TD Ameritrade’s Boneheaded “Enhancement”

TD Ameritrade sent a very blandly worded email claiming an “enhancement” to their ETF lineup.  This removes all Vanguard ETFs from their commission free list.  Of course, only someone with no cognitive ability would see this as an enhancement.  I initiated my account transfer today.


Here are some screenshots to demonstrate why:

In the above table, you can see that AUM is 1/20th of the other two big boys in the market.  A clever move would have been to include the original SPY but of course they didn’t.  You have a palate of relatively less liquid specialized ETF’s that would be very difficult to figure out your asset allocation accurately with overlap and redundancy.

The spread of their “enhanced” fund is the largest of the three, which is not surprising given the it’s the smallest of them.

Roughly similar performance.  I’m not really sure why the AVG market cap is equal in this table because their AUM is different on every other listing.


Anyway,  if you needed an excuse to move to a better commission free platform, both Schwab and Fidelity better platforms IMO.




Beluga whale sign

This elderly patient must have taken a serious header to get that whopper of a forehead and scalp hematoma. Fortunately, there is no intracranial hemorrhage. Just the the usual “brain rot” aka atrophy and underlying chronic ischemic white matter disease.ezgif-5-47bd3735e3


Beluga whales can change the shape of their hump for use in tuning echolocation,  however, I don’t think elderly patients have that luxury, but wouldn’t it be cool if they did?!

Intestinal Ischemia aka Dead Bowel

The superior mesenteric artery was densely calcified. Although the Iliocolic region is frequently spared in the watershed areas are commonly affected, this unfortunate man had classic findings of intestinal ischemia with pneumatosis coli and portal venous gas extending to the periphery of the liver.

This case also demonstrates the importance of looking for pneumatosis and portal venous gas on the lung windows of the abdomen.

One of the Burlington radiologists employed at Greensboro radiology missed an obvious case of intestinal ischemia at CT that was far worse than this case.

It is important to note that intestinal ischemia is not the only cause of portal venous gas and pneumatosis. This can be associated with COPD and other less malignant causes than intestinal infarction or ischemia.

A common perceptual mistake is not noting the location of the portal venous gas in the liver. Portal venous gas follows the flow of blood to the periphery while pneumobilia goes to the non-dependent portions of the liver and is almost always seen at the porta hepatis even in cases where it is not seen in the common bile duct.





When the abdomen is viewed on lung windows, the portal venous gas and pneumatosis coli can be seen in the right lower quadrant.

Greensboro Radiology and Martinsville: Lessons Learned

GR contracted to provide subspecialty reads for Martinsville around 2013. Initially there was not much volume but soon a pattern emerged where 4-5 studies were sent around 5pm. Approximately, 20% of these studies had critical values and all of them were “disaster area” cases which were highly complex postoperative spines, epidural abscesses, tumors, necrotizing fasciitis, and even acute stroke.

Adding insult to injury, try getting a physician on the phone for the mandated critical value notification after 5 for a case from Martinsville, VA.

It became a very painful arrangement to which GR leadership was deaf; all they cared for was the RVU, not the inconvenience associated with the cases. As an MSK rad, I could read 3-4 shoulder/knee MRIs in the same time it took to take 1 Martinsville case. We never saw a case of “routine” pathology from them. GR had incentivized the Martinsville radiologists to cherry pick the easy studies while sending anything remotely painful to GR.

Seriously, why wouldn’t you send anything potentially litigious or complex out?  You can be  halfway into a workout or beverage of choice while those poor saps at GR are slogging through your detritus.

From this, I learned that the following are considerations:

  • Right of refusal for a case must be available.
  • A complexity modifier for payment, either based on pathology or technical factors.
  • Increased pay for pre & post studies. Particularly post studies where the pre has been interpreted and the patient called back for contrast, which leads to re-interpretation of the original study. The additional RVU for pre/post is generally 0.5-1 versus a nonconstrast study alone.
  • Collaborative input on protocols.

Spleen Size by Age


Ultrasound: Normal Spleen Size vs. Age¹

Age Spleen Length (cm)*
0-3 months ≤ 6
3-6 months ≤ 6.5
6-12 months ≤ 7
1-2 years ≤ 8
2-4 years ≤ 9
4-6 years ≤ 9.5
6-8 years ≤ 10
8-10 years ≤ 11
10-12 years ≤ 11.5
12-15 years ≤ 12
15-20 years (female) ≤ 12 (female)
15-20 years (male) ≤ 13 (male)

*Measurement obtained in the coronal longitudinal plane


  1. Rosenberg HK, Markowitz RI, Kolbeg H, et al.  Normal splenic size in infants and children: sonographic measurements.  AJR 1991; 157:119-121.  Table modified and used with permission.