1. ALARA 2.0

2. ALARA 2.0
As Low As Reasonably
Achievable

4. Brenner, DJ, Elliston,
CD, Hall, HJ—AJR
176:297-301

5. 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.

6. Adapted from USA Today publication: January 22, 2001

8. Come on over here my
little Petunia—want to
play with my new toy?

10. Pediatric Radiology Volume 31 Number 6 June 2001
Pediatric Radiology Volume 32 Number 4 April 2002
Pediatric Radiology Volume32 Number 10 October 2002
Pediatric Radiology Volume 34 Supplement 3 October 2004
Pediatric Radiology Volume 36 Supplement 2 September 2006
Pediatric Radiology Volume 41 Supplement 2 September 2011

11. 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

12. Adapted from Hall, EJ Pediatric
Radiology (2002 32:700-706

13. Adapted from Hall, EJ Pediatric Radiology (2002) 32: 225-227

14. Adapted from Hall, EJ
Pediatric Radiology
(2002) 32: 225-227

15. Adapted from Hall, EJ
Pediatric
Radiology(2002) 32 700-
706.

16. Changing World
Adapted
from Hall,
EJ
Pediatric
Radiology
(2002
32:700-
706

17. Brenner,DJ,Elliston,CD,Hall,EJ et al (2001) Estimated risks of radiation induced fatal cancer from pediatric
CT AJR 176:289-296

18. Single CT risk
as 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

19. 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

20. Adapted from:
Eisenberg, RL.
Radiology: An
Illustrated History.
Mosby-Year
Book, St. Louis,
1992

22. What can we change
PITCH
in the land of CT?
DOSE—MA(tube current—flow of electrons)—LESS SO kVp—(energy of each
photon)
SCA N THICKNESS
NUMBER OF SLICES
COVERAGE OF TISSUE
BOWTIE FILTERS
PATIENT POSITIONING—CENTER IS OPTIMAL Adapted from: Callahan,MJ
Pediatric Radiololgy(2011) 41
INDICATION BASED IMAGING/FRIENDLY ENVIRONMENT (suppl 2): S488-S492
COMMUNICATION

23. PITCH/SLICE
THICKNESS
Many machines default to a pitch of 1
Use the fastest pitch and the thickest slice that will answer the question
Pitches of 1.5 and 2 are often quiet adequate
Do you really need HQ scans or will routine scans be enough--

24. Length of Coverage/
Number of Slices
Don’t make ABDOMEN/PELVIS automatic
Image, as much as possible, only those segments of the anatomy that will
answer the question asked.
Yes, this may involve extensive opportunities for interaction and
communication between clinical physicians and radiologists.
Don’t include half the chest unless there is a reason clinicially
Do you really need both a noncontrast and contrasted exam

25. Decrease Dose:
MAS
Dosage differences in exposure can be dramatic:
High Dose: 4.5 mSv: 140 mAS, 140 kVp, Pitch 1.0
Medium dose: 1.6 mSv: 100mAS, 140 kVp, Pitch 1.5
Low Dose: .7 mSv: 60mAS, 120kVp, Pitch 2.0

26. What can we change
PITCH
in the land of CT?
DOSE—MA(tube current—flow of electrons)—LESS SO kVp—(energy of each
photon)
SCA N THICKNESS
NUMBER OF SLICES/COVERAGE OF TISSUE
BOWTIE FILTERS---
PATIENT POSITIONING—CENTER IS OPTIMAL
INDICATION BASED IMAGING
FRIENDLY ENVIRONMENT
SINGLE PHASE IMAGING

27. BOWTIE FILTERS
DIMINSH ―SOFT‖ RADIATION THAT IS ABSORBED BUT NOT USEFUL FOR
IMAGING PRODUCTION
THESE HAVE THEIR EFFECT PRIOR TO RADIATION REACHING THE PATIENT
CONCENTRATE RADIATION APPROPRIATELY TO THE THICKEST PART OF
THE PATIENT
BOWTIE FILTERS CAN REDUCE THE SURFACE DOSE BY 50%

28. PATIENT POSITIONING
--DECREASES ARTIFACT
--ENHANCES FUNCTIONALITY OF THE BOWTIE FILTER
--INCREASES DISTANCE FROM RADIATION SOURCE—THUS
DECREASES DOSE
--ALLOWS AUTOMATIC EXPOSURE CONTROL TO WORK MORE
EFFICIENTLY
--AUTOMATIC EXPOSURE CONTROL ALLOWS DOSE MODULATION—
WHILE CHOOSING NOISE LEVEL--- ESPECIALLY USEFUL IN LESS
ATTENUATING AREAS WHILE SCANNING AND MUST BE USED WITH
CARE AS IT CAN CAUSE UNSAT NOISE ISSUES IF USED IMPROPERLY

29. INDICATION BASED IMAGING
SOME AREAS OF IMAGING ARE ―NOISE TOLERANT‖ THUS CAN BE
DONE AT VERY LOW MA—THUS LOW DOSE IN THE EXTREME
CHEST IMAGING
SKELETAL IMAGING
LUNG IMAGING
ONE SIZE, CLEARLY DOES NOT FIT ALL!!!

30. FRIENDLY ENVIRONMENT
--HAVING A PATIENT HOLD STILL, EVEN WITH OUR FAST CT SCANS
WILL DECREASE THE NECESSITY FOR REPEAT EXAMS/SLICES
--UP FRONT CARE/PERSONAL INTERACTION CAN BE A TIME SAVER
AND A DOSE SAVER
--PROVIDE CARE IN ADDITION TO A BUTTON PUSH
--ENTER ALL INFO INTO THE SCANNER PRIOR TO PUTTING PATIENT
ON THE MACHINE—DECREASES ANXIETY AROUND THE BIG DONUT

31. SINGLE PHASE IMAGING
IS THE DOSIEST NUMBER!!!!

32. 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)

33. 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.

34. Summary– NUCLEAR MEDICINE/PET
INVITE ME
BACK!!!!!!

35. Summary– NUCLEAR MEDICINE/PET
AND
I
THANK YOU
FOR
INVITING
ME
BACK

36. NUCLEAR MEDICINE/PET
Go with
the
guidelines

37. NUCLEAR MEDICINE/PET

38. NUCLEAR MEDICINE/PET
Communication is important
Perceptions of Risk vary even among professional—do your homework!
Media and it’s natural tendency to stir emotions and err on the sensational side—not
helpful—but we must deal with reality
Pediatricians are not educated at all about radiation risks---Radiologists and radiology
professionals must insert themselves in this void
Questions that come up about dose, invariably mean: What is the risk to my body or
my 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.

39. NUCLEAR MEDICINE/PET
Communication is important
POINTERS:
The nuclear medicine procedure will involve the patient receiving small amounts of
internal radiation
Internally, this substance will emit radiation similar to an x-ray machine
The dose will be very similar to other x-ray procedures
The exposure leads to a very slight increase riks of contracting cancer sometime in
the patient’s life—having examples of relative risk often helpful
Risk benefit discussions should be a focal point

40. NUCLEAR MEDICINE/PET
Communication is important
Activity Lifetime Risk of Death
Assault 214
Accident while riding in car 304
Accident as a pedestrian 652
Choking 894
Accidental poisoning 1,030
Drowning 1.127
Exposure to fire or smoke 1.181
Cancer from PET scan 10 year old 1,515
Falling down the stairs 2,024
Cancer from bone scan 10 year old 2,560
Cancer from PET scan 40 year old 2,700
All forces of nature 3,190
Accident while riding a bike 4,734
Cancer from bone scan 40 year old 4.760
Accidental firearms discharge 6,333
Accident from riding in plane 7,058
Falling off ladder 10.606
Hit 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.

41. FLUOROSCOPY
Fluoro Procedures have dramatically declined due to endoscopy and CT—this is
especially true in the adult population
Fluoro still remains a viable option for information especially in the pediatric population
In pediatric population, the most common cases utilizing Fluoro include:
VCU
Upper GI studies
Contrast enemas
Fluoro is also used for :
Orthopedic procedures
Central line placement
Gastroenterology/cardiology
Radiology should be sensitive and proactive about all Fluoro utilization in the hospital
and offer help in maintaining known ALARA standard regardless of where these studies
are being performed—Value add opportunities---assume Radiology to be the fountain of
knowledge for an ALARA culture

42. FLUOROSCOPY
Ohio Is Unique and Very Focused on ALARA
Ohio Department of Health Rule 3701:1-66-07(G)requires that
All individuals operating fluoroscopic equipement, and individuals likely to receive an
annual effective dose equivalent in excess of one millisievert(one hundred millirem)
from participating in flouroscopic procedures shall receive at least two hours of radiation
protection training in FLUOROSCOPY…prior to performing or participating in
flouroscopic procedures.
Additionally, each individual shall receive one hour of re-training whenever the
individual receives in excess of 15 millisieverts(1500millirem) measured over one
calendar year.
ALARA

43. FLUOROSCOPY
Ohio Is Unique and Very Focused on ALARA
Ohio Rule: OAC 3701-72-04(E): Only a licensed radiologic technologist or Licensed
practionier within the scope of practice may perform the following:
Adjust or set technique for the x-ray procedure
Activate the switch to expose the patient
Assure adequate Radiation Protection to the patient and individuals in the procedure
room from unecessary radiation
Even under a physician’s direct orders, nurses, scrub nurses, etc who do not possess a
radiologic technologist’s license may not operate fluoroscopic equipment
ALARA

44. FLUOROSCOPY
Housekeeping and Boring Stuff
Definitions:
Air Kerma: used to report the dose in the fluoro room setting, mandated to be part of the
equipment reporting process:
Stands for: Kinetic Energy Released in Unit Mass(Kerma)—measures the initial amount
of charge liberated by X-ray ionization in the air. The unit is Gray(Gy) or
Milligray(mGy)---a close relative is the Dose Area Product---both designed to allow for
estimation of skin doses exposed to fluoroscopy---both inaccurate measurements, both
still better than just measuring flouro time alone
Prediction: These measurements will become part of the standard reporting requirements
in the not so distant future.
ALARA

45. FLUOROSCOPY
Why all the hype?: ALARA
Two major types of health effects are centered around
radiation exposure and particularly around Fluoroscopy:
DETERMINISTIC EFFECTS
STOCHASTIC EFFECTS

46. FLUOROSCOPY
DETERMINISTIC EFFECTS
EFFECTS DOSE(GRAY) TIME ONSET
EARLY TRANSIENT ERYTHEMA 2 HOURS
MAIN ERYTHEMA 6 APPROX 10 DAYS
LATE ERYTHEMA 15 APPROX 10 WEEKS
DRY DESQUAMATION 14 APPROX 4 WEEKS
MOIST DESQUAMATION 18 APPROX 4 WEEKS
SECONDARY ULCERATION 24 APPROX 4 WEEKS
ISCHEMIC DERMAL NECROSIS 18 10 WEEKS
DERMAL ATROPHY FIRST PHASE 10 14 WEEKS
DERMAL ATROPHY SECOND PHASE 10 1 YEAR
TELANGEICTASIA 10 1 YEAR
LATE DERMAL NECORSIS 12 1 YEAR
SKIN CANCER ? 5YEARS/MORE
TEMPORARY EPILATION 3 3 WEEKS
PERMANENT EPILATION 7 3WEEKS
CATARACT 3 1 YEAR
ADAPTED FROM
―FLUOROSCOPIC SAFETY
COURSE‖: OPMC(Ohio Medical
Physics)

47. FLUOROSCOPY
DETERMINISTIC EFFECTS
6- 8 WEEKS 16-21 WEEKS

48. FLUOROSCOPY
DETERMINISTIC EFFECTS
18-21 MONTHS

49. FLUOROSCOPY
DETERMINISTIC EFFECTS

50. 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)

51. FLUOROSCOPY
OHIO 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.

52. 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 effects
Adapted from
―Fluoroscopic Safety
Course: OMPC: Ohio
Medical Physics,

53. 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 THOUGHT
Adapted from
―Fluoroscopic Safety
Course: OMPC: Ohio
Medical Physics,

54. 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 Safety
Course: OMPC: Ohio
Medical Physics,

55. 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 SAVINGS
Adapted from --BE MINDFUL OF SPACER CONE ON C-ARMS
―Fluoroscopic Safety --KEEP DETECTOR CLOSE TO PATIENT,FAR FROM
Course: OMPC: Ohio
Medical Physics, GENERATOR

56. 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 Safety
Course: OMPC: Ohio
Medical Physics,

57. 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 POSSIBLE
Adapted from --MAKE SPARING USE OF DIGITAL SPOT IMAGES—
―Fluoroscopic Safety CAN INCREASE EXPOSURE SIGNIFICANTLY
Course: OMPC: Ohio
Medical Physics, --USE IMAGE HOLD WISELY/FLUORO SAVE

58. 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 LOGGED
Adapted from TYPE OF EXAMINATION LOGGED
―Fluoroscopic Safety
Course: OMPC: Ohio
Medical Physics, OPERATOR’S NAME

59. FLUOROSCOPY
How 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.

60. FLUOROSCOPY
How 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.

61. DR/CR
What is Image Gently?
--an education, awareness and advocacy campaign
--dedicated to monitoring and providing advice and innovation to ensure ALARA
guidelines are followed in the care of children
-- It is supported by the Alliance for Radiation Safety in Pediatric Imaging which is
composed of greater than 70 Health Care organizations/agencies and greater than
800,000 radiologists—ultimate goal—Change Practice, Raise awareness
--The success of Image Gently helped spawn the Image Wisely campaign which is
directed toward Adult radiation Protection
Please visit their web sites and utilized the ever growing collection of resources!!!!

62. DR/CR
Perspective:
Natural background: 3 mSv/year
Airline Passenger(cross country) .04 mSv
Chest x-ray .01 mSv
Chest x-ray two views .1mSv
Head CT 2mSv
Chest CT 3mSv
Abdominal CT 5mSv
BERT COMPARISONS: Days of Background
Background 1 day
Chest Radiograph 1 day
Head CT 8 months
Abdominal CT 20 months
MRI/US Zero/Nada/Zilch

63. DR/CR
Perspective:
Activity Deaths/million/year
Being 55 10,000
Smoke pack/day 3,500
Rock climb 2 hours 500
Canoe 20 hours 200
Motorcycle for 1,000miles 200
Travel 1500 miles in a car 40
Pedestrian 40
Firefighter-1 week 15
Farmer 1 week 10
Fishing 10
Eating(choking) 8
Skiing 8
Air travel—5,000 miles 5
Chest x-ray 1
Adapted from :

64. DR/CR
Does Medical Radiation Cause
Cancer?
We simply Don’t Know
Above all
---
Do No Harm
Adapted from :

65. DR/CR
So….What Can
We Do Just in
Case---Can we
Save One Child or
Extend a Life?

66. 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
Effectively
Adapted from :

67. 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 dose
Adapted from :

68. DR/CR
Optimize!!!!
GRID Management
Adapted from :

69. 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 environment
Adapted from :

70. 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 :

71. 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 Idol
Adapted from :

72. DR/CR
Optimize!!!! 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!!!!

73. DR/CR
Optimize!!!! 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 :

74. DR/CR
Optimize!!!! 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 :

75. DR/CR
Optimize!!!! Digital ≠ Film screen
New 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 :

76. 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 :

77. 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 squared
Adapted from :

78. 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 patient
Adapted from :

79. 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 :

80. DR/CR
The Alliance for Radiation Safety in Pediatric Imaging as Part of the: Image Gently
Campaign urges you to go:
FULLY
SUPPORTED
Adapted from : BY:

81. DR/CR
IMAGE EVALUATION TOOL
Beam
Artifacts
Shielding
Immobilization and indicators
Collimation
FULLY
Structures SUPPORTED
Adapted from : BY:

82. DR/CR
Hey, just like my mom is always
telling me: ―aim carefully before
BEAM
you….well …press the button!!!
Is the anatomy in the center of the image?
Central Ray
Tube Angle
Device Alignment
FULLY
SUPPORTED
Adapted from : BY:

83. DR/CR
What is it with the flies
and 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:

84. DR/CR
For the love of God and other things, please
take 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:

85. DR/CR
IMMOBILIZATION/INDICATORS
EXPERIENCE INVALUABLE IN ASSESSING
IMMOBILIZATION
Why does
the audience
keep READ THE PARENTS AND THEIR INTERACTIONS
whispering
―Shades of
Gray‖?
IF YOU IMMOBILIZE—DO IT WELL WITH PARENTS
SUPPORT-SAND,PIGGOS,SWADDLE,DESTRACTIONS
IS EXPOSURE INDICATOR IN APPROPRIATE
RANGE(DEVIATION INDICATOR?)
Adapted from :

86. DR/CR
SOMETIMES IF
YOU JUST
TALK SLOW
AND QUIET,
I’LL TRUST
COLLIMATION
YOU.
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

87. DR/CR
DON’T SHOOT FOR
PERFECT IF IT IS
STRUCTURES
GONNA ZAP ME!!!!
IS THE ANATOMY
PROPERLY
DEMONSTRATED TO
ANSWER THE
QUESTION?
Adapted from :

88. SAFETY IN GENERAL
AT
LEAST
ME…
HE
TALKS
TOO
MUCH!!

89. Image Wisely
Radiation Safety in Adult Medical Imaging

90. OTHER WEB SITES OF INTEREST
--HEALTH PHYSICS SOCIETY—WEB SITE FOR THE PUBLIC,
STUDENTS AND TEACHERS
--RPOP—RADIATION PROTECTION OF PATIENTS—SAFETY AND
DOSE 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 CLINICAL
CARE AND SHOULD BE UTILIZED.

91. No, I am not a
blow-hard
TRUMPET PLAYER

92. Where are We Now?

97. & IMAGE

98. An Effervescent and
Elegant
Thank-you!!!!