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1. Communication is important when discussing pediatric nuclear medicine procedures, as perceptions of risk vary. Radiology professionals must provide education to pediatricians and the public about realistic radiation risks. 2. The nuclear medicine procedure will involve small amounts of internal radiation similar to an x-ray, posing a very slight increased lifetime cancer risk. Risk-benefit discussions should focus patients on relative risks. 3. Examples comparing the lifetime cancer risk from common nuclear medicine exams to other risks, like accidents or natural causes, can help provide perspective on the minimal risks involved.

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ALARA 2.0
ALARA 2.0 As Low As Reasonably Achievable
Brenner, DJ, Elliston, CD, Hall, HJ—AJR 176:297-301
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.
Adapted from USA Today publication: January 22, 2001
Come on over here my little Petunia—want to play with my new toy?
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
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
Adapted from Hall, EJ Pediatric Radiology (2002 32:700-706
Adapted from Hall, EJ Pediatric Radiology (2002) 32: 225-227
Adapted from Hall, EJ Pediatric Radiology (2002) 32: 225-227
Adapted from Hall, EJ Pediatric Radiology(2002) 32 700- 706.
Changing World Adapted from Hall, EJ Pediatric Radiology (2002 32:700- 706
Brenner,DJ,Elliston,CD,Hall,EJ et al (2001) Estimated risks of radiation induced fatal cancer from pediatric CT AJR 176:289-296
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
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
Adapted from: Eisenberg, RL. Radiology: An Illustrated History. Mosby-Year Book, St. Louis, 1992
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
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--
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
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
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
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%
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
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!!!
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
SINGLE PHASE IMAGING IS THE DOSIEST NUMBER!!!!
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)
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.
Summary– NUCLEAR MEDICINE/PET INVITE ME BACK!!!!!!
Summary– NUCLEAR MEDICINE/PET AND I THANK YOU FOR INVITING ME BACK
NUCLEAR MEDICINE/PET Go with the guidelines
NUCLEAR MEDICINE/PET
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.
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
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.
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
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
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
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
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
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)
FLUOROSCOPY DETERMINISTIC EFFECTS 6- 8 WEEKS 16-21 WEEKS
FLUOROSCOPY DETERMINISTIC EFFECTS 18-21 MONTHS
FLUOROSCOPY DETERMINISTIC EFFECTS
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)
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.
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,
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,
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,
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
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,
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
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
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.
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.
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!!!!
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
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 :
DR/CR Does Medical Radiation Cause Cancer? We simply Don’t Know Above all --- Do No Harm Adapted from :
DR/CR So….What Can We Do Just in Case---Can we Save One Child or Extend a Life?
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 :
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 :
DR/CR Optimize!!!! GRID Management Adapted from :
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 :
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 :
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 :
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!!!!
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 :
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 :
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 :
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 :
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 :
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 :
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 :
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:
DR/CR IMAGE EVALUATION TOOL Beam Artifacts Shielding Immobilization and indicators Collimation FULLY Structures SUPPORTED Adapted from : BY:
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:
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:
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:
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 :
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
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 :
SAFETY IN GENERAL AT LEAST ME… HE TALKS TOO MUCH!!
Image Wisely Radiation Safety in Adult Medical Imaging
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.
No, I am not a blow-hard TRUMPET PLAYER
Where are We Now?
& IMAGE
An Effervescent and Elegant Thank-you!!!!

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Alara 2 0

  • 1.
  • 2.
    ALARA 2.0 As LowAs 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 USAToday publication: January 22, 2001
  • 8.
    Come on overhere my little Petunia—want to play with my new toy?
  • 10.
    Pediatric Radiology Volume31 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 asfunction 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 WEGET 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 wechange 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 wechange 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 --ENHANCESFUNCTIONALITY 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 SOMEAREAS 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 APATIENT 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 ISTHE DOSIEST NUMBER!!!!
  • 32.
    Summary--CT CT remainsa 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 Reduceradiation 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.
  • 35.
    Summary– NUCLEAR MEDICINE/PET AND I THANK YOU FOR INVITING ME BACK
  • 36.
    NUCLEAR MEDICINE/PET Go with the guidelines
  • 37.
  • 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 havedramatically 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.
  • 48.
  • 49.
  • 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 OFHEALTH 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 weachieve 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 weachieve 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 RadiationCause 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 forRadiation 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 likemy 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 itwith 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 loveof 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 TALKSLOW 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 PERFECTIF 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 Safetyin Adult Medical Imaging
  • 90.
    OTHER WEB SITESOF 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 amnot a blow-hard TRUMPET PLAYER
  • 92.
  • 97.
  • 98.
    An Effervescent and Elegant Thank-you!!!!