Fluoroscopy Fluoroscopy Safety Safety

New Wisconsin Regulations

In 2010, WI enacted new training regulations for clinicians who use fluoroscopy. Unless certified by the American Board of Radiology (or board eligible), clinicians are required to be trained in:

•Principles of operation of the fluoroscopic x-ray system•Biological effects of x-rays•Principles of radiation protection•Fluoroscopic outputs•High Level control options•Dose reduction techniques•Applicable state and federal regulations

What is Fluoroscopy?What is Fluoroscopy?

Fluoroscopy is an imaging procedure that uses a Fluoroscopy is an imaging procedure that uses a continuous x-ray beam to create real-time continuous x-ray beam to create real-time images viewed on a monitor.images viewed on a monitor.

It enables physicians to view internal organs and It enables physicians to view internal organs and vessels in motion.vessels in motion.

Fluoroscopy is used in both diagnostic and Fluoroscopy is used in both diagnostic and therapeutic procedures.therapeutic procedures.

Medical uses of fluoroscopyMedical uses of fluoroscopybegan shortly after Roentgen’sbegan shortly after Roentgen’s

discovery of x-rays in 1895.discovery of x-rays in 1895.

Fluoroscopy for tuberculosis (1940)

Fluoroscopy TodayFluoroscopy Today

1990’s: Injuries Reported to FDA1990’s: Injuries Reported to FDA

From 1992 through 1995, the FDA received From 1992 through 1995, the FDA received more than 100 reports of patients with more than 100 reports of patients with radiation injuries from fluoroscopy.radiation injuries from fluoroscopy.

Since 1992, reports of injuries to patients Since 1992, reports of injuries to patients and physicians have appeared in radiology, and physicians have appeared in radiology, cardiology, and medical physics journals.cardiology, and medical physics journals.

What Kind of Injuries? What Kind of Injuries?

Skin Injury and Time to OnsetSkin Injury and Time to OnsetListed in order of time of initial onsetListed in order of time of initial onset

Effect Approximate Threshold Dose (Gy)

Time of Initial

Occurance

Note

Early transient erythema

2 Hours Inflammation of the skin caused by activation of a proteolytic enzyme that increases the permeability of the capillaries

Acute ulceration

20 < 2 weeks Early loss of the epidermis that results from the death of fibroblasts and endothelial cells in interphase

Epilation 3 2 to 3 weeks Hair loss caused by the depletion of matrix cells in the hair follicles; permanent at doses exceeding 6 Gy

Dry desquamation

8 3 to 6 weeks Atypical keratinization of the skin caused by the reduction of the number of clonogenic cells within the basal layer of the epidermis

Skin Injury and Time to OnsetSkin Injury and Time to Onset

Effect Approximate Threshold Dose (Gy)

Time of Initial

Occurance

Note

Main erythema 3 Days to Weeks

Inflammation of the skin caused by hyperemia of the basal cells and subsequent epidermal hypoplasia

Moist desquamation

15 4 to 6 weeks

Loss of the epidermis caused by sterilization of a high proportion of clonogenic cells within the basal layer of the epidermis

Secondary ulceration

15 > 6 weeks Secondary damage to the dermis as a consequence of dehydration and infection when moist desquamation is severe and protracted

Late erythema 20 8 to 20 weeks

Inflammation of the skin caused by injury of the blood vessels; edema and impaired lymphatic clearance precede a reduction in blood flow

Skin Injury and Time to OnsetSkin Injury and Time to Onset

Effect Approximate Threshold Dose (Gy)

Time of Initial

Occurance

Note

Dermal necrosis

20 >10 Weeks

Necrosis of the dermal tissues as a consequence of vascular insufficiency

Invasive fibrosis

20 Month to years

Method of healing associated with acute ulceration, secondary ulceration, and dermal necrosis, leading to scar tissue formation

Dermal atrophy

10 > 26 Weeks

Thinning of the dermal tissues associated with the contraction of the previously irradiated area

Source: Centers for Disease Control and Prevention. Cutaneous radiation injury: fact sheet for physicians.

Example 1Example 1

A 40-year-old male underwent coronary A 40-year-old male underwent coronary angiography, coronary angioplasty and a angiography, coronary angioplasty and a second angiography procedure due to second angiography procedure due to complications, followed by a coronary complications, followed by a coronary artery by-pass graft, all on March 29, artery by-pass graft, all on March 29, 1990.1990.

Example and images provided by Thomas Shope, U.S. FDA Center for Devices and Radiological Health

6-8 weeks post procedure6-8 weeks post procedure

Note the erythema in Note the erythema in the shape of the the shape of the radiation collimationradiation collimation

16-21 weeks post procedure16-21 weeks post procedure

Erythema reduced, Erythema reduced, Secondary Damage Secondary Damage (not as well imaged)(not as well imaged)

18-21 months post procedure18-21 months post procedure

Close-up view Close-up view of lesionof lesion

Post Skin GraftPost Skin Graft

Example 2Example 2

Injury following three procedures Injury following three procedures involving transjugular intrahepatic involving transjugular intrahepatic portosystemic shunt placement portosystemic shunt placement (TIPS), demonstrating (TIPS), demonstrating disfigurement after surgical disfigurement after surgical correction. correction.

Koenig TR, Wolff D, Mettler FA et al. Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. AJR Am J Roentgenol 2001; 177(1):3-11.

Note EpilationNote Epilation

Example 3Example 3

Injury to arm of patient. Injury to arm of patient. Patient was draped for Patient was draped for procedure and physicians procedure and physicians did not realize that shedid not realize that she had moved her arm so that had moved her arm so that it was resting on the port ofit was resting on the port of the X-ray tube during thethe X-ray tube during the procedure. procedure.

Wagner LK, Archer BR. Minimizing Risks from Fluoroscopic X Rays. 4th edition.

The Woodlands, Texas: Partners in Radiation Management, 2004.    

Why Are Injuries Occurring?Why Are Injuries Occurring?One contributing factor is the growth in number and types One contributing factor is the growth in number and types of interventional procedures using fluoroscopy. But any of interventional procedures using fluoroscopy. But any procedure using fluoroscopy has the potential for patient procedure using fluoroscopy has the potential for patient injury.injury.

Another factor may be more overweight and obese Another factor may be more overweight and obese patients. Higher energy x-rays and higher radiation dose patients. Higher energy x-rays and higher radiation dose rates are required to penetrate through these patients.rates are required to penetrate through these patients.

FDA ActionsFDA Actions

In 1994, the FDA issued a In 1994, the FDA issued a Public Health Public Health Advisory on avoidance of serious skin Advisory on avoidance of serious skin injuries to patients during fluoroscopy-injuries to patients during fluoroscopy-guided procedures.guided procedures.

In 1995, the FDA issued a follow-up In 1995, the FDA issued a follow-up advisory on recording information in the advisory on recording information in the patient’s record that identifies the patient’s record that identifies the potential for serious skin injury from potential for serious skin injury from fluoroscopy.fluoroscopy.

Joint Commission ActionJoint Commission Action

In 2006, the Joint Commission added a Sentinel Event In 2006, the Joint Commission added a Sentinel Event category for radiation overdose involving prolonged category for radiation overdose involving prolonged fluoroscopy with a cumulative dose of more than 15 Gray fluoroscopy with a cumulative dose of more than 15 Gray to a single field.to a single field.

Fluoroscopy machines manufactured after June 2006 Fluoroscopy machines manufactured after June 2006 measure and display a reference patient radiation dose. measure and display a reference patient radiation dose. The reference dose can be monitored during the The reference dose can be monitored during the procedure, and the cumulative dose can be recorded in the procedure, and the cumulative dose can be recorded in the patient’s medical record.patient’s medical record.

SummarySummary

All of the following injuries can beAll of the following injuries can be

caused by radiation:caused by radiation:

– Skin erythema and desquamationSkin erythema and desquamation– EpilationEpilation– Skin ulcerationSkin ulceration

What About Personnel Safety?What About Personnel Safety?

Physicians and staff using fluoroscopy are exposed Physicians and staff using fluoroscopy are exposed to:to:

- Scattered radiation from the patient- Scattered radiation from the patient

- Leakage radiation from Leakage radiation from the x-ray tubethe x-ray tube

- Primary radiation from thePrimary radiation from the x-ray beam if their handsx-ray beam if their hands are in the radiation fieldare in the radiation field

x-ray tube

Detector/image intensifier

Personnel SafetyPersonnel Safety

Although clinician radiation dose is much Although clinician radiation dose is much lower than the patient dose, it is proportional lower than the patient dose, it is proportional to patient dose. to patient dose.

Higher patient doses will usually lead to Higher patient doses will usually lead to higher operator and staff doses. higher operator and staff doses.

Radiation RisksRadiation Risks

High doses of radiation (>1 Gray in a single High doses of radiation (>1 Gray in a single exposure), such as those received by patients exposure), such as those received by patients injured by fluoroscopy, are linked to skin injury injured by fluoroscopy, are linked to skin injury and increased risk of cancer. and increased risk of cancer.

Low doses of radiation over long periods of time, Low doses of radiation over long periods of time, such as those received by medical personnel, such as those received by medical personnel, maymay result in an increased risk of cancer, result in an increased risk of cancer, although this has not been conclusively proven.although this has not been conclusively proven.

ALARA ALARA (As Low As Reasonably Achievable)(As Low As Reasonably Achievable)

Because we know that large doses of radiation Because we know that large doses of radiation can cause long term health effects, such as can cause long term health effects, such as increasing the risk of developing cancer, we increasing the risk of developing cancer, we assume that all radiation exposure entails some assume that all radiation exposure entails some risk.risk.

Therefore, we should try to limit the radiation Therefore, we should try to limit the radiation exposure to patients and staff, consistent with exposure to patients and staff, consistent with obtaining the necessary clinical information.obtaining the necessary clinical information.

In fluoroscopy, there are three practical techniques to In fluoroscopy, there are three practical techniques to reduce radiation exposure to patients and personnel.reduce radiation exposure to patients and personnel.

•Reduce Fluoro TimeReduce Fluoro Time•Increase DistanceIncrease Distance •Provide ShieldingProvide Shielding

The following slides demonstrate how to use these The following slides demonstrate how to use these techniques to reduce radiation exposure.techniques to reduce radiation exposure.

Time: Identify if the patient has had Time: Identify if the patient has had other recent long fluoro proceduresother recent long fluoro procedures

Check the patient’s medical record to see if they Check the patient’s medical record to see if they have had a recent long fluoroscopy procedure in the have had a recent long fluoroscopy procedure in the same location.same location.

If yes, try to change the C-Arm angle so that you are If yes, try to change the C-Arm angle so that you are not irradiating the same area of skin again.not irradiating the same area of skin again.

Time: Recognize the Fluoroscopy Time: Recognize the Fluoroscopy “Beam-On” Controls“Beam-On” Controls

Typical x-ray Typical x-ray “beam-on” foot “beam-on” foot pedal.pedal.

Most units also Most units also have a beam-on have a beam-on button or switch the button or switch the user can operate user can operate by hand.by hand.

Time: Minimize “Beam-On” timeTime: Minimize “Beam-On” time

Use short taps of the fluoroscopy beam-on Use short taps of the fluoroscopy beam-on control. Don’t use a “lead foot” on thecontrol. Don’t use a “lead foot” on thefluoroscopy pedal.fluoroscopy pedal.

Reducing beam-onReducing beam-ontime is the most time is the most effective way toeffective way toreduce dose.reduce dose.

Time: LIH and LFHTime: LIH and LFH

Use Use Last Image Hold (LIH)Last Image Hold (LIH) or or Last Fluoroscopy Hold (LFH)Last Fluoroscopy Hold (LFH) when possible instead of re-when possible instead of re-exposing the patient.exposing the patient.

Last Image Hold saves the last fluoroscopy image Last Image Hold saves the last fluoroscopy image and displays it on the monitor.and displays it on the monitor.

Last Fluoroscopy Hold saves the last video Last Fluoroscopy Hold saves the last video sequence of fluoroscopy images for instant replay.sequence of fluoroscopy images for instant replay.

Time: Fluoroscopy Dose ModesTime: Fluoroscopy Dose Modes

Different dose mode selections may be Different dose mode selections may be available available

– Low Dose (Low Dose (↓patient dose, ↑ image noise)↓patient dose, ↑ image noise)– High Dose (High Dose (↑patient dose, ↓ image noise)↑patient dose, ↓ image noise)– Low Frame Rate (Low Frame Rate (↓patient dose,↓patient dose, ↓ frame rate) ↓ frame rate)

When Image Quality allows, use low dose When Image Quality allows, use low dose mode and/or a lower frame rate.mode and/or a lower frame rate.

Time: Minimize Use of High Dose Time: Minimize Use of High Dose ModeMode

High dose rate High dose rate mode may be mode may be needed for large needed for large patients or for patients or for seeing greater seeing greater detail.detail.

High dose mode High dose mode selection is selection is usually denoted usually denoted by a “+” sign.by a “+” sign.

Do not routinely use high dose mode.

Time: Digital Acquisition ModeTime: Digital Acquisition Mode

X-Ray machines used for X-Ray machines used for interventional procedures have a interventional procedures have a digital acquisition or “cine” mode.digital acquisition or “cine” mode.

A high radiation dose rate is used to obtain a A high radiation dose rate is used to obtain a series of high resolution images with reduced series of high resolution images with reduced image noise.image noise.

The radiation dose per frame for digital The radiation dose per frame for digital acquisitions can be 15 times greater than for acquisitions can be 15 times greater than for fluoroscopy.fluoroscopy.

Time: Use Digital Acquisition/Cine Time: Use Digital Acquisition/Cine Mode AppropriatelyMode Appropriately

The number and length of digitalThe number and length of digitalacquisition or cine “runs” may be acquisition or cine “runs” may be the greatest source of patient the greatest source of patient radiation dose in interventional radiation dose in interventional radiology procedures. radiology procedures.

Be aware of the increased dose rate and do Be aware of the increased dose rate and do not not use digital acquisition/cine mode as a substitute use digital acquisition/cine mode as a substitute for fluoroscopy.for fluoroscopy.

Using Time to Reduce Exposure: Using Time to Reduce Exposure: SummarySummary

When image quality allows, choosing to When image quality allows, choosing to use low dose fluoro modes and last use low dose fluoro modes and last image hold, while limiting the use of image hold, while limiting the use of “boost” fluoro and high dose digital “boost” fluoro and high dose digital acquisitions, will reduce patient and acquisitions, will reduce patient and staff radiation exposure.staff radiation exposure.

Distance: Scattered RadiationDistance: Scattered RadiationDuring fluoroscopy, During fluoroscopy, radiation is scattered radiation is scattered from the surface of the from the surface of the patient where the x-ray patient where the x-ray beam enters.beam enters.

Scattered radiation is the Scattered radiation is the main source of radiation main source of radiation dose to staff. It also dose to staff. It also decreases image decreases image contrast and degrades contrast and degrades image quality.image quality.

x-ray tube

Detector/Image Intensifier

Distance: C-Arm PositionDistance: C-Arm Position

Position the X-ray tube Position the X-ray tube underneath the patient, not underneath the patient, not above the patient.above the patient.

The greatest amount of The greatest amount of scatter radiation is produced scatter radiation is produced where the x-ray beam where the x-ray beam enters the patient.enters the patient.

By positioning the x-ray tube By positioning the x-ray tube below the patient, you below the patient, you receive less scatter receive less scatter radiation.radiation.X-ray Tube

Image Intensifier

Distance: C-Arm PositionDistance: C-Arm Position

For lateral and oblique For lateral and oblique projections, position the projections, position the C-arm so that the x-ray C-arm so that the x-ray tube is on the opposite tube is on the opposite side of the patient from side of the patient from where you are working.where you are working.

This will reduce the This will reduce the scatter radiation scatter radiation reaching you.reaching you.

Always stand closer to the detector/image intensifier.

Always stand farther from the X-Ray Tube.

Distance: C-Arm PositionDistance: C-Arm Position

Position the x-ray tube and Position the x-ray tube and image intensifier so you are image intensifier so you are working on the image working on the image intensifier side of the patient.intensifier side of the patient.

Position the x-ray tube as far Position the x-ray tube as far from the patient as possible.from the patient as possible.

Position the Image intensifier Position the Image intensifier as close to the patient as as close to the patient as possible.possible.

X-ray tube Image intensifier

Distance: Proximity to the X-Ray Distance: Proximity to the X-Ray TubeTube

The patient’s skin should The patient’s skin should never touch or be near the x-never touch or be near the x-ray tube port (where the x-ray tube port (where the x-rays come out).rays come out).

Staff should also never touch Staff should also never touch or be near the x-ray tube or be near the x-ray tube port.port.

Burns can occur in seconds if Burns can occur in seconds if skin is touching or near the x-skin is touching or near the x-ray tube port.ray tube port.

X-ray tube port

Distance: Minimize the Air Gap Distance: Minimize the Air Gap

Move the detector or Move the detector or image intensifier as image intensifier as close to the patient as close to the patient as possible. possible.

A smaller air gap A smaller air gap reduces radiation dose reduces radiation dose to the patient and staff to the patient and staff and improves image and improves image quality.quality.

Distance: When possible increase Distance: When possible increase your distance from the patient when your distance from the patient when

the x-ray beam is onthe x-ray beam is on

When possible, simply When possible, simply taking taking a step backa step back from the from the radiation source whenever radiation source whenever possible will greatly reduce possible will greatly reduce your radiation dose.your radiation dose.

Moving from 30cm to 60 cm Moving from 30cm to 60 cm from the patient will reduce from the patient will reduce your exposure by a factor of your exposure by a factor of 4.4.

Distance: Stay Out of the Distance: Stay Out of the Fluoroscopy BeamFluoroscopy Beam

Don’t put your hands in the fluoroscopy beam unless Don’t put your hands in the fluoroscopy beam unless absolutely necessary for the procedure.absolutely necessary for the procedure.

This is the hand of a This is the hand of a physician who was physician who was exposed to repeated small exposed to repeated small doses of x-ray radiation for doses of x-ray radiation for 15 years. The skin cancer 15 years. The skin cancer appeared several years appeared several years after his work with x-rays after his work with x-rays had ceased.had ceased.

Meissner, William A. and Warren, Shields: Neoplasms, In Anderson W.A.D. editor; Pathology, edition 6, St. Louis, 1971, The C.V. Mosby Co

Using Distance to Reduce Exposure: Using Distance to Reduce Exposure: SummarySummary

• When possible, always position the image When possible, always position the image intensifier over the patient.intensifier over the patient.

• Maximize the distance from the x-ray tube to the Maximize the distance from the x-ray tube to the patient.patient.

• Move the image intensifier as close to the patient Move the image intensifier as close to the patient as you can.as you can.

• Maximize the distance between you and the Maximize the distance between you and the patient during the x-ray exposure.patient during the x-ray exposure.

• Do not put your hands in the primary beam.Do not put your hands in the primary beam.

Shielding: Collimate AppropriatelyShielding: Collimate Appropriately

Collimate tightly to the Collimate tightly to the area of clinical interest to area of clinical interest to reduce patient and staff reduce patient and staff dose, reduce scatter, and dose, reduce scatter, and improve image contrast.improve image contrast.

uncollimated

collimated

Shielding: Magnification ModesShielding: Magnification Modes

Magnification enlarges the anatomy being viewed, but it Magnification enlarges the anatomy being viewed, but it also increases the radiation dose to the patient.also increases the radiation dose to the patient.

Multiple electronic magnification modes may be available.Multiple electronic magnification modes may be available.

Use ShieldingUse Shielding Wisconsin DHS regulations require anyone Wisconsin DHS regulations require anyone

within 6 feet of a fluoroscopy machine to wear within 6 feet of a fluoroscopy machine to wear a lead apron.a lead apron.

You may also wear a lead thyroid shield or You may also wear a lead thyroid shield or leaded eyeglasses, depending on the type leaded eyeglasses, depending on the type and amount of work you do.and amount of work you do.

Shielding: Mini C-ArmsShielding: Mini C-Arms

Although Mini C-Arms produce less Although Mini C-Arms produce less scatter Radiation than full C-Arms, scatter Radiation than full C-Arms, Aspirus Wausau Hospital radiation Aspirus Wausau Hospital radiation safety procedures require the use of safety procedures require the use of lead aprons when performing any lead aprons when performing any fluoroscopy procedure.fluoroscopy procedure.

GE OEC Mini-C

Shielding: Hang Lead Aprons Shielding: Hang Lead Aprons ProperlyProperly

Hanging lead aprons on Hanging lead aprons on hangers/hooks prevents hangers/hooks prevents the lead from cracking the lead from cracking and tearing.and tearing.

This is for your safety, This is for your safety, so please be sure to so please be sure to take care of your lead.take care of your lead.

Using Shielding to Reduce Exposure: Using Shielding to Reduce Exposure: SummarySummary

• Collimate the radiation to the area of interest.

• Minimize the use of high magnification modes.

• Always wear radiation protection devices.

Pediatric PatientsPediatric Patients

Children are estimated to be two to seven times Children are estimated to be two to seven times more sensitive to radiation than adults.more sensitive to radiation than adults.

They have more dividing and differentiating cells and They have more dividing and differentiating cells and have a longer time over which radiation effects such have a longer time over which radiation effects such as cancer can appear.as cancer can appear.

Use techniques taught in this course to minimize the Use techniques taught in this course to minimize the dose to pediatric patients as well.dose to pediatric patients as well.

To Reduce Pediatric Radiation To Reduce Pediatric Radiation ExposureExposure

• Use low dose or low pulse rate mode.Use low dose or low pulse rate mode.• Collimate the beam to only show the area of Collimate the beam to only show the area of

interest.interest.• Maximize the distance from the x-ray tube to the Maximize the distance from the x-ray tube to the

patient.patient.• Minimize the distance from the image intensifier Minimize the distance from the image intensifier

to the patient.to the patient.• Use the minimum electronic magnification Use the minimum electronic magnification

necessary.necessary.• Use the minimum amount of “beam-on” time Use the minimum amount of “beam-on” time

necessary.necessary.

Radiation Dose LimitsRadiation Dose Limits

Occupational radiation exposure to radiation workers Occupational radiation exposure to radiation workers is regulated by the federal government and the is regulated by the federal government and the states. states.

Annual occupational radiation exposure limits are set Annual occupational radiation exposure limits are set to levels at which there is believed to be negligible to levels at which there is believed to be negligible risk of biological effects.risk of biological effects.

Whole Body: Whole Body: 50 mSv/yr 50 mSv/yr Lens of the Eye: Lens of the Eye: 150 mSv/yr150 mSv/yr Extremities, Skin: Extremities, Skin: 500 mSv/yr500 mSv/yr

Dosimetry BadgesDosimetry Badges

Workers likely to receive an occupational Workers likely to receive an occupational radiation dose greater than 5 mSv/year radiation dose greater than 5 mSv/year must be monitored.must be monitored. Radiation exposure reviews determine Radiation exposure reviews determine which categories of workers are required to which categories of workers are required to be monitored.be monitored.

Workers with particular concern regarding Workers with particular concern regarding radiation, such as pregnant workers, may radiation, such as pregnant workers, may also be monitored even if they are not likely also be monitored even if they are not likely to exceed 5 mSv/yr.to exceed 5 mSv/yr.

Dosimetry Badge

Dosimetry BadgesDosimetry Badges

If you have been issued a single dosimetry badge, wear it outside your lead apron at collar level.

If you have been issued two badges, wear the “collar badge” outside your lead apron, and wear the “body badge” underneath your lead apron.

For More InformationFor More Information

These and other policies regarding radiation safety These and other policies regarding radiation safety are available in the Aspirus Wausau Hospital are available in the Aspirus Wausau Hospital Radiation Safety Plan which is available on the Radiation Safety Plan which is available on the hospital network at:hospital network at:

S:\Radiation Safety PlanS:\Radiation Safety Plan

or by contacting the Aspirus Wausau Hospital or by contacting the Aspirus Wausau Hospital Radiation Safety Officer.Radiation Safety Officer.

QuestionsQuestions

For questions about fluoroscopy safety, contact For questions about fluoroscopy safety, contact the Aspirus Wausau Hospital Radiation Safety the Aspirus Wausau Hospital Radiation Safety Officer.Officer.

Raymond Wery, M.S., DABRRaymond Wery, M.S., DABR phone: 715-847-2031 phone: 715-847-2031 rayw@aspirus.org rayw@aspirus.org

Fluoroscopy Safety CertificateFluoroscopy Safety Certificate

A test will follow this presentation, to validate your A test will follow this presentation, to validate your understanding of these safety principles.understanding of these safety principles.

If you would like a certificate documenting that you If you would like a certificate documenting that you have received training in Fluoroscopy Safety, call or have received training in Fluoroscopy Safety, call or e-mail the Aspirus Wausau Hospital Provider Support e-mail the Aspirus Wausau Hospital Provider Support Services Department.Services Department.

The certificate can satisfy other organizations’ The certificate can satisfy other organizations’ requirements for fluoroscopy training, if needed. requirements for fluoroscopy training, if needed.

ContributorsContributors

Mary Ellen Jafari, M.S., DABRMary Ellen Jafari, M.S., DABRAlan M. Daus., M.S., DABRAlan M. Daus., M.S., DABR

Diagnostic Medical Physics SectionDiagnostic Medical Physics SectionImaging DepartmentImaging DepartmentGundersen Lutheran Medical CenterGundersen Lutheran Medical CenterLa Crosse, WisconsinLa Crosse, Wisconsin