DRESS IN LAYERS Proper personal protective equipment is often overlooked and underused.

Radiation's invisible dangers don't make them any less real, but surgical teams continue to jeopardize their long-term health by failing to implement commonsense precautions that reduce their exposure risks. Following these 5 tips will ensure your surgeons and staff have a healthy respect for radiation and shield themselves from scatter whenever C-arms are rolled into the OR.

1 Don't overdo it
ALARA — "as low as reasonably achievable" — must be surgical imaging's guiding principle. Although capturing extra images can provide valuable information during technically demanding procedures, surgeons need to rely on snapshots of anatomy that are only absolutely necessary for performing surgery effectively and safely. Getting surgical images with as little radiation exposure as possible, and magnifying images only when it's clinically necessary, will improve the safety of everyone in the room. There are several ways to adhere to the ALARA principle:

Use fewer shots. Pulsed fluoroscopy captures 1 to 6 images per second and, when clinically appropriate, is preferable to continuous fluoroscopy, which captures 30 images per second.

Have a plan. Mark anatomical landmarks on the patient or on the surgical drapes to let surgeons and radiology techs focus on targeted anatomy with fewer fluoroscopic shots. Using tape to mark where the C-arm should be positioned and repositioned when multiple images are needed can also help limit the shots taken and will shorten case times.

Direct the beam. Collimation involves adjusting the size of the C-arm's aperture to reduce the size of the X-ray beam and focus it on the targeted anatomy. The adjustment limits the radiation dose required to capture images and subsequent radiation scatter.

2 Wear protective equipment
The maximum annual dosage limits for radiation exposure are 20 mSv for the body, 150 mSv for the thyroid and eyes, and 500 mSv for the hands, according to the International Commission on Radiological Protection. The importance of wearing gear that protects against radiation exposure might seem obvious, but personal protective equipment, from eyewear to gloves to thyroid protection, is often overlooked and underused.

Lead aprons. Make sure aprons have a lead-equivalent thickness of at least 0.5 mm, which protects wearers from 95% of scattered radiation. One-piece aprons can offer frontal or wrap-around protection, but two-piece vest-skirt combinations better distribute the weight of the garments and might be more comfortable to wear. Inspect lead aprons annually for cracks and general wear and tear that can leave wearers exposed.

Thyroid shields. The thyroid is extremely vulnerable to radiation exposure, but shields that protect the area often go unused, often because they're not available for the surgical team to wear.

Protective gloves. A surgeon's hands are also particularly prone to exposure, mostly because they are the hardest to protect from direct exposure. Mini C-arms might reduce the overall radiation exposure to the surgeon, but might increase risk of exposure to his hands, which can be in the direct path of the X-ray beam. Protective gloves are an option, but they produce more radiation scatter, and they're no substitute for proper technique. One way to reduce the amount of direct radiation exposure to the hands is to use forceps and other instruments to position anatomy when images are being captured.

Lead eyewear. The eyes are especially sensitive to radiation, and leaded goggles can limit exposure by 90%. On a personal note, my corrective lens prescription has changed twice in the past 5 years. Although I can't pinpoint a direct correlation, the changes were likely due to my work with the C-arm. Make sure your surgeons' eye protection includes lateral shields to protect from scatter off the head and direct exposure when their heads are turned.

3 Agree on verbal cues
Make sure surgeons and radiology techs establish before a case begins the terminology they'll use to indicate how the C-arm should be repositioned. It's suggested that direction and distance should describe linear movements and direction and magnitude of degree should describe rotational movements. Surgeons and radiology techs should also agree on what will be said just before the C-arm is activated, so members of the surgical team can take the necessary steps to protect themselves against exposure, including removing their hands from the imaging field whenever possible.

4 Practice proper positioning
The farther you stand away from the C-arm's X-ray tube, the lower your exposure to radiation. To reduce scatter, position the image intensifier as close as possible to the patient. Doing so will also increase the field of view captured in the image. Also, stand opposite the X-ray tube when the C-arm is placed in the lateral position. When possible, capture anterior-posterior images instead of lateral images, which require higher radiation doses.

5 Understand the risks
Surgeons and staff who understand the risks of exposure are more likely to commit to safer C-arm practices. For example, orthopedic surgeons have an increased incidence of cancer, compared with non-exposed workers, and chronic radiation can cause cataracts to form. Inform your surgical team about the consequences of careless imaging practices and work with them to implement a C-arm safety program that will preserve their careers and long-term health. OSM