Fri 30th Aug 2013
Session 4 / Talk 1
16:00 – 17:00
BROOKLYN 3
STUDENTS W/S
Kathy HOGAN
ABSTRACT
Students –
 DHS
 Resources
 Pedicle Screws
 Trigeminal Nerve Decompression
 Distal Locking Screws
 Shoulders
 Angiography
 How to get the most out of the Pulsera
1
RADIOGRAPHY
CONFERENCE
AUGUST
2013
Prepared by Kathy Hogan – Charge MRT Theatre
2
Overview
This Workshop is to give you a better understanding of
theatre and how everything works:
 Preparation for theatre
 Training
 Image Intensifiers
 Radiation Protection
 Theatre Procedure from start to finish
 Scenarios
 Questions and Answers
3
FIRST DAY JITTERS
4
Wearing The Correct Attire
Theatre Scrubs
Paper hat covering all hair
especially long hair
 ID Badge
 Monitoring badge
 No long sleeved singlet / T
Shirts
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No personal outer gear to be
worn in the theatre suites.
5
Infection Control

Hand washing – on entering and exiting theatre, especially between
theatre cases and after handling cables that have been on the floor
(Sterigel is OK after handling cables)
Masks - wear masks in theatre where there is an open wound
Overshoes – wear overshoes in theatre if outdoor shoes dirty
Change of scrubs – change scrubs if going outside hospital between
theatre cases. Never wear scrubs that you may have taken home and
washed.
Long hair tied back – and covered by your head gear.
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Personal hygiene – high standard.
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Entering Theatre – Use proper doors for entrance
Cleaning IIs - need to be cleaned every morning including the cords,
between cases, clean if necessary, plastic protection bags changed, use
gloves
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Your First Day In Theatre Environment
Introduction / Uniform change
 Guided Tour
 Image Intensifier Cleaning
 Exposure to theatres themselves
 Observation / Adaptation to the theatre
environment
 Supporting structures that are in place

7
What To Expect Mentally?
Questions on entering theatre:
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What do I do?
How am I feeling?
Who’s who?
Where am I allowed to go?
What are we doing?
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What To Expect Physically?
On entering a theatre
Patient – general anaesthetics, or spinal (i.e.. Patient is
awake but sleepy)
 Open wounds with internal organs and bones exposed.
 A lot of equipment
 Two or more sterile trolleys
 Personnel scrubbed wearing sterile gowns
 Anaesthetists and their technicians
 An image intensifier
 Cords everywhere
 Fluids
 Overhead items such as lights, drip poles, cords
 Noises like drill. Sawing
 Smells

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First Impressions

All people dressed the same, and people everywhere
Very Daunting
The unknown factor
Completely out of their comfort zone
Fear of the unknown
Fast Pace
Stressful
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You can help this by
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○
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Relaxing
Thinking before you act
Positive attitude – willingness to learn
Awareness of sterile equipment
Asking questions
Enjoy theatre
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Responsibility
You are initially responsible to the radiographer
that you are with.
You are also indirectly responsible to the
- Theatre Nurses
 Surgeons
 Anaesthetists
 Theatre Coordinator
for your actions and consequences of those actions.
Whatever action you take has a
consequence in theatre.
11
Teams Within The Operating Theatre
WARD – PRE-OP
AND POST-OP
NURSING
PACU
PATIENT
ANAESTHETICS
RADIOLOGY
SURGICAL
12
General Layout Of An Ideal Theatre

Each theatre would consist of an
 Operating room with double doors directly into theatre – can be used
when patient is not in the operating room
 Scrub bay where personnel prepare themselves for performing the
operation.
 Set up bay where the nurses prepare all the sterile trolleys for the
operation.
 Anaesthetic bay where the patients are prepared for their
anaesthetic prior to surgery.
○ Double doors (2 sets) through anaesthetic bay – to be used for entry with II
when patient is in the operating room
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Benefits of Training
14
Problems And Consequences Involved With Training
Lack of actual time in theatre
 Lack of actual performance of procedures
 Lack of confidence
 Problem solving not developed
 Lack of interaction with theatre staff
 Not seen as part of the team
 Little support structures in place
 Lack of experience upon qualification

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Structured Training
Basics taught earlier on in training
Work adjusted to appropriate level of skills
Clear goals, guidelines and achievements
Confidence slowly built
First year can still help with the procedure
Close supervision during first two years
with withdrawal of supervision as
confidence increases.
 Encouragement of student to think outside
the radiological square
 Specifically there to help surgeon
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Expectations Of Students In Theatre – First Year
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Orientation
Observation and familiarisation with the layout of theatre
Sterile procedures
Radiation Safety
Quality control
Hygiene
Basic understanding of the Image Intensifiers
Understanding the dynamics of theatre
Setting up, input of data, image manipulation
Some basic procedures
Observation of other cases
Year One Theatre Checklist
17
Second Year
To develop a further understanding of the image
intensifiers and their potential
 Image manipulation
 More extension of procedures
 Introduction to the more complex cases
 Year two theatre checklist

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Third Year
All procedures with as much hands on as
possible
 Roddings and DHS
 Angiograms
 Practical test – DHS and oral questions
 Year three checklist
 Not released to do theatre cases on your
own until the practical, oral and checklists
are done.
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Supporting Structures In Place at Waikato To Help You
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Theatre Workbook
Theatre Pocket Guide Book
Theatre Protocols and Resource Folder
Theatre X-ray Coordinator
Radiographers
Other Students
Yourself!
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A Quick Overview
21
An Example Of Variance In Values With Different Settings
kVp
mAs
FOV
Low Dose On
82
0.83
23 cm
Low Dose Off
74
1.9
23 cm
Magnification 1
72
2.5
14 cm
Magnification 2
70
3.3
11 cm
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Landmarks
Always use landmarks to arrive at same position every
time you move the C-Arm
 Advantages

 Efficiency
 Confidence
 Less screening dose to patient and personnel.

Landmarks you can use are:
 the measurements on the longitudinal arm,
 vertical height,
 draw marks on patient (up to a point)
 Anything that will remain in one place during the operation
 Tape on IIs to write measurements on
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Examples Of Landmarks
LANDMARKS
LANDMARKS
24
Image Acquisition: Collimation
X-rays pass out of vacuum tube through a window sealed onto
vacuum envelope of x-ray tube
 Size of window can be controlled (collimation)
 The smaller the window, the sharper the x-ray and the smaller the
dose of radiation
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Image Intensifier

X-rays absorbed by image
intensifier, and thereby
fluoresce
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Image intensifier allows lowintensity x-rays to be amplified
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Magnifies intensity produced
in output image
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Result: less radiation emitted
26
27
Radiation: Protective Clothing
Gloves for sterile staff
60–64% protection at 52–58 KV
Eye protection
0.15 mm lead-equivalent goggles provide 70% attenuation of
radiographic beam
Thyroid collar
2.5-fold decrease in scattered radiation
Leaded apron
AP: 16-fold decrease in scattered radiation
Lateral: 4-fold decrease in scattered radiation
All scrubbed personnel are to wear complete lead kit ie lead apron and thyroid
guard for operations that are screening intensive.
Occasional imaging happy with them not wearing lead.
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C-arm 'Attitude' And Technical Contributions To Radiation Dose Reduction

Position x-ray tube under and as far as
possible away from the patient
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Use lasers on x-ray tube and image
intensifier for positioning
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Collimate where and when possible
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Correct parameter / dose for specified body
area
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Select dose rate in line with patient size
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Maintain appropriate distance from source
bearing in mind the operation that you are
assisting
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Exposure Levels With Different Configurations
Normal configuration showing
levels of exposure directed to the
floor
Configuration to be used
occasionally – levels of exposure
directed to the ceiling
Image intensifier in horizontal
configuration (probably 40-50% of the
time showing exposure levels above and
below the patient with more protruding
on the tube side
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X-ray Tube Position
Staff exposed to
increased radiation
Staff exposed to
reduced radiation
31
Absorption And Scatter

For every 1000 photons reaching
patient
• ~20 reach image detector
• ~100–200 scattered
• remainder are absorbed by patient
(radiation dose)

Scattered dose is higher at
x-ray tube side
image intensifier
x-ray tube
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Factors Affecting Patient Doses
Intensifier diameter
12’ (32 cm)
Relative patient entrance
dose mSv/h
Dose 100
9” (22 cm)
Dose 150
6” (16 cm)
Dose 200
4.5” (11 cm)
Dose 300
The smaller the image intensifier diameter,
the greater the patient entrance dose
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Example Of Dose-rate Around The C-arm

For staff, the
further from
the patient the
lower the dose
of scattered
radiation
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How Much Radiation Is Safe?

20 mSv per year,
average over defined
periods of 5 years

How do you know how
much radiation you
have received?
Radiation dosimeter
(monitor)
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Using The Pulsera And Its Parameters
Has many options for exposure
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Parameters
Dose Control
Low and High Quality Images
Can change many factors to alter image quality
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Parameters
II Size
Film Speed
Dose Rate
Exposure button choices
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Parameter Options
New Pulseras today have the following
Orthopaedics - Extremities
HQ Orthopaedics - Torso
OrthoPlus (needs to be purchased) – Thoracic and
Lumbar Spines
 Head/Spine – Skull and Cervical Spine
 Abdomen – used when II is in one place
 Thorax/Urology – used for contrast flows eg
Retrograde Pyelograms and insertion of lines into
chest
 Vascular package – used for angiography
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Exposure Ratings for Orthopaedic Options
Ortho
LDF
HDF
Continuous
½ Dose
¼ Dose
HQ Ortho
LDF
HDF
Ortho Plus
LDF
Continuous
½ Dose
¼ Dose
HDF
Continuous
½ Dose
¼ Dose
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The Call From Theatre
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Information
 Where, when, what for, patient details
Keys, phone etc
 What II will you need
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 Factors
○ Adult / Child
○ ROI
○ Size of patient (if known)
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Radiation Protection
 Theatre Staff
○ Signs on doors
○ Lead gowns
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Where Is The II Placed?
You know what procedure.
 Make sure that II is in a clean state.
 Arrange II on side best for procedure and
surgeon (Usually opposite to where the
surgeon will stand).
 Manoeuvre around before connecting up.
 Connect up II and turn on
 Always connect large cable up first. Try
and keep other cables off floor
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Configuration Of II
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Do you have the right configuration of the II for the procedure?
Decide this before II is covered with sterile plastic bag
Bear in mind the following
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- Skin dose for patient
- Scattered radiation
- Room for surgeon to operate drills etc
- Patient II distance
- Patient movement
It is OK to invert the configuration of the II when you are doing
simple MUAs and you know that images will be limited
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Make sure that all personnel have full lead protection
Increased dose this way but no of exposures and
therefore final dose should be reduced.
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Hazard Awareness 1
Gases used by anaesthetic machines.
 Pneumatic cord for drill in orthopaedic theatres.
 Accidental flying pieces of equipment – k-wires broken off etc.
 Cords / Tubes lying on the floor / cables from IIs. Remove from floor as
much as possible or cover with mat. How are the cables placed on the
floor
 Heavy machinery – IIs etc.
 Lack of room in some theatres. Place equipment in appropriate
places remembering that staff need to get around theatre without
climbing over equipment.
 Other cables in your immediate vicinity? Are they going to be in your
way?
 Theatre equipment – can it be moved to make things easier for you?
 Drips and lines – are they going to be in your way?
 Monitor – Is your monitor easy for the surgeon to see?
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Hazard Awareness 2
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Overhead surgical lights – can be in the way when moving IIs / watch out
for sterile cover on II when moving around theatre.
Slippery floors – blood and body fluids, cleaning up after operation
Iodine and Betadine – antiseptic wipe used in preparation of patient –
stains – unable to remove so cover IIs and tubes at all times. Best practice
is to remove II at all times to a safe distance.
Contrast media – is patient allergic to contrast media specifically Iodine.
Body fluids – blood is quite commonly spilt on IIs so therefore make sure
that both II and tube are covered with plastic bags to prevent these fluids
from entering the machine. Watch that cables are kept clean after messy
operations. Make sure that all IIs are inspected and cleaned after all
operations. Don’t expect other staff to clean up after you.
Electric shocks.
Sterile areas – always watch what you are doing. Do not rush in without
looking around you. Always pass front on and behind when near sterile
trolleys.
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Radiation Protection
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When performing radiation, the following rules should be
followed:
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Radiation Signs on the outside doors
Do not radiate when not necessary
Radiate for as short as time as possible
Use automatic dose rate control whenever possible
Stay as far away as possible from the radiated object / x-ray source
Wear aprons and other protective clothing as appropriate
Use badges to monitor the radiation levels received
Use LDF as much as possible in place of HDF to reduce dose
Collimate as much as possible
Focal spot to skin distance should be kept as large as possible to reduce the
absorbed dose.
Remove objects from FOV especially surgeons hands
Place where possible the x-ray source under table to reduce scattered radiation
resulting in extra safety for staff
Take into account any adverse effects that may arise due to materials located in the
x-ray beam e.g. the operating table
Mobile view station should be positioned so that the radiation indicator on the
mobile view station is visible to all personnel at all positions of the room and where
you and the surgeon can see it.
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Image Intensifier Set-up

Start screening with the C-arm at
halfway stage of the longitudinal
movement.

10cm each way for fine tuning of
positioning.
 10-15° of panning in each direction.

This means limited movement of
the II base resulting in
 more efficient operation
 less exposure for the patient and staff
 you looking good!
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Orientation

Flexiview
 Take your image and rotate
and save
 If on patient’s right and patient
is supine, then push both R
buttons to orientate, then fine
tune with rotation button
 Always save image after orientating or altering

Pulsera
 Take your first image and orientate
 Saves any changes automatically
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Points To Note Before Screening
 Look
out for
Is the patient on the right table
Has the table got an x-ray end on if doing ankles etc
Image reversal – always screen as the surgeon sees
the patient unless he asks for anatomically correct
II – patient distance
Dose saving exposure selected
Saving of images
Patient Positioning
Collimation - sideways or iris cone
Artifacts – bedding, table etc
48
Screening
Image quality will determine dose setting
after initial screening
 Try and anticipate what view the surgeon
will need.
 Change screening projections when
requested.
 When changing projections take note of
landmarks on the II for each projection. Put
tape on your II to write down landmarks
 Always swap images when changing
projections – AP and lateral showing at all
times
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Tips To Help Your Positioning

Look at your II
Various landmarks to use for positioning – longitudinal, height
etc
Makes is easier and more efficient in time, less skin dose to
patient etc
Visual centering to start with then fine tune positioning
 Unless you are way out, there is no need to screen
again until surgeon requests new image
 Keep fine tuning until you are happy
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Hints For Good Images
Use LDF for images as long as image quality is ok
Some operations need HDF for all images eg spinal
work
 Always use HDF for final images.
 If using the Pulsera
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 Change your parameters
 Change your dose rate
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Reduce II patient distance if possible.
Have ROI in middle of screen.
Collimation.
Correct patient positioning at commencement of
operation
 Visual centering rather and expose and re-centre
51
Post Processing Of Images
Choose your images
 Annotate your films
 Comment if needed
 Crop your films
 Negate
 Adjust brightness and contrast, edge
enhancement and noise level if necessary
 When happy, save / flag image.
 Computer entry
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What would you do if…….
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Your II Stops Working In The Middle Of A
Case
Check for error messages – write down
 Inform surgeon of problem m
 Turn off – making sure images are
saved
 Reboot II
 Still not working – repeat
 No success – change II
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Your II Doesn’t Go After Rebooting
Inform surgeon of situation
 Get more senior radiographer
 Meanwhile get back-up II if possible
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What Do You Do If You Know That Your Supervising Radiographer
Is Giving You Wrong Advice Or Is Unsafe In Their Practice?
Tell Radiographer in charge
 Make sure that you have facts to back
you up ? Evidence
 Give as much information as possible
 Responsibility is then that of the
radiographer
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What Do You Do If A Person Refuses To Wear Lead In A
Theatre Where There Is Constant Radiation?
Ask them to wear lead
 Ask them to leave the theatre
 Tell the surgeon
 Consequences to you

 Distraction
○ Mistakes
○ Then becomes your problem
Fill out incident form to cover yourself
 Remember they are adults!!!
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57
Radiation And Pregnancy In Patient

Known before start of operation
 Consent from patient
 Protect patient – lead skirt wrapped around
patient

Find out in middle of operation
 Protect patient if possible
 If not
○ Consider configuration of II
○ Consequences of this
58
Radiation And Pregnancy In Theatre Staff

Wear lead size bigger than normal
 Ensures larger crossover of lead covering stomach area
 Do not turn their backs to the source

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Distance best
Do not scrub for heavy screening cases
 eg roddings, percutaneous pedicle screws etc

Best not to scrub but their choice
59