.png)
Aussie Med Ed- Australian Medical Education
Venture into the captivating world of medicine with 'Aussie Med Ed,' your definitive Australian medical podcast. Journey through the diverse medical landscape in an easy-going atmosphere, guided by your host, Dr. Gavin Nimon - an Orthopaedic Surgeon deeply committed to medical education in Adelaide. Our podcast serves as an illuminating beacon for medical students, practitioners, and anyone passionate about understanding health and wellness.
At Aussie Med Ed, we delve into an array of medical conditions, unraveling their mysteries, diagnosis, and treatment options. Our approach is unique, as we bring in experts from the extensive medical community, encouraging engaging dialogues that help demystify complex health issues. We're more than a medical podcast - we're a bridge between you and the world of medicine. Whether you're an aspiring doctor, a seasoned practitioner, or a curious mind, Aussie Med Ed is the perfect platform to expand your medical knowledge horizons.
Dr Gavin Nimon and the team at Aussie Med Ed acknowledge the traditional custodians of the land on which the podcast is produced that of the Kaurna , Ngarrindjeri and Peramangk people.
Aussie Med Ed- Australian Medical Education
Radiology At The Centre Of Care, the changing role of the Radiologist
What if the most important decision in your patient’s care starts with the right image? We dive into how modern radiology now sits at the centre of medicine, translating complex presentations into clear pathways with faster CT, higher-resolution MRI, and practical algorithms that reduce uncertainty at the bedside and in the clinic.
Join Dr Gavin Nimon (Orthopaedic Surgeon and host of Aussie Med Ed) as he interviews Interventional Radiologist- Dr Adam Koukourou, as they unpack real-world choices that clinicians make every day. When does a chest X-ray suffice and when should you push to CTPA or VQ? How do you balance CT’s breadth against ultrasound’s strengths for gallbladder, renal, and paediatric cases? For MSK problems, we map where X-ray and ultrasound shine and when MRI becomes essential for internal derangement. In trauma, we show why rapid multi-region CT has become a cornerstone once patients are stable, complementing targeted bedside films. We also get hands-on about better request forms, confirming contraindications, reviewing priors, and cutting duplicate orders with digital viewers that let you compare studies across sites in minutes.
If you care about getting the right test first, improving time-to-diagnosis, and working smarter with your radiology colleagues, you’ll find practical steps you can use today.
Heidi Health- AI transcription Software
Aussie med ed is sponsored by HEIDI HEALTH, who provide Heidi AI transcription platform. The team at Heidi have told me that Heidi is the AI scribe built in Australia and trusted in nearly two million consults each week and that Students and trainees get free access to Heidi Pro, which they believe will aid quicker, smarter notes, allowing more time for patients.:-
Aussie Med Ed is supported by HealthShare.
HealthShare is a digital health company that provides solutions for patients, GPs and specialists across Australia. Two of HealthShare's products are Better Consult, a pre consultation questionnaire that allows GPs to know a patient's agenda before the consult begins, as well as HealthShare's Specialist Referrals Directory, a specialist and allied health directory helping GPs find the right specialist.
Aussie Med Ed is sponsored by Avant Medical Indemnity: They state that they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever changing regulatory environment.
AI transcription with Heidi Pro. Students and trainees get free access-visit www.heidihealth.com/pod
Disclaimer: This post contains affiliate links. If you make a purchase, I may receive a commission at no extra cost to you.
20 years ago, many diagnoses relied on a good story, a careful examination, and a fair bit of clinical intuition. Today, radiology has become the third hand, the extra set of eyes, and sometimes a decisive voice in patient care from lifesaving interventional procedures to high resolution imaging that reveals disease earlier than ever. Radiology now sits at the center of modern medicine. In this episode of Aussie Med Ed, we explore how imaging shapes clinical decisions, how students can better understand the tools available to them and what the future holds for this rapidly evolving specialty.
Dr Gavin Nimon:Good day and welcome to Aussie Med Ed. The Aussie style Medical podcast a pragmatic and relaxed medical podcast designed for medical students and general practitioners where we explore relevant and practical medical topics with expert specialists. Hosted by myself, Gavin Nimon, an orthopaedic surgeon, this podcast provides insightful discussions to enhance your clinical knowledge without unnecessary jargon. I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced. I'd like to pay my respects to the elders, both past, present, and emerging, and recognizing their ongoing connection to land, waters, and culture. I'd like to remind you that all the information presented today is just one opinion, and there are numerous ways of treating all medical conditions. It's just general advice and may vary depending upon the region in which you're practicing or being treated. The information may not be appropriate for your situation or health condition. And you should always seek the advice from your health professionals in the area in which you live. It's my pleasure now to introduce Dr. Adam Koukourou. He's an interventional radiologist who holds position of head of interventional radiology at the Flinders Medical Center, and he is also a partner of Radiology SA he serves as head of radiology at the Flinders Private Hospital Board member and chair of the clinical governance committee. Thanks Adam for coming on board. Aussie Med Ed.
Dr Adam Koukourou:Thanks Gavin. Thanks for having me. It's been a long time coming to get this podcast up and running tonight. So, as finally we managed to get the calendars lined up and get it happening.
Dr Gavin Nimon:Well, it is brilliant to have you on board. Well, I thought we'd start off, over the past 20 years? How has imaging changed and how we diagnose, triage and manage patients across the hospital in primary care settings?
Dr Adam Koukourou:Yeah, thanks. It's interesting you've used that 20 year timeframe because that's probably the timeframe I've been doing radiology as certainly as a consultant having graduated in 2006.
Dr Gavin Nimon:I.
Dr Adam Koukourou:Imaging has grown significantly in that time. In the early days of my training, there was obviously the plain x-ray was probably the most used modality and absolutely that's still used today and it serves a vital tool in some of the basic things, fractures chests for looking at pneumonia or chest pathology. Abdominal x-rays for bowel obstruction, for example. So the plain X-rays are still widely used. CT was very limited. It was the old single slice ct, which it took five minutes to get a diagnostic CT head. That information is now captured in five seconds, essentially. It's very, very quick and we've had significant improvement in other modalities, the quality of MRI has just gone from strength to strength to strength. The imaging that we can produce now in MRI has grown so much in those 20 year period. Other modalities has certainly come online as well. So there's the, the, the PET scan, positron emission tomography. That's more the role of the nuclear medicine team. But that's certainly, come on, looking at metabolic activity of parts of the body and very good in the role for tumor staging. How does radiology help the modern. Practitioner, well, it's probably a, I'm gonna be very biased here, but it's probably the forefront of patient care. It's kind of the center hub and everyone loops around that works complimentary with the clinical team, our clinical colleagues. One of my old lecturers back in the late nineties, it said history and examination was 95% of the diagnosis. but yeah, imaging is a complimentary to that and certainly it helps diagnose those weird and wonderful things that you can't necessarily work out or capture c linically, things aren't quite right. What imaging can we do? So the modern radiologist can certainly help in the spaces where. The diagnosis may not be quite clear.
Dr Gavin Nimon:what do you consider the main limitations or pitfalls for imaging for clinicians?
Dr Adam Koukourou:The main limitations and pitfalls? Well, some of it, depending on where you are working, there may be a little bit of a timeframe to get some imaging done. So that would be a limitation. Patients might have to wait. It's like anything you go. Ring your local tradesmen or electrician to come and do some stuff, you may have to wait. And that is a bit of a limitation'cause we know with healthcare that we don't want to wait too long at all. So getting access to some of the imaging, particularly MRI, for example, can be a little bit of a wait and some interventional procedures if they are not life threatening, they can also be a bit of a. Wait, because of the supply demand resource issues. So that would be one of the limitations, for sure. Pitfalls that may potentially fall on ordering the wrong test. A patient has a, you think this is what I'm gonna order if the patient, the patient has a test, but it's the incorrect one. So that's where conversation to avoid those pitfalls. With your local radiologist to then determine the best pathway, avoid some of those pitfalls for sure.
Dr Gavin Nimon:And would there be, do you think there could also possibly be the scenario of like false negatives so you get reassurance that something's okay and it's not quite right and false positives where the opposite occurs as well?
Dr Adam Koukourou:Yeah, absolutely. So sometimes we look at something and go, that's, that's abnormal. Maybe over call it. That's often where the clinical scenario needs to go in. Yeah, this isn't quite right. Dunno what it is. Maybe it's this and that cause a lot of anxiety, stress for everyone involved.
Dr Gavin Nimon:Obviously Radiology's changed a lot over the years. Where do you think things are heading for the future? And what about the role of artificial intelligence
Dr Adam Koukourou:Yeah, so we're already seeing artificial intelligence come into radiology, and it's an adjunct. It helps. So we know, certainly in the public sector where I work at Flinders, we have a chest X-ray AI program called Analise, which helps identify pathology. That's complimentary to your own skills. There's one coming for CT Head, so it's just a little popup that just highlights potential abnormalities to make sure that you can capture those in your review areas. It's moving fast. We have AI software to pick up lung nodules as well. And these are tiny one two millimeter nodules, so that is useful as well. But like most of these things, you can't rely on it completely. It, it's a help. The ultimate onus lies with us as the radiologist, not on the ai. So it's still, it's complimentary, but not, not the, the solution to doing the work for us. And of course, how do, the referrers and the clinicians. talk to an ai program to get the answer when they wanna discuss their patient's findings. I don't think that's quite worked yet.
Dr Gavin Nimon:Yeah. there's no concern amongst the trainees that the AI might take their jobs for the future,
Dr Adam Koukourou:no. Look, I don't think so. No, I don't think so. So I've seen the role of the radiologist evolve over many years. The old adage sit in the dark room, turn the lights on with the films and don't come and talk to us. Versus out of that space and into the realms of the MDTs being part of patient care, which I being bias mentioned earlier, at the center of it, we are involved with helping determine treatment pathways and advising what next follow up might be. I'm not sure AI can necessarily replace that. And there's a human side of things as well, isn't there? I think as a patient you wanna be able to see a face, so I, I don't think necessarily that that's going to be a problem at this point in time. Of course, AI can't do any of the interventional procedures that that I do. There is robotics. Machines around, but I haven't really seen them take off and do things without a human involved, so I'm not too concerned about that. I think they've been talking about AI replacing radiology for many years, but still get to see that, that,
Dr Gavin Nimon:one of the things I have seen replaced over the years is the old films. So now it's all online and we can actually access them easily. In fact, the hardest part for me is actually finding out where the person actually went. So I can actually look at the correct Intelli viewer site. So I've found that a real, real help. In assessing patients both finding out what investigations they've had done and also seeing how they've changed over that time as well. What are your thoughts on the online viewing of radiology
Dr Adam Koukourou:Oh, it's fabulous. It's absolutely fabulous. It's been. Game changing for everyone involved. It makes things a lot more efficient for us to be able to capture that data electronically. You're not storing a whole lot of films. You can review things quite quickly and succinctly. It's very easy to have a conversation with the referrer about images because they can just Ring you up and say, can you have a look at this for me? And as you said, you need to potentially look at multiple different platforms to try and find where these images might be. But you can do it very quickly and succinctly and get the answer that the patient needs when it's compared to previous or have the conversation with the clinical team regarding. Can you just have a look at a few of these other studies? You don't have to wait for the films to be couriered from somewhere else or the patient to bring their films, which invariably might get lost over the, over the journey. So look, it's, it's been fabulous. It's been really good in, in improving patient care, getting accurate diagnoses and producing reports which are more succinct because rather than saying. Please look at the old films in our report.'cause we don't have access to the hard copy of the films. We can easily find where they might be and then compare 'em and give the answer that's needed. There's been no change in this spot. Case closed. So it's, it's been fabulous. It.
Dr Gavin Nimon:Yeah, on that basis. Adam, a couple of thoughts that come to mind about the Intel viewer type imaging. First of all, often I use the, the online measuring, to measure size of, fractures or displacement. How accurate are they? First up? Yeah.
Dr Adam Koukourou:They're much more accurate than what the old crayon text, ruler drawing.'cause there's that error that you get with the x-ray and the patient and and divergence So far more accurate now Absolutely. Is fabulous. We can use some of the software to measure volumes of structures, so the respiratory physicians are quite. Keen in looking at lung nodule volume and seeing how a nodule might change in terms of volume over time. That makes it simple. that would be dead near impossible with the old films, Gavin. So, yeah, that, that is really accurate for sure.
Dr Gavin Nimon:The other thing that comes to mind too is sustainability too. I'm quite into that. And the whole idea of all these films, that would've been a bit of a, impost on recycling
Dr Adam Koukourou:there are companies that have, that do recycle some of the materials within the, within the films, but. The less films produced must be good. I think they must be seen as a positive. Yeah.
Dr Gavin Nimon:Yeah. Excellent. Okay. What about the whole idea of over ordering too? I mean, obviously with such availability of investigations, it must be tricky not to over investigate
Dr Adam Koukourou:Yeah. Look, I, I, I think so. I mean, it's very simple to obviously write a form and let's get this test, let's get that test, but. I suppose it depends on what the clinical scenario with patient, how anxious the patient might be. Are we happy with the answer we're getting? And probably the best way to get around that is to say, right, what is the exact problem that we want? What is going to be the best study? To get me that answer? We'll go to that first, and that would be a conversation with your radiologist. That can help guide you in the right direction because if you had said, I've got a patient in front of me, I just want one test to give me the answer on this problem, what would you say? So for example, if someone had clear achilles tendon inflammation, you go, should I do an MRI? You go, well. You could, but that might be a little bit of overkill. Why don't you just do an ultrasound that may give you all the information that you need and then you don't waste resources, time patient's money on an unnecessary test. So I think it's about having a clear understanding of exactly what the clinical scenario is. I think we'll find that. With some of the, obviously a lot of the musculoskeletal studies MRI is very, very useful, but there are some restrictions with access to that of course, but I think we'll find in a few years with the government releasing some of those restrictions that will become more accessible. And so you might find that less double handling of images or patient. Conditions will occur with that. So that would be very useful.
Dr Gavin Nimon:Yeah, I mean, I would've thought too, the ability to actually review the Intel viewer sites and look at other imaging done at other areas would, it will help reduce the chance of double ordering as well, so.
Dr Adam Koukourou:absolutely. So sometimes a patient, their GP may be right onto it get the diagnosis. But a patient may Present a hospital for another complaint, and they may then get a repeat test, which the gps already done. So yeah, Access to software where possible means that you don't reorder a test.
Dr Gavin Nimon:What about a junior doctor who starts out and they're not sure where they should order an investigation. What are your thoughts what would you say to the interns when you, when they're unsure, what are their process they should go through?
Dr Adam Koukourou:yeah, absolutely. So always review the patient's history, go through their notes where possible, work out what investigations they've had already. They may have had already had a test for the same presentation or the same clinical. Complaint. If that's not helping or not getting the answer that they want, then come and have a chat to us down in radiology and try and work out what's gonna be the best pathway rather than just filling out a form, putting it in, and then coming back the next day. That's gonna be the best way that we can limit resource wastage. And particularly for the interns, it's all about learning. It's all about getting education. It's all about how can we make sure that we're doing the right things, and that's an excellent way to learn about what's going to be helpful for your patient in those situations. It's interesting. So sometimes we get these request forms for, oh, can I have the CT scan? I'm worried about. Some arterial pathology in the abdomen You get the patient down, you've got any allergies? Oh yeah, I'm allergic to intravenous contrast. It's like, ah. So that information, if you'd grabbed that information prior to ordering that test, then you wouldn't have wasted the resources of actually getting 'em down to the department. So how do you work out to get to the answer? So just, yeah, do a bit of research before you put the order in.
Dr Gavin Nimon:Yeah. Adam, what makes a good imaging request form then
Dr Adam Koukourou:yes. what makes a good request form is having the contact details on the form. That makes a good request more because quite often we are finding a lot of pathology that needs urgent attention, and we can never find the referrer. It's a squiggle, it's not a name. It's not clear. There's no, there's no contact details on the form, so I, I think that makes a really good request form. In terms of the diagnosis, I think the information needs to be succinct. What the presentation is, a couple of brief differentials and what you're hoping to find, therefore with the imaging, and that would make a really good request for, and of course with those contact details, if you're not sure, say, can you please call me to discuss? Or something like that. So those sort of things will help. Obviously it needs to be signed and dated correctly and whatnot and need to be able to read the writing.
Dr Gavin Nimon:Yeah, exactly. So, obviously I can't speak 'cause my handwriting's terrible, so I always try and type them up. But, a thought of mine. I like to make myself accessible to my referring doctors and patients. And obviously sometimes people are scared to ring some of the specialists and ask information information You've implied that that's not the case at all in radiology.
Dr Adam Koukourou:Well, I, I can only speak for myself and some of my colleagues that I work closely with. And absolutely, we're always happy to take a phone call. I, I think. People are more appreciative when you do have a conversation and you make yourself accessible. I, I get it. I'm learning all the time as well, and I understand how challenging it can be with a patient across the decks saying, doc, I'm not well. What's wrong with me? I am more than happy to have a conversation. I've got a number of people that I get messages from all the time. It's, it's actually quite rewarding. It gets a bit busy sometimes, like, okay, whose message do I need to get back to? It is actually quite rewarding though. You can help and part of the patient's journey, you can help your colleagues as well.'cause at the end of the day, we're all here, here to help our patients and help each other. I don't think we're working against each other, so how can we best do that? Sometimes it can be a bit challenging getting through phone lines like a call center. Sometimes, you know, you're on hold and, and whatnot. But I, I think if you have a good relationship with your radiologist, just ask 'em if you don't mind getting their, their personal details, even email address and send an email and we'll get back to you. And I think that's probably the best way to help do that. I work mainly down at Flinders and I, and I think that the specialists that I work with there and the gps and local, they're all fabulous. They're really, really good and always happy to have a conversation either ringing me or I have a phone call with them, and I get a lot out of that too.
Dr Gavin Nimon:What about trying to learn more about radiology for the young students and gps? To want to understand how to interpret the x-rays better. Obviously they can, look at the films themselves and read your reports, but is there any other resources apart from speaking to yourselves and asking advice, is there anything they could actually look at to actually try and help them understand things better? That.
Dr Adam Koukourou:absolutely. There's lots of websites that do capture how to look at an X-ray, A lot of that information wasn't online when I did my training. So it was all old school, go to library, finds a book and read through the books. So that's all different now, but it's very simple to get that information And there's some great Australian websites as well that can help do that for you. But I'm always happy to take a phone call and give some advice. If someone wants to come and see me, that's, that's not a problem at all. I can help point someone in the right direction.
Dr Gavin Nimon:Brilliant. Well, if we start with the basics for the medical students So if we go through a few different areas, We start with the respiratory chest x-ray versus CT chest.
Dr Adam Koukourou:Chest x-ray. Absolutely. It's quick, simple. Easy to obtain. There's a chest x-ray in every street corner. Essentially it's, it's the forefront of diagnosis. You know, if someone's got shortness of breath, I don't think you'd go first and get a CT scan. It's a little bit more, I suppose, in invasive there's slightly more radiation than normal chest x-ray, normal chest x-ray, one or two days of background radiation that we all get walking around CT scans a little bit more than that. Having said that, some of the lower dose CTs that we're now producing with the advances in technology in the last few years, that does reduce the radiation dose, but shortness of breath, chest x-ray, if it shows a pneumothorax, you've got your diagnosis. There's no need to perform a CT chest. The chest x-ray is normal. It's normal. And that's when you might go, okay, what other imaging modalities do we have in the Chest imaging space to review pathology, and probably yes, correct that CT chest would be the next line investigation, but I'd certainly encourage a chest x-ray to be done first. Not only can it give you an early diagnosis, for example, of a pneumothorax, even pneumonia, it gives you a baseline to then be able to follow the disease progression during treatment. So pneumothorax, for example, if it's volume of say, 40%. Manage it conservatively, chest x-ray the next day, the volume's reducing so that it gives you a nice baseline. So it al always recommend a chest x-ray for sure. So, absolutely. It's still gold standard in my opinion.
Dr Gavin Nimon:When, they're in hospital and you're worried about pulmonary embolus, what's the role of a CT pulmonary angiography versus the old VQ scans? And is there still a role for a VQ scan
Dr Adam Koukourou:yeah, look, look there is, I'm not a Nuclear Medicine physician, but people go for the CTPA 'cause it's a quicker test. CT scanning is available 24/7. Nowadays, nuclear medicine may require after hours, at least an on-call process. Nuclear medicine, from my understanding. If there is some abnormalities on a chest X-ray pleural effusion or pneumonia, then it may make the diagnosis on a VQ scan a little bit challenging. And so the CT PA will give us the ability to look at the pulmonary arteries. It'll also show any other pathology. Often patients who are in in hospital do have comorbidities, which you won't necessarily pick up on a. VQ scan in isolation, and so a negative CTPA so with no pulmonary embolus, a CT will give you a look at other pathology the aorta, for example, the cardiac structures, for example, even the upper abdominal structure. So just gives you a little bit more information. The VQ scan, yes, I think there's still a role for the V/Q scan clinician's still worried about pulmonary embolus. If the CT is normal, it's chest x-ray is normal. VQ scan does have a role to play, for sure.
Dr Gavin Nimon:When we, look at cardiology, obviously everyone will talk about an ECG as the first line test, but when it comes to radiology and imaging where's the role of, say, plain x-rays? Looking at the size of the heart versus an echocardiogram, versus other things like cardiac MRIs or CT coronary angiography.
Dr Adam Koukourou:Yeah. Look, chest x-ray, as I said before, that's gold standard. Let's do one of those low radiation, easier to get to. Looks at the cardiac size and lung fields, and if that's all okay, then you probably tick the box if there's an abnormality on that. So a big heart. Then the cardiologist may suggest an echocardiogram to look at. Cardiac function, cardiac output flow through the valves, look at the overall size of the ventricles, what their contractility is, the next line of investigation. if it's a coronary artery problem, so you are looking at stenosis calcification, then it'd be a ct. Coronary angiogram in the right patient cohort, and that will be determined by the cardiologists, of course. Otherwise, looking at functional studies of the heart, the MRI is very, very good, but it does take a little bit of hot time. It takes up to an hour to do all the phases in the images of the. Heart looking at the ventricles and the atrium contractility and flow through the valves. Whereas an echocardiogram is very simple. It's an ultrasound underneath the sternum or underneath the chest. There's no radiation involved. And for patients that are claustrophobic or they have a pacemaker, some of the newer pacemakers. Are all MRI compatible or they have the patient have some contraindication, MRI. So echocardiogram is a very simple test to. Do as a first line to look at cardiac function.
Dr Gavin Nimon:Right. What about general surgery I used to learn about doing lateral decubitus x-rays and looking for gas bubbles. I presume those things aren't quite as commonly used nowadays and there's more appropriate investigation.
Dr Adam Koukourou:yeah. Look, not as common. They're still done. Absolutely. Particularly when you are looking at following the degree of bowel dilatation, the setting of a bowel obstruction, for example. But you're right, I think a clinical assessment that suggests there is some intraabdominal pathology and a CT scan would probably be the pathway to go down because the abdominal CT is going to show us a lot of pathology. It's going to look at all the abdominal organs. So someone who has right iliac fossa pain, for example, right sided abdominal pain. So you may be saying query appendicitis, looking for gallstones, inflammation of the pancreas and liver pathology, even bowel obstructions, looking for the level obstructions. The CT just gives you a little bit more information. Of course, the radiation dose is a lot more. Then what you would for an x-ray. So, CT abdomen, pelvis, probably two, two and a half years of background radiation. A normal abdominal x-ray won't necessarily exclude intrabdominal pathology, so a CT is probably certainly the general surgical space becoming more and more used And people don't seem to think twice about ordering a CT abdomen pelvis. It just does give us so much information. Also looks at the vascular structures and quite commonly we do find some incidental findings that, oh, that's the answer we've never found that on an abdominal x-ray bowel ischemia, mesenteric thrombosis, for example. So it gives us a lot of information.
Dr Gavin Nimon:How does that compare to an ultrasound in that scenario? Is that being less used
Dr Adam Koukourou:Complementary. So I talked about before appendicitis or gallstone. So in young kids, absolutely we want to try and avoid radiation where possible. And ultrasound would be the f irst pathway we would go to, but we don't always see the appendix on ultrasound because of the bowel gas gets in the way. Depending on where the appendix is sitting, if it's behind the caecum, for example, you won't see it. So a negative or an ultrasound that doesn't show the appendix can't rule out appendicitis, but it still has a role. And I'll definitely suggest that, particularly in the young patients gallstones I talked about earlier, won't necessarily see. All gallstones on ct. Some of them aren't radio opaque, so they won't show up on the ct, so an ultrasound is required for that. That also gives us a better review of the gall bladder wall, which you won't necessarily appreciate on ct. So it's a complimentary study. We know that liver lesions are quite common. Be that incidental or. Liver lesions that we are following, and so ultrasound can help to determine whether something might be solid or cystic. For example, a simple cyst. I think if you're purely looking for renal pathology, renal function decreasing, you probably wouldn't go for a ct. First up, you'd go for an ultrasound in that instance, because we know that some of the contrast dye that we use, we call it contrast dye, it's a, a intravenous medium that is used to highlight intrabdominal structures. We know that can have an effect on renal function and is contraindicated in patients have poor renal function and so we're definitely do an ultrasound, look for any structural abnormalities, obstruction, for example, renal stones perhaps. So it's complimentary to that. Having talked about renal stones, that then goes back to if someone's got a good history of renal colic, right sided flank pain, haematuria, then the modality of choice for investigation would be a ct because that will show us the stones nicely. And in those instances, we don't often give the intravenous contrast eye. So if the renal function was a bit off, then that wouldn't cause a problem.
Dr Gavin Nimon:Brilliant. Well, when it comes to my area of musculoskeletal medicine, I like to Think of things like plain x-rays and ultrasounds and axial imaging and CT and MRI what are your thoughts on muo skeletal imaging? Yeah.
Dr Adam Koukourou:Look, I think it goes back to what I said at the start, history and examination. I suspect Gavin someone like yourself, you know, patient comes in with shoulder pain or whatnot, and you can probably get a pretty good idea of what the pathology is and absolutely, you don't want to be caught by anything. So. Plan Xray, ultrasound's a fabulous start. Low radiation. Simple tests relatively easy to get and it will probably give us all the information. We know that ultrasound, is fabulous at looking at moving parts, moving tendons, ligaments, looking for joint fluid. It's fabulous in that. Probably gives enough information to go down your treatment pathway. We use ultrasound as well for. Therapeutic interventions. It's how we do a lot of our injections for bursal inflammation, for example. So that's Certainly the first line. The only challenges are that the intraarticular pathology, we won't necessarily appreciate accurately with plain x-ray or ultrasound. So plain x-ray will show us all the bony structures. It won't show the intrinsic. Cartilage and ligaments. Ultrasound shows the extrinsic soft tissue structures, tendons, bursa, but won't also show us internally. So then we need to look at what other modalities may be available to us now. Years ago, we used to go for CT Arthrography. To look at internal structures, just show us the outline of what the ligaments might look like or outlines of what the labrum, for example, in the hip shoulder might look like. And that was quite good, but it's semi invasive. It's a needle into a joint space, which does run the risk of causing further intraarticular problems inflammation or infection, for example. So with MRI. Improving its ability to image these body parts. As I said earlier, then we've moved more from, rather than doing ct, CT, arthrography moved more to MRI to look at the intrinsic structures. Knees, probably one of the more common musculoskeletal referred body part that we get, and the MRI is the gold standard for looking at what I'll call internal derangement. Cartilage defects, meniscal injuries, cruciate injuries, and that's probably the pathway you'd go. You'd also, if someone had a history of significant trauma, then you would probably still, you would do an x-ray first, just to make sure that there wasn't a fracture, for example. In those settings where there is a fracture, CT is fabulous for that really shows the extent of the fracture, the articular surfaces. So in that space, that's where CT is. But if you're looking at intraarticular pathology, MRI's definitely the way to go.
Dr Gavin Nimon:What about the role of MR mri Arthogram? Hmm.
Dr Adam Koukourou:So once again, we, when MRI, quality wasn't as great, now I'm probably going back eight to 10 years. We used to do MR Arthrography for the hip and shoulder quite a lot, even the wrist. It shows some fabulous pictures, but I think with the stronger magnets that are being produced now that we really get a good understanding of what's going inside joint spaces without performing the arthrography. So I think the indication for that is probably a little bit less. You may consider that if the MRI without Arthrography was inconclusive and you are still. Clinically worried about intraarticular pathology like in the shoulder for a small labral tear. That's when you'd probably do arthrography. But I think that would probably be a discussion with the radiologist regarding, these are my clinical concerns I have with this patient. Let's have a look at the imaging. Can we go through that? Is this something you can see? Do we, they need to go onto an arthrogram to further review that.
Dr Gavin Nimon:Right. the scenario of emergency medicine, the old trauma scenario, the old trauma x-ray, the chest, x-ray pelvis, and cervical spine. I see that more and more being replaced by a rapid CT scan. Is that the scenario?
Dr Adam Koukourou:it is. Absolutely. Look, we still do, you know, a quick survey because most of the trauma rooms have an x-ray. In, built in the resuscitation room, so a quick survey with a lateral C spine, chest x-ray, and pelvic x-ray still does occur because it may help guide a pathway if someone, for example, is. Hemodynamically unstable. They have a significant pelvic fracture, then you can stabilize that. Or if they've had a chest x-ray, they've got a hemothorax, then you'll deal with that in the Resus, help stabilize the patient and absolutely the lateral cervical spine in cases significant distraction injury. So all those acute problems can be managed at the bedside, if so to speak, in the resus room. Before the patient then goes to have a ct, and of course we only do multi-trauma cts in a stable patient because you don't wanna have an unstable patient in your CT scan. It becomes a bit of a challenge for everyone. So they're complimentary, like most of things complimentary, but not necessarily being replaced. But we are seeing more what you call multi-trauma cts head chest. the pelvis and neck, it gives us a lot of information in a short period of time. Going back to what I mentioned 20 years ago, one slice cts, five minutes for a CT head. There's no way we could have done multi-region cts. In a short period of time, it would take two, two hours and for the image reconstruction, now things a lot faster. We can get all that information and find out exactly what the pathology is to help then guide the patient management. So it's a, it's yeah, crucial. The multi-trauma cts, now, it's a bane of our existence 'cause the number of images is significant. But it certainly helps for sure.
Dr Gavin Nimon:Excellent. And I'm a young medical student coming through and watching Aussie Med Ed inspired by yourself. Speaking today on, on the YouTube. what's the pathway of becoming a radiologist in, in Australia? How does it actually work from medical school?
Dr Adam Koukourou:Yeah. So the training is a five year program, which is a general radiology program capturing all parts of the body, all modalities, all away from kids It, it captures everything. So it's a five year program for those. Wanting to do a fellowship or subspecialty, so example, interventional radiology. So it might be an extra couple of years on top of that. So you could be looking it up to seven years training in radiology to get to where you need to get to.
Dr Gavin Nimon:And exams along the way.
Dr Adam Koukourou:Yeah, look, there are long time since I did them. Of course it's all changed nowadays, but I think there's a anatomy physics. Pathology radio diagnosis. There may be some that might be a combination of oral and written exams as well, but I'm not close to the. Training program or the exam pathway seems to keep changing and changing for, for, for the good. Of course, there's reasons why all education changes as the journey, but yes, absolutely there's certain exams along, the way
Dr Gavin Nimon:What would be the most rewarding part of being a radiologist, do you think?
Dr Adam Koukourou:For mine, it's just seeing the patient smile at the end of the bed when for me, for the interventional side of things, when they've had a great outcome and they come back and see you in two years time and say, look, I had a fabulous outcome and I'm just here to have another injection, for example. So you get a lot out of that. I think that's really rewarding. When you get a diagnosis that's crucial to the patient's pathway from the diagnostic space you don't necessarily get that feedback unless you are speaking with your clinical colleagues or they might let you know. I had a patient the other night, I was doing a, some reporting on Friday night and had some significant pathology and I luckily managed to Onto the GP after hours, which I was thrilled with, and a patient had, yeah, almost life-threatening pathology or if it wasn't treated, would've become life-threatening. And to be able to pass that information on, look at the images, know that that patient was going to get the correct care at a short period of time was, yeah. I find that fabulous as well.
Dr Gavin Nimon:It's interesting, you're saying very similar things that I say about orthopedics as well, and it sounds like the evolving role of the radiologist is becoming more as part of the whole team as opposed to being separate on the sidelines
Dr Adam Koukourou:Yeah. Look it, it is. That's right. And so we, we keep getting told all the time, and rightly, if you find a significant abnormality. Then you need to phone it through. And even incidental findings that may or may not be significant, you need to phone it through. And so we are always, and more and more moving to that space of becoming primarily involved in the patient's care.'cause we just don't want anything to slip through the system. We don't want anything to slip through the cracks. The MDTs have evolved for sure that. It's a multidisciplinary team, and if I look at my role at Flinders, a HCC, hepatocellular carcinoma liver transplant unit. And that's obviously what we've got. The hepatologist, the surgeons, the radiation oncologist, the oncologist, and that's just grown over the number of years. And so we're kind of sitting there in the, in the middle going, right, this is what the imaging is showing. This is what the potential treatment pathways might be. What do we all think about about this? So you're almost like the the chair, but you're not of the meeting because if you don't give the right information, the imaging, the patient's not gonna need the right treatment. So it's a really important role.
Dr Gavin Nimon:it must be very rewarding
Dr Adam Koukourou:Oh look, it is absolutely, it. It gets a bit busy sometimes, but yeah, everyone else speak to, just finds how rewarding those MDTs are and how how reliant they are on RA are in radiology. I think over time patient care has significantly improved so that multiple people are giving an opinion and guiding what the pathway of treatment is so the patient gets the right treatment. I think that's really important.
Dr Gavin Nimon:Excellent. That's brilliant. Well, it's interesting hearing how Radiology's changed. Where do you think things will head for the radiologists in the future? any extra things that are on the pipeline in radiology in technology.
Dr Adam Koukourou:Well, interventional spaces always new little tools and tricks and. Doing newer procedures that might come around. So I think that will continue to grow the minimally invasive treatment pathways. We've certainly seen the growth of interventional neuroradiology. In the last, 15 years. And that's been a, a massive uptick in terms of what can be done neurovascularly by a pinhole essentially. That's been really good. And there probably some more growth in that space. I do a lot of body intervention at work, so kidneys and liver stuff and yeah, we're seeing new treatment pathways. As well. So I think that's where there'll be some growth. And as we talked about earlier, probably AI making things a little bit easier for the diagnostic realm. Technology is always going to get a little bit faster, a little bit quicker, and the resolution of images are going to be better. So we're going to see the ability to see more parts of the body at a closer level. To make it easier to get a diagnosis so I think that's where it's going to to go.
Dr Gavin Nimon:Yeah, I saw a wrist MRI the other day and I was just in awe how good the quality was
Dr Adam Koukourou:yeah, you certainly do notice good quality versus a. Suboptimal quality, you notice a difference for sure. It makes it very easy for the clinicians to go, well, you know what? I can actually see exactly what that looks like. And you can picture that in your head. If you're doing the operation, you go, well, this is exactly what it's look like. And you can cross reference, which is certainly what I do with interventional space. I can look at the imaging and go, righto. I know exactly where that's gonna be. I know exactly what that's gonna look like, and you get that 3D dimensional thing ahead from the images from that. So I think that's really helpful. For sure.
Dr Gavin Nimon:Yeah. Now showing my age here. I remember this new thing that had just been invented called MRI. And we're talking about how it might influence medicine. is there anything like that coming out? Obviously AI is probably the equivalent in that sense, but anything more in investigational that, apart from AI that might be on the horizon?
Dr Adam Koukourou:Yeah, look, I think some molecular imaging getting down to the, the molecular level is probably gonna be where things are. Further growth in pet scanning, looking at functionality of, of lesions for tumors, for example, the biology of the tumors. I reckon that's probably where it will, will go. And we know that some of the newer immunotherapies treatment pathways are being used in conjunction with imaging to then. Help guide treatment. So it's gonna be a combination of treatment with current imaging and the molecular stuff I think is probably where it's going to be the, the new bastion, I would've thought, in terms of new technology.
Dr Gavin Nimon:Well, Adam, it's been fantastic. Having you on tonight on Aussie Med Ed, and thank you very much for giving up your time. So thank you very much for coming on Aussie Med Ed.
Dr Adam Koukourou:Thanks for having me, Gavin. It's been a fabulous evening, fabulous discussion. I hope your listeners get something out of it tonight and I'm happy to help out No problems at all.
Dr Gavin Nimon:No worries. thanks very much. Thank you.
Dr Adam Koukourou:Gavin.
Dr Gavin Nimon:Thanks again for listening to the podcast and please subscribe to the podcast for the next episode. Until then, please stay safe.
