Finding Safety in C-Arms

New features and a stronger focus on safety keep staff and patients protected from harmful radiation exposure.

The modern X-ray is a story of progress, transitioning from film to the digital era alongside many other modern technologies. Some estimates indicate the amount of radiation required for an X-ray is about 5% what was needed years ago.

A look at the sophisticated safety features in modern C-arms combined with common-sense protocols and training helps explain much of this recent progress. During intraoperative fluoroscopy, radiology experts are finding new ways to lower doses without compromising the image quality they need for successful procedures.

The end result is a higher standard of care, fewer repeat X-rays and a clear path toward the bedrock ALARA principle of radiation safety. “Our primary focus is always As Low (a dose) As Reasonably Achievable,” says John Evans, R.T.(R)(CT)(ARRT), a member of the radiology team at UCHealth Yampa Valley Medical Center in Steamboat Springs, Colo.

Radiation automation

Radiation specialists are dedicated to reducing exposure to patients and staff. Modern C-arms have built-in presets that make this easier than ever, helping to reduce overall exposure time while ensuring patients receive the proper dose.

Context matters when it comes to radiation, as an orthopedic wrist exam will require a smaller dose than a knee or spine exam. The C-arm’s built-in presets (and low-dose modes) can help you lock in the correct amount. The physical size of your patients also factors into this ongoing calculus to manage the dose. “In the past, it was up to the (radiation) tech to build in the preset or set the radiation level for each exam,” says Patrick Adams, plant manager at DISC Surgery Center in Newport Beach, Calif. “If the tech wasn’t savvy in setting those presets they could either be over-radiating or under-radiating the patient, and not getting the necessary image quality that’s required.”

Radiology teams can derive the full benefit of modern C-arms when they master the automated features and know when to switch to manual modes. Automatic exposure control can help you calibrate kilovoltage, mA and exposure levels, but it’s important to remember that you are always in control. For instance, switching between continuous and pulsed fluoroscopy gives you the ability to increase or decrease the dose in real time. This is particularly helpful in those hard-to-image sections of the lower neck, shoulder and spine. Mr. Evans believes radiology is at a “hybrid moment,” as both automated features and medical expertise are used to determine the right technique at the right time. “We have some automation, but we also have technical knowledge,” he notes.

A better view

Mr. Evans recalls the excitement of an orthopedic surgeon after the team acquired a C-arm with a larger, square field of view that would make it much easier to get high-quality hip X-rays in one try. Previously, the radiology team would take individual images of the left and right hips and use software to fuse them together in post-production.

“This was an opportunity to increase standard of care, increase accuracy and reduce steps in these surgeries by evaluating both hips at the same time,” Mr. Evans says. “It’s a really painstaking process when you need to individually X-ray those hips and fuse (the images) together.”

There are other beneficial features that support better imaging, Mr. Evans notes. Collimation adds another level of specificity for X-ray exams, focusing the beam to the precise area of interest. This is particularly helpful in getting images of the lumbar spine. “I’m a huge proponent of using it,” he says.

Reduce your repeats

Reducing radiation exposure is about more than lowering the strength of the radiation you need to get a single image. You must consider the total exposure throughout the exam.

In some cases, that means using a stronger initial dose to avoid repeat exams, says Mr. Evans. Getting the proper image with a stronger technique may mean less overall radiation than if the exam had to repeated multiple times at a lower dose.

“A lot of radiology people focus on reducing the dose,” he says. “But in reality that’s just one piece of the pie. Reducing repeat exams is important. Getting the diagnostic image right the first time is very important to reducing radiation exposures.”

Keeping staff safe

Beyond a focus on C-arms and limiting dosing, staff training and education will help reduce exposure for your team and your patients. That means knowing the technology and the correct distance staff should stand from the X-ray tube to avoid unnecessary exposure. Be sure to talk with your equipment rep and your team as you establish ground rules for your facility.

The fact that radiation doses continue to get smaller and smaller does not mean you can let your guard down. A brief walkthrough before exams can ensure the necessary precautions are in place before your techs ever get to work.

“You essentially want to make sure everyone is being properly leaded for the procedure, making sure everyone has thyroid shields and dosimeter badges on and in the appropriate spot,” says Mr. Adams.

Compliance starts with having the proper signage at your facility. Your team should also wear dosimeters or radiation badges so they can monitor exposure over time. Pregnant people need dosimeters at both the abdominal and collar level. Everyone should know they’re expected to take the proper precautions, especially when it comes to radiosensitive organs like the testicles, ovaries and thyroid.

The bottom line

Low-dosage exams have become the clinical norm, reaching the point that the American Association of Physicists in Medicine, the American College of Radiology and other radiology groups have pivoted away from their long-standing recommendation for lead shielding and aprons to cover patients’ torsos during routine X-ray exams.

Looking forward, radiology specialists will continue to strive for their ALARA aim, but future advances may not come in the form of new technology, according to Mr. Adams. “We’ve already made a lot of progress. I feel like we’re at the pinnacle as far as radiation safety and technology built into the new C-arms,” Mr. Adams says. “I can’t see it being much more friendly and better in that regard.”

Beyond technology, there are still ways to bolster safety. After all, the automated tech available in modern C-arms is only as useful as your staff in the OR. Educate and train your team, and you’ll be well on your way to success. OSM

SAFETY

Critical C-Arm Features

AUTOMATION IN ACTION The latest C-arms have built-in features that help you select the right radiation dose at the right time.  |  UCHealth Yampa Valley

Modern C-arms feature an array of built-in safety features and presets that guide the X-ray beam to the right place at the right time. These features ensure you’re using the correct dosage to get the image, without exposing your patients and staff to unnecessary levels of radiation:

• Laser aimers. Even before you turn on your machine, laser aimers help you pick the perfect placement for the radiation beam and ensure you’re selecting a precise target.

• Continuous or pulse options. Modern C-arms provide the ability to switch between continuous and pulsed fluoroscopy. This helps control the dose and determine if you need real-time imaging or are better served by intervals of radiation at predetermined increments.

• Last-image hold. Sometimes the last image is all you need. With this feature, the last captured image remains on the monitor even after you are done with your X-ray.

• Collimation. Within the X-ray tube, the collimator can help you further define the size and shape of the radiation beam needed for the procedure. Clearly defining the beam puts the quality of the image in your hands and helps reduce overall radiation to patients and staff.

Low-dose modes. Some areas of the body need less intense radiation to penetrate through anatomy. Low-dose modes can help you manage and regulate your dose.
—Matthew Nojiri