Podcast Transcript: How Can AI Help with Acute Aortic Emergencies?

[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The current workflow is pretty cumbersome and outdated, in my opinion.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.