eCCr less than 60 mL/min
• eCCr less than 45 mL/min
• eCCr less than 30 mL/min
The document lists guidelines for how to handle each level of dysfunction. You’ll note that there
are no circumstances in which iodinated contrast is considered to be absolutely contraindicated.
For all levels of renal dysfunction, consider whether or not there is an alternate imaging method
that could provide the necessary information. If there isn’t then you must have a discussion with
the referring physician. Advise them that eCCr is low and that this carries a potential risk of
contrast-induced nephropathy (CIN) that can lead to a further reduction in renal function (NB in
the overwhelming majority of CIN cases – perhaps 80% or more – this reduction in renal function
10

is temporary). The two of you must decide if the clinical question being asked warrants exposing
the patient to this risk – if so, then proceed with contrast using the guidelines outlined in the
document.
h) Body intervention
Body Imaging covers all abdominal and pelvic abscess drains on call.
You are encouraged to participate in Body procedures whenever possible. If you get called about
a drainage procedure and you plan to participate in it, take down all the necessary information,
review the imaging and discuss the case with the staff on call. If you will not be involved in the
procedure, please ask the caller to page the Body fellow (or staff if there is no fellow on call).
Body does not cover chest drains (e.g., empyema) and gallbladder drains (cholecystostomies) –
these are done by VIR.
i) Ultrasound
The on call resident is responsible for fielding all requests for ultrasound (apart from neonatal
ultrasound – any requests on neonates should be passed along to the on call Body fellow or staff)
after 5 pm on weekdays and 24/7 on weekends. If you approve a scan you must convey the
relevant information to the ultrasound technologist on call. If neither the Body fellow nor staff
radiologist is in house, the on call resident is responsible for checking the scan and
issuing a preliminary report (although as with anything else you are encouraged to call for help
if you are unsure of the findings or their significance). Back-up is provided by Body fellow or staff
on call.
Each on call ultrasound examination must have an acceptable indication (see “Emerg CT and US
guidelines” in the Department section of PACSportal). Performing a study just because the
technologist is available in the hospital doing another case is not an acceptable use of the
service.
Consider if the added certainly of CT will be required to answer the clinical question or if there is a
strong clinical possibility the patient will require abscess drainage. If so, rather than duplicating
exams you should simply perform the definitive study for the problem. Ultrasound is particularly
good for the pelvis and biliary tree; CT for suspected abscesses and the retroperitoneum. Survey
US examinations in patients with poorly defined indications “not ill enough for CT” are not
acceptable and should be discussed with the staff radiologist.
Contact details for the on call US tech can be found at
portal.sw.ca/MedicalImaging/ultrasound/Lists/Calendar/calendar.aspx.
If you approve an after-hours ultrasound study get the following information and give it to the
technologist:
• Patient name and MRN
• Patient location
• Clinical history (reason for the exam)
• Pertinent lab work (e.g., beta HCG, WBC count, INR if doing a procedure, etc.)
Preliminary reports for after-hours US exams: When paged by the US tech, go to US (do not
ask the tech to come to you), discuss the case with the tech, then scan the patient yourself.
If you are unsure about the findings or if you disagree with the tech’s opinion, discuss the case
with the Body fellow or staff on call. Once that’s been done:
Write a preliminary report on the “tech sheet”. This must be done before the tech scans the
sheet into the system. There is no need to rewrite the prelim report in the comments box.
11

Use the comments box to record any relevant history that you’ve been given on the phone.
Next-day ultrasound exams: Emerg has six ultrasound booking slots reserved every morning
including weekends. These do not require resident approval. Emerg has a bookings form that
they complete with all of the relevant patient information and they fax it to Ultrasound in the
morning.
j) GI/GU studies
The on call resident is first call for GI/GU studies like swallows, enemas and retrograde
urethrograms and is expected to perform these exams under supervision. Contact the on call
Body fellow or staff for back-up.
k) Chest
The on call Chest radiologist provides resident back-up for all urgent chest imaging. This includes
trauma chest CT (including thoracic aortic trauma) and all CT pulmonary angiograms.
l) Plain films
The on call resident is first call for all requests to review plain films. Back up for plain films is
provided by the staff or fellow on call for the relevant division.
m) Joint aspirations
The on call resident is first call for joint aspirations and is responsible for triaging and organizing
all urgent joint aspirations and for performing them under the supervision of the on call MSK staff.
n) Spine imaging (CT, MR) and interventions
The on call resident is first call for spine imaging and spine intervention (lumbar punctures, disc
aspirations, spine biopsies, myelograms, etc.). The resident triages and organizes this work and
performs all spine related procedures under staff (or fellow) supervision.
Neuro supervises all lumbar punctures. For other spine intervention and imaging (CT, MR):
Neuro covers patients referred from Neurology, Neurosurgery and the cancer clinic.
MSK covers patients referred from all other services including Orthopedics, ER, Rheumatology,
Medicine, Infectious Diseases.
o) MRI
Current hours of MRI operation:
• 24 hours/day from Monday 7:00 AM through Friday 11:00 PM.
• Saturday and Sunday 7:00 AM to 7:00 PM.
During MRI operating hours:
• A technologist is in-house.
• To reach the MR tech call ext. 3300 or 3292 or try Vocera (“Call MRI technologist”).
• The MR tech can at times be unreachable due to being in the magnet (they have to remove
pager and Vocera). It may be necessary for you to walk over to MR in emergent/urgent
situations.
Outside MRI operating hours the MR tech can be reached on pager id. no. 6367.
12

Who can approve urgent add-on MRs
• 3rd or 4th year Radiology residents (PGY4 and PGY5) can approve any urgent after-hours
MRI without clearance with the fellow or staff on call.
• 1st and 2nd year Radiology residents (PGY2 and PGY3) and Emergency staff physicians
can approve urgent MRI for cord compression* or pre-operative brain MRI for OTS/fiducial
placement (protocol code: H12C) without fellow or staff approval. Any other type of MR study
must first be approved and protocoled by the staff or fellow on call.
* Cord compression is defined as compromise of any part of the spinal canal due to suspected
disc herniation, trauma, metastatic disease, etc.
MR paging notes:
During weekday evenings and nights when technologists are in-house the preferred contact
method is to call ext. 3300 or 3292 or use Vocera. If these fail, you can try the pager but the
fastest thing would probably be for you to walk over to the MR department.
On weekends the pager is carried by the on call tech and is turned on at 3:30 pm. Between 7:00
am and 3:30 pm the only way to contact the in-house MR tech is by calling into MRI at ext. 3300
or 3292, by using Vocera, or by walking over to MR.
It occasionally happens that pages don’t get through to the person being paged (if, for example,
they’re in a dead zone). If you page the technologist and they do not answer after 10 minutes or
so, try a second page. If, having done this, you are still unable to reach the on call technologist,
refer to the Emergency Response Plan Manual, printed copies of which are kept in every area of
the department (ask one of the techs to get you a copy). The manual contains a list of phone
numbers for all technologists, divided by division. Start at the top of the list of MRI techs and work
your way down – see if any of them can come in.
p) Neuroimaging
Contact Neuro fellow or staff on call for back-up for imaging. Residents are first call for lumbar
punctures and are expected to perform all LPs under supervision.
Note: If there is an acute subarachnoid hemorrhage and no aneurysm is evident to the resident
on CTA, the resident must call the staff neuroradiologist to check the exam.
q) Interventional Neuroradiology
All acute stroke patients where intra-arterial t-PA is going to be considered should get a full CT
stroke protocol first (CT head, CTA neck and head, and CT perfusion) before we will consult on
the appropriateness of IA t-PA.
13

) VIR CT
Resident back-up for CTA of the aorta, CTA of the abdominal vessels and CTA of the extremities
is provided by the vascular/interventional radiologist on call.
Note: VIR does not cover CT pulmonary angiograms nor does it cover chest or body trauma
(even if there is an aortic injury). Chest trauma work is covered by the Chest radiologist on call
and body trauma work is covered by the Body radiologist on call.
Refer to the Vascular CT protocol index when coding studies.
Please note:
• Some vascular CT studies have requirements with respect to IV size, side and location.
• Blunt trauma, e.g. MVC, should not be scanned with CTA or any VIR protocol. Use Chest or
Body trauma protocols – these are the correct protocols to use for blunt trauma. Do not do
CTA simply because referring service asks for it – CTA is not necessarily appropriate in blunt
trauma, especially when looking for bleeding. CTA protocols can be considered for penetrating
trauma when looking for branch vessel pseudoaneurysms or occlusions.
s) VIR procedures
While you are not first call for VIR procedures, we encourage you to make every effort to get
involved in VIR procedures whenever possible.
Most calls for VIR procedures are made directly to the staff or fellow on call. A minority of calls go
to the resident (it all depends on how Locating directs the call). VIR does not routinely notify the
resident when paged directly. Residents are encouraged to participate in this work whenever
possible. If you would like to participate in after-hours procedures, then let the IR on call know in
advance and they will page you. If you get called for a VIR procedure and you would like to
participate in it, discuss the case with the caller, get all relevant information, and page whoever is
first call for VIR. If you get called and feel you will not be able to participate then please ask the
caller to page the VIR on call.
Occasionally, the Emergency Department needs to arrange next working day procedures for
semi-urgent problems. Under these circumstances, please jot down the necessary information
and pass it along to the one of the interventional radiologists in the morning – ideally whomever is
scheduled as “Angio 1”.
VIR (“Angiography/Interventional” on the call schedule) covers all non-neuro angiography and
related intervention plus non-vascular intervention (apart from abscess drainages which are done
by Body Imaging).
t) Nuclear Medicine
A technologist is on call for Nuclear Medicine. If an urgent nuclear study is needed (e.g. V/Q
scan, bleeding scan) page the tech. The on call resident is responsible for reading these exams,
with one exception: brain death scans must be read by a staff radiologist. If you need back-up for
any of the scans that you read or if a brain death scan is needed then try to reach either Dr.
Ehrlich or Dr. Zukotynsky (contact information is in the Radiologist section of PACSportal – use
your Impax log-on to open the document). If you cannot reach either of them then page Dr.
Moody.
14

u) Handling disagreements with referring services
If you feel a requested exam is not indicated or if you disagree with the level of urgency being
attached to it (meaning middle of the night versus next day), rather than entering into a dispute
with the requesting service you must do one of the following:
Either
• Discuss the matter with the on call staff radiologist who may then wish to speak with the
requesting physician directly. We encourage you to do this whenever you feel this to be
necessary, no matter what time it is. If you disagree with a request, call your staff. Don’t forget
that when you are on call at Sunnybrook there are five radiologists on call with you; in addition
to being on call to help with interpretation we are on call to deal with conflicts should they arise.
Or
• Do the study and discuss the matter with the appropriate staff radiologist the next day.
Again – those are the only two options available to you, meaning that you may not refuse to do
an exam without the express approval of your staff. Back and forth discussions/arguments
with staff from Emerg or other services take a lot of energy, do not generate positive results, may
be unprofessional (on one or both sides) and cause impediments to patient flow.
Under no circumstances should you refuse to do an exam without first discussing it with your
staff.
Some residents have said to others “We are not allowed to say no to anything at Sunnybrook”.
This is not the case. All we ask is that you discuss things with your staff before turning a study
down.
v) Requests for second opinions
If a referring service asks for a second opinion on a study please do not get offended, do not get
adversarial and do not tell them to page your staff directly. Page the appropriate back up
radiologist (fellow or staff) yourself, discuss the case with them, then call the referring service
back with the second opinion. If the referring service would prefer to speak with your staff directly,
ask for their contact information, call your staff and give it to them.
w) Problems on call
If you run into problems that you think need to be addressed, please let us know about them so
that we can deal with them in a constructive manner.
15

x) Call feedback and follow up
Your “Needs Review” worklist (see page 6) will list cases that have been flagged by staff as being
particularly important for you to review, but you should make a point of going over the final reports
for all of the exams you review on call. There are two ways you can do this – either one is fine to
use:
Method 1:
This method probably works best if you do it at the end of the night as you’re coming off call.
Make sure the “Resident Call” worklist is open.
Once that’s done, open the worklist library by clicking the “Worklists” button in
the top left side of the text screen above the Search area.
Go to the “Scheduled Worklists” section in the bottom portion of the window
and click on the button that says “Reviewed Cases (Call)” under the date you
started call (meaning if it’s after midnight use the date for the day before). Then
Click “OK”.
In the Resident Call worklist, select all the cases you’ve provided a preliminary report for (you can
see the beginning of your preliminary report in the “Study Comments” column if you scroll over to
the right side of the worklist, and if you hover over the comment, you’ll see the entire thing in a
balloon [see below]). Drag and drop all cases you’ve reported into the “Reviewed Cases (Call)”
worklist.
Method 2:
This method works best if you do it through the night while you are reviewing cases.
When you have a case open, click on the Snapshot button
(camera graphic) at the top left side of the screen.
A library of worklists organized by date will pop up. Under the
date when your call started (meaning if it’s after midnight, use the date for the day before), click
on the “Reviewed Cases (Call)” worklist. This will create a list of all cases you reviewed on call.
After the cases have been dictated, open “Reviewed Cases (Call)” for the date you were on call
and go through the reports. Staff will be happy to review any imaging findings you may have
questions about. Note: Cases where findings were missed will be placed in your “Needs Review”
worklist, as described earlier.
Regardless of the method you use to review your work, please remember that staff are always
happy to provide in-person feedback. If there are any cases you’d like to discuss with staff,
please do not hesitate to do so.
16

4. Preliminary reports on call
Preliminary reports must be written for all (*exceptions listed below) urgent Ultrasound, Nuclear
Medicine, CT and MR exams that are done during the call period as well as for any plain films
you are asked to review during that time. Preliminary reports must available in Impax within
one hour of study completion. If a resident is unable to provide a preliminary report within
an hour of completion then as matters of both professionalism and patient safety they are
required to contact the appropriate back-up fellow or staff for assistance.
The Neuroradiology division has a late shift on weekdays. The staff radiologist who is scheduled
for the late shift works until at least 7:00 pm (often later) and before they leave they make sure
that all inpatient and ER Neuro exams have been reported. This means that when you come on
call at 5:00 you are not required to write preliminary reports for the Neuro cases on the Resident
Call worklist (because they should be reported shortly and will drop off the list). There will be rare
situations where the night shift neuroradiologist is in a procedure and you will have to pick up
cases before 7:00.
The Body division also has a weekday late shift that is covered by the Body fellows. The late shift
schedule is included in the weekly work schedule that is posted on PACSportal. The late shift
fellow works until 10:00 pm. It is mandatory for the late shift fellow to be in-house until 10:00 pm
no matter what’s going on (even if it’s a quiet night). The purpose of the late shift is to support the
on call resident during our peak after-hours period. By “support” we mean two things:
• That the late shift fellow will take some of the reporting burden off the resident only when
things get too busy for the resident to be able to report cases promptly. This does not mean
that the on call resident is not responsible for looking after Body studies during this period. It
means that if the resident is busy with other work, the Body fellow is there to pick up some
cases. If the resident has no other work and there are Body cases on the worklist, the resident
is expected to look after them. The idea is that the Body fellow functions as a safety valve,
taking cases when the resident is not able to get to them within a reasonable time frame. NB
During the late shift both the fellow and resident should review trauma studies at the scanner
console in CT4 with the Trauma Team as the scans are being done – do not wait for them to
hit Impax to review them.
The Body fellow is expected to fill any available time working on outpatient cases, for which
there is always a backlog (which is why the late shift ends at 10:00 pm, even if Emerg is quiet).
• That the late shift fellow will be readily available to the resident to answer questions and teach.
This means staying logged on to Vocera until the shift ends as well as being physically
available.
The “Resident Call” worklist brings up all unreported Emerg and inpatient CT, MR, US and
Nuclear Medicine exams from the last 24 hours. We make every effort to not do “routine” inpatient
studies after hours. All of the services should clear their inpatient and Emerg cases before leaving
for the day – in other words, we try to ensure that the on call resident starts with a clean slate,
although this isn’t always possible. If the worklist includes a case that is clearly not urgent and
doesn’t need a preliminary report (e.g., “follow-up fracture”) then don’t bother reporting it. For US
cases, you must only report those exams that you have supervised yourself. The process for US
is a little different – explained on page 11.
Place a preliminary report in the comment section on the Impax text screen (NB Once text has
been entered it can’t be changed so you may want to type your preliminary report in Word and
paste it into the comment box after you’re happy with it). Important: If there are any urgent or
unexpected yet important findings you should call the referring service directly and tell them what
17

they are (in addition to writing them down in the comment box). Record that you’ve done this by
writing “Dr. X informed at ABCDh.” in the comment box).
What should go in a preliminary report Remember, because these aren’t final reports their
purpose is different; it is not to describe every single finding such as hiatus hernias and
granulomas. The purpose of the preliminary report is to answer the question being asked
and to advise the clinical service of any other findings of immediate importance or that
need follow-up (e.g., incidental renal cell carcinoma on a trauma CT or a lung nodule that needs
follow-up).
Please do not use the voice recognition system to dictate preliminary reports – type them yourself
in point form, just as though you are jotting the preliminary report down on paper – this will be
incentive for you to be succinct, which is what referring physicians want. You can type your
preliminary report directly into the comment box. Many residents prefer to type the report into a
Word document, then copy and paste it into the comment box. Either method is fine.
When you’re ready to enter your report in the text box, the first thing to do is record who the
responsible on call staff radiologist is (weekly staff call schedule is posted on PACSportal). Use
the “Favorite Study Comments” tab in the text box for this purpose. Follow that with your
preliminary report. Please do not put the prelim first and the on call staff radiologist information
last (has led to problems in the past). You can tell which division is responsible for a case by
looking at one of two things – the Impax Specialty or the suffix on the exam descriptor.
Preliminary reports should:
Division
Impax Specialty Suffix
VIR ANG/INTERV -A
Body BODY -B
Chest CHEST -C
Cardiac CARDIAC -H
Musculoskeletal MSK -M
Neuroradiology NEURO -NU
Spine * SPINE -S
Nuclear Medicine NUCMED -N
* shared by Neuro and MSK, see page 12 for details.
• include any useful history that has come to your attention and that has not already been
included in the electronic request.
• not begin with disclaimers like “PRELIMINARY REPORT BY PGY2 RADIOLOGY RESIDENT.
FINAL STAFF REPORT TO FOLLOW.” The reports are clearly preliminary because they have
not been transcribed or signed.
• not offer lengthy discussions of technique used (“… axial volumetric blah blah blah”).
• not contain radiology jargon and acronyms that non-radiologists may not understand.
• be written in point form using telegraphic statements.
• highlight all pertinent positive findings.
• highlight all pertinent negative findings.
• not use meaningless expressions like “tracheobronchial tree patent” (a patient with a tracheal
malignancy that is narrowing the lumen by 99% has a patent tracheobronchial tree – in other
words the term “patent” simply means not obstructed – it doesn’t mean “normal”).
18

• deal with insignificant incidental findings like renal cysts and calcified lymph nodes in a
sensible way – either don’t mention them at all or if you feel you must mention them, put them
in a paragraph at the bottom of your report with INCIDENTAL FINDINGS as a header.
• make every effort to avoid wishy-washy interpretations such as “may be compatible with ABC
but cannot rule out XYZ.” (If you’re that uncertain and the distinction is important, then call the
responsible staff.).
• not rely on crutches like “clinical correlation required” or “as clinically indicated” – things like
this are rarely needed but if you have a valid reason for stating that clinical or biochemical
correlation is needed then be a little more specific – say “Is there a palpable mass in this
location” or “Is the patient’s bilirubin elevated” – in other words direct them to the type of
correlation you think is needed. If you can’t direct them this way, then don’t bother saying
anything.
• end with an OPINION or INTERPRETATION (do not simply write down a list of findings and do
not end with IMPRESSION - ever).
• include a record of any verbal communication of results to the referring service. Do not be
vague (e.g., “Results discussed with Gen Surg”) – say exactly who you spoke with. If all you
say is “Report called to referring service” you may as well say nothing because there is no way
we can use this information to track anything down if something falls through the cracks. If you
speak with someone, be sure to know their name and write it down (if it’s an MD, in addition to
getting their name, get their four digit pager id number). Remember, your name will be on the
report for the whole world to see so if you’ve spoken with someone about it, it’s entirely
appropriate for their name to appear as well. This applies to nurses as well as MDs (“Findings
discussed with Marcus Welby, Gen Surg resident, id no 1234 at 11:15 am” or “Report called to
nurse Margaret Houlihan on C4 at 2:45 pm”.)
19

5. Staff radiologist coverage on call
There are five staff/fellow call groups. Staff (or fellows) take first
call for Body intervention, Interventional Neuroradiology and VIR
procedures. All other work is covered by staff on a second call
basis (as support to the on call resident). Staff (or fellows) come
in on weekends and holidays to report all inpatient and
Emergency studies covered by their call groups.
The radiologists’ weekly call schedule is posted in the Radiologist
section of PACS portal. If you are unable to reach someone
using their preferred method (as indicated on the call schedule),
try a different method. Note: Do not give any staff’s contact
information (pager or phone numbers) to callers unless given
permission to do so by the radiologist in question. If a caller does
not want to go through you to reach someone, refer them to
Locating at extension 4244.
PLEASE do not hesitate to page
the covering staff radiologist at
any time if you need help with
something that will have an
impact on the immediate care a
patient will receive. Don’t feel
reluctant to page the staff –
nobody will think badly of you for
doing so. We would prefer that
you call us instead of trying to go
it alone. For questions around
non-urgent matters, please wait
to review the staff’s report or
discuss the matter with them
electively.
Body Imaging:
• Body CT.
• Ultrasound.
• GI and GU exams.
• Abdominal and pelvic abscess drainages.
• Thoracentesis, paracentesis.
• Thrombin injection of pseudoaneurysms.
Chest:
• Chest plain films and CT. This includes
trauma chest CT (including thoracic aortic
trauma) and all CT pulmonary
angiograms.
Musculoskeletal Imaging:
• MSK plain films, trauma series, CT, MR
and US.
• Joint aspirations.
• Spine imaging (shared with Neuro).
• Spine procedures (shared with Neuro).
Neuroradiology:
• Neuro CT and MRI.
• Spine imaging (shared with MSK).
• Spine procedures (shared with MSK).
• Neuroangiography and intervention.
Vascular/Interventional Radiology:
• Non-neuro angiography.
• Non-neuro intervention (other than
percutaneous abscess drains in the
abdomen or pelvis) for example
cholecystostomies, nephrostomies, biliary
drains, embolizations, IVC filters,
thrombolysis, etc.
• Chest drainages (e.g., empyema).
• Non-neuro CTA apart from PE studies
and thoracic aortic trauma.
On call staff have remote access to the Sunnybrook PACS from home and review the Resident
Call worklist at regular intervals. If they agree with your interpretations, they will write “Agree” in
the comment box. If they disagree on something important, they will contact you about it.
If you need help interpreting a study and the responsible staff radiologist is somewhere without
remote access, they may have to come in to the department to view the exam. Unless there are
extenuating circumstances, residents are not to e-mail images to obtain staff back-up.
20

Sunnybrook’s radiologists
Radiologist-in-Chief: Dr. Alan Moody
Body Imaging
Breast Imaging
Cardiothoracic
Vascular/Interventional
Musculoskeletal Imaging
Neuroradiology
Nuclear Medicine
Dr. Anna-Marie Arenson
Dr. Carrie Betel
Dr. Hournaz Ghandehari
Dr. Phyllis Glanc
Dr. Kalesha Hack
Dr. Paul Hamilton*
Dr. Elaine Martinovic
Dr. Caitlin McGregor
Dr. Laurent Milot
Dr. Dan Mozeg
Dr. Bonnie O’Hayon
Dr. Josée Sarrazin
Dr. Mia Skarpathiotakis
Dr. Hallie Taylor
Dr. Jane Wall
Dr. Carrie Betel
Dr. Belinda Curpen*
Dr. Roberta Jong
Dr. Kalesha Hack
Dr. Bonnie O’Hayon
Dr. Lara Richmond
Dr. Mia Skarpathiotakis
Dr. Barbara Wright
Dr. Gorka Bastarrika
Dr. Pat Dunlop
Dr. Klaus Gast
Dr. Laura Jimenez Juan
Dr. Alan Moody
Dr. Harry Shulman
Dr. Anna Zavodni
Dr. Ganesh Annamalai
Dr. Elizabeth David
Dr. Chris Dey
Dr. Robyn Pugash*
Dr. Monique Christakis*
Dr. Andrea Donovan
Dr. Linda Probyn
Dr. Joel Rubenstein
Dr. Richard Aviv
Dr. Allan Fox
Dr. Peter Howard
Dr. Sean Symons*
Dr. Robert Yeung
Dr. Lisa Ehrlich*
Dr. Katherine Zukotynsky
*Division head
21