1 brooklyn 3 students w/s kathy hogan fri 30 th aug 2013 session 4 / talk 1 16:00 – 17:00 abstract...
TRANSCRIPT
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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
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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.
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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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