A person suffering an apparent stroke is rushed to a hospital in Ventura County sometime after 7 p.m. Almost instantly, e-mailed images of the patient's brain emerge on Dr. James Brull's computer in Hays, Kan.

Brull is a nighthawk — one of a growing group of specialists who read complicated X-rays, MRI and CAT scans at night from hospitals that might be located nearby or hundreds of miles away. Brull, who has staff credentials at about 1,000 hospitals across the nation, studies the images on four computer monitors then dictates a preliminary diagnosis that is transmitted back to Ventura.

And it all happens within an average of 20 minutes.

As part of a reliance on distance medicine and technology spreading throughout the healthcare industry, radiology groups from at least six hospitals in Ventura County outsource their night coverage. When a patient shows up in the emergency room after-hours, his or her scans likely will be transmitted off-site — as nearby as Alhambra in the San Gabriel Valley or, in Brull's case, to a remote Kansas town once roamed by Wild Bill Hickok and George Armstrong Custer.

"Literally, I can be almost anywhere and be working for NightHawk Services," Brull said in a phone interview from his car after a stint reading images in Milwaukee.

Radiology groups for at least five hospitals in Ventura County use NightHawk, a company in Coeur d'Alene, Idaho, that serves about 1,500 hospitals nationwide. NightHawk sends images to 120 board-certified radiologists across the country as well as in Sydney, Australia, and Zurich, Switzerland.

Quicker treatment received

Although Brull occasionally works on images sent from Community Memorial Hospital in Ventura, radiologists from that hospital and several others in the county said the bulk of their night work is sent to nighthawks in Southern California, and all of it remains in the United States. They said the service means patients receive quicker treatment and have access to radiology specialists all hours of the night.

Radiologists and hospital officials said the program relieves pressure on doctors who already work long hours.

"We wanted to keep our doctors rested and clear," said Dr. Stanley Frochtzwajg, chief medical officer at Community Memorial Hospital. "If they don't have to stay up all night, they'll perform much better."

As technology has increased, so has the use of computerized scans that can detect spinal injuries, complicated fractures, head trauma, heart problems, blood clots and other abnormalities. Dr. Charles North, a senior radiologist based at Community Memorial, said an emergency room might see 10 to 20 radiology cases a night, and each can include hundreds of images.

Hospitals and radiology groups either have to ask their staffs to work marathon hours, hire more hospital-based radiologists or find nighthawks.

"It's cheaper to contract it out," said Jim Lott of the Hospital Association of Southern California, and it helps patients.

Medical experts say the lack of direct contact with a patient isn't important, because everything the radiologist needs for a preliminary diagnosis is contained in the computerized scan or X-ray. They note that even hospital-based radiologists don't typically interact with patients when reading their images.

A task force at the American College of Radiology voiced concerns about the possibility of overseas doctors working as nighthawks without proper credentials. But hospitals require all off-site radiologists to have staff credentials and be certified by the American Board of Radiology.

Even the doctors employed by NightHawk in Australia and Switzerland were trained in the United States and transported abroad.

The task force also worried about "ghosting," in which a freelance radiologist signs off on work done by unqualified support staff.

"It's easy to police what's going on if you only practice in the bricks and mortar of the hospital," said Arl Van Moore Jr., president of the American College of Radiology. "Do you pop in for inspections at India and Australia? That's not like going downstairs to the next floor and sticking your head in."

But companies like NightHawk prohibit ghosting. All of their diagnoses are considered preliminary and are reviewed the next day by hospital-based radiologists. In some critical situations where a final diagnosis is needed immediately, hospitals call in on-site radiologists.

NightHawk, one of many companies that offer distance radiology, was started seven years ago by Dr. Paul Berger, a Long Beach radiologist. He was pushed by the realization that the need for 24-hour coverage was causing doctors to burn out or ask for more money.

He opened a radiology-reading center in Sydney, because the time change meant doctors working in the day in Australia could offer night coverage for hospitals in America. Now reading centers have been set up in Zurich and San Francisco.

Images are compressed

The vast majority of readings were once sent abroad, but now about 80 percent of the work happens in the United States, much of it conducted from doctors' home offices, said Scott Giordanella, NightHawk's marketing director. Some hospitals request their images not be sent abroad.

Images are compressed, so hundreds can be sent in an e-mail over a secure network. If questions arise, the emergency room doctor can call the radiologist.

Private hospitals don't hire their own radiologists, instead contracting with groups that provide hospital-based doctors. Some of the larger groups offer 24-hour coverage, but many others contract with groups like NightHawk.

They say there's just too much night work.

"It's unrealistic for us to provide this service and to be able to function the next morning as a radiologist. It's become pretty much the standard of care," said Dr. Ivan Hayward of Pueblo Radiology Medical Group, which uses NightHawk to provide coverage at hospitals in Oxnard, Camarillo and Ojai.

Long-distance radiology is just a beginning. Psychiatrists can use video and audio equipment to meet with patients who might be in a different city. Hospitals can use similar equipment to do triage in trauma units. There are even robotic devices known as "robo-docs" that visit a patient's room and transmit images and sounds to a doctor at another site.

Most patients adapt quickly to the technology, although some face a slight learning curve, said Elizabeth Krupinski of the American Telemedicine Association.

"The younger generation is going to have no problem with this at all," she said. "This is just part of their lifestyle."