BROOKLYN 3 STUDENTS W/S Kathy HOGAN

1. Fri 30thAug 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

2. RADIOGRAPHYCONFERENCEAUGUST 2013 STUDENT THEATRE WORKSHOP Prepared by Kathy Hogan – Charge MRT Theatre

3. 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

4. FIRST DAY JITTERS PREPARATION FOR THEATRE

5. 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.

6. 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. • 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

7. 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

8. 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?

9. 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

10. 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

11. 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.

12. Teams Within The Operating Theatre WARD – PRE-OP AND POST-OP NURSING PACU PATIENT ANAESTHETICS RADIOLOGY SURGICAL

13. General Layout Of An Ideal Theatre • Each theatre would consist of an • Operating roomwith 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

14. Benefits of Training TRAINING

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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!

21. A Quick Overview IMAGE INTENSIFIERS

22. An Example Of Variance In Values With Different Settings

23. 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

24. Examples Of Landmarks LANDMARKS LANDMARKS

25. 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

26. 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

27. RADIATION PROTECTION

28. 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 collar2.5-fold decrease in scattered radiation Leaded apronAP: 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.

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

30. 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

31. X-ray Tube Position Staff exposed to reduced radiation Staff exposed to increased radiation

32. 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

33. Factors Affecting Patient Doses Relative patient entrance dose mSv/h Intensifier diameter 12’ (32 cm) Dose 100 Dose 150 9” (22 cm) 6” (16 cm) Dose 200 Dose 300 4.5” (11 cm) The smaller the image intensifier diameter, the greater the patient entrance dose

34. Example Of Dose-rate Around The C-arm • For staff, the further from the patient the lower the dose of scattered radiation

35. 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)

36. 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

37. 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

38. Exposure Ratings for Orthopaedic Options

39. THEATRE PROCEDURE FROM START TO FINISH

40. 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 Protection • Theatre Staff • Signs on doors • Lead gowns

41. 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

42. 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.

43. Hazard Awareness 1 • Gasesused by anaesthetic machines. • Pneumatic cordfor drill in orthopaedic theatres. • Accidental flying pieces of equipment – k-wires broken off etc. • Cords / Tubeslying 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?

44. 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.

45. 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.

46. 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!

47. 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

48. 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

49. 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

50. 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