Dalai in RSNA 'Wonderland'

CHICAGO - For years, the PACSman Awards were an annual tradition in AuntMinnie.com's coverage of the RSNA conference. With the PACSman hanging up his typewriter in 2010, the baton has now passed to the Dalai Lama of PACS, radiologist and blogger Dr. Sam Friedman, who shares his unique RSNA experience.

Down the scanner bore

Dalai was beginning to get very tired of sitting at his workstation, getting slammed beyond belief. Twice, he had peeped over to his partners' stations, but they were lost in conversation, leaving the list for Dalai.

Suddenly, there appeared out of nowhere none other than Dear Departed PACSman, wearing a white T-shirt and with bloodshot eyes. "Goombah! I'm late for my scan," he muttered.

Dalai was not generally prone to hallucination, and it later occurred to him that the white-clad PACSman should not have actually been there in the reading room at that time. But Dalai followed his mad dash out the door of the reading room and into the MRI enclosure.

The PACSman popped into the MRI bore and disappeared. In another moment, Dalai followed, not stopping to think just how foolish this action might be.

The journey down the bore was slow and rather odd. It was quite dark, but here and there he could see glowing jars of radium, and chest x-rays on old-style viewboxes. Where would this end? Perhaps Dalai would exit another MRI in China or perhaps New Zealand, or maybe in the clinicians' 0.05-tesla device across the street. What would Mrs. Dalai think? Probably that Dalai had gone to hike the Appalachian Trail, or was otherwise misbehaving.

With no warning, Dalai found himself sprawled on the floor of the Grand Concourse of McCormick Place, having narrowly missed a delegation of sonographers from Japan standing by the Starbucks counter. He spotted the white-shirted PACSman bouncing down the concourse, headed for the Technical Exhibits.

Dalai tried to follow but was stopped by the guards. "Badge, please," they insisted. All Dalai had was his radiation badge, and clearly this wasn't what was needed.

Behind him appeared a pedestal with a large red button labeled "Scan Me." Dalai pressed it, and a warm glow enveloped him, turning his badge blue. "Only vendors ‘til 10, Doc!" cried the guard. Another pedestal and the "Scan Me" button appeared. Dalai pressed this as well. He felt a tingle up his leg, and his badge turned brown. "You may pass!" cried the guards.

The rat race

Dalai wandered into the thick of the exhibit hall and soon encountered a cluster of rather odd-looking black-suited men, milling about the various technical displays in a more or less circular fashion.

"Whatever are you doing?" asked Dalai timidly.

"Why my good man, we are running the Imaging Sales Rat Race!" said the first of the gentlemen. "It serves no purpose, we end up where we began, but we look busy and everyone gets a prize. Did you bring enough for all of us?"

"Um ... well, I only have my iPhone," mumbled Dalai.

"Hand it over. We'll use it to place orders for all of our modalities, and everyone wins!"

The dark-suited man grabbed for Dalai's phone. "Patience! First, we must ..." Dalai cried.

"Yes, Dalai! Patients First! The patients deserve the best of the scanners, which you cheap doctors seem loath to provide!"

"I didn't mean it that way!" he quickly added. "It's administration's fault! They hate spending money, and salesmen, too! And they want to comply with the laws, known and unknown! But of course for me, Patients First! Don't be so easily offended!"

And with that, the salesmen got up and resumed their circular trek.

The PACSman gets a little bill

The white-clad PACSman reappeared, rounding a corner behind a huge display of plastic phantoms containing bones. He looked straight at Dalai and howled, "My bill! My bill! This is outrageous! $5,725 to look in my head? I'll have someone bumped off, I will! Get going buddy, right now! Leave the scan, bring the cannoli."

"He thinks I'm his personal radiologist," Dalai thought to himself. "Patients First," yes, but really ...

Another pedestal arose with another button labeled "Scan Me." Dalai pushed it, and this time felt a migrating itch travel from head to toe. His badge turned green, the RSNA color of important people who are not physicians.

As he was unable and, by virtue of the new badge, unqualified to fix the PACSman's bill, Dalai was able to escape to the next booth.

Advice from Aunt Minnie

Dalai's flight took him to a booth containing several plush leather massage chairs. Seated in the last was a little old lady, smoking a Cuban cigar.

"Who are you?" she cackled.

"I'm not quite sure anymore," said Dalai rather hesitantly. "I was once a radiologist, but I seem to have become a number of other things. I started out trying to care for Patients First, but now I seem to have to please everyone! I have to fix bills and such. I'm not sure I even remember what FEGNOMASHIC stands for."

"Repeat it for me, sonny!"

"OK, if you insist ... fibrous dysplasia, eosinophilic granuloma, granuloma ..."

"Wrong!" She puffed the cigar for a moment. "So if you don't know who you are, why do you think you were a radiologist? Why can't you go with whatever you are now? Like they say, if it looks like your Aunt Minnie and sounds like your Aunt Minnie, it's your Aunt Minnie. That's me, Dalai!" And she cackled some more.

"By the way, sonny, if you push that button behind you, you'll turn into something else entirely, since you don't know who you are anyway. Neither looking nor sounding like a duck, eh? Push it and get outta here!"

Dalai looked and there was yet another pedestal and red button, although it lacked the "Scan Me" label. He pushed it, experienced a transient rash across his torso, and his badge turned red for a nonmember physician.

Cheshire CAT-Scanner

The next booth over was the home of the Cheshire CAT-Scanner. Dalai walked up to the massive device, which had a huge display panel on top.

"What shall I do, dear Scanner?"

"It depends on what you wish to accomplish," read text that scrolled across the display.

"I don't care much at this point. I just want to scan gently, and put my Patients First."

"Then it doesn't matter much where you go on the exhibit floor ... they all do the same thing. Except for this!"

And with that, the Scanner faded from view, with only the flashing alphanumeric display still visible.

"You've come to an area of unreality, of madness. The real world doesn't work this way, Dalai, and now you're mad too. You must be, or you wouldn't have come here."

"And you know I'm mad how?" Dalai asked.

The scanner faded back into solidity. "Look at me. I can scan the entire volume of a patient in 0.066 seconds, and rather than irradiate the patient, I draw radioactivity from the body. The patient leaves my gantry with less dose than when he arrived. Because you believe every bit of the hype you see around you when you come to the exhibit floor, you are therefore mad. Now, do you wish to play footsie with the King and Queen today?"

"I don't think I would," demurred Dalai.

"Too bad," flashed the Cheshire CAT-Scanner. "You're booked for one in the afternoon at the palace. But you need to have a bit of a chat with the vendors first." And with that, the scanner vanished from the booth. A new pedestal appeared in its place, with the familiar "Scan Me" button. Dalai shrugged and pressed it.

The Mad Vendor's cappuccino party

With a sudden, brief attack of GERD, and the conversion of his badge back to blue, the color of full members of RSNA, Dalai walked down to a very large booth, finding a lovely Danish Modern dining room table and chairs placed directly in front of a huge brass espresso machine. Several dark-suited types were scattered about the table, with one wearing a meatball-splotched tie.

"Have some cappuccino, Dalai," said one of the diners.

"But we're out of cappuccino!" said another.

"Hey, Dalai," said the man with the tie. "How do you qualify for meaningful use?"

"I believe I can guess that," responded Dalai.

"Do you mean that you think you can find out the answer to it?" said another dark-suit.

"Exactly so," said Dalai. "It's simple, really, isn't it? But wait ... what's meaningful use anyway?"

"You mean you don't know?" cried the Mad Vendor. "Darn. Neither do we. But that won't stop us from trying to sell it to you!" And the dark-suited men began to bicker amongst themselves, telling stories of customers who got away.

Dalai got up and left the table, ultimately exiting the madness of McCormick altogether and wandering south.

A witness at the palace

After walking quite a distance, Dalai found himself in a quaint, tree-lined neighborhood, with one house that stood out, clearly a palace. The King and Queen themselves were inside, sitting on matching thrones. They were clearly angry, calling out, "Off with your revenue! Decapitate your capitation!"

Sprawled before the thrones were a dozen other radiologists, just as confused as Dalai by the whole proceeding.

"Patients First!" bellowed the King. "You tried to steal the revenue! Call the witnesses!"

The Mad Vendor approached. "I tried to get them to participate in meaningful use! But they wouldn't buy my wares. I'm a poor man, your Majesty, and a very poor salesman."

"And a very poor speaker. But you tried to put Patients First. Stand down."

"But your Majesty, I'm already on the floor as it is!" he exclaimed.

"Then sit down!"

The assembled courtiers snickered in delight.

"Call Dalai to the stand!" the King shouted.

Dalai approached with hesitation, but then stood straight but with head bowed.

"What do you know of this business?" asked the King, and the Queen nodded, sure of what was to come.

"Why, nothing, your Majesty. I've always tried to put Patients First, but to no avail. With the coming cuts and revenue shifts, we radiologists can't serve them as we once did. And no one knows how radiologists might participate in meaningful use!"

"Matters not," said the King. "If you can't transmit your patient data to us, you are not worthy. Haven't they signed the meaningful use attestation?"

"No, your Majesty."

"Aha! All of you must have meant some mischief, or else you'd have signed your names like honest men! Off with their revenue! Decapitate their capitation!"

Back home

Dalai sat up with a start, and looked around at his reading room. His colleagues were still locked in conversation, and the list had grown to gargantuan proportions. He picked up the microphone, put it down again, got up, and walked out of the hospital.

The other radiologists eventually discovered his absence, after several frantic calls from the emergency department inquiring after reports. They realized what had happened, although Dalai's trip to Wonderland could never be known to them. Still, they longed for the simple life when Patients really did come First.

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