Carl Maronich (Host): Welcome to the ISH Dish Podcast. I'm Carl Maronich, your host. And today, we're going to be talking with Erin Heitland. Erin is with Iowa Specialty Hospitals and Clinics, and we're going to be talking MRI. Welcome, Erin.

Erin Heitland: Hi. Thank you so much. Thanks for having me.

Host: Absolutely welcome. And before we jump into that conversation about MRIs, let's get a little bit of your background. How long have you been an MRI tech?

Erin Heitland: I have been a certified MRI tech since 2003. So, I'm into, I guess, this would be my 24th year. I did 14 months of training before I took my licensure test.

Host: So, you've been doing this a little while. Do you have a total count of how many MRIs you've done over that time?

Erin Heitland: I think I'm north of 30,000 exams now.

Host: So, you definitely know what you're doing. To that point, let's ask a little bit about what an MRI is so people know exactly what we're talking about. What is an MRI?

Erin Heitland: Sure. An MRI stands for magnetic resonance imaging. Basically, it uses magnets, large, strong field magnets and radio frequency. That makes the resonance and vibrations when you have the scan. And between the two of them, it creates some images with a little bit of physics and a little bit of software in there.

Host: So, it's a diagnostic tool.

Erin Heitland: It is.

Host: Not a treatment tool. To make sure we're clear there. Very good. We'll talk a little more about the nuances of MRIs as we get into it, but let's talk now about what really differentiates the MRI technology used at Iowa Specialty Hospitals from other local providers.

Erin Heitland: Well, one thing is Iowa Specialty Hospitals really stays well updated with their machines. Some places run 20, 20 plus years, with a few software upgrades in there. But the machine itself is about the same. And we have a new one here in Belmont. It's been here about a year and a half. So, that has the latest technology when it was installed, and it's the same technology as Clarion. That one's a little older, but that was updated just under four years ago after having been there about 11 years with the one prior to that. So, they really do keep up to date with their machines. And every time you get a different machine and a different software level, it helps make the exam faster, the software's better. The machines are getting quieter if you get a newer one. They're wide bore, which is a huge thing for claustrophobia, and comfort in general.

Host: Very good. And let's talk a little bit about comfort. During an MRI, some individuals who are claustrophobic may struggle a bit. What do you do to help those folks?

Erin Heitland: I think the biggest thing we can do is a good prep. Having enough time to talk about the exam, what's to expect. Because if the patient, even if they've had one before or not, if they know what to expect, it's just easier. The imagination is a very powerful thing. So instead of being rushed and that heightens anxiety and talking fast, all of that heightens that up. So being able to take the time to do that. But then, everything I mentioned with our newer machines, you have a wide bore, so it's not as tight. Our bores are 71 centimeters wide. Older machines, which I've worked on were 60 centimeters. So, that's a big difference when you're talking circumference all the way around and some room to move. Now, we don't want people to move.

Host: It eliminates that claustrophobic feeling. I'm sure. What about clarity of image with regard to the wider bore? Has it helped in that regard?

Erin Heitland: It can. It's not necessarily apples to apples with that. The image comes more from the software and the magnetic gradients that are in the machine themselves. The clarity and the resolution. So, the wide bore is more about comfort. When it is a wide bore, those magnetic components are actually closer to the patient. There's not as much insulation between them and the patient.

So, one thing people need to be aware of is not having the skin touch directly on the side of the machine. That doesn't have to be that much of a barrier. But it can heat up a little bit and that's one of the safety things we have to think about. There's a lot of safety things that we have to think about with the physics behind it.

Host: Once someone has an MRI, how quickly can they expect to get the results? And what role does realtime provider access play in that?

Erin Heitland: We have a radiologist, Monday through Friday, 8:00 to 4:30 30, which is the same hours we run the MRI. And they read them fairly quickly. Well, one exam in particular, because it's a radiologist specialty for some of the MRI breast imaging, so they need to read some of them on site if they're not on site that day. And there's only two or three radiologists that actually read those because of some post-processing. So, those can take a while depending on when they are assigned to be here. but everything else can be read within 24 hours. And it's usually read within two to three, honestly, unless they're in procedures, and tied up otherwise.

Host: Yeah. So, pretty quick turnaround there.

Erin Heitland: Very much. And those reports, because we use myChart and the Epic system, those reports as soon as they're read, do show up on myChart. If the patient is signed up and has that, so they will see that that's the same time it goes back to the provider as well.

Host: Their primary care provider or whoever referred.

Erin Heitland: Yes, whoever ordered the exam. Correct.

Host: So, let's talk a little about the benefits of using MRI over some other imaging methods such as CT and x-ray and such, particularly for soft tissue evaluation.

Erin Heitland: It is the best imaging for soft tissue, is a long maybe simple answer. A lot of that has to do with physics. So without going into physics too far, what happens is the magnet lines up hydrogen protons in the body, and the radio frequency knocks them out of that alignment. And because hydrogen is in varying amounts, in the different tissues in the body-- fat, muscle, blood, bone, water, all of that-- it relaxes back into alignment at a different rate. And that's why the different tissues, all those different soft tissues show up differently. Anywhere from brighter white, down to a darker gray.

That's also why metal, if people have metal-- now that doesn't mean we can't do the scan-- but if we're looking at the area that has metal in it, metal is black because there is no hydrogen in titanium steel, whatever, usually it's titanium, platinum, whatever the metal is, so, it shows up, that's black.

Host: When you mentioned proton, I got very nervous and had flashbacks back to high school science class, and I was nervous. But you did a great job of explaining that. So, we all appreciate that. Now, let's talk a little about implants and metal. If someone has an implant, a pacemaker or something, are they still able to have an MRI?

Erin Heitland: Now, back when I started, we'll take a flashback here, things were unsafe or safe. There was really no in-between. So, pacemakers, a lot of these more active implants, they have a job, stimulators, pacemakers, sleep apnea stimulators, they are conditional. So, they've said everything's conditional. Really hardly anything is unsafe anymore. So, that means your machine has to meet the conditions, and whatever scan you're doing also has to meet the conditions for that implant.

Now, we can meet a lot of conditions. We do not scan pacemakers here at Iowa Specialty because we don't meet some of the monitoring conditions that have to go along with that. And then, also, we don't scan any of the Inspire sleep apnea stimulators or deep brain stimulators because we don't meet the conditions set forth by the manufacturer. So, there has to be some investigation by the technologist with some of that. A lot of it we can scan, but some of it we can't.

Host: And I would guess ideally all that's handled initially at scheduling to make sure so they don't get there ready to do it, and then realize it can't be done.

Erin Heitland: Yes. It's all a big safety issue because of course we don't want to hurt a patient with any of these implants. So when we do schedule a patient, there are some hard stop questions before we even get them on the schedule. And that is pacemakers, stimulators, aneurysm clips cochlear implants. There's certain questions we ask. It doesn't mean it's a no necessarily. We need to investigate it or we need to plan it appropriately how we schedule it.

Host: Sure. Now, would that include any orthopedic implants?

Erin Heitland: No. We don't ask anything about, say, hip or knee replacements, shoulder replacements, any hardware, back surgery, ankle surgery. Those are all considered passive implants. They're going to be made of titanium. Sometimes, now if I have to do a knee scan on someone who has a total knee replacement, we already kind of talked about, "Well, it shows up black, so how are we going to see anything?" That's one of the things with the newer machines, that we have, what's called MARS software, and that's metal artifact reduction software, MARS. So, we have protocols set up where we can see the tissue around that better. With some metal reduction software, you're still not going to see it absolutely a hundred. You know, the metal is black and it always will be, but you can see the tissue around it. Is there something going on there? Is there inflammation? Is there some problem with that? So, those orthopedic implants are not a problem.

Host: Yeah. Good to know that. And how does Iowa Specialty Hospitals coordinate with insurance providers, which I know can often be a kind of a headache for the patient. How do you guys work through that?

Erin Heitland: Well, we're kind of on the back end of that process in radiology. The provider puts in the order for the system, and even if their provider is an external provider, they just have to fax us an order with insurance information on it. And it goes to our prior auth team, which works hard-- they're a very hard working group-- to keep all this stuff straight and sends it to the insurance and gets the prior authorized. Most of the time, it's authorized. There's a few times it's denied because the patient, the insurance says they have to do PT first, physical therapy, or they need something else. They need to try some more conservative therapy first, something like that.

But once it's authorized, then it falls into our radiology work queue, so we can see all the exams ordered by providers for radiology. And then, we call the patient and that's when we ask those questions, get them scheduled. And most of the time, it's pretty quick. Occasionally, because they do say, you know, the insurance companies can take up to 14 days, it's really rare that it goes that long before it's approved.

Host: That's good. That helps everybody along. You talked earlier about it's not a treatment modality, but a diagnostic one. Maybe you can talk a little about early detection and the prevention of some serious health conditions and how MRI can work in that regard.

Erin Heitland: Most of MRI is you already have a problem. You came to the doctor for a problem, a pain, an injury, something like that. But there are a couple instances where we are on the front end of that. And again, back to MRI breast imaging, and this is something that changed probably 15 years ago, where insurance companies, they were paying for women to be screened if they were high risk for breast cancer for varying reasons. So, that is one where we can catch cancers early, because women at high risk can have an MRI breast exam once a year, just like a mammogram if they choose with that.

Another way that's possible, if somebody gets a new diagnosis of cancer, in particularly let's say lung cancer, a lot of oncology departments, they'll order a PET scan, and then an MRI of the brain right off the bat to see the extent of the disease, if it's spread anywhere else. And so, there may not be any symptoms for the patient, but it's an earlier way to kind of track stuff.

Host: Yeah, I mean, catch that on the early side, which as we know in all aspects of health, early detection's always going to be the best route to go. You spoke a little bit about this when you talked about the wide bore component, but any other things you guys do to help those patients who may have some anxiety about having the MRI done, particularly new patients that haven't had one before?

Erin Heitland: If anybody's head is inside the bore, there are a few exams where their head's outside the machine, anything basically that's a knee, lower leg, foot, their head is outside the machine, so it's not really an issue. But anytime their head is in the machine, whether they're going in feet first or head first, I strongly suggest they close their eyes and not look at it. It goes better overall. But if somebody wants to try a washcloth over their eyes like an eye mask, that's a good tool. if they look then and peak, they just see that and the brain registers that and not the machine itself. We also have aromatherapy. If people don't have an aversion to lavender, it's a very calming scent. That can help calm people. And I also will tell people concentrate on something else. We do give music. So, you can concentrate on listening to the music. They can choose what they want through Pandora. But also, breathing, breathe in to the count of four, kind of that meditative breathing. Breathe in, breathe out to the count of four. Think about how the chest goes up and down. it's just focusing on something else.

Host: Well, that's 24 years of experience offering some anti-anxiety tips. So, those are good ones. And you mentioned music, are you guys using aromatherapy also?

Erin Heitland: We can. I don't use it as often unless it's really needed because some people do have an aversion to sense. it can linger in the room a little bit sometimes. So, I don't want to offend somebody else by trying to help someone. But I should mention too sedation medication. If anybody's claustrophobic, the doctor can prescribe a prescription for some sedation. They take it before they come so it's already working. You know, when they get here, they have to have a driver with that.

Host: As you say, that has to be arranged prior. So with their primary care doctor, if he is telling them they're going to need an MRI, then they should have that conversation then.

Erin Heitland: Yes. And it is also one of those hard stop questions that we ask, are you claustrophobic? Because then, we can catch it as we're scheduling and plan accordingly with that as well.

You said 24 years experience. A lot of great information here you're providing. What new developments or future developments in MRI technology do you see coming or anticipate?

Well, with the evolution of computers, it always can get faster. It's not probably ever going to be as quick as what an x-ray is now, that instant digital. And that's again the physics behind it. But it is always getting faster. This machine has parallel imaging. A lot of the newer manufacturer machines have parallel imaging, which cuts time. They're always working on that. They're also getting quieter. the machines I started on were about 130 decibels. I've been in them. You couldn't hear the music, even with the headphones turned up full blast. And we're down to about 80 decibels on our machines. And very easily, you can hear the music. Oftentimes, I'm turning it down for people, because it is too loud. It drowns out the noise very well. So, they're always working on some of that. And I haven't heard or read about it lately, but shortening that bore, the bore is the length of the machine and it's about five foot long now. So as they get new technology, they can really get that down to a shorter bore, because they've done that over time. The first ones came out, they were 12 feet long and they were eight feet long. They've been about five feet long here for a couple decades.

Host: And ultimately, that would speed the process if it's a shorter bore.

Erin Heitland: It could. Software is really what would shorten up the time of the test. But the shorter bore would definitely make it better claustrophobia-wise.

Host: Gotcha. Very good. Now, Erin, let me ask you, can anyone come to Iowa Specialty Hospitals and Clinics for an MRI or they already have to be an established patient?

Erin Heitland: Nope. They don't have to see anybody here. As long as we have an order, we always have to have an order for the test. We can't do anything without that. But as long as their provider, if they're in the area, they fax us the order and we can put it in our system, and get that rolling here.

Host: And no matter where their doctor is, he'll communicate back to their provider who referred, whether they're established there or not.

Erin Heitland: Yes. The report goes back to the provider who ordered it. So, whether it's Mayo Clinic, it could be McFarland in Ames, UnityPoint in Fort Dodge, Mason City, the report will go back to the provider that ordered the test.

Host: Very good. Well, Erin, you've shared a lot of great information from all your years of experience. Anything we didn't cover that you want to mention?

Erin Heitland: One thing I really enjoy here at Iowa Specialty, and this is a personal thing, but it does help the patients as well. We are given enough time to sit down and decrease that anxiety and talk about the test and explain everything well, more of that personal touch, that customer service, if you will.

I hear a lot of places-- and I've worked at other places-- where that's not the priority. it's about how fast you can do it, how many you can get in. And it's nice to have that be a priority here at Iowa Specialty that, yes, we want to get people in, but most of the time we do have same day or next day service, honestly, or at least the same week, unless one of us techs is on vacation, then it can get a little backlogged. But if we're all running, we really have availability every week for people to get in.

Host: Well, that's great. That's great to put the experience of the patient first. It sounds like that's the important goal. Very good. Erin Heitland, Radiology Tech with Iowa Specialty Hospitals and Clinics. Thanks so much for joining us and giving us all the info on MRIs.

Erin Heitland: Yes. Thank you so much for talking about it.

Host: For more information, go to iowaspecialtyhospital.com. And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest. I'm Carl Maronich, and this has been The ISH Dish Podcast from Iowa Specialty Hospitals and Clinics. Thanks for listening.