staff and patient radiation protection in the cath lab andrés sinisterra assistant radiation safety...

Staff and Patient Radiation Protection

In The Cath Lab

Andrés Sinisterra

Assistant Radiation Safety Officer for Medicine

Radiation vs. Radioactivity

RadiationEnergy in transit in the form of high speed particles and electromagnetic waves.

Ionizing RadiationRadiation with enough energy so that during an interaction with an atom, it can remove tightly bound electrons from their orbits, causing the atom to become charged or ionized.

RadioactivitySpontaneous transformation of an unstable atom and often results in the emission of radiation. This process is referred to as a transformation, a decay or a disintegration of an atom.

External vs. Internal Radiation Exposure

External Exposure – X-rays, Diagnostic Procedures.

Internal Deposition – Contamination from nuclear medicine patient undergoing a diagnostic or therapeutic procedure resulting in an ingestion of radioactive materials by the staff.

+

=T E D E

Units of Radiation Exposure

Roentgen Measure of electrical charge produced in air1,000 mr = 1R

Fluoro @ SSD ~3-10 R/min

Measure of energy absorbed, usually in tissue or bone.200 rad = transient erythema1 Gray = 100 Rad

Rad (Gray)

Units of Radiation Exposure

Rem (Sievert)

Measure of occupational risk (cancer) from radiation exposure1,000 mrem = 1 Rem1 Sievert = 100 Rem

1 R = 1 Rad = 1 Rem

A wave is a wave & nothing but a wave!

CAUTIONX-RAY

THIS EQUIPMENT PRODUCESX-RAYS WHEN ENERGIZED

TO BE OPERATED ONLY BYQUALIFIED PERSONNEL

CAUTION RADIATION

ROTOR

ROTATING ANODE

FILAMENT

TARGET

CATHODE

TUBE WINDOW

EVACUATED GLASS TUBE

Image Quality Vs Exposure

Area of Interest Collimation

Calcification of the vas deferens. These bilateral asymmetric calcifications occur in the lower to middle portion of the male pelvis

INCIDENT X-RAY

PHOTOELECTRON

Photoelectric effect occurs when an incident x-ray is totally absorbed during the ionization of the inner-shell electron. The incident photon disappears and the k-shell electron, now called a photoelectron, is ejected from the atom.

Compton effect occurs between moderate-energy x-rays and outer-shell electrons. It results in ionization of the target atom, change in photon direction and reduction of photon energy. The wavelength of the scattered x-ray is greater than that of the incident x-ray.

COMPTON ELECTRON

INCIDENT X-RAY

SCATTERED X-RAY

ANGLE OF DEFLECTION

<

INCIDENT ELECTRON

EJECTED ELECTRON LEAVES A HOLE TO BE FILLED

O Shell M Shell L Shell K ShellN Shell

Characteristic X-ray Photons(Characteristic Cascade)

Primary Primary BeamBeam

Scatter Scatter RadiationRadiation

Leakage Leakage RadiationRadiation

Scatter Scatter RadiationRadiation

Leakage Leakage RadiationRadiation

X-Ray X-Ray TubeTube

CaudalCaudal

Know Where Your Head Is At……!!!Know Where Your Head Is At……!!!

CoronalCoronal

Maximum Scatter

plus Leakage

Minimum Scatter

Head

and shoulders

knees

and toes !!!!!

Be aware of critically exposed areas

30-cm FOV

Image intensifier

70-cmSSD

1Medium conventional fluoroscopy2Setting C for fluorography3Floor kVp is 110

Dose = 50 rad

Pail of water

28-cm deep

55-cmSSD

1Medium conventional fluoroscopy2Setting C for fluorography3Floor kVp is 80

Dose = 140 rad

15-cm air gap

Pail of water

28-cm deep

23-cm FOV

Image intensifier

The effects of an air gap are significant, even if the image is properly collimated

The effects of an air gap are significant, even if the image is properly collimated

Know Where Your Head Is At……!!!Know Where Your Head Is At……!!!

The greater the distance the greater the scatter

The following Table illustrates the effect of changing Field-Of-View, or magnification modes, for a typical fluoroscopy

system

Mag Mode (Field-Of-View)

ESE (R/min) Increase Factor

Normal(9 inch)

1.2 1.0

Mag 1(6 inch)

2.9 2.4

Mag 2(4.5 inch)

5.2 4.3

Inverse Square Law (X-Rays & Gamma Rays)

For a point source, the intensity varies inversely as the square of the distance from the source.

1 1 cmcm

10,000 2 2

cmcm2,500

5 cm5 cm400

10 10 cmcm100

20 cm20 cm

25

Leakage Leakage RadiationRadiation

X-Ray X-Ray TubeTube

Scattered Scattered X-raysX-rays

Basic Radiation Safety Principles

TTimeime

DDistanceistance

CContaminationontamination ControlControl

SShieldinghielding

Whole Body Radiation Badge

Worn Underneath Pb

Apron

Collar Radiation Badge

Worn Outside Pb Apron At Neck

Level

BLACK ICON RED ICON

Extremity Radiation Badge

Worn on Primary Hand

Closest to Radiation Source

Radiation Exposure and Monitoring

Whole Body Whole Body Radiation Radiation

BadgeBadgeWorn Worn

Underneath Underneath Pb ApronPb Apron

Collar Collar Radiation Radiation

BadgeBadgeWorn Worn

OutsideOutside Pb Apron At Pb Apron At Neck LevelNeck Level

At Breast

~30 cm

At Thyroid

~45 cm

So what’s the big deal where I put my &#@% badges ? D’O

H !

Get The Lead Out but Watch Your Back !!

PROTECTIVE EQUIPMENTPROTECTIVE EQUIPMENT

AAs s LLow ow AAs s RReasonably easonably AAchievable chievable

ALARA Level IALARA Level I

> 10% of the maximum > 10% of the maximum quarterly exposure limit quarterly exposure limit

(125 mrem)(125 mrem)ALARA Level IIALARA Level II

> 30% of the maximum > 30% of the maximum quarterly exposure limit quarterly exposure limit

(375 mrem)(375 mrem)

ALARA Investigational Level IALARA Investigational Level I

Reducing Patient Dose During Fluoroscopy Reducing Patient Dose During Fluoroscopy (And Yours)(And Yours)

Get off the pedal!! – Fluoro intermittentlyGet off the pedal!! – Fluoro intermittently

Collimate and only expose clinical areaCollimate and only expose clinical area

Use larger fields when possibleUse larger fields when possible(Magnification increases patient dose)(Magnification increases patient dose)

Use distance of at least 30 cm for mobile Use distance of at least 30 cm for mobile units and 38 cm for fixed installationsunits and 38 cm for fixed installations

Use appropriate mA and KVpUse appropriate mA and KVp

Reducing Patient Dose During Fluoroscopy Reducing Patient Dose During Fluoroscopy (And Yours)(And Yours)

Remember the egg timer!!!Remember the egg timer!!!Be aware of the 5 minute timer (especially Be aware of the 5 minute timer (especially in high level mode)in high level mode)

Have sufficient beam filtrationHave sufficient beam filtration> 90 KVp requires 2.5 mm Al to 3.5 mm Al > 90 KVp requires 2.5 mm Al to 3.5 mm Al @ 130 KVp@ 130 KVp

Fluoro only when necessaryFluoro only when necessary

Schedule annual QA of equipmentSchedule annual QA of equipment

Radiation DoseThe amount of energy deposited in any substance by ionizing radiation per unit mass of the substance. It is expressed numerically in rads (traditional units) or grays (SI units).

Absorbed Dose Dose Equivalent Deep Dose Equivalent Eye Dose Equivalent Shallow Dose Equivalent Effective Dose Equivalent Committed Dose Equivalent Total Effective Dose Equivalent

Absorbed Dose - The amount of energy deposited in any substance by ionizing radiation per unit mass of the substance. It is expressed numerically in rads (traditional units) or grays (SI units).

Dose Equivalent - The dose equivalent (H) is the product of the absorbed dose in tissue, the quality factor and all other modifying factors at the location of interest. The unit is the rem (R) or the sievert (Sv).

Radiation Dose

Deep Dose Equivalent (Hd) - Applies to external whole body exposure, means the dose equivalent at a tissue depth of 1 cm or greater.

Eye Dose Equivalent - The external dose equivalent to the lens of the eye at a tissue depth of 0.3 cm.

Shallow Dose Equivalent (Hg) - Applies to the external exposure of the skin or extremity. The dose equivalent at a tissue depth of 0.007 cm averaged over an area of 1 cm2.

Radiation Dose

Committed Dose Equivalent (HE.50) - The dose equivalent (H) is a given organ or tissue that will be accumulated over 50 years following a single intake of radioactive material.

Effective Dose Equivalent (HE) - The sum of the products of the dose equivalent (HT) to each organ or tissue and the weighting factor (WT) applicable to each of the body organs or tissues that are irradiated (HE = ‡” WTHT).

Total Effective Dose Equivalent - The sum of the deep dose equivalent for external exposures and the committed effective dose equivalent for internal exposures.

Radiation Dose

Radiation Exposure Limits

Whole body; head and trunk; active blood-forming organs; lens of eyes, or gonads.

Hands and forearms; feet and ankles.

Skin of whole body.

1.25

18.75

7.5

((1,250 mrem)(5.0 rem/yr)

(18,750 mrem)(75 rem/yr)(7,500 mrem)(30 rem/yr)

Rem Per Calendar Rem Per Calendar QuarterQuarter

Type of Exposure Type of Exposure

(State of Connecticut Administrative Regulations Sect. 19-24-5) (State of Connecticut Administrative Regulations Sect. 19-24-5)

FetusFetus 500 mrem Total Gestation500 mrem Total Gestation(0.5 rem)(0.5 rem)

Radiation Exposure Limits

The total effective dose equivalent. 5.0 (0.05 Sv)

Rem Per Calendar Rem Per Calendar YearYear

Type of Exposure Type of Exposure

(USNRC 10CFR20 (USNRC 10CFR20 - § 20.1201- § 20.1201 ) )

The sum of the deep-dose equivalentand the committed dose equivalent toany individual organ or tissue otherthan the lens of the eye

50 (0.5 Sv)

Radiation Exposure Limits

Rem Per Calendar Rem Per Calendar YearYear

Type of Exposure Type of Exposure

(USNRC 10CFR20 (USNRC 10CFR20 - § 20.1201- § 20.1201 ) )

In Utero exposure to the FetusIn Utero exposure to the Fetus 0.5 rem Total Gestation0.5 rem Total Gestation(500 mrem & <50/mo) (500 mrem & <50/mo)

An eye dose equivalent

and

A shallow dose equivalent to the skin or to any extremity.

15 rem ( 0.15 Sv )

50 rem ( 0.50 Sv )

Conditions For Exceeding Quarterly Doses To Whole Body

< 3.0 rem< 3.0 rem

Total Whole Body DoseTotal Whole Body Dose <= 5 (N-18) rem<= 5 (N-18) rem

All Previous Whole Body DosesAll Previous Whole Body Doses

PlusPlus N = N = Your Your Age Age In Years In Years

Prior Dose Must Be On a Clear RecordPrior Dose Must Be On a Clear Record

! ! ! ! ALARA PROGRAM EXISTS ! ! ! !! ! ! ! ALARA PROGRAM EXISTS ! ! ! !

Total Dose For Any Quarter

Confidential Declaration of Pregnancy

NRC requires a signed declaration of pregnancy

for occupational workers to limit exposures

to 500 mrem/9months or 50 mrem in any one

month.

The United States Nuclear Regulatory Commission requires in the Code of Federal Regulations

Title 10, Chapter I, Part 20.1208, that special consideration be given to limitation of embryo/fetus

radiation exposure only in those instances where a woman has declared the pregnancy to the

appropriate representative of the employer (the UCHC). In cases where a pregnancy is not declared

in writing, the larger occupational exposure limit for the working mother is used as a maximum

permissible dose limit. The purpose of this form is to officially notify the employer, through the

Medical Director of Employee Health Services, that dose limitation to your embryo/fetus is

requested. The information contained on this form will be treated as confidential, and only those

directly involved in assessing the potential for embryo/fetal exposures will be informed. Please

sign the form where indicated and forward to:

PREGNANCY DECLARATIONConfidential Document

Marcia Trape-Cardoso, M.D., Medical Director Employee Health ServicesMC-6210

I, _________________________________ ______ , formally declare my pregnancy and request

dose limitation to my embryo/fetus such that my total radiation exposure during the gestational

period does not exceed 500 mrem, and if exposed, received at a uniform rate of no more than 50 mrem

per month. As required by the Nuclear Regulatory Commission, my approximate date of conception

was __________________.

Signed: Date:

Department:

Telephone #:

c:\flw\pregwrk.pre ( rev. 10/2000 )

A question of riskA question of risk

Radiation Exposures From ?

Smoking a pack and a Smoking a pack and a half of cigarettes a day half of cigarettes a day

will add about 1,300 will add about 1,300 mrem/year to one's mrem/year to one's

effective doseeffective dose

Flying from New York to Flying from New York to London results in the absorption London results in the absorption

of an extra of an extra 2-3 mrem of cosmic radiation2-3 mrem of cosmic radiation6-8 mrem from NY to Japan 6-8 mrem from NY to Japan

Risks which Increase Chance of Death by 1 Risks which Increase Chance of Death by 1 in 1 millionin 1 million aa

Drinking Miami drinking water for 1 year Cancer from chloroform

Drinking 30, 12 oz. cans of diet soda Cancer from saccharin

Living 5 years at site boundary of a typical nuclear power plant in the open

Cancer from radiation

Drinking 1000, 24 oz. soft drinks from banned plastic bottles Cancer from acrylonitrile monomer

Living 20 years near PVC plant Cancer from vinyl chloride (76 standard)

Living 150 years within 20 miles of a nuclear power plant Cancer from radiation

Eating 100 charcoal broiled steaks Cancer from benzopyrene

Risk of accident by living within 5 miles of a nuclear reactor for 50 years

Cancer from radiation

Eating 40 tablespoons of peanut butter Liver cancer from aflatoxin B

a B.L. Cohen and I.S. Lee, “Catalog of Risks Extended and Updated”, Health Physics, Vol. 61, Sept. 1991.

Estimated Loss of Life Expectancy Estimated Loss of Life Expectancy from Health Risks from Health Risks

Health Risk Average Days of Life Expectancy Lost

Smoking 20 cigarettes/day 2370 (6.5 years)Overweight (by 20%) 985 (2.7 years)All accidents combined 435 (1.2 years)Auto accidents 200Alcohol consumption 130Home accidents 95Drowning 41Natural background radiation 8Medical diagnostic x-rays 6All catastrophes (fire, flood, etc.) 3.51,000 mrem (1 rem) occupational radiation dose 11,000 mrem (1 rem)/yr for 30 years 30

Note: Average U.S. occupational radiation dose is estimated at 0.34 - 0.65 rem/year.

PROGRAM FOR IMPLEMENTING PROGRAM FOR IMPLEMENTING

PATIENT INFORMED CONSENTPATIENT INFORMED CONSENT

AND AND

FOLLOW UPFOLLOW UP REGARDING HIGH DOSE SPECIAL REGARDING HIGH DOSE SPECIAL

X-RAY PROCEDURESX-RAY PROCEDURES

There are certain x-ray guided procedures There are certain x-ray guided procedures that could result in the delivery of a radiation that could result in the delivery of a radiation dose to an area of a patient’s skin of dose to an area of a patient’s skin of sufficient magnitude to produce clinical sufficient magnitude to produce clinical symptoms.symptoms.

This program was developed to inform patients of this potential risk prior to such procedures, determine if a procedure may lead to a large skin dose and to follow up with the patient if there is a possibility of a skin reaction.

Purpose:Purpose:

This program is applicable to following x-ray This program is applicable to following x-ray guided proceduresguided procedures::

Policy:Policy:

Percutaneous Transluminal AngioplastyPercutaneous Transluminal AngioplastyRadiofrequency Cardiac Catheter Ablation Radiofrequency Cardiac Catheter Ablation Vascular Embolization Vascular Embolization Stent and Filter Placement Stent and Filter Placement Thrombolytic & Fibrinolytic Procedures Thrombolytic & Fibrinolytic Procedures Percutaneous Transhepatic Cholangiography Percutaneous Transhepatic Cholangiography and/or Biliary Drainage and/or Biliary Drainage

Any other x-ray guided procedure that could Any other x-ray guided procedure that could expose the expose the same area of the skin for more area of the skin for morethan 30 minutesthan 30 minutes

Policy (continued):Policy (continued):Endoscopic Retrograde Endoscopic Retrograde

Cholangiopancreatography Cholangiopancreatography Transjugular Intrahepatic Portosystemic Shunt Transjugular Intrahepatic Portosystemic Shunt Percutaneous Nephrostomy Percutaneous Nephrostomy Urinary/Biliary Stone Removal Urinary/Biliary Stone Removal

Or

For such cases, the patient must be For such cases, the patient must be informed in writing prior to the informed in writing prior to the procedure of the risks associated with procedure of the risks associated with large x-ray skin doses. large x-ray skin doses.

Appropriate follow up must be made, if Appropriate follow up must be made, if after completion of a procedure, a large after completion of a procedure, a large skin dose is possible. skin dose is possible.

Policy (continued):Policy (continued):

Connective tissue diseases (e.g. scleroderma, lupus erythematosus, mixed connective tissue disease), diabetes mellitus, hyperthyroidism and the homozygous form of ataxia telangiectasia have been associated with an increased sensitivity to radiation.  Some chemotherapy agents are also known to increase radiation effects. 

To avoid injuries when using an oblique or lateral beam projection, the patient's arm must be secured away from the primary beam.  Direct exposure of the female breast, especially entrance-beam exposure, must also be avoided.

Policy (continued):Policy (continued):

Radiation Biology

Radiosensitivity of Cells 1

As cells mature they become less sensitive to radiation

As metabolic rate increases cells become more sensitive to radiation

As reproductive rate increases cells become more sensitive to radiation

Cell types that are most sensitive to radiation include lymphocytes and stem cells

Cell types that are least sensitive to radiation include muscle and ganglion cells

1 Adapted from The 1906 Law of Bergonie and Tribondeau

Various degrees of sensitivity to radiation exist due to the type of tissue which receives the

exposure

RadiosensitiveRadiosensitive RadioresistantRadioresistant

Breast tissueBreast tissue Heart tissueHeart tissue

Bone marrow cellsBone marrow cells Large arteriesLarge arteries

Mucosa lining of small intestinesMucosa lining of small intestines Large veinsLarge veins

Sebaceous (fat) glands of skinSebaceous (fat) glands of skin Mature blood cellsMature blood cells

Immune response cellsImmune response cells NeuronsNeurons

All stem cell populationsAll stem cell populations Muscle cellsMuscle cells

LymphocytesLymphocytes   

Radiation Induced Skin InjuriesRadiation Induced Skin Injuries

SKIN EFFECT Single-Dose Threshold rad (Gy) Time to Onset

Early transient erythema 200 (2) Hours

Main Erythema 600 (6) ~10 d

Temporary epilation 300 (3) ~3 wk

Permanent epilation 700 (7) ~3 wk

Dry desquamation 1400 (14) ~4 wk

Moist desquamation 1800 (18) ~4 wk

Secondary ulceration 2400 (24) >6 wk

Late erythema 1500 (15) ~6 – 10 wk

Ischemic dermal necrosis 1800 (18) >10 wk

Dermal atrophy (1st phase) 1000 (10) >14 wk

Dermal atrophy (2nd phase) 1000 (10) >1 yr

Induration (Invasive Fibrosis) 1000 (10) >1 yr

Telangiectasia 1000 (10) >1 yr

d: day(s); wk: week(s); yr: year(s)

Stochastic Effects (by chance)

Health effects that occur randomly. Effects that occur by chance, generally occurring without a threshold level of dose, whose probability is proportional to the dose and whose severity is independent of the dose. .

(examples: cancer incidence and genetic effects)

1,000,000 persons buy a lottery ticket for $1,00 each.

999,999 persons will not get the large prize. Only one will win the BIG ONE.

Return on scratch tickets is not certain.

Stochastic Effects (by chance)

Nonstochastic (Deterministic) Effects

Health effects that can be induced upon reaching an apparent threshold, and their severity varies with the radiation dose.

examples:

cataract in the lens of the eye, non- malignant damage to the skin

100 persons invest $1,000 at 5% interest

Each person will receive $1,050.00

Return is certain

Nonstochastic (Deterministic) Effects

So....., how really dangerous is this so called

“RADIATION??”

Radiation Injuries - Cases

Industrial Radiation AccidentIndustrial Radiation Accident

An example of a skin injury attributable to x-rays from An example of a skin injury attributable to x-rays from

fluoroscopy is shown in Figure 2. fluoroscopy is shown in Figure 2.

This case, patient A in Table 2, is that of a 40-year-old This case, patient A in Table 2, is that of a 40-year-old

male who underwent coronary angiography, coronary male who underwent coronary angiography, coronary

angioplasty and a second angiography procedure due angioplasty and a second angiography procedure due

to complications, followed by a coronary artery by-to complications, followed by a coronary artery by-

pass graft, all on March 29, 1990. pass graft, all on March 29, 1990.

Source:Thomas B. Shope, Ph.D. (HFZ-140)FDA/Center for Devices and Radiological Health

Figure 2(a).Figure 2(a). Condition of patient's Condition of patient's back six to eight weeks back six to eight weeks following multiple following multiple coronary angiography coronary angiography and angioplasty and angioplasty proceduresprocedures

Source:Thomas B. Shope, Ph.D. (HFZ-140)FDA/Center for Devices and Radiological Health

Figure 2(b).Figure 2(b).

Appearance of skin Appearance of skin injury approximately injury approximately 16 to 21 weeks 16 to 21 weeks following the following the procedures with small procedures with small ulcerated area ulcerated area present.present.

Source:Thomas B. Shope, Ph.D. (HFZ-140)FDA/Center for Devices and Radiological Health

Figure 2(c).Figure 2(c).

Appearance of skin Appearance of skin injury approximately injury approximately 18 to 21 months 18 to 21 months following procedures, following procedures, evidencing tissue evidencing tissue necrosis.necrosis.

Source:Thomas B. Shope, Ph.D. (HFZ-140)FDA/Center for Devices and Radiological Health

Figure 2(d).Figure 2(d).

Close-up view of lesion Close-up view of lesion shown in 2(c).shown in 2(c).

Source:Thomas B. Shope, Ph.D. (HFZ-140)FDA/Center for Devices and Radiological Health

Figure 2(e).Figure 2(e). Appearance of Appearance of patient's back patient's back following skin grafting following skin grafting procedure.procedure.

Source:Thomas B. Shope, Ph.D. (HFZ-140)FDA/Center for Devices and Radiological Health

Transjugular Intrahepatic Portosystemic Shunt

Source:Koening, Wagner, et al., University of Texas Health Science Center

6 month7.5 month10 month22 month23 month

This patient received 3 TIPS procedures within a week

Radiofrequency Cardiac Catheter Ablation

Source:Koening, Wagner, et al., University of Texas Health Science Center

Tissue necrosis 5 months after procedure, and deep ulceration with exposure of the humerus at 6.5 months

Both patients with Discoid Lupus Erythematosis received skin doses believed insufficient to cause such effects in normal skin.

Reproduced with permission from Gironet et al, 1998, Ann Dermatol Venerol, 125, 598 - 600

Reproduced with permission from Wagner et al, 1999, Radiology, 213, 773 - 776

Radiation-sensitive patientsRadiation-sensitive patients

In right photo, G = graft, R = ribCourtesy of IAEA

Lessons from injured patients

Case #1:Electrophysiological and ablation procedure

Three attempts in 4 months, each with more than 100 minutes of fluoroscopy.

After first attempt erythema observed by patient, but not recognized as due to procedure.

Erythemas on back healed. Arm lesion required grafting.

Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.

Courtesy of IAEA

Lessons from injured patients

If cause of initial erythemas was correctly identified, injury would likely have been avoided because failures of initial ablations would not have been blamed on faulty equipment.

Erythemas on back healed. Arm lesion required grafting.

Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.

Courtesy of IAEA

Lessons from injured patients

Case #2: PTCA and stent placement of RCA. Involved 63 minutes of fluoroscopy and nearly 5000 frames of cine in LAO orientation with cranial tilt.

Lesion required grafting.

Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.

Courtesy of IAEA

Lessons from injured patients

Case #2: Dose buildup due to long fluoroscopy and fluorography with steep angle through thick chested patient not recognized

Lesion required grafting.Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.

Courtesy of IAEA

Lessons from injured patients

Case #2: Cause of injury initially misidentified as pressure wound due to defibrillator pad.

Lesion required grafting.Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.

Lessons from injured patients

Case #3: PTCA : 51 minutes high-dose fluoroscopy, 74 seconds cine in 141 kg man. Dose estimated retrospectively at 22 Gy.

Lesion required grafting.

Courtesy of IAEA

Lessons from injured patients

Case #3: Cumulative buildup of dose for steeply angled high-dose beam through large patient not recognized Lesion required grafting.

Courtesy of IAEA

If you use too much radiation …you will get your ass in trouble

RULE 1

Courtesy of IAEA

RULE 2

Excess radiationcan sneak up on you and catch youunaware

A fluoroscope can be a dangerous beast

Courtesy of IAEA

Rule 3

Use all protective

measures at your disposal to

minimize risk

The EndThe End