AI for Aortic Injury: Emergent vs Elective Care

[Dr. Sabeen Dhand]
Let's talk about an aortic emergency, whether it's a rupture or a dissection. When the diagnosis is made, usually I'm guessing by the radiologist reading the scan in the ER, what's the next step in the workflow at UW before any kind of platform or anything? What would happen? Would they call the ER, would they call you?

[Dr. Ben Starnes]
The current workflow is pretty cumbersome and outdated, in my opinion. Normally, we'll get a call from a physician in an emergency room somewhere in the state where he says, "I have a 74 year old patient who presented with abdominal pain. We got a CT scan, and we found an eight centimeter ruptured AAA." and then basically, they will call the Transfer Center, which is kind of a centralized service, who gets in touch with the vascular surgeon on call. We will then have to find our way to a computer somewhere, typically a desktop but not on your iPhone, to look at the images.

We then look at the images once we've gotten on the computer, and we accept the patient and transfer. Sometimes we'll give the referring provider some tips on how to manage the patient, whether it's blood pressure regimens, that sort of thing, and then the patient starts on their way, either by ambulance or by rotary aircraft, and then we'll prepare for the patient to arrive. We'll have the images to look at and prepare for the case by grabbing the appropriate graphs, that sort of thing.

[Dr. Sabeen Dhand]
Are these transfers within just the four hospitals that you're working on, or are all the community practices around Seattle or in that area? How big is your catch zone?

[Dr. Ben Starnes]
It's interesting because we work in a very unique place. We're the only level one trauma center for five American states, Washington, Alaska, Wyoming, Montana, Idaho. That's 27% of the landmass of the United States, but only 15 million people, so we get calls from Montana, we'll get calls from Anchorage, Alaska, where they have very few vascular surgeons available. I think they only have one or two in Anchorage. We'll get calls from all over the state, all over the five-state region. When it's within our own system it's pretty streamlined. All of the aortic emergencies will come through Harborview mostly. We'll take those patients directly to the operating room and fix their problems.

[Dr. Sabeen Dhand]
One thing you mentioned, seeing the images. From my radiologist's standpoint, are all the images on the same PACS system? How do you have access to all that five states' wide? That's hard.

[Dr. Ben Starnes]
That becomes an issue as well. It's taken about 10 years for us. Every time someone calls, if they're not part of our network, they are by the end of the evening, because the transfer center will be obligated to get them to sign in to our PACS system and have our PACS systems be able to communicate seamlessly. Sometimes it boils down to the fact that we can't get the images across and I'll have that provider, whether it's an ER physician or another surgeon, take snapshots of the CT scan with their iPhone and just text them to me. I know that's old school. It's not HIPAA compliant at all.

[Dr. Sabeen Dhand]
It’s cumbersome. That happens. It's very hard. I know from a technical standpoint from PACS that it's not that easy, or it takes some time to get those images to you. It's a very important fact there about images because we'll round back to that. What about contacting? We're going analog, we're calling you on a cell phone, transfer center. Who else is being notified other than you? Are the ICU hospitalists being notified or are you —

[Dr. Ben Starnes]
Not at all. They're usually surprised by the fact that we have a patient that's post-op from a ruptured AAA.

[Dr. Sabeen Dhand]
Exactly. Who's calling the OR, is it you personally calling the OR/surgery too?

[Dr. Ben Starnes]
Typically me, a resident, or a fellow is calling the front desk of the operating room to let them know. It's multiple phone calls. It's not seamlessly integrated at all.

[Dr. Sabeen Dhand]
Exactly. This is very similar to what we were dealing with, with stroke. Even right now with our aortic emergencies at my hospital, again, like you were saying, ICU doesn't even know until the case is done and we're calling them. It's a lot of these analog connections now. What about reps? Are reps frequently supporting your cases or you have all the grafts available at your hospital and you do all of that on your own?

[Dr. Ben Starnes]
We're lucky because we treat. Last year we did more than 350 aortic cases across-

[Dr. Sabeen Dhand]
Wow, that's amazing.

[Dr. Ben Starnes]
-our four-hospital system. Most of those aortic cases are focused in two hospitals, Harborview and UW Montlake. It depends on the physician. I typically don't ask for reps to be in the room. We have over 300 aortic stent grafts on our shelves so we can choose the right graft for the right anatomy, but we're very comfortable in using the grafts. Some of our newer faculty may like to have the reps in the room to help them get through the case successfully. It's vascular surgeon dependent, I would say.

[Dr. Sabeen Dhand]
All the measurements then, are you sitting down there on your PACS and measuring the neck and this and that?

[Dr. Ben Starnes]
Yes, we do it all. I try and tell the residents, especially in a rupture setting, if it's an intrarenal rapture and the patient is a suitable candidate for EVAR, I'll tell them really the two most important measurements are the D1 and the L1, so the diameter of the aorta just below the renal arteries. Then the length from the renal arteries to the aortic bifurcation. The limbs you can sort out later, but those are the two most important measurements.

[Dr. Sabeen Dhand]
Very good point. Obviously, we've identified like you said, a pretty antiquated system of what goes on. After the repair, then who's being notified? ICU hospitalists, you or a resident are calling them?

[Dr. Ben Starnes]
We're basically walking with the patient up to the ICU and doing a handoff to the ICU team.

[Dr. Sabeen Dhand]
What about non-emergent? Let's shift our focus and go to elective aortas. Would you be planning to use AI to also identify non-ruptured aorta that are five centimeters or above?

[Dr. Ben Starnes]
Absolutely. Well, any aneurysm really, even the smaller aneurysms. Here's what happens and it's really a reflection of our outdated healthcare system. A patient will go to the emergency room, let's say with right upper quadrant abdominal pain and be diagnosed with cholecystitis, whether it be by ultrasound or CT scan, but oh, by the way, on that imaging study, they detected an aneurysm that was three and a half or four centimeters. Well, the patient will get treated for their gallbladder, but this incidentally detected aneurysm will not be addressed and it'll be forgotten and the patient, you can't rely on the patient to know that what was in their imaging report.

If the word aneurysm is in any report anywhere, Viz.ai can scan millions of documents and find those words and give you a list of patients who have aneurysms that have not been treated. Those patients can be captured and brought into your system and be evaluated and then tucked under the wing, so to speak, to treat once they reach a certain size.

[Dr. Sabeen Dhand]
Absolutely. We deal with that a lot where there's things exactly how you described it, where it's an incidental finding and then just forgotten about or lost to follow up. I do think that using these platforms will really capture and help and benefit patients to be worked into a system and followed. Do you imagine, like when we have stroke cases or when you have ruptures, this system notifies you, it sends you a message or it blasts a tone on your phone. Would you want that for any aneurysm or you would want something more-- I don't know. Sometimes I would feel like that would be disruptive sometimes if it's just elective, but that may still be--

[Dr. Ben Starnes]
Absolutely. I think that's one of the topics that people get afraid of. I can't imagine having my phone go off every time the word aneurysm was reported on a CT scan within our system, because my phone would basically just be going off all day long. I think you can tone it down to the point where you get a list or maybe one of your providers, your PA or your ARNP check at the end of the week, a list of patients to then be able to go in and look at their imaging and then give the appropriate referral when needed.

[Dr. Sabeen Dhand]
Sure. One interesting, we find this conundrum in interventional radiology, sometimes in radiology, is say you have this finding and how do you then follow up? Do you wait for the primary person to call you and make the referral or do you kind of be more proactive and you call them and say, "Hey, look, this is what's here. Do you want us to take care of this?" How do you approach that?

[Dr. Ben Starnes]
Sabeen, that's the scary part to me is that, right now the way the system is without artificial intelligence, it's a clunky outdated system where we don't have any idea who's out there that has an aneurysm or dissection that is not symptomatic. We have no idea, and we rely on the primary care providers to put in the referral to us where we can actually evaluate the images. I think by having those patients be identified across a vast, incredibly enormous system or healthcare system, we can be proactive about providing life-saving treatments to patients who don't even know that they have an aneurysm or may have been lost to follow up.