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Alara 2 0

  1. 1. ALARA 2.0
  2. 2. ALARA 2.0As Low As Reasonably Achievable
  3. 3. Brenner, DJ, Elliston,CD, Hall, HJ—AJR176:297-301
  4. 4. Conclusion The best available risk estimates suggest that pediatric CT will result in significantly increased lifetime radiation risks over adult CT, both Because of the increased dose/milliamp-second and the increased lifetime Risk/dose….. Although the risk benefit balance is still strongly tilted toward benefit…. Estimates that quantitative lifetime radiation risks for children undergoing CT are not negligible may stimulate more active reduction of CT exposure settings for pediatric patients.
  5. 5. Adapted from USA Today publication: January 22, 2001
  6. 6. Come on over here mylittle Petunia—want toplay with my new toy?
  7. 7. Pediatric Radiology Volume 31 Number 6 June 2001Pediatric Radiology Volume 32 Number 4 April 2002Pediatric Radiology Volume32 Number 10 October 2002Pediatric Radiology Volume 34 Supplement 3 October 2004Pediatric Radiology Volume 36 Supplement 2 September 2006Pediatric Radiology Volume 41 Supplement 2 September 2011
  8. 8. Radiation Conversion Sievert(Sv) and rem are terms of radiation protection absorbed dose equivalents; Gray(Gy) and Rad are units of absorbed dose.---BERT: Background Equivalent Adapted from Hall, EJ Pediatric Radiology (2002) 32: 225-227
  9. 9. Adapted from Hall, EJ PediatricRadiology (2002 32:700-706
  10. 10. Adapted from Hall, EJ Pediatric Radiology (2002) 32: 225-227
  11. 11. Adapted from Hall, EJPediatric Radiology(2002) 32: 225-227
  12. 12. Adapted from Hall, EJPediatricRadiology(2002) 32 700-706.
  13. 13. Changing World Adapted from Hall, EJ Pediatric Radiology (2002 32:700- 706
  14. 14. Brenner,DJ,Elliston,CD,Hall,EJ et al (2001) Estimated risks of radiation induced fatal cancer from pediatricCT AJR 176:289-296
  15. 15. Single CT riskas function of age Brenner,DJ,Elliston,C D,Hall,EJ et al (2001) Estimated risks of radiation induced fatal cancer from pediatric CT AJR 176:289-296
  16. 16. HOW DID WE GET IN THIS ALARA CONUNDRUM? 1980---3,000,000 CT SCANS 2005—68,000,000 CT SCANS --PATIENT/PARENT DEMANDS --LITIGATION --DEMANDS FOR IMMEDIATE CARE AND TRIAGE --LACK OF PROPER RADIATION TRAINING ACROSS ALL SPHERES --CONVIENCE
  17. 17. Adapted from:Eisenberg, RL.Radiology: AnIllustrated History.Mosby-YearBook, St. Louis,1992
  18. 18. What can we changePITCH in the land of CT?DOSE—MA(tube current—flow of electrons)—LESS SO kVp—(energy of eachphoton)SCA N THICKNESSNUMBER OF SLICESCOVERAGE OF TISSUEBOWTIE FILTERSPATIENT POSITIONING—CENTER IS OPTIMAL Adapted from: Callahan,MJ Pediatric Radiololgy(2011) 41INDICATION BASED IMAGING/FRIENDLY ENVIRONMENT (suppl 2): S488-S492COMMUNICATION
  19. 19. PITCH/SLICE THICKNESSMany machines default to a pitch of 1Use the fastest pitch and the thickest slice that will answer the questionPitches of 1.5 and 2 are often quiet adequateDo you really need HQ scans or will routine scans be enough--
  20. 20. Length of Coverage/ Number of SlicesDon’t make ABDOMEN/PELVIS automaticImage, as much as possible, only those segments of the anatomy that willanswer the question asked.Yes, this may involve extensive opportunities for interaction andcommunication between clinical physicians and radiologists.Don’t include half the chest unless there is a reason cliniciallyDo you really need both a noncontrast and contrasted exam
  21. 21. Decrease Dose: MASDosage differences in exposure can be dramatic:High Dose: 4.5 mSv: 140 mAS, 140 kVp, Pitch 1.0Medium dose: 1.6 mSv: 100mAS, 140 kVp, Pitch 1.5Low Dose: .7 mSv: 60mAS, 120kVp, Pitch 2.0
  22. 22. What can we changePITCH in the land of CT?DOSE—MA(tube current—flow of electrons)—LESS SO kVp—(energy of eachphoton)SCA N THICKNESSNUMBER OF SLICES/COVERAGE OF TISSUEBOWTIE FILTERS---PATIENT POSITIONING—CENTER IS OPTIMALINDICATION BASED IMAGINGFRIENDLY ENVIRONMENTSINGLE PHASE IMAGING
  23. 23. BOWTIE FILTERSDIMINSH ―SOFT‖ RADIATION THAT IS ABSORBED BUT NOT USEFUL FORIMAGING PRODUCTIONTHESE HAVE THEIR EFFECT PRIOR TO RADIATION REACHING THE PATIENTCONCENTRATE RADIATION APPROPRIATELY TO THE THICKEST PART OFTHE PATIENTBOWTIE FILTERS CAN REDUCE THE SURFACE DOSE BY 50%
  24. 24. PATIENT POSITIONING--DECREASES ARTIFACT--ENHANCES FUNCTIONALITY OF THE BOWTIE FILTER--INCREASES DISTANCE FROM RADIATION SOURCE—THUSDECREASES DOSE--ALLOWS AUTOMATIC EXPOSURE CONTROL TO WORK MOREEFFICIENTLY--AUTOMATIC EXPOSURE CONTROL ALLOWS DOSE MODULATION—WHILE CHOOSING NOISE LEVEL--- ESPECIALLY USEFUL IN LESSATTENUATING AREAS WHILE SCANNING AND MUST BE USED WITHCARE AS IT CAN CAUSE UNSAT NOISE ISSUES IF USED IMPROPERLY
  25. 25. INDICATION BASED IMAGINGSOME AREAS OF IMAGING ARE ―NOISE TOLERANT‖ THUS CAN BEDONE AT VERY LOW MA—THUS LOW DOSE IN THE EXTREMECHEST IMAGINGSKELETAL IMAGINGLUNG IMAGINGONE SIZE, CLEARLY DOES NOT FIT ALL!!!
  26. 26. FRIENDLY ENVIRONMENT--HAVING A PATIENT HOLD STILL, EVEN WITH OUR FAST CT SCANSWILL DECREASE THE NECESSITY FOR REPEAT EXAMS/SLICES--UP FRONT CARE/PERSONAL INTERACTION CAN BE A TIME SAVERAND A DOSE SAVER--PROVIDE CARE IN ADDITION TO A BUTTON PUSH--ENTER ALL INFO INTO THE SCANNER PRIOR TO PUTTING PATIENTON THE MACHINE—DECREASES ANXIETY AROUND THE BIG DONUT
  27. 27. SINGLE PHASE IMAGINGIS THE DOSIEST NUMBER!!!!
  28. 28. Summary--CT CT remains a major diagnostic tool---performed for appropriate indications and with thought, communication and proper technical factors—This modality remains spectacular---the benefits far exceed the very small individual risk--- Slovis Children are more sensitive to radiation that adults by a factor of 10----girls are more sensitive than boys There is an excess cancer incidence in individuals who were exposed to radiation doses comparable to the dose seen with helical CT---the mortality excess is very small over the lives of these individuals—it is far more a public health issue compared to an individual issue Dosing expression is still a question---best parameter now is BERT(Background dose equivalent)
  29. 29. Summary-- CT Reduce radiation dose but still maintain acceptable image quality(diagnostic) Only do examinations for appropriate indications—do them well ---once Use published weight parameters especially in children Pay attention to indication---much less may be needed on a follow-up compared to an initial study Move away from fixed mA protocols---see more dose caps, modulating mAs and auto mAs. ? Kv dose reduction possibilities. We must participate in the education of our peers and participate in any and all active discussions---we must be the radiologist consultant.
  30. 30. Summary– NUCLEAR MEDICINE/PET INVITE ME BACK!!!!!!
  31. 31. Summary– NUCLEAR MEDICINE/PET AND I THANK YOU FOR INVITING ME BACK
  32. 32. NUCLEAR MEDICINE/PET Go with the guidelines
  33. 33. NUCLEAR MEDICINE/PET
  34. 34. NUCLEAR MEDICINE/PET Communication is importantPerceptions of Risk vary even among professional—do your homework!Media and it’s natural tendency to stir emotions and err on the sensational side—nothelpful—but we must deal with realityPediatricians are not educated at all about radiation risks---Radiologists and radiologyprofessionals must insert themselves in this voidQuestions that come up about dose, invariably mean: What is the risk to my body ormy child?Great resource: Radiation Dose and Risk in Pediatric Nuclear Medicine: Frederic H.Fahey, DSc, S. Ted Treves, MD and S. James Adelstein. J Nucl Med. 2011;52:1240-1251.
  35. 35. NUCLEAR MEDICINE/PET Communication is important POINTERS:The nuclear medicine procedure will involve the patient receiving small amounts ofinternal radiationInternally, this substance will emit radiation similar to an x-ray machineThe dose will be very similar to other x-ray proceduresThe exposure leads to a very slight increase riks of contracting cancer sometime inthe patient’s life—having examples of relative risk often helpfulRisk benefit discussions should be a focal point
  36. 36. NUCLEAR MEDICINE/PET Communication is important Activity Lifetime Risk of DeathAssault 214Accident while riding in car 304Accident as a pedestrian 652Choking 894Accidental poisoning 1,030Drowning 1.127Exposure to fire or smoke 1.181Cancer from PET scan 10 year old 1,515Falling down the stairs 2,024Cancer from bone scan 10 year old 2,560Cancer from PET scan 40 year old 2,700All forces of nature 3,190Accident while riding a bike 4,734Cancer from bone scan 40 year old 4.760Accidental firearms discharge 6,333Accident from riding in plane 7,058Falling off ladder 10.606Hit by lightening 84,388 From: Radiation Dose and Risk in Pediatric Nuclear Medicine. Frederic H. Fahey, DSc, S. Ted Treves, MD and S. James Adelstein J Nucl Med. 2011;52:1240-1251.
  37. 37. FLUOROSCOPYFluoro Procedures have dramatically declined due to endoscopy and CT—this isespecially true in the adult populationFluoro still remains a viable option for information especially in the pediatric populationIn pediatric population, the most common cases utilizing Fluoro include: VCU Upper GI studies Contrast enemasFluoro is also used for : Orthopedic procedures Central line placement Gastroenterology/cardiologyRadiology should be sensitive and proactive about all Fluoro utilization in the hospitaland offer help in maintaining known ALARA standard regardless of where these studiesare being performed—Value add opportunities---assume Radiology to be the fountain ofknowledge for an ALARA culture
  38. 38. FLUOROSCOPY Ohio Is Unique and Very Focused on ALARAOhio Department of Health Rule 3701:1-66-07(G)requires thatAll individuals operating fluoroscopic equipement, and individuals likely to receive anannual effective dose equivalent in excess of one millisievert(one hundred millirem)from participating in flouroscopic procedures shall receive at least two hours of radiationprotection training in FLUOROSCOPY…prior to performing or participating inflouroscopic procedures.Additionally, each individual shall receive one hour of re-training whenever theindividual receives in excess of 15 millisieverts(1500millirem) measured over onecalendar year. ALARA
  39. 39. FLUOROSCOPY Ohio Is Unique and Very Focused on ALARAOhio Rule: OAC 3701-72-04(E): Only a licensed radiologic technologist or Licensedpractionier within the scope of practice may perform the following:Adjust or set technique for the x-ray procedureActivate the switch to expose the patientAssure adequate Radiation Protection to the patient and individuals in the procedureroom from unecessary radiationEven under a physician’s direct orders, nurses, scrub nurses, etc who do not possess aradiologic technologist’s license may not operate fluoroscopic equipment ALARA
  40. 40. FLUOROSCOPY Housekeeping and Boring StuffDefinitions:Air Kerma: used to report the dose in the fluoro room setting, mandated to be part of theequipment reporting process:Stands for: Kinetic Energy Released in Unit Mass(Kerma)—measures the initial amountof charge liberated by X-ray ionization in the air. The unit is Gray(Gy) orMilligray(mGy)---a close relative is the Dose Area Product---both designed to allow forestimation of skin doses exposed to fluoroscopy---both inaccurate measurements, bothstill better than just measuring flouro time alonePrediction: These measurements will become part of the standard reporting requirementsin the not so distant future. ALARA
  41. 41. FLUOROSCOPY Why all the hype?: ALARA Two major types of health effects are centered aroundradiation exposure and particularly around Fluoroscopy:DETERMINISTIC EFFECTSSTOCHASTIC EFFECTS
  42. 42. FLUOROSCOPY DETERMINISTIC EFFECTSEFFECTS DOSE(GRAY) TIME ONSETEARLY TRANSIENT ERYTHEMA 2 HOURSMAIN ERYTHEMA 6 APPROX 10 DAYSLATE ERYTHEMA 15 APPROX 10 WEEKSDRY DESQUAMATION 14 APPROX 4 WEEKSMOIST DESQUAMATION 18 APPROX 4 WEEKSSECONDARY ULCERATION 24 APPROX 4 WEEKSISCHEMIC DERMAL NECROSIS 18 10 WEEKSDERMAL ATROPHY FIRST PHASE 10 14 WEEKSDERMAL ATROPHY SECOND PHASE 10 1 YEARTELANGEICTASIA 10 1 YEARLATE DERMAL NECORSIS 12 1 YEARSKIN CANCER ? 5YEARS/MORETEMPORARY EPILATION 3 3 WEEKSPERMANENT EPILATION 7 3WEEKSCATARACT 3 1 YEAR ADAPTED FROM ―FLUOROSCOPIC SAFETY COURSE‖: OPMC(Ohio Medical Physics)
  43. 43. FLUOROSCOPYDETERMINISTIC EFFECTS6- 8 WEEKS 16-21 WEEKS
  44. 44. FLUOROSCOPYDETERMINISTIC EFFECTS 18-21 MONTHS
  45. 45. FLUOROSCOPYDETERMINISTIC EFFECTS
  46. 46. FLUOROSCOPY Stochastic effects CANCER LEUKEMIA HEREDITARY EFFECTS--RISK INCREASES WITH INCREASING DOSE--AGE: CHILDREN MORE PRONE TO DAMAGE--GENDER: WOMEN MORE PRONE TO EFFECT(BREAST SENSITIVITY)--GENETIC PREDISPOSITION(GORLIN’S SYNDROME)--LIFESTYLE CHOICES(OBESITY,SMOKING,ALCOHOL)
  47. 47. FLUOROSCOPYOHIO DEPARTMENT OF HEALTH RADIATION LIMITS ON MONITORED PERSONNEL Total effective dose equivalent annual limit: 50 millisieverts(5 rem) Dose to the lens of the eye: 150millisievert(15rem) Skin of body/extremity: 500 millisievert(50 rem) **There is no lifetime limit Adapted from **There is no patient dose limit ―Fluoroscopic Safety Course: OMPC: Ohio **Declared pregnancy limit: 5 millisievert Medical Physics, By law: Flouro unit can’t exceed 88mGy/min in normal mode and 176 mGy/min in boost mode. Typical flouro unit substantially below these numbers.
  48. 48. FLUOROSCOPY So what kind of radiation exposure do typical fluoro exams generate? STUDY FLOURO TIME SKIN DOSE BARIUM ENEMA 3.3 MINUTES 44mGy BARIUM SWALLOW 3.8 MINUTES 66mGy RENAL ANGIO 5.1 MINUTES 100mGy CEREBRAL ANGIO 12.1 MINUTES 220mGy HEPATIC ANGIO 12.1 MINUTES 340mGy PTC 14.6 MINUTES 210mGy NB: PTCA can see skin doses of up to 3 gray— remember 2 gray is where we see skin effectsAdapted from―Fluoroscopic SafetyCourse: OMPC: OhioMedical Physics,
  49. 49. FLUOROSCOPY How can we achieve maximum safety and follow ALARA guidelines in the Fluoroscopic suite? Give attention to these Four Factors: 1. TIME 2. DISTANCE 3. SHIELDING OPPORTUNITIES 4. USE EQUIPMENT WISELY AND WITH THOUGHTAdapted from―Fluoroscopic SafetyCourse: OMPC: OhioMedical Physics,
  50. 50. FLUOROSCOPY How can we achieve maximum safety and follow ALARA guidelines in the Fluoroscopic suite? TIME --BE EFFICIENT WITH PEDAL TIME—IF NOT WATCHING MONITOR, DON’T FLUORO --BE RECEPTIVE TO FELLOW MONITORING ROOMATES—WATCHFUL EYES CAN HELP --WHEN USING PULSE FLOURO, REMEMBER IF MOTION IS NOT AN ISSUE, ONE CAN SAVE RADIATION EXPOSURE TO PATIENT AND ROOM BY DECREASING THE PULSE RATE --MAKE EFFECTIVE USE OF IMAGE HOLD AND ALLOW THIS FEATURE TO GUIDE PLANNING NUMBER OF DIGITAL RUNS SHOULD BE CAREFULLY MONITORED AND PLANNED.Adapted from―Fluoroscopic SafetyCourse: OMPC: OhioMedical Physics,
  51. 51. FLUOROSCOPY How can we achieve maximum safety and follow ALARA guidelines in the Fluoroscopic suite? DISTANCE --DOUBLING THE DISTANCE CAN QUARTER THE DOSE---INVERSE SQUARE LAW --THIS SHOULD BE KEPT IN MIND BY ALL IN THE ROOM INCLUDING THE PRIMARY USER— STANDING ONE STEP BACK IMPORTANT --IF THE PATIENT CAN BE MANAGED AWAY FROM THE EDGE OF THE TABLE CLOSEST TO THE PRIMARY FLUOROSCOPIST—THIS WILL DECREASE SCATTER --WHEN DOING LATERAL FLUORO—ALWAYS CONGREGATE ON THE SIDE OF THE IMAGE INTENSIFIER AND NOT ON THE SIDE OF THE GENERATOR—SIGNIFICANT SAVINGSAdapted from --BE MINDFUL OF SPACER CONE ON C-ARMS―Fluoroscopic Safety --KEEP DETECTOR CLOSE TO PATIENT,FAR FROMCourse: OMPC: OhioMedical Physics, GENERATOR
  52. 52. FLUOROSCOPY How can we achieve maximum safety and follow ALARA guidelines in the Fluoroscopic suite? SHIELDING: --CAN BE 99% EFFECTIVE --IF IN ROOM, MUST HAVE APRON OR SHIELD --NOT THE PLACE TO BE STYLING—NO PLUNGING NECK LINES OR MINI-SKIRT SHIELDS --USE DRAPES ON FLOURO TOWERS(MYELO EXPECTION) --THYROID SHIELD OPTIONAL BUT USEFUL --GLASSES SHOULD BE USED FOR HEAVY FLUOR USERS --MUST USE GLOVES –AVOID PUTTING HANDS IN BEAM AT ALL COSTS --SIDE DRAPES VERY HELPFUL IF TOLERATED.Adapted from―Fluoroscopic SafetyCourse: OMPC: OhioMedical Physics,
  53. 53. FLUOROSCOPY How can we achieve maximum safety and follow ALARA guidelines in the Fluoroscopic suite? GENERAL USE RECOMMENDATIONS : --KEEP IMAGE INTENSIFIER CLOSE TO PATIENT --KEEP PATIENT AWAY FROM X-RAY GENERATOR --USE PULSE, USE LOWEST FRAME RATE --LARGEST FIELD OF VIEW, AVOID MAGNIFICATION --AGGRESSIVELY COLLIMATE --REMOVE GRID IF PATIENT IS THIN/PEDIATRIC --USE BOOST MODE VERY SPARINGLY(CAN INCREASE EXPOSURE 10x) --GET USED TO AIR KARMA FOR MEASURING/ESTIMATING RADIATION(BETTER THAN FLUORO TIMES -ADD FILTRATION WHEN POSSIBLEAdapted from --MAKE SPARING USE OF DIGITAL SPOT IMAGES—―Fluoroscopic Safety CAN INCREASE EXPOSURE SIGNIFICANTLYCourse: OMPC: OhioMedical Physics, --USE IMAGE HOLD WISELY/FLUORO SAVE
  54. 54. FLUOROSCOPY How can we achieve maximum safety and follow ALARA guidelines in the Fluoroscopic suite? BACK TO THE OHIO POLICE --ALL PEDIATRIC FLOURO EXAMS, PREGNANT PATIENT - EXAMS, INTERVENTIONAL AND CARDIAC PROCEDURES MUST RECORD: CUMULATIVE AIR KERMA OR DOSE-AREA PRODUCT IF THIS IS NOT AVAILABLE: FLOURO TIME RECORDED, NUMBER OF PICTURES AND MOD E OF OPERATION PATIENT NAME LOGGED DATE OF PROCEDURE LOGGEDAdapted from TYPE OF EXAMINATION LOGGED―Fluoroscopic SafetyCourse: OMPC: OhioMedical Physics, OPERATOR’S NAME
  55. 55. FLUOROSCOPYHow can we achieve maximum safety and follow ALARA guidelines in the Fluoroscopic suite?NOW A WORD FROM OUR NATIONAL POLICE(NRCP) --Fluoroscopy timer must be a 5 minute cumulative timer with an audible tone --Exposure switch must be a dead man type in which pressure must be applied o cause an exposure --SID no less 12 inches for mobile and 15 inches for stationary fluoroscopy --Generators and timers must be checked and maintained— keep a log --The patient must be visible to the technologist at all times --Lead curtain must be at least .25mm lead equivalency --All persons in the radiographic room during exposure must wear lead apron of at least .5mm lead equivalency --Intermittent beam on-off is recommended as well as use of image hold technique.
  56. 56. FLUOROSCOPYHow can we achieve maximum safety and follow ALARA guidelines in the Fluoroscopic suite? COMMUNICATE - BE SURE YOU HAVE SERVED AS A GREAT CONSULTANT HAVE NON-RADIATION METHODOLOGIES BEEN EXPLORED MENTALLY TO ANSWER THE QUESTIONS? IS THE CORRECT EXAM BEING ORDERED FOR THE CORRECT INDICATION? BE THE PROTECTOR OF THE PATIENT, YOUR CREW AND RADIATION USAGE ---BE AN ADVOCATE.
  57. 57. DR/CR What is Image Gently?--an education, awareness and advocacy campaign--dedicated to monitoring and providing advice and innovation to ensure ALARAguidelines are followed in the care of children-- It is supported by the Alliance for Radiation Safety in Pediatric Imaging which iscomposed of greater than 70 Health Care organizations/agencies and greater than800,000 radiologists—ultimate goal—Change Practice, Raise awareness--The success of Image Gently helped spawn the Image Wisely campaign which isdirected toward Adult radiation ProtectionPlease visit their web sites and utilized the ever growing collection of resources!!!!
  58. 58. DR/CR Perspective:Natural background: 3 mSv/yearAirline Passenger(cross country) .04 mSvChest x-ray .01 mSvChest x-ray two views .1mSvHead CT 2mSvChest CT 3mSvAbdominal CT 5mSvBERT COMPARISONS: Days of BackgroundBackground 1 dayChest Radiograph 1 dayHead CT 8 monthsAbdominal CT 20 monthsMRI/US Zero/Nada/Zilch
  59. 59. DR/CR Perspective:Activity Deaths/million/yearBeing 55 10,000Smoke pack/day 3,500Rock climb 2 hours 500Canoe 20 hours 200Motorcycle for 1,000miles 200Travel 1500 miles in a car 40Pedestrian 40Firefighter-1 week 15Farmer 1 week 10Fishing 10Eating(choking) 8Skiing 8Air travel—5,000 miles 5Chest x-ray 1 Adapted from :
  60. 60. DR/CRDoes Medical Radiation Cause Cancer? We simply Don’t Know Above all --- Do No Harm Adapted from :
  61. 61. DR/CR So….What Can We Do Just in Case---Can weSave One Child or Extend a Life?
  62. 62. DR/CR Measure Part Use collimation Thickness to decrease Only include patient exposure necessary anatomy Automatic Select Appropriate Exposure control Technique lowers dose but No grids used for may not be an parts less than 10-12 option for cm in thickness smaller children Immobilize effectively---Aim EffectivelyAdapted from :
  63. 63. DR/CR Optimize!!!! Measure Part Thickness Accurately(Calipers) Design, Maintain, Discuss and USE a Technique Chart for consistency—ALARA IS A TEAM SPORT Update you Technique Chart to provide accurate exposures Check your anatomical programming for accuracy Use AEC on larger patients for consistent images at a lower doseAdapted from :
  64. 64. DR/CR Optimize!!!! GRID ManagementAdapted from :
  65. 65. DR/CR Optimize!!!! GRID Management Can improve Contrast significantly Allow primary x-rays to pass through efficiently and allow scattered x-rays to be absorbed Clean-up the primary beam and prevent unnecessary exposure to patient and the surrounding environmentAdapted from :
  66. 66. DR/CR Optimize!!!!GRID Management-When to Use? Grids improve film Quality for large patients—Unfortunately--they add to patient dose Use on parts where greater thickness will produce scatter Use a grid for body parts over 10-12 cm in thickness Very few instances where grids should be used for younger or smaller children---Do Not Use Age— Measure and Adapt especially given the population weight trends Adapted from :
  67. 67. DR/CR Optimize!!!! Digital ≠ Film screen Uncoupling Effect sandbag Film/Screen: direct relationship between exposure and image Digital imaging: Computer processing adjusts image for acceptable gray scale regardless of exposure Fertility IdolAdapted from :
  68. 68. DR/CROptimize!!!! Digital ≠ Film screen Uncoupling Effect Screen film:too high a dose = black film over under optimal Digital—Computer masks dosage error— can’t feel the sand, statue disappears and the ball is rolling down at you!!!or at Adapted from : least it should!!!!
  69. 69. DR/CROptimize!!!! Digital ≠ Film screen Intro to Exposure Indicators Designed to be a primary tool to ensure that accurate exposure factors are being used when using digital equipment Provides a measure of the efficiency and sensitivity of the digital receptor to x-rays-----this information is then provided as feedback to the technologist Adapted from :
  70. 70. DR/CROptimize!!!! Digital ≠ Film screen Intro to Exposure Indicators Proprietary exposure indicators exist across the major vendors including Fuji, AGFA, Kodak, Etc but are not Harmonized or comparible---this is about to change Very important to understand these issues if buying new equipment We strongly urge the radiology community to be very involved in equipment purchases with ALARA firmly in minds eye. Adapted from :
  71. 71. DR/CROptimize!!!! Digital ≠ Film screenNew Day Dawning: New Exposure Index IEC(62494-1) has created a unified international standard to eliminate confusion and allow for more effective cross-talk among all practioners Will be applied to all future digital equipment but not mandated as of yet Participate in our attempts to make the ―fly paper‖ user patient friendly and cooperative Adapted from :
  72. 72. DR/CR Optimize!!!! Patient Dose As with all of radiology, often measuring things to allow for estimate of Patient Dose—inexact science still Influencing Factors: Beam quality, kVp, Filtration Entrance Skin Exposure(ESE) Distance from source Body part imaged Area of entrance beam Participate in ACR dose Registry(NRDR)Adapted from :
  73. 73. DR/CR Optimize!!!! Patient Dose DAP: Dose Area Product --familiar from our flouro discussion --combines recognition of radiation amount and size of field --Expressed in Gray centimeters squaredAdapted from :
  74. 74. DR/CR Optimize!!!! Do it Once,Do it Right Reasons for Redos: Artifacts Mispositioning Over collimation Patient Motion Double exposure Poor inspiration Over exposure(high EI) Under exposure(Low EI) Marker wrong Wrong exam Wrong patientAdapted from :
  75. 75. DR/CR Optimize!!!!Do it Once,Do it Right—Digital Issues Utilization of image cropping in place of collimation Routinely use overexposure—‖it’s easier and I don’t have to repeat‖ Detector Lag Misunderstanding EI Histogram Hysteria Adapted from :
  76. 76. DR/CRThe Alliance for Radiation Safety in Pediatric Imaging as Part of the: Image Gently Campaign urges you to go: FULLY SUPPORTED Adapted from : BY:
  77. 77. DR/CR IMAGE EVALUATION TOOL Beam Artifacts Shielding Immobilization and indicators Collimation FULLY Structures SUPPORTEDAdapted from : BY:
  78. 78. DR/CRHey, just like my mom is alwaystelling me: ―aim carefully before BEAMyou….well …press the button!!! Is the anatomy in the center of the image? Central Ray Tube Angle Device Alignment FULLY SUPPORTED Adapted from : BY:
  79. 79. DR/CRWhat is it with the fliesand butterflies? ARTIFACTS DOES ANYTHING OBSTRUCT THAT REQUIRES A REPEAT THE GOAL HERE IS TO BE PROACTIVE PRIOR TO FIRING THE FLIES INTO THE FLY PAPER AND THUS ELIMINATE THIS AS AN ISSUE PRE-RADIATIONAND PROACTIVELY FULLY SUPPORTED Adapted from : BY:
  80. 80. DR/CRFor the love of God and other things, pleasetake time to protect!!! SHIELDING RULE OF THUMB : A SHIELDED GONAD IS A HAPPY GONAD NO MATTER IF YOU ARE A BOY OR A GIRL!!! FULLY SUPPORTED Adapted from : BY:
  81. 81. DR/CR IMMOBILIZATION/INDICATORS EXPERIENCE INVALUABLE IN ASSESSING IMMOBILIZATIONWhy doesthe audiencekeep READ THE PARENTS AND THEIR INTERACTIONSwhispering―Shades ofGray‖? IF YOU IMMOBILIZE—DO IT WELL WITH PARENTS SUPPORT-SAND,PIGGOS,SWADDLE,DESTRACTIONS IS EXPOSURE INDICATOR IN APPROPRIATE RANGE(DEVIATION INDICATOR?) Adapted from :
  82. 82. DR/CRSOMETIMES IFYOU JUSTTALK SLOWAND QUIET,I’LL TRUST COLLIMATIONYOU. APPROPRIATE: YES OR NO RELIANCE ON ELECTRONIC CROPPING AS AN AFTERTHOUGHT IS NOT APPROPRIATE---THINK, COLLIMATE, PROTECT!!!!! THERE ARE SERIOUS LEGAL RAMIFICATIONS IF AN AREA WAS EXPOSED AND NOT UTILIZED FOR DIAGNOSIS---EXPOSED AREAS MUST BE PRESENTED FOR REVIEW, IF UNNEEDED TO ASSESS, DON’T INCLUDE IN THE BEAM--- Adapted from : PLEASE
  83. 83. DR/CRDON’T SHOOT FORPERFECT IF IT IS STRUCTURESGONNA ZAP ME!!!! IS THE ANATOMY PROPERLY DEMONSTRATED TO ANSWER THE QUESTION? Adapted from :
  84. 84. SAFETY IN GENERAL ATLEAST ME… HETALKS TOOMUCH!!
  85. 85. Image WiselyRadiation Safety in Adult Medical Imaging
  86. 86. OTHER WEB SITES OF INTEREST--HEALTH PHYSICS SOCIETY—WEB SITE FOR THE PUBLIC,STUDENTS AND TEACHERS--RPOP—RADIATION PROTECTION OF PATIENTS—SAFETY ANDDOSE ISSUES FOR PUBLIC DEALTH WITH IN PLAIN LANGUAGE--ACR RADIATION SAFETY SITE--ACR-RSNA COLLABORATIVE PATIENT EDUCATION WEB SITE—RADIOLOGY INFO.ORG--VENDOR WEB SITES/CONTACTS--PHYSICS PARTNERS ARE BECOMING MORE TIED TO CLINICALCARE AND SHOULD BE UTILIZED.
  87. 87. No, I am not a blow-hardTRUMPET PLAYER
  88. 88. Where are We Now?
  89. 89. & IMAGE
  90. 90. An Effervescent and Elegant Thank-you!!!!

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