INTERNSHIP PROJECT

MEDICAL MACHINES IN APPOLO HOSPITAL DHAKA

FOR- SIEMENS BANGLADESH

Done by

TASDIDAA SHAMSI BIOMEDICAL ENGINEERING STUDENT THE UNIVERSITY OF SHEFFIELD, UK

At Dhaka, 27Jun 14 Jul 2005

INTRODUCTION
Apollo hospitals Dhaka is a joint project of Apollo Hospitals Enterprise Limited and STS Holdings Limited It is a 450-bed super specialty facility poised to deliver advanced tertiary care of international standards at an affordable price to the people of Bangladesh. The Hospital has 4,00,000 sq.ft on 4 acres of land, focuses on Departments of 1. 2. 3. 4. 5. 6. 7. 8. 9. Advanced Cardiology, Cardiac-Surgery, Neurology, Nuro-Surgery, Urology, Uro-Surgery, Endocrinology, Gastroenterology. Critical care (incl. Pediatrics, Neonatal), Orthopedics, Apart from other secondary care specialties. Telemedicine is also available. The skilled nurses, technologists and administrators at Apollo Hospital Dhaka, aided by state-of-the-art equipment, provide a world-class standard of healthcare to the Bangladeshi people. The contemporary healthcare infrastructure at the Apollo Hospital Dhaka will result in the reversal of the brain drain as already many highly qualified and experienced specialists of Bangladesh are returning from the west to provide their services to benefit the people of Bangladesh. The establishment of this new hospital initiative will also present immense employment opportunities, increase GDP, strengthen healthcare delivery attract foreign exchange and boost healthcare tourism.
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 The hospital has a complete range of the latest diagnostic, medical and surgical facilities for the care of its patients. The hospital has all the latest healthcare machines including

1. 2. 3. 4. 5.

64-slice CT machine 1.5 Tesla MRI Ultrasound X-ray Color Doppler and All Others

Apollo hospital, Dhaka, Bangladesh

64-slice CT machine

64 Slice CT Machine The most advance CT Machine in South-East Asia Capable of doing advanced CT Angiogram

CT MACHINE USAGE IN APOLLO HOSPITAL DHAKA The scanner 64 Slice CT Machine has four times as many detectors as a typical multi-detector CT scanner, combines unrivaled image quality with remarkable speed. It can produce detailed pictures of any organ in a few seconds and provide sharp, clear, three-dimensional images, including 3-D views of the blood vessels, in an instant. A 40-slice scanner collects images covering 20 to 32 millimeters in a single pass and a tightly packed 64-slice device can cover about 40 millimeters at a pass, which takes 0.4 seconds. A 40-slice scanner collects images covering 20 to 32 millimeters in a single pass and a tightly packed 64-slice
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device can cover about 40 millimeters at a pass, which takes 0.4 seconds. At that rate, a 64-slice scanner can gather a high-resolution image of a heart, brain or a pair of lungs in about five seconds. A scan of the whole body, (in search of a blood clot, for example, that has become a source of emboli) takes about 30 seconds. The technology has been particularly exciting for studying the beating heart, providing the first clear non-invasive images of the heart and its major vessels. The scans can be timed to use only images gathered between contractions, so that the heart and its vessels can be seen without the blurring caused by motion.

Other promising indications for multi-slice scanners include evaluation of plaque within the carotid arteries (5 to 8 seconds), searching for pulmonary emboli (5 seconds, less than an easy breath hold), coronary artery imaging (10 seconds, including distal segments and multiple arterial branches). The scans have their own limitations. Although the scanner table is built to support up to 450 pounds, it can be difficult to accommodate patients who are morbidly obese. Each scanner costs between $1.5 million to $2 million.

CT SCAN MACHINE-BASICS

CAT is the acronym of Computerized Axial Tomography. CAT Scan combines x-rays with computers to produce highly detailed cross sectional images of the body. It is used instead of a conventional x-ray in cases where specific anatomy or pathology cannot be seen. Conventional x-ray can only show dense bone structures. CAT Scan has the capability to visualize bone and soft tissue. Now with new technologic advancement there is a procedure in CAT Scan called CTA, which allows the radiologist to study the blood vessels with the help of contrast media or dye.

Contrast dye highlights the blood vessels and allows the radiologist to see if there are blockages in the arteries, without using the invasive method of angiography. CT SCAN- HISTORY CAT Scan was invented in 1972 and has become one of the most popular methods of imaging in the last ten years. The first scanners were very slow, thus making the time factor important in trauma patients when it was very important to get an accurate diagnosis as quickly as possible. Scanners today are so fast that patient who comes in through the emergency room for a questionable stroke can have a CT of their brain in less than three minutes scan time. CAT Scanners with slip rings can now rotate continuously and do not have to slow down to stop and start. These new scanners are called helical or spiral scanners. Helical scanning acquires a volume of data in about 20-30 seconds, and usually in one breath

hold. There is little or no patient motion shown because the data is acquired so quickly. The data can then be computer reconstructed to show three-dimensional images of any part of the body being scanned. For example, in the event of a severe facial fracture, three-dimensional imaging allows the surgeon to realign fractures prior to reconstructive surgery.
Somatom Emotion at its best

1.5 Tesla MRI

The MRI 1.5 Tesla, The first Tim system High-end 1.5 Tesla system and the first equipped with Tim (Total imaging matrix) technology.

MRI MACHINE-BASICS

Magnetic resonance imaging (MRI) is an imaging technique used primarily in medical settings to produce high quality images of the inside of the human body.

MRI is based on the principles of nuclear magnetic resonance (NMR), a spectroscopic technique used by scientists to obtain microscopic chemical and physical information about molecules.

The technique was called magnetic resonance imaging rather than nuclear magnetic resonance imaging (NMRI) because of the negative connotations associated with the word nuclear in the late 1970's.

MRI started out as a tomographic imaging technique that is it produced an image of the NMR signal in a thin slice through the human body. MRI has advanced beyond a tomographic imaging technique to a volume imaging technique. This package presents a comprehensive picture of the basic principles of MRI.

MRI MACHINE-HISTORY Felix Bloch and Edward Purcell, both of whom were awarded the Nobel Prize in 1952, discovered the magnetic resonance phenomenon independently in 1946. In the period between 1950 and 1970, NMR was developed and used for chemical and physical molecular analysis. In 1971 Raymond Damadian showed that the nuclear magnetic relaxation times of tissues and tumors differed, thus motivating scientists to consider magnetic resonance for the detection of disease. In 1973 the x-ray-based computerized tomography (CT) was introduced by Hounsfield. This date is important to the MRI timeline because it showed hospitals were willing to spend large amounts of money for medical imaging hardware. Paul Lauterbur first demonstrated magnetic resonance imaging on small test tube samples that same year. He used a back projection technique similar to that used in CT. In 1975 Richard Ernst proposed magnetic resonance imaging using phase and frequency encoding, and the Fourier Transform. This technique is the basis of current MRI techniques. A few years later, in 1977, Raymond Damadian demonstrated MRI called field-focusing nuclear magnetic resonance. In this same year, Peter Mansfield developed the echo-planar imaging (EPI) technique. This technique will be developed in later years to produce images at video rates (30 ms / image). Edelstein and coworkers demonstrated
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imaging of the body using Ernst's technique in 1980. A single image could be acquired in approximately five minutes by this technique. By 1986, the imaging time was reduced to about five seconds, without sacrificing too much image quality. The same year people were developing the NMR microscope, which allowed approximately 10 m resolution on approximately one cm samples. In 1987 echo-planar imaging was used to perform realtime movie imaging of a single cardiac cycle. In this same year Charles Dumoulin was perfecting magnetic resonance angiography (MRA), which allowed imaging of flowing blood without the use of contrast agents. In 1991, Richard Ernst was rewarded for his achievements in pulsed Fourier Transform NMR and MRI with the Nobel Prize in Chemistry. In 1992 functional MRI (fMRI) was developed. This technique allows the mapping of the function of the various regions of the human brain. Five years earlier many clinicians thought echo-planar imaging's primary applications was to be in real-time cardiac imaging. The development of fMRI opened up a new application for EPI in mapping the regions of the brain responsible for thought and motor control. In 1994, researchers at the State University of New York at Stony Brook and Princeton University demonstrated the imaging of hyperpolarized 129Xe gas for respiration studies. In 2003, Paul C. Lauterbur of the University of Illinois and Sir Peter Mansfield of the University of Nottingham were awarded the Nobel Prize in Medicine for their discoveries concerning magnetic resonance imaging. MRI is clearly a young, but growing science.

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Opportunities in MRI In 2003, there were approximately 10,000 MRI units worldwide, and approximately 75 million MRI scans per year performed. As the field of MRI continues to grow, so do the opportunities in MRI. There will always be a need for radiologists trained in MRI to read the magnetic resonance images. A radiologist is a medical doctor that has specialized in the field of radiology. The need is expected to grow so much that there will be and increased use of Radiology Practitioner Assistants and Radiology Physician Assistants. An MRI technologist is an individual that operates the MRI scanner to obtain the images that a radiologist prescribes. Based on the number of current MRI systems, it is estimated that there will be a constant need for over 1000 MRI technologists per year. A good resource for MRI technologists is the Society for Magnetic Resonance Technologists (SMRT). Two new specialist positions have recently evolved in MRI: the post processing technologist and the health safety specialist. The MRI post-processing technologist applies various post processing algorithms to magnetic resonance images to either extract more information from or enable better visualization of information in magnetic resonance images. An MRI health safety specialist assists hospitals and clinics in setting up and maintaining a safe MRI system. Because of the complexity of the MRI system, there will always be a need for MRI service technicians. Both the MRI manufacturers and some larger sites to keep the MRI system operating properly hire Service technicians. MRI service technicians usually have a BS or associates degree in electrical technology and a good knowledge of MRI.
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In any field, there will be a need for scientists trained in the basic sciences of chemistry, biology, and physics to perform basic research and push back the frontiers of the science. Some specific needs for these scientists include contrast agent and molecular imaging development, and advanced imaging pulse sequence design. These individuals typically have an advanced degree in their respective field and have had significant training in MRI. A good resource for scientists is the International Society for Magnetic Resonance in Medicine (ISMRM). Biomedical engineers and material scientists are needed for MRI subsystem development. One of these subsystems where continued demand is seen is imaging coil development. An emerging area requiring many skilled individuals is the development of MRI compatible devices. These devices include pacemakers, defibrillators, surgical clips and pins, and catheters. Many of these devices will require discoveries at the molecular level, such as biocompatible antireflective coatings for pacemaker wires and strong non-metallic synthetic joints and pins. Imaging scientists are needed for algorithm development for post processing of magnetic resonance images, and intelligent code for identifying and diagnosing pathology. Computer scientists are still needed to design user-friendly efficient graphical user interfaces (GUI) for newly developed software. Lastly, there is a need for architects to design safe and efficient MRI centers and clinics. The Basics of MRI is a good starting place for all the above individuals interested in starting their training in pursuit of a career in MRI or a related field.

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Microscopic Property Responsible for MRI The human body is primarily fat and water. Fat and water have many hydrogen atoms, which make the human body approximately 63% hydrogen atoms. Hydrogen nuclei have an NMR signal. For these reasons magnetic resonance imaging primarily images the NMR signal from the hydrogen nuclei. Each voxel of an image of the human body contains one or more tissues. For example here is a voxel with one tissue inside. Zooming in on the voxel reveals cells. Within each cell there are water molecules. Here are some of the water molecules. Each water molecule has one oxygen and two hydrogen atoms. If we zoom into one of the hydrogens past the electron cloud we see a nucleus comprised of a single proton. The proton possesses a property called spin which: 1. Can be thought of as a small magnetic field, and 2. Will cause the nucleus to produce an NMR signal.

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Ultrasound
General Ultrasound Imaging Ultrasound imaging, also called ultrasound scanning or sonography, is a method of obtaining images from inside the human body through the use of high-frequency sound waves. The reflected sound wave echoes are recorded and displayed as a realtime visual image. No ionizing radiation (x-ray) is involved in ultrasound imaging. Obstetric ultrasound refers to the specialized use of sound waves to visualize and thus determine the condition of a pregnant woman and her embryo or fetus. Ultrasound is a useful way of examining many of the body's internal organs, including but not limited to the heart, liver, gallbladder, spleen, pancreas, kidneys and bladder. Because ultrasound images are captured in real time, they can show movement of internal tissues and organs and enable physicians to see blood flow and heart valve functions. This can help to diagnose a variety of heart conditions and to assess damage after a heart attack or other illness. Some common uses of the procedure Millions of expectant parents have seen the first "picture" of their unborn child with pelvic ultrasound examinations of the uterus and fetus. Ultrasound imaging is used extensively for evaluating the eyes, pelvic and abdominal organs, heart and blood vessels, and can help a physician determine the source of pain, swelling or infection in many parts of the body. Because ultrasound provides real-time images it can also be used to guide procedures such as needle biopsies, in which needles are used to sample cells from organs for laboratory testing. Ultrasound is now being used to image the breasts and to guide biopsy of breast cancer (see the Ultrasound-Guided Breast Biopsy page). Ultrasound is also used to
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evaluate superficial structures such as the thyroid gland and scrotum (testicles). Doppler ultrasound is a special technique used to examine blood flow. Doppler images can help the physician to see and evaluate:

Blockages to blood flow (such as clots). Narrowing of vessels (which may be caused by plaque). Tumors and congenital malformation

Ultrasound of the abdomen

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Sample Image: Ultrasound of the gallblader

Sample image: Power Doppler ultrasound of the kidney

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Preparation for the procedure Comfortable, loose-fitting clothing should be worn for ultrasound exam. Other preparation depends on the type of examination. For some scans the doctor may instruct the patient not to eat or drink for as many as 12 hours before the appointment. For others the patient may be asked to drink up to six glasses of water two hours prior to the exam and avoid urinating so that the bladder is full when the scan begins. The equipments appearance Ultrasound scanners consist of a console containing a computer and electronics, a video display screen and a transducer that is used to scan the body. The transducer is a small hand-held device about the size of a bar of soap, attached to the scanner by a cord. The physician or technologist spreads a lubricating gel on the patient's abdomen in the area being examined and then presses the transducer firmly against the skin to obtain images. The ultrasound image is immediately visible on a nearby screen that looks much like a computer or television monitor. The physician or technologist watches this screen during an examination and captures representative images for storage. Often, the patient is able to see it as well. The procedure Ultrasound imaging is based on the same principles involved in the sonar used by bats, ships at sea and anglers with fish detectors. As the sound passes through the body, echoes are produced that can be used to identify how far away an object is, how large it is, its shape and its consistency (fluid, solid or mixed). The ultrasound transducer functions as both a generator of sound (like a speaker) and a detector (like a microphone). When the
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transducer is pressed against the skin it directs inaudible, high frequency sound waves into the body. As the sound echoes from the bodys fluids and tissues the transducer records the strength and character of the reflected waves. With Doppler ultrasound the microphone captures and records tiny changes in the sound wave's pitch and direction of the sound. These echoes are instantly measured and displayed by a computer, which in turn creates a real-time picture on the monitor. The "live" images of the examination are usually recorded on videotape but one or more frames of the moving picture may be "frozen" to capture a still image. The procedure is done in the following way The patient is usually positioned on an examination table. A clear gel is applied to the patient's body in the area to be examined to help the transducer make secure contact with the skin. The sound waves produced by the transducer cannot penetrate air so the gel helps eliminate air pockets between the transducer and the skin. The technologist or radiologist presses the transducer firmly against the skin and sweeps it back and forth to image the area of interest. When the examination is complete the patient may be asked to dress and wait while the ultrasound images are reviewed either on film or on a TV monitor. Often though, the technologist or radiologist is able to review the ultrasound images in real time as they are acquired and the patient can be released immediately.

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Patients experience during the procedure Most ultrasound examinations are painless, fast and easy. You will lie on your back on an examining table. The technologist or doctor will spread some warm gel on your skin and then press the transducer firmly against your body, moving it until the desired images are captured. There may be varying degrees of discomfort from pressure as the technologist guides the transducer over your abdomen, especially if you are required to have a full bladder. The examination usually takes less than 30 minutes.

Interpretation of the results is done by A radiologist or other physicians experienced in ultrasound and other radiology examinations will analyze the images and send a signed report with his or her interpretation to the patients personal physician. The patient receives ultrasound results from the referring physician who ordered the test results. In some cases the radiologist may discuss preliminary results with you at the conclusion of your examination. New technology also allows for distribution of diagnostic reports and referral images over the Internet at many facilities.

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The benefits vs. risks Benefits

Ultrasound scanning is noninvasive (no needles or injections in most cases) and is usually painless. Ultrasound is widely available and easy to use. Ultrasound uses no ionizing radiation and is the preferred image modality for diagnosis and monitoring of pregnant women and their unborn infants. Ultrasound provides real-time imaging, making it a good tool for guiding minimally invasive procedures such as needle biopsies. Ultrasound images can visualize structure, movement and live function in the body's organs and blood vessels.

Risks For standard diagnostic ultrasound there are no known harmful effects on humans.

The limitations of General Ultrasound Imaging Ultrasound has difficulty penetrating bone and therefore can only see the outer surface of bony structures and not what lies within. For visualization of bone, other imaging modalities such as magnetic resonance imaging (MRI) may be selected. Ultrasound waves do not pass through air; therefore an evaluation of the stomach, small intestine and large intestine may be limited. Intestinal gas may also prevent visualization of deeper structures
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such as the pancreas and aorta. Patients suffering from obesity are more difficult to imagethis is because tissue attenuates (weakens) the sound waves as they pass deeper into the body.

Ultrasound equipment

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X ray

General X-Ray Information X-rays, also known as Roentgen rays after the man who accidentally discovered them in 1895, are a type of electromagnetic radiation of high-energy photons having a wavelength of approximately 0.01 to 10 nanometers. It is because of this highenergy quality that many different scientific fields utilize X-ray technology, such as bioimaging and patient therapy. X-Ray examinations constitute at least 70% of all medical diagnostic examinations (Vladimirov and Kanter, 2002). Different parts of the body behave differently when exposed to X-rays; structures such as bone readily absorb X-rays while other components, such as the skin and the air in the lungs, allow them to pass right through. This reaction is because the heavier (atoms of higher atomic number) calcium atoms in the bones absorb the high-energy photons as opposed to lighter atoms (e.g. oxygen, hydrogen, carbon) that compose skin and air that absorb little to none. Therefore, when a uniform strength field of X-rays passes through the body and comes out, they have different strengths depending on which part of the body they passed through. At this point of travel, the X-rays hit a photographic film and expose it depending on the variation in strength. Developing the film shows these different levels of photograph exposure in the form of a standard X-ray radiograph (Anonymous, 2003d).

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Creating X-Rays There are two different ways of creating X-rays. The first method, the Bremsstrahlung or braking radiation method, involves shooting high-energy electrons into the electrical field of a tungsten atom. The electron slows down after swinging around the nucleus and radiates energy in the form of high-energy photons, Xrays. The second method is K-shell Emission. The K-shell of an atom is the lowest energy state of an atom. In this method, a highenergy electron is shot into an atom, and its target is a K-shell electron. The high-energy electron bumps the electron out of the K-shell, allowing a higher energy electron to move into its K-shell spot. The energy lost by the falling electron produces the highenergy photons of X-rays. Generally, the K-shell method produces higher intensity X-rays than the Bremsstrahlung method, and all the radiation comes out at the same wavelength. In addition to creating the X-rays necessary for imaging techniques, other steps must be taken to ensure an efficient X-ray device (i.e. the weaker X-rays must be weeded out, and the rays must be focused on the intended target). There are several different designs for X-ray imaging devices, but all work on these same principles (Anonymous, 2003d).

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Bremsstrahlung Method

X-Ray Machine Design The general design for an X-ray machine is not very complex. The main piece of equipment is an electrode pair, a cathode and an anode, which rest inside a glass vacuum chamber. A current is passed through the cathode filament, heating it up. The heat causes the cathode to emit electrons from its outer surface. These electrons are drawn across the chamber to the positively charged anode, a flat disc usually made of tungsten. The large difference in voltage between the cathode and anode creates a very large electromotive force, propelling the electrons through the chamber at a very high speed. The amount of voltage input depends on the desired X-ray intensity. Real-time monitoring and adjustments to the voltage input can therefore be controlled through monitoring radiation yield and intensity (Vladimirov et al., 2000). If the machine follows the K-shell Emission method of X-ray creation, the high-speed electrons collide with the tungsten atoms and knock loose low-energy electrons. This collision allows higher energy electrons to move into the lower energy spaces and release the Xray photons. The machine can also operate using the Bremsstrahlung method as well. During this process, the highspeed electron interactions create a large amount of heat; therefore, the anode is rotated on a motor to reduce the focus to one specific area and is surrounded by a cool oil bath to absorb the heat byproduct. The emitted multi-directional X-rays are shielded by lead, focused through a narrow beam, and filtered for safety purposes. The X-rays pass through a patients body and are developed on film (usually silver halide). The film is darkened by the interaction with the photons of X-ray radiation; the darker areas indicate less dense materials through which the X-rays can easily pass whereas the lighter areas represent materials of higher absorption (higher
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density materials). For dynamic radiography, specialists utilize fluorescent or digital screens for real-time X-ray imaging. Sometimes doctors also need to differentiate between blood vessels and the surrounding tissues. For this special case, the patient ingests a mixture of heavy elements to show more contrast in the radiograph (angiography). However, radiologists need to have extensive background in how to read these radiographs, analyze the results, and prepare their diagnosis (Harris, 2003).

The X-ray Machine

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X-Rays: Harmful Side Effects There are many pros to X-rays and their imaging potential. However, X-rays can also be very harmful to the human body. Long-time exposure of an individual to X-ray radiation can cause him or her serious sickness. X-rays are a form of ionizing energy, meaning that when X-rays collide with an atom, they can knock electrons off the atom to create an ion. As more electrons are freed, they create more ions. The problem with ions is that they begin chemical reactions not normally seen in living organisms. There are several ways these reactions can harm living beings. For one, the charged ion can break chains of DNA, deleting the cells instructions for carrying out life-dependent processes. The cell will either die or develop a mutation. Numerous cell deaths can develop into various diseases and disorders, while mutations can develop into cancerous tumors that spread throughout the body. Mutations in sperm or egg cells can produce a baby with birth defects or disorders. For all these reasons, doctors use this tool very sparingly and with strict safety procedures (Harris, 2003).

Radiography Equipment Designs Currently, there are several X-ray equipment designs available for a multitude of imaging needs. There are a variety of X-ray systems for routine, emergency trauma, or orthopedic circumstances. These systems provide images showing the depths of areas such as the skull, spinal column, abdomen, and even extremities such as blood vessels. The various creative and innovative designs provide a large range of uses for such devices. Among the devices available at present is the digital X-ray station. This device
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captures the X-ray photons on a photoelectric screen and converts the differential information into an amount of electrical current that corresponds to the transmitted X-ray intensity. Basically, instead of having to develop film, the image appears on the computer screen in mere seconds. Digital X-ray technology proves to be very convenient, but analog X-ray stations, X-ray intensity developed on radiographic film, are still being used today. Another X-ray device, the fluoroscope, is a dynamic X-ray imaging device currently used by doctors to take dynamic radiographs of targeted areas. This device is very similar to the real-time X-ray devices airports use to inspect luggage. One of the latest developments in X-ray technology is the X-ray computed tomography (CT scanning). The device takes 3-D images and collects anatomical information on the positions of air, soft tissues, and bone. Each of these devices has its own unique features that make it more useful in different situations (Anonymous, 2003a).

1) Analog X-Ray Machine

2) Mobile X-Ray Machine

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Color Doppler

Color Doppler uses standard ultrasound methods to produce a picture of a blood vessel. In addition, a computer converts the Doppler sounds into colors that are overlaid on the image of the blood vessel and that represent the speed and direction of blood flow through the vessel.

Sample Image from a color Doppler

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References:

http://www.apollodhaka.com/tech.html http://www.ctnetwork.net/machine.htm http://www.cis.rit.edu/htbooks/mri/inside.htm http://www.radiologyinfo.org/content/ultrasound-general.htm

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