Speaking the Same C-arm Language

Intraoperative fluoroscopy is a powerful but potentially dangerous aspect of many surgeries. The goal is to get the exact images the surgeon needs without exposing everyone in the room to harmful radiation. It seems like a simple enough concept, but in some cases what the surgeon wants in terms of operating or positioning the C-arm is not what the radiology technologist is hearing. As a result, the image is unsuitable, members of the surgical team are unnecessarily exposed and, from an operational standpoint, precious time is wasted.

Communication problems between surgeons and radiologic techs are by no means universal — especially in outpatient centers where surgeons and techs often know each other's tendencies and verbiage well and work with each other regularly — but it can be an issue.

Seth Yarboro, MD, an associate professor of orthopedic surgery at the University of Virginia in Charlottesville, was experiencing occasional C-arm communication problems during surgery. "It wasn't one specific incident, but the variability of different experiences," he says. "Some-times you'd have a technologist in the room who knew all the steps of the case, and you barely needed to talk. Other times somebody who had a little less experience needed to be told how to get the appropriate fluoroscopy shots to proceed with the case safely and effectively."

Dr. Yarboro coauthored a paper published in the Journal of the American Academy of Orthopaedic Surgeons (osmag.net/3xKI5BJ) that outlines a standardized language surgeons and techs can use to communicate effectively during surgery. "There are typical movements the C-arm needs to accomplish during most surgeries across different specialties," says Dr. Yarboro.

He brought surgeons and radiologic techs together to negotiate common terminology that worked for the facility. "'Roll' is the one that comes up a lot — roll the C-arm forward and roll it back," he says. "We probably had three or four different terms that were considered for that. It really helped to agree on a term and use it consistently moving forward."

Once the common language was agreed upon, short training sessions were held, and later in the project, follow-up meetings allowed everyone to review the language's effectiveness and implementation. Dr. Yarboro saw a need to reinforce the protocol with retraining.

He laminated the protocol and attached it to all of the fluoroscopy displays. "Everybody's aware we've got the protocol in place, and you can revert back to it in those times when maybe it's a little more challenging to communicate exactly what we're trying to accomplish," he says.

Ame Allen, MHA, R.T.(R)(CT), CIIP, professional practice manager at the American Society of Radiologic Technologists in Albuquerque, N.M., is a radiographer with credentialing in CT and imaging informatics. While she acknowledges that C-arm-related communication problems do exist, she doesn't believe a universal C-arm language is necessary. "All credentialed radiological technologists use a standard terminology for tube projection, whether it's for a diagnostic study or fluoroscopic procedure," she says. "The true dilemma is a lack of communication prior to the intervention."

Ms. Allen says registered radiologic technologists firmly understand human anatomy and pathology for positioning as well as terms such as caudal/cephalic tilt, left/right oblique, raise/lower table and raise/lower C-arm. "It shouldn't be necessary to recreate a 'language' when the terms are already universal." she says.

Rather than devising a standard language, Ms. Allen believes surgeons and techs should huddle before procedures to prevent intraoperative communication problems. Ms. Allen believes effective preoperative communication can also prevent the capturing of wasted images and minimize radiation dosage. "You get into a flow with those you work with, like any working relationship," she adds

Dr. Yarboro acknowledges that he works with many inexperienced techs in an academic environment, but he still sees value in developing a standard language, if just for use in your own facility. "There's benefit to agreeing on how to describe C-arm movements, even if the surgeon and tech are experienced," he says.

For example, at his facility, the standardized language protocol was modified based on input from surgeons and techs. "We said, 'Here's what we're proposing, review this so everybody is on the same page for what we're hoping to accomplish,'" he explains. "I've been very pleased with the impact of this effort on our ability to do good work, take excellent care of patients and communicate better in the process."

One positive result of the standard language, says Dr. Yarboro, is that techs feel empowered to speak up, which can be a problem in some ORs.

There’s value in agreeing on how to describe C-arm movements, even if the surgeon and tech are both experienced.
— Seth Yarboro, MD

"I've tried to be very upfront about the expectation that they be vocal if there's a lack of clear communication, because the result of miscommunication is less efficient imaging, additional radiation exposure and longer cases," says Dr. Yarboro. "One of the best things about using a standardized language is that it establishes a baseline means of communication that opens the doors to saying, 'I'm not sure what you're looking for' or 'I'm having trouble accomplishing what you're asking.'"

Concerns about speaking up contribute to a lot of communication challenges in the operating room, but Dr. Yarboro says team members who have already communicated about terms related to the C-arm language protocol feel more comfortable discussing related issues.

While Dr. Yarboro says the patient and provider safety impact of wasted intraoperative imaging requires further study, he and his teams do whatever they can to avoid the issue in the first place. "Any opportunity to limit our exposure to radiation, given that we work with it on a daily basis in some fields, is worth taking," he says.

Dr. Yarboro also points out that using standardized language is crucial from an efficiency perspective. "If cases don't take as long and you're able to minimize the amount of radiation you need to use, then you'll have more resources available," he says. "You can use C-arms for more cases or just improve workflow in general, which is certainly a priority in the outpatient setting." OSM