Amazing radiology images: How sharing them is changing medicine

In 2005, a Melbourne radiology student started uploading his notes onto the web as a way of keeping track of them. Ten years later, millions of people from around the world visit his site every month to share their images and knowledge.

SpongeBob SquarePants ... you can see him so clearly because he's metallic and metal ridges outline his features, even his freckles.

Ten years ago, if a radiologist in Saudi Arabia found the smiling image of SpongeBob SquarePants staring at her from the oesophagus of a 16 month old, chances were only her colleagues would have got the chance to see it.

But recently, the crystal clear image, lit by the familiar black and grey of a standard X-ray, was seen around the world after it was uploaded to the Melbourne website Radiopaedia.

In 2005, when Dr Frank Gaillard, founder of Radiopaedia, was studying to become a radiologist, the profession was rapidly changing.

"2005 sort of coincided with a general shift in the radiology world ... where we would report not on printed film but on computer monitors and no-one really had an easy way of keeping digital film libraries," he said.

"I tried to experiment with printing film and keeping that but it's heavy and expensive and you can't carry it with you.

"I tried putting it on USB drives or hard drives as jpegs but you can never find what you're after and labelling it or keeping track of it is really difficult."

So using Wikipedia as inspiration, Dr Gaillard "hacked together on some spare computer equipment" a place where he could upload his cases.

In your forearm you usually have a radius and ulnar... in this rare congenital syndrome instead of developing the radius you develop a second ulnar instead.

"The thumb side of the hand develops with the radius, and if that is absent then you are not going to develop your thumb but if you are developing two ulnars then you are going to develop two sides of the hand that are exactly the same and creates a mirror image. There are a few examples on our website despite it being very rare."

A lot of people get hyperthyroidism and very occasionally that can lead to a condition called thyroid acropachy which can produce dramatic swelling of the digits and the hand.

The site began as a private personal collection but in 2007 Dr Gaillard made it public.

"Everyday I'd see these amazing cases at work, which no-one got to see and I knew that there were radiologists all over the world that had exactly the same problem in that they weren't exposed to lots of great cases just because they weren't local," he said.

"It occurred to me that if you could build a platform that made the sharing of cases easy, than everyone uploading a single case would immediately create the best reference library anyone's ever seen."

Ten years later, in 2015, Radiopaedia attracted 7 million hits a month from 2 million unique users and represented every country in the world, according to managing editor Dr Andrew Dixon.

On Facebook it had more than 312,000 likes and more than 10,600 Twitter followers.

For a website aimed at medical professionals, which actively discouraged the public from using it for self-diagnosis, it had quite a following.

As of January 2015, Radiopaedia had a total of 17,660 cases uploaded to the site from radiologists around the world.

All those cases were sorted into 7,636 articles. So if a radiologist wanted to know more about gun shot injuries, for example, all the relevant cases could be found under that one headline.

You're looking at the humerus with gun shot pellets scattered through the arm, the bone is shattered into multiple parts.

"You're looking at the humerus with gun shot pellets scattered through the arm, the bone is shattered into multiple parts. That's a close up shotgun wound to the arm, the further away you are the more scattered those pellets are going to be and the less the damage there will be - you have to be pretty close to cause that damage."

Dr Gaillard said his site was an example of how opening access to information was beginning to revolutionise the way medicine was taught and practiced around the world.

"A typical text book, for a sub-speciality especially, will be a couple of hundred dollars to buy – and that's in one space, in one shelf, locked in one office," he said.

"Digital versions of those text books are just as expensive, and very carefully controlled because the whole infrastructure is built around monetising the restriction to access to information.

It's still really hard to convince people to give stuff away, even to give stuff away that they would never make any money from.

"If you want be grandiose or paranoid about it, the medical information industry makes its money by stopping people accessing the information that they need to better treat and diagnose their patients.

"What we're about is thinking that that's not such a great thing, and thinking that you can make this information for free."

Dr Dixon said the editors regularly received positive feedback, particularly from developing nations.

"Traditionally textbooks, conferences and courses have not been accessible to developing nations, either for financial reasons or because of the physical location they're in," he said.

"We're finding now that [with] the internet being almost to the point of being universal, having free access to high quality information is something people really appreciate."

But Dr Gaillard said the revolution was not quite complete.

"It's still really hard to convince people to give stuff away, even to give stuff away that they would never make any money from," he said.

"For a lot of my older colleagues especially, but the younger ones too, the idea of putting up one of their cases and saying as long as you're not making money from this, as long as you say it's mine, you can use this – feels kind of weird for people.

"As people get used to the idea of being much more open with their content and see the benefits of doing that - not just to the world at large, but personal benefits as well, in terms of personal brand and reputation - then I think it does change the way people view the sharing of information."

The Clockwork Orange eyelash - it's just mascara on the eyelash - in radiology you very often see things in images that remind you of day-to-day things.

Some of the images on the site were just for amusement's sake - like the Clockwork Orange eyelash - but Dr Gaillard said the vast majority were there to be learnt from.

"Aside from the selfish reasons you use the site, in terms of keeping your own case library and looking up things for your own study or work, the thing that's come out of it is that in Australia we forget how lucky we are to have the sort of health system we do have," he said.

"To be able to give radiologists or doctors in third world nations, who don't have the teaching, or the expertise, or the hardware that we do, the ability to see some of these cases and better treat and diagnose their patients is probably what gives me the greatest sense of satisfaction on a day-to-day basis."

Basically this person was just fishing and stuck the hook onto their own ear accidentally, and the prawn is still attached to the hook.

Dr Dixon said with an open-source medical website such as Radiopaedia, it was "critically important" to ensure that the people shown in the images were not identifiable.

"We require exactly the same standards of image confidentiality on our site as any medical journal or any medical textbook," he said.

"With most of the imaging systems used in hospitals, when you export an image, all of the identifying information is automatically removed.

"On our website we only allow images to be uploaded that are jpegs and are stripped of any metadata, in medical imaging there is a file type which does contain the patient's name, address and other details, we don't allow any of those files to ever be uploaded to our site."

He said of the more than 17,000 cases on the site an image had only been recognised by a patient once.

"The only reason that they recognised it was because the image was uploaded by a doctor at the same hospital that they worked at, and they had to have the image side-by-side to their own copy of the image to determine that it was them." he said.

He said in the very rare cases with physically distinctive characteristics, the editors would request that the image be taken down by the person who uploaded it, or that they request permission from the patient.

Such situations were "extremely rare", he said.

CT scans can very easily identify illicit drugs like cocaine and amphetamine - because they're very dense when tightly packed.

"You can use the CT scan to determine exactly how many there are and ensure you retrieve them all - the important thing medically is if one of these things ruptures. This is a 3D reformat, so basically the radiographers have stripped it back to the densities that you want to show and created a 3D rendering of that. Medically, it's not that useful, but it looks really cool."

Dr Gaillard said it could be difficult to keep the balance of making information available for medical purposes while discouraging patients from visiting the site for self-diagnosis.

"A lot of the users come through Google, and a lot of them will be people who are searching for a condition for some reason, I think a number of them are probably patients trying to interpret their radiology report," he said.

"That's certainly not the emphasis of our site, we don't attempt to attract lay people, in fact we actively try to discourage them.

"We're not trying to replace the role of diagnosticians or doctors or clinicians at all, but at the same time anything we do to try to lock ourselves away makes it harder for people to get access to it."

He said it was important for the site to remain open to medical professionals other than radiologists.

"I get a lot of feedback not just radiologists, but from emergency physicians or neurosurgery trainees who use our cases for their training," he said.

"These days the role of medical imaging is not just the purview of radiologists, even though we're the ones who spend the majority of our time doing it and doing all the reporting.

"All specialities are involved in medical imaging in one way or another and should know something about it, so I think we're an increasingly important resource for anyone in the health profession."

Cherubism is a rare bone condition which is related to a relatively common condition called fibrous dysplasia. It dramatically expands the jaw creating a physical appearance reminiscent of a cherub.

"They will be doing imaging to try to look for how to treat complications of it. Important nerves come out of your skull base that control your facial muscles and taste and if this bone expansion is impinging those nerves then you need to work out which bits of bone need to be removed to relieve the pressure. Surgery might also be considered for cosmetic reasons."

Despite the large following, the site is still owned by Dr Gaillard and two friends, also Melburnians, who runs the tech side of things.

While it was not run as a not-for-profit organisation, all the money made from advertising went into developing the site, Dr Gaillard said.

"What we see is that our mission is to provide the best resource that we can ... and at no stage do we intend to put our content behind a pay wall," he said.

"If we can generate enough funds to not only keep the site going, but pay for some of my time and for other people to help out, and even one day make a profit, that'd be great."

For now, he and the other radiologists uploading and editing the content do it in their spare time, for free.

"I think my wife probably sees Radiopaedia as a mistress, I spend too long on it and come home late at night because of it," Dr Gaillard said.

"She's been long suffering, but very supportive – she's also a radiologist so she uses it as well."

Mermaid syndrome is a rare congenital condition, where the legs are fused together.

"They can do quite a few things to improve the functionality, the reason why they would do the X-rays is because they want to know what the bone structure looks like ahead of potential operations to improve function."

There is a clinical photograph that goes with this one which looks like an aubergine - basically you can't see the man's penis because it's just surrounded by swelling and haematoma but on the MRI you can precisely locate the site of penile rupture.

Topics: medical-research, health, doctors-and-medical-professionals, information-technology