2. PORTABLE OR applications and Considerations Week 13 RTEC 124

3. CAUTION: SOME IMAGES MAY BE DISTURBING BUT AS HEALTHCARE PROFESSIONALS THIS IS WHAT YOU MAY EXPERIENCE

4. Who are these people?

5. Importance of maintaining a sterile field…. Your role as an RT

6. STERILE IN OR Must change clothing Must change clothing Wear a “cover gown” when leaving Wear a “cover gown” when leaving Masks, hair cover, and shoe covers Masks, hair cover, and shoe covers Change when you leave the OR room Change when you leave the OR room DO NOT TAKE HOSP SCRUBS HOME!! DO NOT TAKE HOSP SCRUBS HOME!!

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

8. What to expect…

10. From your point of view do not touch sterile field

11. Surgical Radiography Imaging is commonly used in surgical procedures Imaging is commonly used in surgical procedures But the surgeon already has the patient’s body open, right? But the surgeon already has the patient’s body open, right? Sometimes it is used as a guide Sometimes it is used as a guide

17. Must cover equipment in sterile drapes when it may come into contact with patient, instruments, or surgeons hands Must cover equipment in sterile drapes when it may come into contact with patient, instruments, or surgeons hands

21. Sterile trays

22. The sterile incision covered for portable Instruments away from portable Never use portable over sterile field USE CAUTION!

23. Exchange the IR into the sterile drape

26. SURGERY Sterile procedures must be followed Sterile procedures must be followed –Not to contaminate surgical site –Don’t touch anything BLUE or GREEN –Be careful not to run into trays, etc

27. IMAGING IN THE OR Moblie Radiographic Moblie Radiographic Mobile C-arm – fluoroscopic Mobile C-arm – fluoroscopic Dedicated room Dedicated room –Cystography –Radiography room

28. Equipment in the OR must be covered Equipment in the OR must be covered –Must be cleaned before bringing into room Protects patient Protects patient –Prevents contamination of sterile field and instruments UNLIKE PORTABLE EXAMS ON THE UNITS

29. C- ARM Mobile Fluoro

31. Can rotate 360° side to side Can rotate 360° side to side 90° top to bottom 90° top to bottom

32. C-Arm FLUOROSCOPY C-Arm FLUOROSCOPY Tube at one end and I.I. at other end Tube at one end and I.I. at other end TV Monitor control cart separate from unit TV Monitor control cart separate from unit Uses Digital Fluoroscopy Uses Digital Fluoroscopy Last Image Hold Last Image Hold Image Enhancement Image Enhancement Save for hard copies from disk and video Save for hard copies from disk and video Photographic Magnification Photographic Magnification Subtraction Subtraction Static (pulsed) and continuous fluoroscopy Static (pulsed) and continuous fluoroscopy

34. Set up room in advance if possible

35. Fluoroscan

36. Hand surgery table Never use IR as a table Never use IR as a table –Blood –Fluids –Water

37. Some tables have a gap Some tables have a gap –Allows for cassette placement without contaminating sterile field

38. Tables without gap Slide cassette at top with help of anesthesiologist Slide cassette at top with help of anesthesiologist

39. Considerations before procedure Find out where surgeon wants you to go Find out where surgeon wants you to go Be careful not to contaminate Be careful not to contaminate Plug in C-arm and test it Plug in C-arm and test it –Marker check on II if possible –Guard FOOT Switch Park portable equipment in corner –out of the way Park portable equipment in corner –out of the way

40. Orient anatomy using markers

41. Mobile Radiography Considerations If surgery is already in progress If surgery is already in progress –Before entering, park machine outside of room –Survey room to get lay-out –Rearrange equipment/furniture if necessary Place cassette in a STERILE WRAP Place cassette in a STERILE WRAP

43. PATIENT CONSIDERATIONS DURING SURGERY Patient may not always be “unconscious” Patient may not always be “unconscious” –Pain management –Twilight state Always treat patient with respect and courtesy Always treat patient with respect and courtesy –They may be hearing everything

44. USING C-ARM vs PORTABLE C-ARM Faster- instant image Faster- instant image More radiation More radiation Smaller field of view Smaller field of viewPortable Must have accurate technique Must have accurate technique Processing needed Processing needed –Longer Larger field of view Larger field of view

45. Various Imaging Procedure in Operating Room

46. SURGERY - Common Procedures Ortho (Bone) Work Pinning/ Rod / Screw placement Pinning/ Rod / Screw placement Fracture realignment Fracture realignment Organs / Vessels with contrast Arteries / Veins in the extremities Arteries / Veins in the extremities Cholangiograms = ducts Cholangiograms = ducts Urography Urography Pacemaker and Line Placements etc

47. TECHNIQUE CONSIDERATIONS Same principles of ALARA Same principles of ALARA Change techniques if using grid Change techniques if using grid –3-5 times more if using grid –Body parts larger than 12cm SID – SID – – VERY IMPORTANT TO MEASURE –Chest usually done at 63-72” –All others done at 40”

48. DEDICATED UNIT- CYSTO RM

51. Cystoscopic Studies for Foreign Objects

52. Percutaneous Nephrolithotomy

53. Laparoscopic Cholecystecomy

54. . Be careful not to hit laparoscopic instruments Be careful not to hit laparoscopic instruments

55. Cholangiogram Cholangiogram –Sterile lead drape used –Contrast used

56. Operative cholangiogram

57. Op CHOLE Digital can reverse images

58. Hickman Catheter placement Starts at upper thorax and ends in heart

59. Catheter In Jugular

60. Upper Extremity Arteriogram

61. Bypass Surgery

62. Cervical Spine Shoulder pull down Shoulder pull down Boost mode Boost mode Magnification mode Magnification mode HIGHER DOSE

63. Scout placement Scout placement –Checks placement Sequential imaging Sequential imaging –Watches placement of screws and pins –Final image for documentation Print a hard copy Print a hard copy

64. USE OF PORTABLE CROSS TABLE LATERAL C.SPINE Lateral projection of the cervical spine with patient supine. Done to verify the correct position of instruments before continuing surgery. Often a spinal needle is placed in the disc space to show position.

66. Discectomy

68. Lateral Lumbar Drape C-arm with sterile plastic conver to protect patient and equipment

69. PA Lumbar AP or PA to lateral AP or PA to lateral –Caution not to hit patient or equipment –KEEP STERILE Familiarize yourself with locks Familiarize yourself with locks –PRACTICE WITH CI, RT’S

71. X-table Lateral Lumbar Spine

73. Challenges ? Positioning CR ?

74. Hip Pinning

75. Lateral Hip

78. Field of View smaller with C-arm

83. Rod Placement in Femur

86. II parallel with long axis of leg

87. Image of tibial nail screw holes in incorrect alignment and oblong in shape. Image of tibial nail screw holes in incorrect alignment and oblong in shape. Image of tibial nail screw holes perfectly round, and magnified to assist proper alignment.

88. Image of tibial nail screw holes in incorrect alignment and oblong in shape. Image of tibial nail screw holes in incorrect alignment and oblong in shape. Image of tibial nail screw holes perfectly round, and magnified to assist proper alignment.

91. NOTE THE POSITION OF THE II AND TUBE KEEP II CLOSE TO PATIENT KEEP TUBE AS FAR AWAY AS POSSIBLE MUST BE AT LEAST ________ INCHES FROM PT

92. 91 DSA A subtraction mask is taken before contrast injected A subtraction mask is taken before contrast injected Each of digitized image is from the mask Each of digitized image is from the mask Images acquired form Images acquired form –1 image every 2-3 sec –Up to 30 images per sec

93. 92 Three Dimensional (3-D) Intraarterial Angiography

95. RAD PROTECTION in the O.R. It’s your duty to protect the patient, yourself and others (healthcare professional) It’s your duty to protect the patient, yourself and others (healthcare professional) Politely ask whoever can, to move back from the area Politely ask whoever can, to move back from the area Provide aprons to those who cannot leave Provide aprons to those who cannot leave Announce your intent to make an exposure and give time for others to move back Announce your intent to make an exposure and give time for others to move back IF personnel are in sterile drape – may not be able to put on apron IF personnel are in sterile drape – may not be able to put on apron

97. RAD PROTECTION in the OR C-ARM = HIGHER DOSE C-ARM = HIGHER DOSE STAND BEHIND C-ARM UNIT WHEN POSSIBLE STAND BEHIND C-ARM UNIT WHEN POSSIBLE

101. RAD PROTECTION RULES OF GOOD PRACTICE Never place your hand or other body part in primary beam Never place your hand or other body part in primary beam Provide gonadal protection for the patient if possible Provide gonadal protection for the patient if possible FOR C-ARM – IF BEAM FROM BELOW – PLACE APRON ON TABLE BEFORE PATIENT IS ON TABLE FOR C-ARM – IF BEAM FROM BELOW – PLACE APRON ON TABLE BEFORE PATIENT IS ON TABLE Achieve maximum distance from the patient and tube (stand 90° from the patient) Achieve maximum distance from the patient and tube (stand 90° from the patient) Minimum 6 foot exposure cord for radiography Minimum 6 foot exposure cord for radiography Label and handle cassettes carefully Label and handle cassettes carefully

102. RADIATION PROTECTION Remember the “Cardinal Rules” RADIOGRAPHIC 6 ‘ exposure cord 6 ‘ exposure cord Minimum source to skin distance = 12” Minimum source to skin distance = 12” Preferred SID of 40”to 72”+ (  mag  detail) Preferred SID of 40”to 72”+ (  mag  detail)  Distance from tube and patient  Distance from tube and patient At least.25mm lead apron At least.25mm lead apronFLUOROSCOPIC Minimum source to skin distance = 12” Minimum source to skin distance = 12” Preferred SSD OF 18” Preferred SSD OF 18”  Distance from tube and patient  Distance from tube and patient 5 min Audible Alarm 5 min Audible Alarm At least.25mm lead apron to be worn At least.25mm lead apron to be worn 5 R/min - 10 R/min 5 R/min - 10 R/min

103. Post operative Portables

104. Post operative images taken in recovery room

109. All hardware must be included in the image

110. Pre-op Post-OP How were these images taken?

112. The Recovery Room and good Radiation Safety Practices

113. Medical errors & Foreign Bodies How to avoid them

114. Medical errors & imaging IT STARTS WITH YOU CORRECT MARKER On the correct side of the patients body

115. There are many Opportunities For mistakes And safeguards to Prevent medical errors

117. About 1,500 people About 1,500 people Small amount considering about 28.4 million operations Small amount considering about 28.4 million operations Yet this is no consolation for the people who've had it happen to them. Yet this is no consolation for the people who've had it happen to them.

118. Sponges Most common Most common Sponges fill up with blood and can resemble parts of the body Sponges fill up with blood and can resemble parts of the body

121. Common medical devices left inside patients Eyebrow Tweezer Eyebrow Tweezer Tissue expander Tissue expander Retractor Retractor Syringe Syringe Purple Latex Gloves Purple Latex Gloves Sharpie Sharpie Speculum Speculum Mouth gag, Mouth gag, Hemostat Hemostat Chest Spreader Chest Spreader

122. Nail in femoral artery

123. Chicken bone

124. Did you lose something?

125. A few more examples of OR

131. Peds images www.hawaii.edu/medicine/pediatrics www.hawaii.edu/medicine/pediatrics www.hawaii.edu/medicine/pediatrics

132. Don’t get yourself in trouble…

133. Portable and Mobile Competencies YOU MUST ALWAYS HAVE SUPERVISION YOU MUST ALWAYS HAVE SUPERVISION EVEN AFTER COMPETENCY IS DONE per JRCERT EVEN AFTER COMPETENCY IS DONE per JRCERT DO NOT PUT YOURSELF IN A SITUATION WHERE YOU DO NOT HAVE APPROIATE SUPERVISION !

134. OR / PORT COMPS Still need direct supervision- even after you have a competency Still need direct supervision- even after you have a competency Must have “DIRECT” supervision for portables and C-arm at ALL times Must have “DIRECT” supervision for portables and C-arm at ALL times

135. PORTABLE & C- ARM COMPETENCIES Must do a Pre-Portable check –off first Must do a Pre-Portable check –off first C- Arm check off C- Arm check off Must do more than 3 exams of each area – portable – before attempting competency Must do more than 3 exams of each area – portable – before attempting competency

136. ?