portable or applications and considerations week 13 rtec 124
TRANSCRIPT
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PORTABLE PORTABLE OR applications OR applications
and Considerationsand Considerations
Week 13 Week 13 RTEC 124 RTEC 124
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CAUTION: CAUTION: SOME IMAGES MAY BE DISTURBING SOME IMAGES MAY BE DISTURBING
BUT AS HEALTHCARE PROFESSIONALS BUT AS HEALTHCARE PROFESSIONALS THIS IS WHAT YOU MAY EXPERIENCETHIS IS WHAT YOU MAY EXPERIENCE
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Who are these people?Who are these people?
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Importance of maintainingImportance of maintaininga sterile field…. Your role as an a sterile field…. Your role as an
RTRT
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STERILE IN ORSTERILE IN OR
Must change clothingMust change clothing Wear a “cover gown” when leavingWear a “cover gown” when leaving Masks, hair cover, and shoe coversMasks, hair cover, and shoe covers Change when you leave the OR roomChange when you leave the OR room
DO NOT TAKE HOSP SCRUBS HOME!!DO NOT TAKE HOSP SCRUBS HOME!!
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The Operating Room The Operating Room Team…you are part of it!Team…you are part of it!
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What to expect…What to expect…
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From your point of viewFrom your point of viewdo not touch sterile fielddo not touch sterile field
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Surgical RadiographySurgical Radiography Imaging is commonly used in Imaging is commonly used in
surgical proceduressurgical procedures
But the surgeon already has the But the surgeon already has the patient’s body open, right?patient’s body open, right?
Sometimes it is used as a guideSometimes it is used as a guide
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Must cover equipment in sterile drapes when Must cover equipment in sterile drapes when it may come into contact with patient , it may come into contact with patient , instruments, or surgeons handsinstruments, or surgeons hands
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Sterile traysSterile trays
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The sterile incision covered for portable
Instruments away from portable
Never use portable over sterile field
USE CAUTION!
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Exchange the IR into the sterile drape
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SURGERYSURGERY
Sterile procedures must be followedSterile procedures must be followed– Not to contaminate surgical siteNot to contaminate surgical site
– Don’t touch anything BLUE or GREENDon’t touch anything BLUE or GREEN
– Be careful not to run into trays, etcBe careful not to run into trays, etc
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IMAGING IN THE ORIMAGING IN THE OR
Moblie RadiographicMoblie Radiographic
Mobile C-arm – fluoroscopicMobile C-arm – fluoroscopic
Dedicated roomDedicated room– CystographyCystography– Radiography roomRadiography room
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Equipment in the OR Equipment in the OR must be coveredmust be covered– Must be cleaned before Must be cleaned before
bringing into roombringing into room
Protects patientProtects patient– Prevents contamination Prevents contamination
of sterile field and of sterile field and instrumentsinstruments
UNLIKE PORTABLE EXAMS ON THE UNLIKE PORTABLE EXAMS ON THE UNITS UNITS
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C- ARM Mobile FluoroC- ARM Mobile Fluoro
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Can rotate Can rotate 360° side to 360° side to sideside
90° top to 90° top to bottombottom
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C-Arm FLUOROSCOPYC-Arm FLUOROSCOPY Tube at one end and I.I. at other endTube at one end and I.I. at other end TV Monitor control cart separate from unitTV Monitor control cart separate from unit Uses Digital FluoroscopyUses Digital Fluoroscopy Last Image HoldLast Image Hold Image EnhancementImage Enhancement Save for hard copies from disk and videoSave for hard copies from disk and video Photographic MagnificationPhotographic Magnification SubtractionSubtraction Static (pulsed) and continuous fluoroscopy Static (pulsed) and continuous fluoroscopy
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Set up room in advance if Set up room in advance if possiblepossible
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FluoroscanFluoroscan
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Hand surgery tableHand surgery table
Never use IR as a Never use IR as a tabletable– BloodBlood– FluidsFluids– WaterWater
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Some tables have Some tables have a gapa gap– Allows for Allows for
cassette cassette placement placement without without contaminating contaminating sterile fieldsterile field
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Tables without gapTables without gap
Slide cassette at top Slide cassette at top with help of with help of anesthesiologistanesthesiologist
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Considerations before procedureConsiderations before procedure
Find out where surgeon wants you to goFind out where surgeon wants you to go
Be careful not to contaminate Be careful not to contaminate
Plug in C-arm and test itPlug in C-arm and test it– Marker check on II if possibleMarker check on II if possible– Guard FOOT Switch Guard FOOT Switch
Park portable equipment in corner –out of Park portable equipment in corner –out of the waythe way
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Orient anatomy using Orient anatomy using markers markers
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Mobile Radiography Mobile Radiography ConsiderationsConsiderations
If surgery is already in progressIf surgery is already in progress– Before entering, park machine outside Before entering, park machine outside
of roomof room– Survey room to get lay-outSurvey room to get lay-out– Rearrange equipment/furniture if Rearrange equipment/furniture if
necessary necessary
Place cassette in a STERILE WRAPPlace cassette in a STERILE WRAP
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PATIENT CONSIDERATIONSPATIENT CONSIDERATIONSDURING SURGERYDURING SURGERY
Patient may not always be Patient may not always be “unconscious” “unconscious” – Pain managementPain management– Twilight stateTwilight state
Always treat patient with respect and Always treat patient with respect and courtesycourtesy– They may be hearing everythingThey may be hearing everything
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USING C-ARM vs PORTABLEUSING C-ARM vs PORTABLE
C-ARMC-ARM
Faster- instant Faster- instant imageimage
More radiationMore radiation
Smaller field of Smaller field of viewview
PortablePortable
Must have accurate Must have accurate techniquetechnique
Processing neededProcessing needed– LongerLonger
Larger field of viewLarger field of view
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Various Imaging Various Imaging Procedure in Operating Procedure in Operating
RoomRoom
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SURGERY - Common SURGERY - Common ProceduresProcedures
Ortho (Bone) Work Ortho (Bone) Work Pinning/ Rod / Screw placement Pinning/ Rod / Screw placement Fracture realignmentFracture realignment
Organs / Vessels with contrastOrgans / Vessels with contrast Arteries / Veins in the extremitiesArteries / Veins in the extremities Cholangiograms = ductsCholangiograms = ducts UrographyUrography
Pacemaker and Line Placements etcPacemaker and Line Placements etc
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TECHNIQUE TECHNIQUE CONSIDERATIONSCONSIDERATIONS
Same principles of ALARASame principles of ALARA Change techniques if using gridChange techniques if using grid
– 3-5 times more if using grid3-5 times more if using grid– Body parts larger than 12cmBody parts larger than 12cm
SID –SID –– VERY IMPORTANT TO MEASUREVERY IMPORTANT TO MEASURE– Chest usually done at 63-72”Chest usually done at 63-72”– All others done at 40”All others done at 40”
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DEDICATED UNIT- CYSTO DEDICATED UNIT- CYSTO RMRM
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Cystoscopic Studies Cystoscopic Studies for Foreign Objectsfor Foreign Objects
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Percutaneous Percutaneous NephrolithotomyNephrolithotomy
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Laparoscopic Laparoscopic CholecystecomCholecystecom
yy
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..
Be careful Be careful not to hit not to hit laparoscopic laparoscopic instrumentsinstruments
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CholangiograCholangiogramm– Sterile lead Sterile lead
drape useddrape used– Contrast Contrast
usedused
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Operative cholangiogramOperative cholangiogram
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Op CHOLEOp CHOLEDigital can reverse imagesDigital can reverse images
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Hickman Catheter Hickman Catheter placement placement
Starts at upper Starts at upper thorax and thorax and ends in heartends in heart
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Catheter In JugularCatheter In Jugular
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Upper Extremity Upper Extremity ArteriogramArteriogram
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Bypass SurgeryBypass Surgery
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Cervical SpineCervical Spine
Shoulder pull Shoulder pull downdown
Boost modeBoost mode
Magnification Magnification modemode
HIGHER DOSEHIGHER DOSE
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Scout placementScout placement– Checks placementChecks placement
Sequential imagingSequential imaging– Watches placement of Watches placement of
screws and pinsscrews and pins– Final image for Final image for
documentationdocumentation
Print a hard copy Print a hard copy
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USE OF PORTABLE
CROSS TABLE LATERAL C.SPINE
Lateral projection of the cervical spine with patient supine.
Done to verify the correct position of instruments before continuing surgery.
Often a spinal needle is placed in the disc space to show position.
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DiscectomyDiscectomy
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Lateral LumbarLateral Lumbar
Drape C-arm with sterile plastic conver to protect patient and equipment
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PA LumbarPA Lumbar
AP or PA to lateralAP or PA to lateral– Caution not to hit patient Caution not to hit patient
or equipmentor equipment– KEEP STERILEKEEP STERILE
Familiarize yourself with Familiarize yourself with lockslocks– PRACTICE WITH CI, RT’SPRACTICE WITH CI, RT’S
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X-table Lateral Lumbar Spine
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Challenges ?
Positioning CR ?
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Hip PinningHip Pinning
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Lateral HipLateral Hip
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Field of View smaller with C-arm
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Rod Placement inRod Placement inFemurFemur
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II parallel with long axis of legII parallel with long axis of leg
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Image of tibial nail Image of tibial nail screw holes in screw holes in incorrect alignment incorrect alignment and oblong in and oblong in shape.shape.
Image of tibial nail screw holes perfectly round, and magnified to assist proper alignment.
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Image of tibial nail Image of tibial nail screw holes in screw holes in incorrect alignment incorrect alignment and oblong in and oblong in shape.shape.
Image of tibial nail screw holes perfectly round, and magnified to assist proper alignment.
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NOTE THE POSITION OF THE NOTE THE POSITION OF THE II AND TUBEII AND TUBE
KEEP II CLOSE TO PATIENT
KEEP TUBE AS FAR AWAY AS POSSIBLE
MUST BE AT LEAST ________
INCHES FROM PT
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9191
DSA DSA
A subtraction mask is A subtraction mask is taken before contrast taken before contrast injectedinjected
Each of digitized Each of digitized image is from the image is from the maskmask
Images acquired Images acquired formform– 1 image every 2-3 sec1 image every 2-3 sec– Up to 30 images per Up to 30 images per
secsec
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9292
Three Dimensional (3-D) Three Dimensional (3-D) Intraarterial AngiographyIntraarterial Angiography
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RAD PROTECTION RAD PROTECTION in the O.R.in the O.R.
It’s your duty to protect the patient, It’s your duty to protect the patient, yourself and others (healthcare yourself and others (healthcare professional)professional)
Politely ask whoever can, to move back Politely ask whoever can, to move back from the areafrom the area
Provide aprons to those who cannot leaveProvide aprons to those who cannot leave Announce your intent to make an Announce your intent to make an
exposure and give time for others to exposure and give time for others to move backmove back
IF personnel are in sterile drape – may not IF personnel are in sterile drape – may not be able to put on apron be able to put on apron
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RAD PROTECTION in the RAD PROTECTION in the OROR
C-ARM = HIGHER DOSEC-ARM = HIGHER DOSE STAND BEHIND C-ARM UNIT WHEN POSSIBLESTAND BEHIND C-ARM UNIT WHEN POSSIBLE
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RAD PROTECTIONRAD PROTECTIONRULES OF GOOD PRACTICE RULES OF GOOD PRACTICE
Never place your hand or other body Never place your hand or other body part in primary beampart in primary beam
Provide gonadal protection for the Provide gonadal protection for the patient if possible patient if possible
FOR C-ARM – IF BEAM FROM BELOW – FOR C-ARM – IF BEAM FROM BELOW – PLACE APRON ON TABLE BEFORE PLACE APRON ON TABLE BEFORE PATIENT IS ON TABLEPATIENT IS ON TABLE
Achieve maximum distance from the Achieve maximum distance from the patient and tube (stand 90° from the patient and tube (stand 90° from the patient)patient)
Minimum 6 foot exposure cord for Minimum 6 foot exposure cord for radiographyradiography
Label and handle cassettes carefullyLabel and handle cassettes carefully
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RADIATION PROTECTIONRADIATION PROTECTIONRemember the “Cardinal Rules”Remember the “Cardinal Rules”
RADIOGRAPHICRADIOGRAPHIC 6 ‘ 6 ‘ exposure cordexposure cord Minimum source to Minimum source to
skin distance = 12”skin distance = 12” Preferred SID of 40”to Preferred SID of 40”to
72”+ (72”+ ( mag mag detail) detail) Distance from tube Distance from tube
and patientand patient At least .25mm lead At least .25mm lead
apronapron
FLUOROSCOPICFLUOROSCOPIC Minimum source to Minimum source to
skin distance = 12”skin distance = 12” Preferred SSD OF 18”Preferred SSD OF 18” Distance from tube Distance from tube
and patientand patient 5 min Audible Alarm5 min Audible Alarm At least .25mm lead At least .25mm lead
apron to be wornapron to be worn 5 R/min - 10 R/min5 R/min - 10 R/min
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Post operative Post operative PortablesPortables
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Post operative images taken Post operative images taken in recovery roomin recovery room
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All hardware must be included in the image
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Pre-op Post-OPPre-op Post-OP
How were these images How were these images taken?taken?
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The Recovery RoomThe Recovery Roomand good Radiation Safety Practicesand good Radiation Safety Practices
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Medical errors Medical errors & Foreign Bodies& Foreign Bodies
How to avoid themHow to avoid them
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Medical errors & Medical errors & imagingimaging
IT STARTS WITH YOU
•CORRECT MARKER
•On the correct side of the patients body
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There are many
Opportunities
For mistakes
And safeguards to
Prevent medical errors
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About 1,500 peopleAbout 1,500 people
Small amount Small amount considering about considering about 28.4 million 28.4 million operationsoperations
Yet this is no Yet this is no consolation for the consolation for the people who've had it people who've had it happen to them.happen to them.
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SpongesSponges
Most commonMost common
Sponges fill up with Sponges fill up with blood and can blood and can resemble parts of resemble parts of the bodythe body
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Common medical devices Common medical devices left inside patientsleft inside patients
Eyebrow Tweezer Eyebrow Tweezer Tissue expander Tissue expander Retractor Retractor Syringe Syringe Purple Latex Gloves Purple Latex Gloves Sharpie Sharpie Speculum Speculum Mouth gag, Mouth gag, Hemostat Hemostat Chest Spreader Chest Spreader
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Nail in femoral arteryNail in femoral artery
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Chicken boneChicken bone
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Did you lose something?
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A few more examples of OR
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Peds imagesPeds images
www.hawaii.edu/medicine/www.hawaii.edu/medicine/pediatricspediatrics
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Don’t get yourself in Don’t get yourself in trouble…trouble…
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Portable and Mobile Portable and Mobile Competencies Competencies
YOU MUST YOU MUST ALWAYSALWAYS HAVE HAVE SUPERVISION SUPERVISION
EVEN AFTER COMPETENCY IS EVEN AFTER COMPETENCY IS DONE per DONE per JRCERTJRCERT
DO NOTDO NOT PUT YOURSELF IN A SITUATION WHERE PUT YOURSELF IN A SITUATION WHEREYOU DO NOT HAVE APPROIATE SUPERVISION !YOU DO NOT HAVE APPROIATE SUPERVISION !
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OR / PORT COMPSOR / PORT COMPS
Still need direct Still need direct supervision- even after you supervision- even after you have a competencyhave a competency
Must have “DIRECT” Must have “DIRECT” supervision for portables supervision for portables and C-arm at ALL timesand C-arm at ALL times
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PORTABLE & C- ARM PORTABLE & C- ARM COMPETENCIESCOMPETENCIES
Must do a Pre-Portable check –Must do a Pre-Portable check –off first off first
C- Arm check offC- Arm check off
Must do more than 3 exams of Must do more than 3 exams of each area – portable – before each area – portable – before attempting competency attempting competency
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?