R.Paul Consulting
R.Paul Consulting

2020 Blog Entries


Don't know how to get ahead in the work-place? 2021 is just around the corner, and you still have plenty of time to plan your New Year's resolution!


After receiving countless emails asking for advice, I figured I'd go ahead and just share my perspective on what it takes to elevate your sense of self-worth.


1. Getting comfortable with the uncomfortable.  When doing so, it means you're learning something new.  Embrace it, don't reject!

2. Treat every-single-person respectfully the same, regardless of title, or degree.

3. Don't prioritize your personal needs when on the clock. We've all been there, it's 4pm, you have personal errands to run, and a patient is being added on. Without hesitation, do you start the patient's exam or lie and say your dose expired?

4. Document. Every. Single. Contribution. That goes over-and-beyond.  This alone has doubled my net worth.  Don't know where to start? Read step one. Oh, and master the art of OCB (organizational citizenship behavior).

5. It's the small tasks that make the big picture.  Remember this the next time you're asked to help clean the bathroom, or take out the trash.

6. Obsessed with making decent money? Assuming you have mastered everything on this list, have at least 15 years under your belt, and seriously have your shit together, start building your network by consulting on the side, and aim for middle-management positions for your full-time gig. Those who refuse to work unpaid overtime (assuming salaried), the occasional weekend, and after-hours won't survive.

7.  Don't let poor money management habits fuel unrealistic upward mobility.  For those new grads - I get it.  You want that new car, house, etc. to show others how hard you've worked. But it can be a massive counterweight, especially if the pretense results in a sense of entitlement.

8.  Advocate for anyone, even if they're in another department, or business.  Recognize people when they do great work!  Want to go that extra mile?  A hand-written letter can result in extraordinary outcomes.

9.  Don't underestimate the importance of constantly refining your emotional intelligence.

10. Put the ego aside, and just admit when you're wrong.  Your staff and peers will respect you more in the long run.

11. Strive to surround yourself with the decision makers.  Yeah, that means possibly dealing with quirky, awkward, over-demanding personalities (read step 1 again!), but this will guarantee your accomplishments will be recognized.

12.  Not responding to work related emails within 48 hours.  It's the same concept as never picking up the phone. Take email etiquette seriously, and stop being rude.

13.  Don't underestimate the power of leverage when negotiating with your employer, as well as when to compromise.  Very rarely do we get everything we want, when we want it, but that doesn't mean one has to leave empty-handed.

14.  Random acts of kindness is a guaranteed way to build staff loyalty.

15.  Set clear boundaries between your work and home-life. 

16.  Creating empathy in the workplace.  Somewhat of a lost art this day and age.  Having an active role in supporting staff through extremely difficult circumstances can result in increased staff retention. 
17.  Don't make assumptions.  There's a reason why the first three letters are a-s-s.

18.  While this isn't practical given the current state of affairs, once we're all vaccinated - show off those pearly whites and try smiling more!  The old adage "happiness is contagious" couldn't be truer!


It can't be all work and no play! When I'm not overseeing the imaging logistics at Atlanta Heart Specialists nine imaging locations, I have quite a few passions that keep me busy during my spare time:
1. I'm a drummer for a 'Geek-Rock' band in Atlanta called Hyperspace: https://lnkd.in/dgqTu4e
2. I love to cook! My most prized cooking possessions are my Shun knives and 16 qt cast-iron dutch oven.
3. I build/fix computers! Anyone who has access to an AMD Ryzen 9 5900x CPU - message me ASAP!
4. I fix/tinker cars! Starters, alternators, brakes, etc. - I've done it all!
5. I'm a runner! Thanks to custom orthotics, my New Balance 840v4's feel like I'm running on clouds.
6. I'm an audiophile! Being a musician, music fidelity is something that deserves much more attention, especially during an era where all streamed music is highly compressed.

Thanks for reading and I hope all of you have a wonderful, safe holiday!




Why is it that OPPS pays out $10/Tc99m dose if it's derived from a non-HEU source by billing Q9969, but yet there's nothing comparable on the CMS fee schedule?



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59 y/o male in for testing after having chest discomfort while drinking coffee. Calcium scoring came in at 211 finding three focal, densely calcified lesions in the left main, proximal LAD, and proximal circumflex. Baseline EKG shows prominent Q-waves inferiorly with a repolarization abnormality. 3 minutes into Bruce, 2-3mm's of ST elevation is seen in the same inferior leads, and diffuse reciprocal ST depression develops, more-so in leads AvL and V2. The patient ultimately refused a cardiac catheterization.


45 y/o male with a history of tuberculosis induced constrictive pericarditis. Once the perfusion images were completed, without first researching the patients history, at first glance I suspected situs inversus, however the SPECT images quickly ruled that out. When comparing the mid-lateral wall between echo and perfusion imaging, the scarred, thickened pericardium is what's contributing to its 'bent in' shape.

Next food marketing trend outside of organic?

41 year old COVID+ male on day 15 after mandatory quarantine. No prior history of CAD, only risk factor was hypertension. Stress images were not completed due to patient being admitted to a local ER.

This is why we perform daily floods! Gamma camera was off for an extended period of time which resulted in our peaks swaying around -7 keV. Tune has already been scheduled!



A great case study in this months JNC depicting how long-term PPI use can cause unwanted gastric wall uptake during perfusion imaging.

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Classic false-positive EKG response in a 67 year old female. It's been hypothesized pre and post-menopausal women have these ST segmental changes due to estrogen fluctuations, both natural and synthetic. While adding perfusion SPECT images and the ejection fraction does appreciably increase the overall prognostic value, one has to wonder how FFR's could add a much higher specificity in the detection of present coronary disease.

As I've said before - fully understand your injected radiopharmaceuticals normal organ biodistribution and pharmacokinetics. Working in Nuclear Cardiology we tend to only focus on what's centered in our ROI's during post-processing. Take the time to keenly scower your SPECT images for anything that appears to be 'not right.' Speaking of odd uptake - ever notice right auricle uptake (atrial appendage) with certain Tc99m perfusion agents? Often confused as a mediastinal mass, it's classified as a normal variant, however if that's the case - why don't we see that uptake pattern in all studies?


Looks like GE has HeartFlow in its cross-hairs!

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Civilian derived radioactive cloud over Europe? While Fukishima would be a likely culprit, after analyzing the isotope ruthenium-106, scientists can't pinpoint an exact culprit, however it was cited that - "The isotope signature discovered in the air filter exhibits no similarities with nuclear fuels of conventional Western pressurized or boiling water reactors. Instead, it is consistent with the isotope signature of a specific type of Russian pressurized water reactors—the VVER series. Worldwide, approximately 20 reactors of this type of VVER are currently operational,"




This patient arrived for a routine outpatient nuclear stress test. Only complaint was shortness of breath and palpitations. A quick baseline found the attached EKG. 5mg of Metoprolol and 150mg of Amiodarone put him back in sinus rhythm, however he was still rushed to the ER for further evaluation.

Imaging volumes are definitely on an upward rebound. Optimistic this trend will continue!


Spectrum Dynamics is once again pushing molecular imaging's technology to a higher echelon. Their latest patent illustrates multiple collision-free detectors having adjustable bore sizes with 'shutter-like' collimating cells granting the end user not just an unparalleled amount of configuration options, but the ability to selectively choose between SPECT, and PET imaging -- or even simultaneous!

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High first-pass extraction - check.
Relatively short-half life and low energy - check.
Optimal post-injection imaging time - check.
High myocardial retention - check.
Acceptable myocardial washout kinetics - check.
MBF quantification feasible - check.

These characteristics were all found with 99mTc-3SPboroxime, a novel perfusion agent that shares many similarities to 99mTc-Teboroxime.

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Forgive the tepid response, but this isn't exactly an earth-shattering revelation. Scroll on down to the article's disclosure and you'll see where I'm coming from.

GE: The Tetrofosmin 'interest-well' is running dry my friends. Please focus your sponsored marketing efforts into Flurpiridaz!

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As one of the most widely used perfusion radiotracers, Tc99m-Tetrofosmin lies at the very bottom of the 'perfusion pyramid' plateauing at 1.5 - 2mL/min/g. For comparative purposes, Tc99m-Teboroxime plateaus right around 4.5mL/min/g. What's the clinical significance? Frankly put - Tetrofosmin underestimates occlusive coronary disease with some studies measuring a 36% cause of false-negative MPI. When using this radiotracer, interpretive confidence should be multi-factorial with patients symptoms, EKG changes, TID, blunted heart rate response, and wall thickening abnormalities having a precedence in the setting of normal perfusion images.

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A great case study reminding us that even endurance athletes are susceptible to cardiovascular disease, albeit they are an extreme minority. The below images are from a 53 y/o male competitive marathon runner with recent complaints of fatigue and palpitations. Completed an impressive 20 minutes on the Bruce stress protocol, only symptom being fatigue, however 2-3mm of horizontal ST depression was present at peak exercise, and there was a salvo of NSVT during recovery. Perfusion images and polar maps displayed a mild, partially reversible defect in the anteroapical wall. Cardiac catheterization found a 80% mid-LAD lesion.


In this months JNC, an entry was submitted by The Cleveland Clinic stating that the H/CL ratios produced when performing a PYP-TTR Amyloid scan are not enough to conclusively diagnose TTR cardiac amyloidosis if there's presence of prior infarcts. For those of you who've been in the field long enough, this shouldn't come as a surprise when considering Tc99m-PYP was first commercially available in 1976 specifically for infarct avid and bone imaging. Prior to ordering a PYP study, providers will need to screen these patients for a recent echocardiogram, perfusion imaging, baseline EKG changes, and a cardiac biomarker lab panel for any indication of an old or recent infarction which could compromise the exams overall sensitivity/specificity.



Getting back to the basics with Dr.Ernest Garcia!

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Prone power! Just one extra 3-minute SPECT can avoid a potential false-positive.

A great example of clinical intuition paying off. 59 year old female in for preop evaluation. Went over 8 minutes with the Bruce protocol completely asymptomatic, however had diffuse 2.5-3mm down-sloping ST depression. Perfusion slices only within the short-axis displayed a very minuscule area of reversibility in the anteroseptal region. Ejection fraction and wall thickening were both normal at 63%. An elevated TID of 1.5 was present as well. Cardiac catheterization found a 70% occluded diagonal branch.
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