Implementation of the First CT Scanner in
the Eastern Arctic
May 28 – 30, 2015, Montréal, Québec
Disclosure Statement: No Conflict of Interest
I do not have an affiliation, financial or otherwise, with a pharmaceutical company, medical
device or communications organization.
I have no conflicts of interest to disclose ( i.e. no industry funding received or other
commercial relationships).
I have no financial relationship or advisory role with pharmaceutical or device-making
companies, or CME provider.
I will be discussing the results of ____ (“off-label” use), which is currently classified by
Health Canada as investigational for the intended use.
I will not discuss or describe in my presentation at the meeting the investigational or
unlabeled ("off-label") use of a medical device, product, or pharmaceutical that is
classified by Health Canada as investigational for the intended use.
May 28 – 30, 2015, Montréal, Québec
Implementation of the
First CT Scanner in the
Eastern Arctic
PRESENTED BY: JENNIFER SHARPE
MANAGER OF DIAGNOSTIC IMAGING, QIKIQTANI GENERAL HOSPITAL
Iqaluit, Nunavut
Iqaluit - ᐃᖃᓗᐃᑦ - 'Place of many
fish'

City of Iqaluit is located on Baffin Island, at the northern end of
Frobisher Bay, near the mouth of the Sylvia Grinnell River.

Iqaluit is the territorial capital of Nunavut, the largest and fastestgrowing community in the territory.

The landing strip is long enough to land the space shuttle, so it is
often used for cold weather testing of the world's largest new
aircraft.

Formerly known as Frobisher Bay, the modern city of Iqaluit is rich
with traditional Inuit culture.

The friendly people of Iqaluit — the 'Iqalumiut' — love to go out on
the land, sea and ice at all times of the year to enjoy a variety of
outdoor activities.
Iqaluit, Nunavut
Iqaluit - ᐃᖃᓗᐃᑦ - 'Place of many
fish'

POPULATION 7,250

60% Inuit

Languages – Inuktitut, English, French

From May through August, days are long and sunny, averaging 16 hours
of daylight with temperatures of 5°C to 25°C.

The city enjoys nearly 24 hours of sunshine in late June and early July,
with beautiful twilight skies for two hours around midnight.

The shortest days of December have four hours of daylight, with the sun
hovering on the southern horizon.

Northern Lights are frequently seen from October to April.

Winter temperatures of -10°C to -50°C are common.
Where the heck is Iqaluit, anyway?
Qikiqtani General
Hospital
QGH is a 35 bed acute care facility in Iqaluit.
The hospital serves the approximately 16,000
people in the Qikiqtani (Baffin) Region, which is
home to 12 communities spread over
approximately one million square miles! It is the
only hospital located in the territory of
Nunavut.
Relevant Statistics

Lung cancer is the leading cancer amongst Nunavummiut, accounting for 32% (247cases)
of reported cancer cases.

60% of Nunavummiut aged12 years or older report smoking, which is three times higher
than the national average.

62 % of Nunavummiut diagnosed with lung cancer died within one year of diagnosis.

A CT scan can reveal small lesions in the lungs that might not be detected on an X-ray.

Colorectal Cancer is the second leading cancer in Nunavut, accounting for 19% (136
cases) of reported cancer cases.

Risk factors include alcohol and tobacco use, diet and obesity.

26% of Nunavummiut who were diagnosed with colorectal cancer died within one year of
diagnosis.
Relevant Statistics

Since its inception as a Territory in 1999, Nunavut has faced the highest reported
tuberculosis (TB)incidence rate in Canada.

The rate of TB infections in Nunavut is 62 times the Canadian average.

Crowded housing conditions, poor nutrition and high smoking rates partly contribute
to the high rate of TB incidents.

TB primarily attacks the lungs and can be deadly without treatment.

HRCT scanning in the investigation of TB may be helpful in differentiating active TB from
LTBI more reliably.

Lung mass is not visible on conventional X-rays unless they are larger than 5-6 mm in
diameter.

Modern CT machines can detect lesions up to 1-2 mm in diameter.

CT is more sensitive than chest radiography and can accurately detect tumor site, size
and invasion to adjoining structures such as mediastinum, chest wall, etc.
Referrals South

Transportation by scheduled commercial airline for elective referrals ($1400 approx.
cost of return flight to Ottawa).

Approx. Duration of stay for patients transported to Ottawa averaged 12.8 days
($2600 approx. cost for accommodation and expenses for this duration).

Length of stay is due to wait times for diagnostic work-ups prior to specialist visits or
scheduled appointments being cancelled.

Standard process allowed 3 to 4 days between diagnostic testing and clinic visit to
ensure results are available before seeing specialist.

Medevac for emergent cases, service includes physician or nursing escort as
appropriate ($25,000 approx. cost for flight and crew PER RETURN FLIGHT!)

Over 400 patients were flown south for CT examinations in 2010.

Approx. 11% of these were medevac patients due to trauma.

About 50 transports were for scans to rule out head and neck injuries.
Impact on Patients

Wait times were often 3-4 months for a CT, despite preferential
treatment by Ottawa for Iqaluit patients.

Physicians related situations where wait times for CT diagnostics
were so long that the patients’ conditions moved beyond
treatment.

Extended stays (up to 12 days) in Ottawa can cause anxiety for
residents of the Baffin Region as many are unfamiliar with or do not
speak English.

Patients from communities have to first travel to Iqaluit and then on
to Ottawa (depending on which community, flights to Iqaluit can
be anywhere from 2-5 hours).

Have to travel alone or with one escort depending on severity of
symptoms.
Coroner’s Inquest Reiterates Need for
CT Machine in Iqaluit

Elisapee Michael, 52, fell head-first down the stairs
outside the Nova Inn on Aug. 9, 2009.

Police put Michael in a cell where, hours later, they
discovered that she was unresponsive.

Michael was then medevaced to Ottawa, where she died
Aug. 13 from her head injury.

If CT was available at the time, injury could have
possibly been diagnosed sooner.
Challenges Around Implementation
of CT

Only possible if a PACS is in place so that radiologists can effectively guide
its operation and promptly interpret CT studies.

Web presentation is limited by Government of Nunavut’s (GN) bandwitdh;
GN network must be upgraded.

Network is run on Satellite, which slows transmission times and limits amount
of traffic.

No Radiologist on site.

Inappropriate to expect family physicians to conduct even preliminary
interpretations on CT exams due to breadth of pathologies for which CT is
applicable and unique orientation of images.

Staffing: recruitment and retention of CT technologists may prove difficult.

Geographic location!
Benefits
Patients

More accurate diagnosis

Shorter wait times,
particularly for elective

Reduced travel (fewer trips
and shorter duration of
stay)
Physicians


Increased confidence in
diagnosis
Improved
communications with
Specialists

Reduced dependency on
inclement weather for
emergency travel
Ability to treat more
local patients

Service closer to home in
familiar environment
Improved diagnostic
capabilities during clinic
days

Early diagnosis and
improved outcomes

Increased confidence in
local health care


Fewer lost work days due to
medical travel
Shorter turnaround time
for Radiology reports (1
hour for Stat cases VS 3-4
days)


Department of
Health/QGH

Platform to offer
additional specialty
clinics

Improved public
perception of Nunavut
Health Services

Possibility of attracting
and retaining
permanent physicians

Early diagnosis leads to
reduced administrative
costs

Reduced travel costs
The Process

Established new Radiology contract with The Ottawa Hospital (TOH) to
incorporate PACS solution and increased availability of Radiology service.

Network upgrades completed in 2013 to handle increased traffic on GN
network and availability of increased transmission times for Iqaluit.

Dedicated server to accommodate PACS integration.

RFP generated to include provisions unique to geographic location, Turnkey
Operation and White Glove Delivery.

Workflow created to include community films (still wet processing) due to
lack of Network infrastructure outside of Iqaluit.

Job Shadowing with Rob Chatelain at Civic Campus of TOH to enhance
understanding of overall functionality of CT program.
And So It Begins…

Construction for the renovations required to implement CT machine
began in September 2013.

All supplies, tools and equipment needed for renovations had to be
flown up with the construction crew due to lack of availability in
Iqaluit.

When the hospital was built in 2007, considerations were already
made in anticipation of acquiring a CT machine.

Renovations to CT room and Control room were completed by early
December 2013.

As I headed to Milwaukee, WI to participate in training, the CT
machine was being prepared for travel to Iqaluit.
The Delivery

The CT machine weighs approx. 10,000 lbs.

Only possible way to deliver machine was by air cargo.

Had to be flown up with 2 SCI passengers to ensure safe
transportation of machine and all necessary equipment for
installation.

Transportation of CT machine alone was in excess of $50,000!

QGH ambulance bay was used to receive machine and all of its
parts.

Provisions had to be made to ensure machine was kept at a
constant temperature due to the risk of components freezing in our
extreme cold environment!

Installation was completed within 2 days of arrival.
History is Made!

Due to lack of on site Radiologist, the process of
protocolling CT requests was not feasible for TOH to do.

January, 2014 I spent a week in Ottawa training with a
radiologist to learn how to protocol these requests.

On February 2, 2014, the applications specialist was on site
and the first ever CT scan was performed in Nunavut!

At this point, PACS went live for Iqaluit, but was still not quite
ready for integration with TOH PACS.

CT examinations were burned to CDs and mailed to TOH for
Radiologists to report.

Final reports were then faxed back to DI department in
Iqaluit for distribution to physicians.
Photo: Qikqitani hospital acquires long-awaited CT scanner
Excerpt from Nunatsiaq News, February 17, 2014
Jennifer Sharpe, manager of diagnostic imaging at
Qikiqtani General Hospital in Iqaluit, operates the
hospital’s new computed tomography, or "CT"
scanner, Feb. 14. In operation since Feb. 3, the
$2.1-million CT scanner helps medical staff make
more accurate diagnoses and is expected to reduce
patient wait-times, now that Nunavummiut do not
have to travel south for the procedure, Nunavut’s
health department says. The hospital will share
records from the scans by April of this year with a
hospital in Ottawa through a network connection.
(PHOTO BY PETER VARGA)
Nunavut’s first CT scanner starts service at Qikiqtani Hospital
Qikiqtani General to link patient records with The Ottawa Hospital
“They’re very comfortable to be able to come to their own
hospital, and get the exam done, versus going to Ottawa, and
having to find their way around three huge hospitals,” Sharpe
said Feb. 14.
“No one else in Canada operates a CT over a satellite network,
and equipment vendors never had to deal with that before,” he
said.
“So you have to educate (them) as they come through. And
when something like this works out, it’s absolutely impressive.”
“It reduces some trips to Ottawa, for sure,” MacDonald said.
“It’s $25,000 a medevac – that’s a lot of money. You would only
have to save $2 million of those dollars to pay for the CT
scanner.”
PACS Goes Live With TOH

April 2014, Nunavut and TOH PACS go live.

Xrays and Ultrasounds have transmission of less than 5 minutes.

CT Head: ~8 minutes

CT Abdomen & Pelvis: ~20 minutes

CT Lower Extremity Runoff: ~30 minutes

Films from 12 communities in Baffin Region are sent to Iqaluit via air
cargo, digitized, and sent to TOH through PACS.

Significant increase in turn around time for reports – both in Iqaluit
and communities.

Remarkable increase in patient care, especially in Emergent
Situations.
Demographics

CT Scans
Since acquiring the
CT machine in
February 2014, QGH
has completed
1750 CT
examinations!
Spine
11%
Chest
24%
Neck
3%
Head
29%
Facial
4%
Extremities
4%
Chest
Neck
Abdo/Pel.
Abdo/Pel.
25%
Extremities
Facial
Head
Spine
Only in Nunavut…
Nunavut Polar Bear Attack Survivors
Thankful to be Alive!
a polar bear’s
bite is 1,200
pounds per
square inch; a
shark has a psi
of 669 and a
Rottweiler dog,
328
“When it was biting my head, I could
see inside its mouth. It was all black
and smelly. I could see the tooth
biting just beside my eye,”
What The Physicians in Iqaluit Are
Saying…

“Having CT in Iqaluit has decreased our miss rate on potentially
serious diagnosis, improved patient care, and easily paid for itself by
saving costs on flights to Ottawa.”
Dr.Greg Devet

“Despite initial worry that we would be keeping sicker patients than
we would have without a CT it has become an excellent resource
which has taken much guess-work out of clinical care. My work is
principally in outpatient care and CT has been invaluable in
managing many cases where the diagnosis was suspect but not
critical and would not warrant a trip to Ottawa. It is also sometimes
an alternative to have access to when Ultrasound is delayed.”
Dr.Alison McCallum
References

www.gov.nu.ca/health

www.nunatsiaqonline.ca

www.cbc.ca/north

JRS Partners Inc.

Martin Joy, Director IT, Government of Nunavut

www.nunavuttourism.com/regions-communities/iqaluit

Thank you to Rob Chatelain, OHRIA, Karina Burt, Imad AlChikie,
Sandra Clark