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Chapter 47

Diagnostic Imaging in Small Hospitals

This chapter is written for the radiologist (or anyone) who is asked to advise a mission hospital or a government on the best type of imaging equipment in any small hospital. Similar equipment will also be ideal for all the "routine" general x-ray and ultrasound examinations in any larger hospital, because about 80% or more of imaging in almost every hospital is "plain radiography" and "general ultrasonography."

Radiology in the tropics does not have to be primitive; it does have to be practical. The ability to produce a good chest x-ray is much more important in the majority of rural hospitals in the tropics than the ability to diagnose early pancreatic carcinoma (for example).

So, this chapter is not about the sophisticated imaging equipment used for computed tomography, magnetic resonance imaging, and advanced ultrasonography, except to warn that these expensive items will probably be required for less than 20% of imaging, even in a university or major referral center. Such huge expenditure is not justified unless tertiary care, such as advanced surgery or oncology, is also in the hospital. There can be no reason to perform highly specialized neuroradiology where there is no immediate access to a neurosurgeon, for example. No country has enough money for health care, and the money available for imaging should first provide for the everyday needs of the majority, because this will directly affect the well-being, work, and health of so many people and their families (Figs. 47.1, 47.2).

Unfortunately, many radiological training programs do not devote much time to the choice of equipment available. The World Health Organization (WHO) has had the advice of experienced radiologists and physicists, all well aware of the needs of what are called "first referral hospitals," the hospital to which a patient will go when referred by their primary care practitioner or nurse. Worldwide, the work of these hospitals in every country is very similar. All varieties of illness and trauma are diagnosed and treated by one or perhaps two or more physicians. Most of the doctors will be "general duty" medical practitioners, seldom with any special experience in imaging or knowledge of the equipment needed. When imaging equipment must be bought, many turn to the x-ray salesman for advice, which is certainly not the best way to get an unbiased view of the alternatives. Most salesmen (or saleswomen) will claim that any equipment they sell is not only a real bargain, but so efficient that it will image anything the doctor desires; it may be so wonderful that a thoughtful purchaser should wonder why anything more expensive is even made.

Cheap x-ray equipment is usually a bad investment: it cannot produce high-quality images, and poor image quality leads to errors. It often uses a high dose of radiation for each exposure, it may not be safe, and it will usually need a lot of maintenance and repair. The initial capital expense and the maintenance of imaging equipment is a major item for most hospital budgets; cutting purchase costs by buying cheap equipment can prove to be a false economy. Gifts of equipment may be even worse. Too often, the donated equipment is out-of-date, and no spare parts are available. The same criteria should be applied to gifts as to new equipment.

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Fig. 47.1 A, B. Diagnostic imaging should be available to all who need it. (A) A Maasai lady in traditional dress having her wrist x-rayed. (Courtesy of WHO: D. Gibson.) (B) Yemeni Arabs looking at a chest x-ray on their way to see the doctor. (Courtesy of WHO).

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Fig. 47.2 A-D. Large or small, first referral hospitals should have diagnostic imaging, such as these hospitals in Africa (A), South America (B), Asia (C), and the South Pacific (D).

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Copyright: Palmer and Reeder