SERVE AND PROTECT Radiation exposure is an invisible — and cumulative — danger.

The best way to protect yourself and your patients from radiation harm during C-arm use? Keep in mind the trinity of imaging safety: time, distance and shielding. Read on for practical ways to reduce exposure risks and ensure your staff and those in their care remain protected from fluoroscopy's invisible dangers.

1. Always wear protection. Wear aprons, lead glasses with side shields and thyroid collars, depending on the procedure. Staff members who stand with their backs to the radiation beam must wear wrap-around aprons. Staffers who must place their hands near the beam during procedures should wear leaded gloves. The 0.5mm lead-equivalent aprons used by physicians during fluoroscopy weaken 95% of the scattered radiation to the shielded torso, compared with 80% for the lightweight 0.25mm aprons, says Carol Cappella, MSN, RN, CNOR, the clinical director at the Delray Beach (Fla.) Surgery Center.

"Disposable radiation protection products, including specially treated scrub hats and thyroid collars, are now available," she adds. That's especially welcome when it comes to thyroid collars. Staff sweat in those collars, and while reusable collars might be cleaned between uses, it's much more pleasant — and hygienic — to put on fresh single-use throat protection before cases.

2. Proper storage and inspection. Protective shields should be hung, not folded, on hangers. Inspect shields frequently, especially older ones, for flaws or wear. A 2013 study by South Korean researchers analyzed the wear and tear of protective shields — aprons and thyroid protectors — and discovered most damage occurred at the waist of aprons (tinyurl.com/p9cxbad). "We have a consulting radiologist inspect our equipment every year, and dispose of any that have issues," says Ms. Cappella.

3. Monitor exposure. Physicians and staff should wear dosimeters that measure the amount of radiation to which they're exposed. The dosimeters should be worn against the body, not on a chain, because a chain lets the badge-like devices rotate away from the radiation source. Be sure the dosimeters are sent back to the vendor or staffer charged with tracking exposures at the end of the monitoring period. Never launder badges or lend them to another staff member. Leave them at work so they're never stored in a hot car.

LESS IS MORE
How Low Is Low Enough?

SAFETY SHIELDS Staff and physicians must wear proper protection during all imaging procedures, even when the lowest possible exposure is achieved.

Radiation safety rules emphasize that exposure should be ALARA (as low as reasonably achievable). For healthcare workers it gets more specific. OSHA and other entities recommend exposure of no more than 5 rads (energy imparted per unit mass of tissue) per minute in the direct beam. However, orthopedic surgeon Brian D. Giordano, MD, who uses the C-arm in many of his procedures, points out that healthcare professionals have defined radiation limits "because we're exposed to protracted radiation that can be cumulative over a lifetime." The dose limit for patients, he says, is not defined.

Dr. Giordano, an assistant professor of orthopedics at the University of Rochester Medical School in New York, firmly believes "this is a flaw in our appreciation for patient-related safety factors, although there isn't a strong causal link between certain dosages and type of effect."

Whatever the lack of data, staff must ensure their own safety while also closely monitoring and protecting patients from overexposure to radiation during procedures involving fluoroscopy. Dr. Giordano suggests you dial down C-arm doses in order to capture images that, while not as sharp as possible, provide surgeons with the views they need to perform successful surgery.

— Gail O. Guterl

4. Move back. Stepping away from the patient when the C-arm is operating can significantly reduce radiation exposure. When using fluoroscopy across a patient, stand on the same side as the image intensifier, not the X-ray tube, says Ms. Cappella. Radiation exposure is a cumulative danger: At 1m from the radiation source, physicians or staff members will absorb about 0.1% of the dose, due to scatter and leakage through the side of the imaging tube housing, says Ms. Cappella.

5. Focus on positioning. Place the C-arm's image intensifier as close to the patient as possible (no closer than 12 to 15 inches, however) to eliminate the scatter of radiation rays.

6. Check patients' records. Review every patient's healthcare history for previous radiation exposure. Patients with multiple exposures could be at increased risk because of radiation's cumulative effects.

7. Drape where appropriate. Place a lead apron over the pelvic area of female patients to protect the ovaries and over the groin area of male patients to protect the testes. Perineal surgical aprons can also be used. (Be sure these aprons are disinfected according to manufacturer and regulatory standards, cautions Ms. Cappella.) Shield the patient's eyes and thyroid if radiation will impact the upper part of the body during surgery. Another option is a new FDA-approved surgical drape with special chemicals embedded in the fabric to protect against radiation, says Ms. Cappella.

8. Position patients properly. Ensure non-targeted body parts are positioned out of the radiation beam's focus. If possible, suggests Ms. Cappella, vary the radiation's beam entry point to spread the radiation over more skin area and reduce the likelihood that any one spot will be overexposed. Place the targeted extremity directly over the C-arm's image intensifier to keep it as far as possible from the X-ray source, says Brian D. Giordano, MD, an assistant professor of orthopedics at the University of Rochester Medical School in New York.

9. Position C-arms carefully. In 2006, surgeons in California reported that the bottom end of a C-arm wedged onto the floor control of the OR table, causing it to tilt and almost dump the patient onto the floor (tinyurl.com/q79uqwe). An unusual situation, but be vigilant as the C-arm is adjusted.

10. Equipment considerations. New C-arm equipment has low-dose features that ensure superb pictures at low radiation exposure. Although using the low-dose equipment option may produce more image noise, the operator is subjected to less radiation exposure, so use the setting whenever possible. Activate the C-arm only when actually looking at the fluoro image, and use intermittent fluoro — pulses of radiation — rather than continuous radiation.

Employ tight collimation, coning down the beams to the targeted area. "This improves your view and reduces staff radiation exposure," says Dr. Giordano. It also reduces the patient's total skin exposure, points out Ms. Cappella. Use the "last image hold" feature — which stops the fluoro, letting you study the last captured image on the split-screen monitor — to further reduce radiation exposure risk for everyone in the OR.