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BROOKLYN 3

STUDENTS W/S

Kathy HOGAN

Fri 30th Aug 2013

Session 4 / Talk 1

16:00 – 17:00

ABSTRACT

Students – DHS Resources Pedicle Screws Trigeminal Nerve Decompression Distal Locking Screws Shoulders Angiography How to get the most out of the Pulsera

STUDENT THEATRE WORKSHOP

Prepared by Kathy Hogan – Charge MRT Theatre

RADIOGR

APHY CONFERENCEAU

GUST2013

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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

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PREPARATION FOR THEATRE

FIRST DAY JITTERS

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Wearing The Correct Attire

Theatre Scrubs Paper hat covering all hair

especially long hair ID Badge Monitoring badge No long sleeved singlet / T

Shirts

No personal outer gear to be worn in the theatre suites.

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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.

Personal hygiene – high standard. 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

Infection Control

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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

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What To Expect Mentally?

Questions on entering theatre: 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 You can help this by

○ Relaxing○ Thinking before you act○ Positive attitude – willingness to learn○ Awareness of sterile equipment○ Asking questions○ Enjoy theatre

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ResponsibilityYou are initially responsible to the radiographer

that you are with.You are also indirectly responsible to the

- Theatre NursesSurgeonsAnaesthetistsTheatre Coordinator for your actions and consequences of those actions.

Whatever action you take has a consequence in theatre.

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Teams Within The Operating Theatre

PATIENT

PACU

ANAESTHETICS RADIOLOGY

NURSING

WARD – PRE-OP AND POST-OP

SURGICAL

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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 roomScrub 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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TRAINING

Benefits of Training

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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 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

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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

Theatre Workbook Theatre Pocket Guide Book Theatre Protocols and Resource Folder Theatre X-ray Coordinator Radiographers Other Students Yourself!

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IMAGE INTENSIFIERS

A Quick Overview

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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 EfficiencyConfidenceLess 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 operationTape on IIs to write measurements on

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Examples Of Landmarks

LANDMARKS LANDMARKS

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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

Image intensifier allows low-intensity x-rays to be amplified

Magnifies intensity produced in output image

Result: less radiation emitted

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RADIATION PROTECTION

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Leaded apronAP: 16-fold decrease in scattered radiationLateral: 4-fold decrease in scattered radiation

Thyroid collar

2.5-fold decrease in scattered radiation

Eye protection0.15 mm lead-equivalent goggles provide 70% attenuation of radiographic beam

Gloves for sterile staff60–64% protection at 52–58 KV

Radiation: Protective Clothing

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.28

Position x-ray tube under and as far as possible away from the patient

Use lasers on x-ray tube and image intensifier for positioning

Collimate where and when possible

Correct parameter / dose for specified body area

Select dose rate in line with patient size

Maintain appropriate distance from source bearing in mind the operation that you are assisting

C-arm 'Attitude' And Technical Contributions To Radiation Dose Reduction

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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

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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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Dose 150

Dose 200

Intensifier diameterRelative patient entrance

dose mSv/h

12’ (32 cm)

9” (22 cm)

6” (16 cm)

4.5” (11 cm)

Dose 100

Dose 300

The smaller the image intensifier diameter,

the greater the patient entrance dose

Factors Affecting Patient Doses

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For staff, the

further from

the patient the

lower the dose

of scattered

radiation

Example Of Dose-rate Around The C-arm

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Radiation dosimeter(monitor)

20 mSv per year,

average over defined

periods of 5 years

How do you know how

much radiation you

have received?

How Much Radiation Is Safe?

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Using The Pulsera And Its Parameters

Has many options for exposure Parameters Dose Control Low and High Quality Images

Can change many factors to alter image quality 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

Continuous

½ Dose

¼ Dose

Ortho Plus LDF HDF

Continuous

½ Dose

¼ Dose

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THEATRE PROCEDURE

FROM START TO FINISH

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The Call From Theatre Information

Where, when, what for, patient details Keys, phone etc What II will you need

Factors○ Adult / Child○ ROI○ Size of patient (if known)

Radiation ProtectionTheatre 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 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

- 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

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 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 When performing radiation, the following rules should be

followed: 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 saveIf on patient’s right and patient

is supine, then push both R

buttons to orientate, then fine

tune with rotation buttonAlways save image after orientating or altering

Pulsera Take your first image and orientateSaves any changes automatically

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Points To Note Before Screening Look out for

Is the patient on the right tableHas the table got an x-ray end on if doing ankles etcImage reversal – always screen as the surgeon sees the patient unless he asks for anatomically correctII – patient distanceDose saving exposure selectedSaving of imagesPatient PositioningCollimation - sideways or iris coneArtifacts – bedding, table etc

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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 etcMakes 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

Change your parametersChange your dose rate

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

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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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SCENARIOS

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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Radiation And Pregnancy In Patient Known before start of operation

Consent from patientProtect patient – lead skirt wrapped around

patient Find out in middle of operation

Protect patient if possibleIf not

○ Consider configuration of II○ Consequences of this

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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

Distance best Do not scrub for heavy screening cases

eg roddings, percutaneous pedicle screws etc Best not to scrub but their choice

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