1. Radiation hazards AO Trauma Basic Principles Course
Published: July 2013
Revised: 2018
Reviewer: Mamoun Kremli
AO Trauma Basic Principles Course

2. Learning objectives
Describe effect of radiation on human organs and cells
Outline how the radiation exposure will affect the operation room (OR) personnel
List the various factors for minimizing radiation hazards during intraoperative imaging
Describe how to use the C-arm to minimize radiation hazards and provide optimal intraoperative imaging
Teaching points: Highlight how to use a C-arm correctly.

3. Why discuss radiation hazards?
A number of orthopedic surgeons have been diagnosed with tumors during their working life
Some do not take enough care while using x-rays in the OR
What you are about to hear,
may affect your life-span!

4. Physical facts Radiation is energy from electromagnetic waves
X-radiation = ionizing radiation
Ionizing
Non-ionizing
First, some physical facts:
Radiation is energy from electromagnetic waves—ionizing radiation or x-radiation.
It has a frequency higher than UV (wave length smaller than UV).
Ionizing radiation is harmful.
Harmful
Harmless

5. Physical facts Unit of measurement: Sievert (Sv) 1 Sv = 1 Joule/kg
Dose equivalent, reflects the biological effect
The energy produced by x-radiation is measured in Rems (roentgen equivalent in men).
Gray is the unit that represents the energy deposited in material. (1 Gy=1 Joule/kg)
The energy deposited in biological material is expressed as a dose equivalent.
This dose equivalent is called Sievert and it reflects the biological effect of radiation. 1 Sv=1 Joule/kg
The three units are equivalent and are used depending on the location of its measurement.

6. Physical facts Normal exposure
13 μSv/hour
3.7 μSv/hour
0.03 μSv/hour
The amount of radiation encountered in daily life ranges in the dimension of 100 milirems=1 m > Gy=1 mSv or 1000 μ/Sv.
The higher the altitude, the more the radiation
Examples of normal exposure are:
Cosmic rays during high altitude flights ranges from to 0.01 mSv/hour
Natural background radiation that we receive daily is 0.01 mSv/day
In the United States, the dose from natural cosmic radiation is 0.27 mSv a year
Cosmic rays in high-altitude flights: 0.001–0.01 mSv/hour
Higher altitude = more radiation
Natural background radiation: 0.01 mSv/day

7. Physical facts Medical exposure Chest x-ray 0.1 mSv CT scan, head
15 chest x-rays
CT scan, whole body
9.9 mSv
100 chest x-rays
The most important radiation exposure for patients usually takes place in the radiology department:
a chest x-ray is 0.1 mili-Sievert
a CT scan of the head is 1.5 mili-Sieverts
a CT of the entire body is 9.9 mili-Sieverts
whereas, a cardiac CT angio has 6.7–13 mili-Sieverts.
The latter represents a rather high amount of x-ray absorption into the body.

8. 50–100 whole body CT scans! Physical facts
The dose of radiation required to produce radiation sickness is between 500 and 1000 mSv, which is equal to the amount that the citizens of Hiroshima were exposed to in 1945.
Radiation from a nuclear bomb: 500–1000 mSv
50–100 whole body CT scans!

9. Biological facts—ionizing radiation
Somatic effects (500–1000 mSv):
Radiation sickness
Radiation cataract
Thyroid cancer
Leukemia
Directly related to dose
Below certain threshold, no increased risk
Ionizing radiation has different effects on the body.
Somatic effects are directly related to the dose of radiation. Early somatic effects include radiation sickness, which occurs after exposure to a large amount of radiation (500–1000 mSv). Late somatic effects include leukemia, thyroid cancer, or radiation cataracts. The good news about somatic effects is that once you get below a certain threshold there is no increased risk on exposure to radiation.

10. Biological facts—ionizing radiation
Stochastic effects:
(NOT determined by dose - chance)
Thyroid cancer
Leukemia
No safe threshold
Cumulative damage with multiple exposures
Ionizing radiation has different effects on the body.
Stochastic effects of radiation are different. There is no safe threshold and damage is cumulative with multiple exposures to radiation. The late effects of this are thyroid cancer or leukemia.

11. Biological facts—ionizing radiation
Genetic effects:
Mutagenic effects (dose related) proven in animals
Teratogenic effects:
At 18–85 days of gestation provoked by 10 mSv
Ionizing radiation has different effects on the body.
Genetic effects of radiation are dose-related and have proven to show mutagenic effects in animals.
Teratogenic effects can be observed in animals between 18 and 85 days of gestation and are provoked by 10 mili-Sieverts.

12. Specific body exposure
Hands:
Have greatest exposure risk
Eyes:
Radiation cataract
Thyroid:
85% of papillary carcinoma are radiation induced
Which part of the body is most exposed to radiation?
In orthopedic trauma surgeons, this is of course the hands. Surgeons often use their hands for reduction and checking reduction at the same time.
The second part of the body are the eyes. They are more distant from the radiation source but are the most sensitive area of the body to radiation. The dose of radiation received by the eye is the limiting factor determining the amount of radiation a surgeon can be exposed to during a period of time. This somatic effect causes radiation cataracts.
The third is the thyroid with 85% of papillary carcinomas being radiation induced.
References:
Devalla KL, Guha A, Devadoss VG. The need to protect the thyroid gland during image intensifier use in orthopaedic procedures. Acta Orthop Belg Oct;70(5):474-7.

13. Modern orthopedic trauma surgery
Increased exposure of surgeon, patient, and team to radiation by minimally invasive procedures
Intramedullary (IM) nailing
Percutaneous K-wire fixation
Minimally invasive plate osteosynthesis (MIPO)
Vertebroplasty
The trend to use minimal invasive procedures in trauma care is increasing, like IM nailing, percutaneous K-wire fixation, vertebroplasty, and minimally invasive plate osteosynthesis. All of these techniques expose the patient, team, and surgeon to more radiation.

14. How to protect patients, staff, and yourself
Now, you have some knowledge of the biological and physical effects of x-rays.
Next you will learn how to protect patients, staff, and yourself from the potential dangers of exposure to radiation.

15. Physical facts—absorption and scatter
For every 100 photons reaching the patient:
~10–20 are scattered
~ 2 reach the image detector
~ 80 are absorbed by patient (radiation dose)
The radiation not absorbed by the patient is scattered, and this scattered radiation can affect the team and surgeon.
In this example, the x-ray tube is emitting photons, which are either reflected or absorbed by the patient. Just a fraction of the x-rays pass through the patient to the image intensifier.
For every thousand photons reaching the patient, 100–200 photons are scattered. Just 20 reach the image detector and the rest are absorbed by the patient. This is the radiation dose.
Richter PH, Dehner C, Scheiderer B, Gebhard F, Kraus M. Emission of radiation in the orthopaedic operation room: A comprehensive review. OA Musculoskeletal Medicine 2013 Jun 01;1(2):11.
Richter, et al. OA Musculoskeletal Medicine 2013 Jun 01;1(2):11.

16. Physical facts—absorption and scatter
Radiation scatter is mainly directed toward the source
Main source of radiation
for team and surgeon is
scattered radiation from patient
The radiation not absorbed by the patient is scattered, and this scattered radiation can affect the team and surgeon.
In this example, the x-ray tube is emitting photons, which are either reflected or absorbed by the patient. Just a fraction of the x-rays pass through the patient to the image intensifier.
For every thousand photons reaching the patient, 100–200 photons are scattered. Just 20 reach the image detector and the rest are absorbed by the patient. This is the radiation dose.

17. Scatter-dose is lower when distance from patient increases
This example illustrates how much scattered radiation you can be exposed to when an x-ray tube is emitting 100 kilovolts with 1 milliampere on a patient which is 1 meter from the x-ray tube.
The patient shown here has a thickness of 18 cm. Standing 50 cm from the patient, the eyes of the staff/surgeon are exposed to 3.2 mili-Siverts per hour and the thyroid 2.4 mili-Siverts per hour.
The staff/surgeon’s genital area receives 1.2 mili-Siverts of radiation per hour. Standing at a 1 meter distance from the patient lowers radiation exposure to one-fourth of the radiation received when standing 50 cm from the patient.
Finally, the scatter dose rate is lowered when the distance to the patient increases.

18. When distance is doubled, scatter dose is reduced to 1/4
0.5 m
1 m
This example illustrates how much scattered radiation you can be exposed to when an x-ray tube is emitting 100 kilovolts with 1 milliampere on a patient which is 1 meter from the x-ray tube.
The patient shown here has a thickness of 18 cm. Standing 50 cm from the patient, the eyes of the staff/surgeon are exposed to 3.2 mili-Siverts per hour and the thyroid 2.4 mili-Siverts per hour.
The staff/surgeon’s genital area receives 1.2 mili-Siverts of radiation per hour. Standing at a 1 meter distance from the patient lowers radiation exposure to one-fourth of the radiation received when standing 50 cm from the patient.
Finally, the scatter dose rate is lowered when the distance to the patient increases.

19. Distance Reasonably safe at 3 m away from source!
If you measure the dose rate around a mobile C-arm you have scattered radiation as illustrated in this picture.
The further away you are from the x-ray tube, image intensifier, and the patient the lower the dose of scattered radiation.
It is therefore very important to ensure that you stand at a safe distance from the patient, image intensifier, and x-ray tube.

20. Who receives the most exposure?
3-month period: 107 consecutive operations
Surgeon always >90 cm from beam
Assistant ~10 cm from beam
Radiation dose:
Dose measurement
Surgeon
Assistant
Outer dosimeter
mSv
0.21 mSv
Tasbas and others have measured the radiation dose to surgeons and assistants in 107 consecutive orthopedic trauma operations performed in a 3-month period.
During surgery the surgeon was always over 90 cm from the beam and the assistant approximately 10 cm from the beam, because he had to do the reduction.
The outer dosimeter reading showed that the surgeon received micro-Sieverts of radiation, whereas the assistant received 0.21 micro-Sieverts.
The under gown dosimeter showed that the surgeon standing 90 cm from the beam received no x-ray exposure, whereas the assistant still received 0.05 mili-Sieverts.
References:
Tasbas BA, Yagmurlu MF, Bayrakci K et al. Which one is at risk in intraoperative fluoroscopy? Assistant surgeon or orthopedic surgeon? Arch Orthop Trauma Surg. 2003; 123 (5):242–244.
Tasbas BA et al (2003) Arch Orthop Trauma Surg

21. Experience and exposure during IM nailing
22 procedures of IM nailing of long bones
Senior group (12) versus junior group (10)
Fluorometric time statistically greater
for junior group
More experienced surgeons receive less radiation exposure than younger surgeons.
A study published in the Archives of Orthopaedic and Trauma Surgery, compared a senior group of 12 surgeons against a junior group of 10 surgeons.
Dosimetry data and fluorometric time during the 22 procedures of intramedullary nailing of long bones was measured for both groups.
The junior group had statistically greater fluorometric time. This is quite expected since the junior group of surgeons has less experience and will need more C-arm time.
References:
Blattert TR, Fill UA, Kunz E et al. Skill dependence of radiation exposure for the orthopaedic surgeon during interlocking nailing of long-bone shaft fractures. Arch Orthop Trauma Surg. 2004; 24 (10):659–664.
Blattert TR et al (2004) Arch Orthop Trauma Surg

22. ✗ ✗ ✔ ✔ X-ray tube position X-ray tube up Intensifier down
Tube position below OR table
reduces radiation dose to eye lens by 3 or more times
Best configuration
Intensifier up
As a rule you should position the x-ray tube below the OR table. This reduces high dose rates to the eyes and lens.
The best configuration during surgery is with the intensifier up and the x-ray tube down. This will reduce the radiation dose to the team and surgeon’s lens by 3 or more times. ✔ ✔
X-ray tube down

23. X-ray tube position Exception: hand, small-part surgery
Scatter is minimal
X-ray tube up
Intensifier down
Avoid direct exposure to beam
Stay away as much as possible
Tremains, et al. JBJS-Am, May V83 - 5

24. Stay away from the x-ray tube side
X-ray tube position ✗ ✔
Exposure at x-ray tube side:
Thyroid X 3–4
Torso X 25
The surgeon should not to stand on the x-ray tube side, since they will receive scattered radiation up to 4–8 mili-Siverts per hour.
Standing on the intensifier side reduces the amount of radiation exposure received by one tenth.
When the surgeon performs a locking procedure they should stand close to the intensifier and ensure that the x-ray tube is not close to their hands.
Staff should stay clear of the x-ray tube area during fluoroscopy.
References:
Rampersaud YR, Foley KT, Shen AC et al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion.
Spine (Phila Pa 1976) Oct 15;25(20):
Stay away from the x-ray tube side
during fluoroscopy

25. ✗ ✔ X-ray tube position Hug the intensifier!
Exposure at x-ray tube side:
Thyroid X 3–4
Torso X 25
The surgeon should not to stand on the x-ray tube side, since they will receive scattered radiation up to 4–8 mili-Siverts per hour.
Standing on the intensifier side reduces the amount of radiation exposure received by one tenth.
When the surgeon performs a locking procedure they should stand close to the intensifier and ensure that the x-ray tube is not close to their hands.
Staff should stay clear of the x-ray tube area during fluoroscopy.
References:
Rampersaud YR, Foley KT, Shen AC et al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion.
Spine (Phila Pa 1976) Oct 15;25(20):
Hug the intensifier!

26. Factors affecting staff and patient doses
Patient size increases skin dose and scattered radiation
The skin dose in larger patients and the level of scattered radiation are two factors that affect the dose of radiation received by the patient, team, and surgeons.
Therefore, it is important to use additional protective devices or keep a safe distance from large patients.
Use additional protective devices
Keep a safe distance from large patients

27. Factors affecting patient doses
Intensifier diameter
Patient entrance dose
32 cm (12 in)
Dose 100
Dose 150
22 cm (9 in)
More magnification
Dose 200
16 cm (6 in)
Another factor which increases scattered radiation to surgeons is the diameter of the intensifier.
The more you want to magnify your image the higher the relative patient entrance dose has to be.
Do not use too much magnification because you will then have to increase your patient entrance dose and will, as a result, increase scattered radiation.
Dose 300
11 cm (4.5 in)
More magnification (smaller diameter)
increases patient entrance dose

28. Factors affecting patient doses✗
Intensifier diameter
Patient entrance dose
32 cm (12 in)
Dose 100
Dose 150
22 cm (9 in)
More magnification
Dose 200
16 cm (6 in)
Another factor which increases scattered radiation to surgeons is the diameter of the intensifier.
The more you want to magnify your image the higher the relative patient entrance dose has to be.
Do not use too much magnification because you will then have to increase your patient entrance dose and will, as a result, increase scattered radiation.
Dose 300
11 cm (4.5 in)
Do not use too much magnification

29. Factors affecting staff and patient doses
Patient dose will increase if:
Focus–skin distance is short
Patient–image intensifier distance is large
Small focus-skin distance ✔ ✗
Large patient-image intensifier distance
Another important factor to reduce scattered radiation is the distance of the x-ray tube in relation to the patient.
To reduce scattered radiation, the patient must be placed as close to the image intensifier and as far away from the x-ray tube as possible.

30. Factors affecting staff and patient doses
Patient dose will increase if:
Focus–skin distance is short
Patient–image intensifier distance is large
large focus-skin distance ✔ ✔
small patient-image intensifier distance
Reduce patients’ dose & scatter:
Place patient close to image intensifier
Another important factor to reduce scattered radiation is the distance of the x-ray tube in relation to the patient.
To reduce scattered radiation, the patient must be placed as close to the image intensifier and as far away from the x-ray tube as possible.

31. Remember to protect patients
Away from x-ray tube
Protective shield for patients must be placed on the side of x-ray tube
On patient if tube is above
Under patient if tube is below
Remember to place the protective shield of patients on the proper side!! (the side of the x-ray tube):
If the x-ray tube is above the patient, the shield should be placed above the patient
If the x-ray tube is below the patient, the shield should be placed below the patient
(Common sense!!)

32. Protect yourself – use protective gear
0.15 mm lead-equivalent goggles provide 70% attenuation of radiographic beam
Thyroid collar 2.5-fold further decreases
Apron AP: decreased 16-fold
Lateral: decreased 4-fold
When you remember how many mili-Sieverts per hour you are exposed to when standing 50 cm from the patient, you then see how important it is to protect your eyes, thyroid, body, and hands.
Goggles with 0.15 mm lead equivalent attenuate radiographic beams by 70%.
A thyroid collar decreases the scattered radiation 2.5-fold further.
An apron in the AP or in the lateral position makes a respective decrease of 16-fold to 4-fold.
Hand and glove protection is claimed to be from 60% to 64% with 52–58 KV.
Protective gloves
60–64% protection at 52–58 KV

33. If not provided by hospital Buy your own protection!
Protective gear
If not provided by hospital
Buy your own protection!
When you remember how many mili-Sieverts per hour you are exposed to when standing 50 cm from the patient, you then see how important it is to protect your eyes, thyroid, body, and hands.
Goggles with 0.15 mm lead equivalent attenuate radiographic beams by 70%.
A thyroid collar decreases the scattered radiation 2.5-fold further.
An apron in the AP or in the lateral position makes a respective decrease of 16-fold to 4-fold.
Hand and glove protection is claimed to be from 60% to 64% with 52–58 KV.

34. ✗ Protective gear Apron and thyroid collar
Treat them well to get good protection ✗
Aprons and thyroid collar protect you. They are your friends. Treat them well, they will treat you (protect you) well.
If they are thrown around after use, mini breaks happen and the protection they provide is lost. They must be kept hanging properly all the time.
They should be routinely checked.

35. ✔ Protective gear Should be routinely checked Apron and thyroid collar
Treat them well to get good protection ✔
Aprons and thyroid collar protect you. They are your friends. Treat them well, they will treat you (protect you) well.
If they are thrown around after use, mini breaks happen and the protection they provide is lost. They must be kept hanging properly all the time.
They should be routinely checked.
Should be routinely checked

36. Technical contributions to radiation dose reduction
Iso-centric C-arms:
Repositioning of C-arm is not needed when changing from AP to lateral
There are also features like selectable dose rate according to the patient size.
An important feature is iso-centricity. Iso-centric C-arms maintain exposure of the same area in AP and lateral positions. While in non iso-centric C-arms, there is a need to change the position of the C-arm each time when changing between AP and Lateral exposures in order to see the same area of interest.
Another important feature, is the ability to compensate for off-centered images, which reduces the need for repeated exposures.
The quality of compensation for metals in the field might necessitate increased dosage to maintain good quality bone images. Therefore every effort should be made to remove or reduce the metals in the field.

37. Technical contributions to radiation dose reduction
Good quality off-center imaging
No need to repeat exposure
Remove/reduce metals in the field
C-arms automatically increase exposure to improve bone image
There are also features like selectable dose rate according to the patient size.
An important feature is iso-centricity. Iso-centric C-arms maintain exposure of the same area in AP and lateral positions. While in non iso-centric C-arms, there is a need to change the position of the C-arm each time when changing between AP and Lateral exposures in order to see the same area of interest.
Another important feature, is the ability to compensate for off-centered images, which reduces the need for repeated exposures.
The quality of compensation for metals in the field might necessitate increased dosage to maintain good quality bone images. Therefore every effort should be made to remove or reduce the metals in the field.

38. Clinical C-arm application: “C-arm attitude”
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.

39. Clinical C-arm application: “C-arm attitude”
Landmarks (floor)
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.

40. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.

41. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Laser aiming
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.
We should use laser aiming.

42. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Laser aiming
Pulsed acquisition
1 second of fluoroscopy =
15–25 frames of
pulsed acquisition!
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.
We should use laser aiming.
We should use pulsed acquisition and avoid screening, if possible.
Best by a technician!

43. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Laser aiming
Pulsed acquisition
Distance
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.
We should use laser aiming.
We should use pulsed acquisition and avoid screening, if possible.
We should keep our distance from the patient.

44. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Laser aiming
Pulsed acquisition
Distance
Position of x-ray tube
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.
We should use laser aiming.
We should use pulsed acquisition and avoid screening, if possible.
We should keep our distance from the patient.
We should check that the x-ray tube is positioned under the patient and not stand next to the x-ray tube.

45. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Laser aiming
Pulsed acquisition
Distance
Position of x-ray tube
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.
We should use laser aiming.
We should use pulsed acquisition and avoid screening, if possible.
We should keep our distance from the patient.
We should check that the x-ray tube is positioned under the patient and not stand next to the x-ray tube.

46. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Laser aiming
Pulsed acquisition
Distance
Position of x-ray tube
Protective gear
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.
We should use laser aiming.
We should use pulsed acquisition and avoid screening, if possible.
We should keep our distance from the patient.
We should check that the x-ray tube is positioned under the patient and not stand next to the x-ray tube.
We should always wear the appropriate protection.

47. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Laser aiming
Pulsed acquisition
Distance
Position of x-ray tube
Protective gear
Keep hands away from the beam
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.
We should use laser aiming.
We should use pulsed acquisition and avoid screening, if possible.
We should keep our distance from the patient.
We should check that the x-ray tube is positioned under the patient and not stand next to the x-ray tube.
We should always wear the appropriate protection.
We should keep hands away from the radiation field.

48. Clinical C-arm application: “C-arm attitude”
Landmarks (floor, body)
Laser aiming
Pulsed acquisition
Distance
Position of x-ray tube
Protective gear
Keep hands away from beam
Shout when exposing and scream “Screening!”
Our goal should be to reduce scattered radiation and radiation exposure to ourselves.
This requires a change in attitude.
For example:
We could use markers on the floor when we have to change the position of the C-arm.
We should mark the body where the optimal position of the C-arm beam is needed.
We should use laser aiming.
We should use pulsed acquisition and avoid screening, if possible.
We should keep our distance from the patient.
We should check that the x-ray tube is positioned under the patient and not stand next to the x-ray tube.
We should always wear the appropriate protection.
We should keep hands away from the radiation field.
Finally we should shout out clearly when screening (screaming!!) so that all people in the room are aware and can get protection.

49. We work in a field of radiation!
Summary
We work in a field of radiation!

50. Apply what we have discussed
Summary
We have an obligation towards the safety of:
Our patients
Our staff
Ourselves
Apply what we have discussed
Inform your friends

51. Take-home messages Scattered radiation to be avoided Keep x-ray tube:
Underneath the patient
Away from patient
Away from you (lateral view)
Use pulsed acquisition
Landmarks on the floor/body, use laser aiming
Use protective gear routinely
Keep your hands out of the beam
Shout out when screening

52. Take-home messages
Hug the intensifier!