We concluded the procedure training with the physicians continuing to improve their venous access skills and understanding of chronic venous insufficiency. We were joined by a new physician Yukihisa Ogawa, “Yuki” for short, pronounced; (u-key). He was a great addition; very productive and with good ultrasound skills. He seemed very young but they all look that way. This last segment concludes the training. I am relieved the 11 hour days have come to an end.

Dr. Ogawa, Dr. Nakajima, Dr. Yoshimatsu, & Dr. Raabe

I mentioned in previous entries Dr. Katayama who owns and runs the largest imaging center in Japan; he insisted we come see his center. They have 4 PET CT, 1 mamm PET CT, 2 MRI and assorted other modalities. The building is rather large with 5 floors. They employ 110 employees throughout the imaging center and have PACS/RIS, etc. I don’t believe the Inland radiologists would like the reading rooms/areas. They all sit in one large room with 2 monitors and read. No barriers or privacy at all. In certain areas you have to switch from your street shoes into the customary Japanese slippers.

Japanese slippers.

The imaging center sees 1000 patients per month who are referred to it. The center is rather stark and sterile looking, but certainly functional. We had the tour at 6pm and the whole center was closed. They conclude business promptly at 5pm. Even though this is a private pay center, the social aspect of their medicine still has an impression.

Dr. Katayama, Dr. Raabe, & Dr. Ogawa

As usual we then proceed to dinner. This time we went to an area in Tokyo which is popular with foreigners named Rowpunga. The menu is very diverse. After dinner we proceed to a Jazz Bar which is probably the smallest bar I have ever been in. In order to get to some of the seating you have to walk behind the bar. We met up with former Gonzaga player Cory Violette and his girlfriend Beatrice. They seemed to enjoy talking with Americans for a change. Cory plays for Team Toshiba. The team’s name is called “The Brave Thunders“. No one knows what a Brave Thunder is, Cory got a great laugh out of this. Cory really didn’t fit in this bar as he is 6′9″. He is quite the spectacle amongst the Japanese population.

Nate, Beatrice, Cory Violette, Dr. Raabe

The next morning we traveled to St. Mariana University Hospital to tour the radiology department. My battery died on my camera so, unfortunately, I didn’t get many pictures. The hospital is huge and I was shocked by how many patients are waiting. Chairs line most hallways and are nearly all full with people waiting. We got to meet many physicians and technologists and saw many of the same technology we use in the U.S. It is a rather stark and aged environment.

Steamed radish or something. Not my favorite.

Our hosts invited us to travel to Hokane which is a mountain town near Mt. Fuji. We stayed here one night and enjoyed the traditional Japanese baths and an immersion in Japanese customs. The first order upon arriving is changing into a Yutawka which is a casual kimono. Yes, we left on our boxers. You also have to wear these sandals which are made out of hardwood and were treacherous to walk in. I never did figure out the technique. Of course once again we eat a meal which had amazing sushi, sashimi, and other bizarre offerings.

These were actually pretty tasty, heads and all.

Sushi!!!

Traditional Japanese breakfast.

All of this travel was done by train including a switchback train which goes up a series of tracks then backs up a switchback, so on and so forth until reaching the top. It was quite snowy and cold up here. The next morning we traveled up a cable car to a view point for Mt Fuji. It was a very clear day and we got a fantastic view of Mt. Fuji.

Cable Car Station

Mt. Fuji

We boarded one of the bullet trains for our trip back to Tokyo. These babies cruise at 200 mph and ride really smooth. Watching them go by the station was incredible. As you just start to hear one it hauls by and is gone!

We are now back in Tokyo at a great hotel next to the train station, which is always important as the train is the best way to commute and get around. The difficulty with the train is the intricacy of getting the right ticket and then figuring out where to catch your train. There are 4-5 levels of basement involved in the maze of Tokyo Station. Cory Violette invited us to attend his game in Tokyo for tonight. So again we board the train with Dr. Takazawa and head to a gym somewhere in Tokyo. This was a good time, mainly watching how the game is played. They can only have 1 American on the floor at any one time, so Cory shares play time with Tyler Newton who played college ball at University of the Pacific Stockton. Tyler is 6′11″ so he and Cory walking down the streets of Tokyo is quite the spectacle. The best part of this night is eating dinner at Outback Steakhouse in Sheboyen. I am not a big fan of Outback in Spokane, but tonight it is awesome to have some American food!!

You can see where an American basketball player might stand out in Japan.

We fly back on Saturday which since you fly east there is generally a tail wind and the flight will only be 9 hours.

Thanks for reading,

-Monte

Each morning, we jump in with the mass of Japanese people and commute to the Kato Clinic where we perform and educate on the vein cases. The Japanese men seem to all wear predominantly black which makes the mass of people really seem larger than it may be. We (especially Dr. Raabe with his gray hair) stick out prominently and get some odd looks from our fellow commuters. As I mentioned before our hotel is above the main train station, so we get to see the spectacle of humanity daily.

Nate Raabe in the daily commute.

As part of our training we are trying to get the Japanese Physicians to perform the procedure on their own. The socialized medicine mentality seems to have created a “busy” but unproductive work environment. I am being very frank, but it is frustrating coming from our work culture and our adherence to being on time and effective, to a situation where that isn’t 2nd nature. We are trying to “kick them out of the nest” at this point and I am optimistic they will rise to the challenge.

Dr. Raabe instructing Dr. Yoshimatsu on an ablation case.

We performed 4 cases yesterday in an 11 hour day. This pales significantly to what we accomplished even in the early stages of developing the work flow at Inland Vascular Institute/Vanishing Veins. The language barrier is a larger hurdle than I anticipated.

I have been working with two ultrasound machines while here. The first is a Siemens X300 which I have used in the U.S. before, the second is a Konica, which I have never seen or heard of before. I think the operation of them would be simple; however all the control labels are in Japanese! So I just keep trying what seems obvious and hoping that works for gain, color, and Doppler. Very challenging. The keyboard and annotation is all in English so that’s a good thing from my self-serving standpoint.

Lunch today was Bento boxes again. The one I had is the most popular one in Japan and has been unchanged for 20 years. They are good the first time, okay the second time and not so great the third time.

The Bento Box lunch, most popular in Japan. Looks yummy doesn't it?

Kaye Suzuki took us to dinner on the 40th floor of the Princess Hotel at a really nice traditional Japanese Restaurant. This dinner was awesome. Five¬ courses with very small helpings, but a flavor explosion on each serving. The sashimi and beef is prepared meticulously. The presentation is like none other.

Drinking Saki out of little tiny glasses at the Princess Hotel.

Sashimi

The usual suspects.

Another long day is in store for tomorrow with 4 cases. We are hoping to meet up with former Gonzaga basketball player Cory Violette to go to one of his professional basketball games. Cory has played here for about 2 years. I will let you know how that turns out.

Thanks for reading,

-Monte

I don’t think I would have believed this unless I was there.

We are staying in a nice, “business” hotel. The hotel is only 1 year old and sits on top of the station for the Japan Bullet train, which travels at 200 mph around the region.

View from the 13th floor of Shin Yokohama Hotel. The Walkway goes to the train station.

The lobby of our hotel sits on the 10th floor of this complex. A very nice breakfast is included in a person’s stay. Fairly westernized food is offered at this breakfast, although they like their bacon lightly cooked and I won’t eat the fish offering again. I could taste it the rest of the day until lunch when I ate what appeared to be a seaweed wrap with rice and tuna salad. So then I had that taste filling my senses the rest of the day.

The clinic where we are performing the procedures is a short walk from our hotel. Kaye Suzuki joined us this morning to walk to the clinic. Kaye lives an hour away by train (non-bullet). Walking to the clinic with the rest of Japanese Humanity was a true cultural education. Many people wear surgical face masks while commuting to avoid illness.

Following Kaye Suzuki to the Clinic

We started the day performing some diagnostic ultrasounds on patients who had been undiagnosed or misdiagnosed for venous stasis ulcers for several years. The 1st gentleman was a sushi chef in Yokohama and a very kind man. His legs were a mess from the years of venous reflux disease. This is where it gets interesting. As we were preparing the procedure room for this gentleman’s case we realized that the laser generator was the newest model; however the laser fibers were only to be used in the older model of laser generators. These had been shipped from 2 different locations (which we were cautioned against beforehand) hence the mistake.

Nate made a trip to Starbucks.

We are now dead in the water, no way to perform the procedures, no work around despite calls all around the world for advice. The outlook was very grim for what was to be our primary reason for coming to Japan. Dr. Nakajima had a MD friend in downtown Tokyo who had been doing some of the procedures over the course of a couple years. This physician said he had an older generator that he hadn’t used in about 1 year that may work with our fibers. We checked with some contacts in the U.S. and they agreed if this generator was indeed the model cited it would work. So Dr. Raabe, Dr. Nakajima, Sagee (lab assistant) and myself jump in a small weird Toyota car and take off for a 2 hour round trip to Tokyo. On the way on the freeway (which aren’t free at all as there are toll booths every 10 miles or so) we come upon a motorcycle wreck in which we are the 2nd car on the scene. The motorcycle was a courier type of bike and there was all types of stuff spread all over the freeway. The rider was up and collecting his things, so we all jumped out and helped pick everything from hats to the fender, maps etc. Dr. Nakajima checked briefly with the rider and he seemed to confirm he was ok. It was raining pretty hard at this point. Well, we pile back in and onward we go. About 5 miles later I realize my cell phone is gone. I figure it must have fell off my belt when we helped at the motorcycle wreck. I was really bummed; I figured it was a pancake on the freeway.

Sagee the lab assistant started making calls for the rest of the 2 hours we traveled calling various police contacts to see if anyone had turned in or picked up my phone. He talked the whole time we traveled. Dr. Raabe and I were sure it was history.

First case with the sushi chef.

So we get to the MD’s office in central Tokyo and sure enough the laser works for us. We cannot believe how lucky we are to find this generator. Our whole project is back online. We pile back in to the car and head back to Yokohama. We forge ahead with the 2 scheduled cases. Both go relatively smoothly.

Near the end of the last case, Sagee runs up with a big smile and says (through interpretation) that they found my phone and have it at a police station! He takes off to get it. Our good luck continues!

The "team" from left Dr. Nakajima, Dr. Yoshimatsu, Dr. Takaza, Dr. Raabe, me and first patient completed at Shin Yokohama clinic.

Shabu Shabu, me and Dr. Takazawa.

We conclude the day at the clinic and head to dinner which once again was a culinary adventure. Shabu Shabu is raw fatty beef which you boil for 10-15 secs in a tuna stock. Then you dip into various sauces, delicious.

Long, long, lucky day. Thanks for reading,

-Monte

Monte Madsen

Eighteen months ago, Dr. Rod Raabe was asked by an acquaintance of his, Dr. Yasuo Nakajima from Tokyo, Japan if Dr. Raabe could come to Japan to teach them how to treat varicose vein disease using lasers and other methods. The initial contact was in May of 2008. Dr. Nakajima had interest in varicose vein therapy, specifically using thermal (laser) ablation.  The conversations continued with interested parties consisting of Dr. Raabe, Yasuo Nakajima MD, Nate Raabe and myself.  Nate owns a practice development company that helps vein centers in the United States use marketing and management tools to enhance their vein practices. Dr. Nakajima is a former head of the Japanese Society of Interventional Radiology. Dr Nakajima had heard of the success of Inland Vascular Institute’s Vanishing Veins Center (a company owned by Inland Imaging vascular surgeons) in Spokane from other American radiologists.

The Japanese contingency came to the United States for the first level of training in September 2009. This group consisted of Dr. Yasuo Nakajima, Dr. Kenji Takazawa (interventional radiologist, figure skater and jazz drummer) and Dr. Misako Yoshimatsu (interventional radiologist). They traveled to Phoenix, Arizona where the initial training was done.  Dr. Nakajima had some other obligations in Arizona so the timing worked well.  After the Arizona training we were asked to travel to Japan and assist them with their first laser cases and help them with some of the business and setup aspects of establishing a vein center. Angiodynamics, manufacturer and proprietor of the laser devices, came on board to help subsidize the travel and supply product for Japan.

The use of lasers to treat chronic venous insufficiency does not have a “Shonan” or their equivalent of FDA approval. It is still legal for private physicians to perform the procedure, but there is no reimbursement from the governments socialized form of healthcare, yet.

Now that we have that covered, that brings us to this “Blog”. I was asked to write a blog during our trip to Japan to give insight to Japanese culture, medicine and patients.  So here we go.

Dr. Rod Raabe, Nate Raabe and I left Los Angeles Airport at 11:39am on Saturday, January 30^th, 2010.  The flight to Tokyo’s Narita airport is 10.5 hours long. So after 4 movies, a feeble attempt at sleeping and lot’s of food and drink provided by United Airlines, we arrived in Tokyo at 4:30 pm on Sunday, January 31^st, 2010. Did I mention we flew Economy Class?  So you can do the math You lose nearly one whole day somewhere over the Pacific Ocean and you never flew at night. I had always heard the random expression “it’s halfway around the world.” Well, Japan is halfway around the world. We all felt good, though.

We were met at the airport by Dr. Takazawa, Dr. Yashimoto, and an internal medical MD – Atsushi Katayama. We boarded into a large new Toyota van that isn’t sold in the U.S. and drove 80 minutes to Yokohama, Japan, which is southeast of Tokyo. Shin Yokohama or “New” Yokohama is Japan’s second largest city. Yokohama’s port to Tokyo Bay was one of the first ports to be opened to foreign trade in 1859. Consequently, Yokohama quickly grew from a small fishing village into one of Japan’s major cities.

A picture says a lot. Click to enlarge

Arriving in Yokohama, I am impressed by the modern appearance and cleanliness of the city.  I am amazed by the automation of doors, parking meters and, frankly, the toilets. The first picture is the controls for the toilet in my hotel room.  Even the public restrooms have this high degree of technology.  Heated seats, by the way.

After arriving, we picked up “fast food” which consisted of Bento boxes which have a combination of rice, vegetables, sweet eggs, shrimp, chestnuts and what they told me was a pork-something or other. It looked like raw sausage, but tasted great.  The fast food joint was positioned like a small off-ramp from the freeway; you just drive up, pick up and turn right back into 65 mph traffic.

Dr. Atsushi Katayama who drove the van is an internal medicine physician who doesn’t practice but owns and operates the largest imaging center in Japan. He drove us by the center on the way to the clinic where we were going to perform the procedures and it was very impressive even by Inland Imaging standards. I don’t recall the exact numbers, but within a 5 story imaging center they have 3 MRI machines, 2-3 standard CT systems, 3 PET CT units and the only Mamm PET machine in all of Japan. Ultrasound, Nuclear Medicine are all there as well. What most impressed me was there are 2 cyclotrons in the imaging center as well! Interesting guy!

Dr. Katayama and Keisuki (Kaye) Suzuki at the Kato Clinic.

We then visited the clinic where the training and procedures will take place; very modern and space efficient.  Space comes at a premium in Japan so it appears no space is wasted.

We made contact with a Japanese businessman, Keisuki Suzuki, when this project started. He is well known in the U.S. and has provided help to medical device companies with regulatory pathways, etc., for introducing products into Japan. Very cool character. He is basically our liaison for this trip.

I was asked to come for the ultrasound training aspect and am looking forward to that.

It was a busy first day. The jet lag is in full force, so waking up at 4 a.m. Japan time has given me the time window to write this.

Thanks for reading,

-Monte

Janet (not her real name) is a woman who was prepared to deal with crisis. As the regional public affairs director for one of the area’s largest employers, she dealt with government relations and public policy issues, legislative matters, public and media relations, crises (as in multiple) communications, and more. And while that may seem like more than a full plate to most of us, Janet’s role as a wife and mother was every bit a full-time vocation as well.

Her years of experience, education and training, and the guidance of strong mentors meant Janet understood and performed her roles very, very well.  It went without saying that she was more than prepared to deal with just about any crisis she might confront.

“Expect the unexpected. Hope for the best, but prepare for the worst — these are the watchwords of crisis management,” says Janet. And as prepared as she was for most contingencies, there was little that readied her for an unwelcome discovery one morning in 1986.

During one of the monthly self-examinations she’d occasionally performed for years, Janet found a lump in her breast. A follow-up examination by her physician and a mammogram at Inland Imaging confirmed it. Janet scheduled her mastectomy surgery and began planning for her recovery. “I didn’t want to waste time and felt like moving forward with surgery would mean a better chance at beating the disease, getting my recovery going, and coming back to my life sooner,” says Janet.

Following a successful procedure and six weeks away from the job, Janet returned to work. “It took time, energy and the support of my family and friends, the doctors and medical staff, my colleagues at work, and too many others to thank to get me through it all. It almost seems unreal to say, but it’s true — I’m a 23 year breast cancer survivor who’s living well and feeling strong,” says Janet.

In the years since her surgery, Janet has handled governmental affairs for several city administrations, and most recently opened her own business as a public affairs consultant serving corporate, governmental, and non-profit clients.

Through it all, she remains committed to the support and promotion of efforts to help women battling breast cancer. “Information, education, prevention and awareness are critical to beating the disease. I participate in the Komen Foundation’s Race for the Cure, and other efforts to promote breast cancer awareness and fund research. And most recently, I joined Inland Imaging’s Every Woman Can Campaign by commenting on its Facebook page,” says Janet.

“I encourage the women I know to be informed and educated on the subject, too. Along with the intellectual part of breast cancer awareness, another huge piece of the puzzle is simply being aware of your own body — and taking the time to do regular self-exams every month. Every extra day you gain through early detection gives you more time to put medicine to work for you. The science has come so far — today if breast cancer is caught early enough, it’s more and more treatable and survivable.”

For many women though, just the prospect of finding a lump can be enough to put them off doing regular exams. “That seems counter intuitive, but it’s true. Just the idea of finding a lump can be frightening and a lot of women would rather not think about it,” says Janet.

But according to Janet, the experience doesn’t have to be daunting. “It’s to every woman’s benefit to self-examine monthly and schedule a screening mammogram every year. I make my own appointments for my annual mammograms and have always done them at Inland Imaging. I’ve been impressed with how the people there make what could be an emotionally overwhelming experience easy and less stressful. The atmosphere is light and friendly, as I find humor often overcomes adversity. It’s something every woman should do.”

And every woman can.

The Holy Family Foundation recently received a donation from Inland Imaging to upgrade to a new portable digital x-ray system, purchased through Core Medical Systems. The upgrade allows digital radiography to be used  throughout Holy Family Hospital.

The biggest benefit to patients is realized when this technology is used in the operating room and for emergent cases on the nursing units.

On the old analog system, a physician had to wait as much as 20 minutes to receive an image on film. Now, the images take just seconds to be captured and seen on a computer monitor for instant viewing by the doctor, greatly improving patient care.

Images are then quickly sent to Inland Imaging’s picture archiving and communication system (PACS) via wireless connection for interpretation by the Radiologists. Moving from analog to digital technology also improves image quality and resolution which increases the accuracy of the diagnosis.

Access to an image archive allows physicians throughout the region to electronically view and compare medical images for their patients.

“Going Green,” seems to be the all the buzz these days and Inland Imaging wants to be an active participant. Inland Imaging is making changes to not only better the environment, but also create a positive and streamlined patient experience. As a digital company, it is our goal to provide a sustainable and eco friendly medical community to work and visit.

We are currently in the process of remodeling two centers to reduce unnecessary waste and increase our power efficiencies. Not only will the remodeled centers be more comfortable and aesthetically pleasing, but should eliminate unneeded power expenditures.

In a recent study done by the U.S. Environmental Protection Agency, it noted that the average office generates approximately two pounds of paper every day. As a result, contributing to the deforestation of the planet.

A couple of years ago, Inland Imaging implemented a new software system that greatly reduces the amount of paper needed at our centers. We also print documents and marketing materials on recycled paper, using ink that is less harmful to the environment. Whenever possible, we make full use of a piece of paper by printing on both sides.

In order to cut down and eliminate the company’s use of unsustainable products, we have provided all employees with re-usable water bottles, coffee mugs, lunch bags, and grocery sacks. Each week, we gather and take all plastic water bottles, cans, and cardboard boxes to the local recycling center.

Inland Imaging is aware the effect that heavy traffic can have on air quality. We now provide discounted bus passes to employees and encourage patients to ride the bus to their appointment. Bike racks also are provided for employees and patients that ride to one of our locations.

Inland Imaging supports local groups that are helping to keep the Inland Northwest a viable place to live and work. We have worked closely with organizations such as Spokefest, Unity in the Community, Spokane Transit Authority, and others.

Inland Imaging realizes there are plenty more opportunities to reduce our impact on the envroment. Simple habit changes can greatly make a difference in people’s lives over time.

We would like to take a moment to congratulate the breast imaging section at Inland Imaging. We have just received notification that we are breast ultrasound and breast ultrasound biopsy accredited at our imaging center located in the Sacred Heart Doctor’s Building. Inland staff members Rosemary, John, and Penny worked diligently to achieve this honor.

Inland Imaging has been Stereobiopsy accredited thanks to the hard work of Jan, Julie, and the dedicated team of mammography technologists at our imaging center located in the Sacred Heart Doctor’s Building.

We have always been MQSA (Mammography Quality Standards Act) accredited as required by Federal law. Again, thanks to Jan and all the Breast Imaging team.

By virtue of all these accreditations, the Inland Imaging Center at Sacred Heart Doctor’s Office Building is now deemed a Breast Imaging Center of Excellence as deemed by the American College of Radiology.

It is truly an honor to work with these dedicated professionals!

Shortly, we will apply for Breast Ultrasound and Breast Ultrasound Biopsy accreditation at the Inland Imaging facilities at Holy Family and Valley Center, also making them Breast Imaging Centers of Excellence.

Click Here to read the official announcement

Inland Imaging meets with Congresswoman Cathy McMorris Rogers

Inland Imaging has been working closely with Washington State governing officials to share our insight on how to better the health care system, particularly how it relates to medical imaging. The Obama Administration has made it top priority to soon reform the current system in order to reduce costs, ensure affordable care for everyone, and guarantee that patients can choose their health care provider no matter how they are covered.

It is our hope, that whatever legislation ultimately is passed by Congress, that we are prepared and actively involved. Recently, we met with Washington State Senator, Maria Cantwell, and Congresswoman Cathy McMorris Rogers to discuss how best to reduce the cost of medical imaging procedures and increase the accessibility to quality patient care.

We spoke of introducing appropriateness criteria for ordering medical imaging studies and how to reduce the amount of unnecessary studies. We also discussed ways to introduce and mandate accreditation standards for radiologists and the facilities performing the studies, something we actively participate in doing now.

We believe that efforts in these areas will provide substantial Medicare cost reduction from over-utilization of imaging, while also increasing the quality of care. It is our goal to see legislature adopt appropriateness criteria set forth by the American College of Radiology (ACR) or other evidence based medical organizations.

In the area of accreditation, we believe that programs such as the Mammography Quality Standards Act (MQSA) offer a well-documented model for accrediting other imaging modalities such as magnetic resonance imaging (MRI) and computed tomography (CT).

Inland Imaging is also helping to design and implement a network for sharing and the storing of electronic medical records. Specifically, Inland Imaging is working with area medical offices to store medical images and make them more readily available to referring physicians no matter where they are located. Such efforts will allow physicians to see a patient’s medical history and view their images anytime, anywhere.

In all, Inland Imaging is dedicated to working closely with legislators and the medical community to help in strengthening health care locally and nationally. We understand the importance of communicating with area physicians and implementing a best practice approach to offering services to our patients.

Jon Copeland - Inland Imaging Business CEO

Recently, Inland Imaging Business Associates CEO, Jon Copeland traveled to Colima, Mexico in support of Project Amigo. The program is designed to break the poverty cycle and help educate children in underdeveloped areas of Mexico.

Jon’s sister and brother-in-law have been instrumental in the success of the project. In 20 years time, they have developed a sustainable system that provides a positive learning environment that encourages children to stay in school.

One such success story of Project Amigo is of a girl that started as a sponsored child at age 5. The girl would ride in with her father on horseback to go to school, get a pair of shoes, and have a meal. She was able to maintain a B average and continue to be sponsored through high school and college. Today, she is a practicing physician for the same Village in which she grew up, aiding medical support to her family and friends.

Last year, Jon lost his sister to cancer and wanted to continue her legacy of making a difference by taking her place in Project Amigo. During his trip, Jon helped to open an Internet café to give students a place to have a supervised area to learn and grow. They held a grand opening and invited the children to learn how to use the new technology.

Today, there are over 600 sponsored children receiving a proper education in a fun and nurturing environment. Jon plans to return in the fall to check the status of his Internet café and see the progress of those that he is sponsoring. He says he will bring his daughter, so she can appreciate the joy giving and partake in making a difference with her dad.

If you would like to find more information about Project Amigo, please visit – www.projectamigo.org

Program Amigo graduate is now a practicing physician in her village

Colima, Mexico is located near an active volcano

Grand opening of new internet cafe