PORTABLE PORTABLE OR applications OR applications

and Considerationsand Considerations

Week 13 Week 13 RTEC 124 RTEC 124

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

Who are these people?Who are these people?

Importance of maintainingImportance of maintaininga sterile field…. Your role as an a sterile field…. Your role as an

RTRT

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!!

The Operating Room The Operating Room Team…you are part of it!Team…you are part of it!

What to expect…What to expect…

From your point of viewFrom your point of viewdo not touch sterile fielddo not touch sterile field

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

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

Sterile traysSterile trays

The sterile incision covered for portable

Instruments away from portable

Never use portable over sterile field

USE CAUTION!

Exchange the IR into the sterile drape

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

IMAGING IN THE ORIMAGING IN THE OR

Moblie RadiographicMoblie Radiographic

Mobile C-arm – fluoroscopicMobile C-arm – fluoroscopic

Dedicated roomDedicated room– CystographyCystography– Radiography roomRadiography room

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

C- ARM Mobile FluoroC- ARM Mobile Fluoro

Can rotate Can rotate 360° side to 360° side to sideside

90° top to 90° top to bottombottom

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

Set up room in advance if Set up room in advance if possiblepossible

FluoroscanFluoroscan

Hand surgery tableHand surgery table

Never use IR as a Never use IR as a tabletable– BloodBlood– FluidsFluids– WaterWater

Some tables have Some tables have a gapa gap– Allows for Allows for

cassette cassette placement placement without without contaminating contaminating sterile fieldsterile field

Tables without gapTables without gap

Slide cassette at top Slide cassette at top with help of with help of anesthesiologistanesthesiologist

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

Orient anatomy using Orient anatomy using markers markers

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

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

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

Various Imaging Various Imaging Procedure in Operating Procedure in Operating

RoomRoom

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

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”

DEDICATED UNIT- CYSTO DEDICATED UNIT- CYSTO RMRM

Cystoscopic Studies Cystoscopic Studies for Foreign Objectsfor Foreign Objects

Percutaneous Percutaneous NephrolithotomyNephrolithotomy

Laparoscopic Laparoscopic CholecystecomCholecystecom

yy

..

Be careful Be careful not to hit not to hit laparoscopic laparoscopic instrumentsinstruments

CholangiograCholangiogramm– Sterile lead Sterile lead

drape useddrape used– Contrast Contrast

usedused

Operative cholangiogramOperative cholangiogram

Op CHOLEOp CHOLEDigital can reverse imagesDigital can reverse images

Hickman Catheter Hickman Catheter placement placement

Starts at upper Starts at upper thorax and thorax and ends in heartends in heart

Catheter In JugularCatheter In Jugular

Upper Extremity Upper Extremity ArteriogramArteriogram

Bypass SurgeryBypass Surgery

Cervical SpineCervical Spine

Shoulder pull Shoulder pull downdown

Boost modeBoost mode

Magnification Magnification modemode

HIGHER DOSEHIGHER DOSE

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

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.

DiscectomyDiscectomy

Lateral LumbarLateral Lumbar

Drape C-arm with sterile plastic conver to protect patient and equipment

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

X-table Lateral Lumbar Spine

Challenges ?

Positioning CR ?

Hip PinningHip Pinning

Lateral HipLateral Hip

Field of View smaller with C-arm

Rod Placement inRod Placement inFemurFemur

II parallel with long axis of legII parallel with long axis of leg

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.

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.

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

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

9292

Three Dimensional (3-D) Three Dimensional (3-D) Intraarterial AngiographyIntraarterial Angiography

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

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

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

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

Post operative Post operative PortablesPortables

Post operative images taken Post operative images taken in recovery roomin recovery room

All hardware must be included in the image

Pre-op Post-OPPre-op Post-OP

How were these images How were these images taken?taken?

The Recovery RoomThe Recovery Roomand good Radiation Safety Practicesand good Radiation Safety Practices

Medical errors Medical errors & Foreign Bodies& Foreign Bodies

How to avoid themHow to avoid them

Medical errors & Medical errors & imagingimaging

IT STARTS WITH YOU

•CORRECT MARKER

•On the correct side of the patients body

There are many

Opportunities

For mistakes

And safeguards to

Prevent medical errors

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.

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

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

Nail in femoral arteryNail in femoral artery

Chicken boneChicken bone

Did you lose something?

A few more examples of OR

Peds imagesPeds images

www.hawaii.edu/medicine/www.hawaii.edu/medicine/pediatricspediatrics

Don’t get yourself in Don’t get yourself in trouble…trouble…

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 !

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

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

?