Soundeffects news | Dr Tom Watson (UK)

Dr Tom Watson (UK)

Great Ormond Street Hospital for Children

PAEDIATRIC & GENERAL

Meet Dr Tom Watson, a consultant paediatric radiologist at Great Ormond Street Hospital for Children in London, UK. Trained at the University of Birmingham, Dr Watson’s expertise in paediatric radiology flourished during fellowships at Great Ormond Street and The Hospital for Sick Children, Toronto. Appointed as consultant radiologist in 2014, he now leads in ultrasound and serves as the specialist radiologist for gastroenterology and oncology services. Dr Watson’s research focuses on ultrasound and MRI techniques in bowel imaging, paediatric inflammatory bowel disease, and applications of ultrasound in paediatric oncology. We ask him a few questions about his approach to paediatric radiology.

What are some of the unique challenges or considerations specific to performing contrastenhanced ultrasound in young children, and how do these differ from imaging adults?

Many of the issues in paediatric contrast ultrasound are the same as for general paediatric ultrasound. Deciding which lesions are suitable for CEUS also involves an assessment of the child: Can they lie still for a few minutes? Is IV access possible? Is the lesion big enough to keep in the field of view without a breath hold? After you have decided that a contrast ultrasound is needed, the next most important consideration is whether the child can stay still and hold their breath for a few minutes. If not, this can make it difficult to keep the lesion of interest in the image, which is critical when you are trying to assess the vascularity of a lesion and may mean that a different modality is required.

Intravenous contrast ultrasound requires IV access and this can be distressing for children. Getting IV access can be much more difficult in children. It is often better to arrange for this to be done in advance away from the ultrasound department by an experienced practitioner to give the child some time to relax. CEUS is much easier in a calm and relaxed child.

In the UK, the contrast agent we tend to use (Sonovue TM, Bracco Italy) must be prescribed as an ‘off-label’ medication, meaning that it does not have regulatory approval to be used in children. This is the case for many commonly used paediatric drugs, but it does mean you need to coordinate with your pharmacists and a parent needs to give consent for the contrast to be used intravenously.

How do you assess the learning curve and proficiency of surgical teams in incorporating IOUS into their practice, and what strategies do you employ to facilitate ongoing training and skill development?

A fundamental part of IOUS is trust between colleagues in different specialties. IOUS relies on a good working relationship between radiologists and surgeons. The surgeon must be confident in the ultrasound findings. At my hospital, we have a dedicated pre-surgery meeting to plan the surgical approach and the specific imaging questions that need to be answered on the day. During surgery, it is imperative to have two people from radiology present: one to scan and one to operate the ultrasound machine and optimise images. This helps to make things as clear as possible for the operating team. Post-surgery, we have a debrief about what went well and what could be improved. We continuously audit the IOUS service and the outcomes in terms of positive or negative resection margins and postoperative complications.

How do you navigate communication with patients and parents when discussing imaging findings of soft tissue lumps in paediatric patients, particularly when addressing concerns about potential malignancy?

This is one of the most challenging aspects of paediatric radiology. I cannot claim to be an expert at this, but I have learnt a few important principles over the years:

• Some parents need a definitive answer at the time of the scan, some parents do not want to know anything. Judging which parent you have in the room takes time and experience and a few wrong turns …

• Being economical with the truth is the worst thing you can do. Either tell the parents what you know or ask them to contact their doctor for the results.

• Be confident expressing uncertainty – ultrasound is not histopathology.

• If you tell a parent that you are not sure what the lump is, spell out what steps you are going to take next to help get to an answer. Don’t leave a parent/patient more uncertain than when you started the scan.

• Regardless of how many times you have seen a normal 5 mm cervical lymph node, remember that this is usually the first time a parent or child has encountered a lump on their body.

Can you share a specific experience or project in your career that has had a profound impact on your approach to sonography?

No single experience comes to mind. In general, paediatric radiology is an ultrasound-based specialty. There is almost no part of the body that you can’t see with ultrasound at some point in a child’s life. If you take your time and look hard enough there is very little pathology that you can’t diagnose with ultrasound that you could do with a different imaging modality. Ultrasound is one of the few opportunities in radiology where you can take a history, examine the patient, and diagnose the problem all at the same time. There is nothing as rewarding as being able to help a sick child and their worried parents and family; it is a privilege.