Lampignano and Kendrick Bontrager's Textbook of Radiographic Imaging PDF

594 C H A P T E R 15 TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY SURGICAL RADIOGRAPHY Radiography in surgery is one of the most demanding challenges The technologist must communicate radiation safety concerns...

594 C H A P T E R 15 TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY SURGICAL RADIOGRAPHY Radiography in surgery is one of the most demanding challenges The technologist must communicate radiation safety concerns encountered by a radiologic technologist. The technologist will be with the surgical team, including failure to wear aprons, overuse of called on to perform procedures quickly and accurately in a sterile C-arm real-time imaging, and placement of hands into the radiation environment, with a minimum number of repeat exposures (Fig. field. In these situations during surgery, the technologist is the 15.85). For most surgical procedures, the patient is under general radiation safety expert and must minimize exposure for the anesthesia and time is of the essence, because the less time a surgical team. patient spends under general anesthesia, the less likely it is that complications will occur. Therefore, the surgeon expects the tech- PROBLEM-SOLVING SKILLS nologist to perform any requested procedure without error or delay. Even when the technologist has used the best knowledge and These added pressures may create uncertainty and anxiety for preparation, unexpected problems can occur during surgery. C-arms the radiography student or recent graduate. However, with a can cease to work, reliable exposure factors may fail to produce a solid knowledge of the surgical procedure and operation of the diagnostic image, or the sterile field may be violated. Although it is imaging equipment, the technologist can function effectively in the difficult to predict every situation that might occur in the OR, surgical suite. the radiologic technologist must be able to find solutions to Through supervised observations with an experienced surgical these problems quickly. Perhaps the most important skill of the technologist, the student can become comfortable and confident technologist is the ability to problem-solve unforeseen situations in the surgical environment. It is essential that the student technolo- immediately. gist be kept under the direct supervision of an experienced tech- nologist in the OR until he or she has achieved competency for a MASTERY specific procedure. Mastery of all aspects of radiography, including use of the C-arm This section of the chapter identifies essential skills and com- and mobile radiographic equipment, is essential. The technologist monly used equipment, and previews the surgical environment to must be able to operate and troubleshoot conventional and digital provide the student radiographer with a baseline knowledge. More equipment. The technologist must also know reliable exposure commonly performed procedures are discussed at the end of this factors for patients of different sizes and for various procedures. chapter; however, it is important for student radiographers to understand that they will participate in a variety of surgical proce- dures based on their clinical setting. Rather than focus on specific surgical procedures, student radiographers should focus their efforts on developing the essential skills and transfer their newly acquired skills from one procedure to the next. Essential Attributes of the Radiologic Technologist in Surgical Radiography Although confidence and knowledge of procedures are needed in all aspects of radiography, certain personal attributes, skills, and insight are the trademark of a competent radiologic technologist in the surgical setting. CONFIDENCE Although no one can teach a technologist confidence, it is the first attribute that the other members of the surgical team expect to see in the technologist. Confidence is judged by the technologist’s level of comfort and ease in the OR suite, including the skilled Fig. 15.85 Radiography in the surgical suite. use of imaging equipment, ability to problem-solve situations, and respect for the sterile field. The surgical team expects the technologist to be confident in his or her abilities to perform the procedure quickly and accurately, with a minimum of repeat expo- sures. However, confidence comes only with experience and knowledge of all aspects of radiography. As the technologist gains experience and success in the OR, confidence will grow. COMMUNICATION It is essential that the technologist be an excellent communicator. He or she must communicate with other members of the surgical team regarding any concerns that arise during the procedure. Clear communication between the technologist, surgeon, and anes- thesiologist is paramount for most radiographic procedures. For example, during operative cholangiography, the technologist must 15 coordinate the exposure with the surgeon who is injecting the contrast medium and with the anesthesiologist who is suspending respiration. Without this team approach, motion may result and the quality of the exposure may be compromised.  TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY C HA PTE R 15 595 Surgical Team The composition of the surgical team will vary, depending on the surgeon, institutional policy, type of procedure, and other factors. A typical surgical team consists of the following members (Fig. 15.86). SURGEON The surgeon is a physician licensed and trained in general surgery or a specialty such as cardiovascular or orthopedic procedures. She or he has the primary responsibility for the entire surgical procedure and for the well-being of the patient prior to, during, and immedi- ately following surgery. ANESTHESIOLOGIST A physician anesthesiologist or a certified nurse anesthetist special- izes in administering anesthetic drugs to induce and maintain anesthesia to the patient during surgery. This person has the responsibility of ensuring the safety of the patient and monitoring Fig. 15.86 Surgical team—surgeon, certified surgical technologist physiologic functions and fluid levels of the patient during surgery. (CST), and radiologic technologist discussing procedure with patient. SURGICAL ASSISTANT A physician, physician’s assistant, certified surgical technologist (CST), or registered nurse (RN) assists the surgeon. This person’s range of responsibilities may include suctioning, tying and clamping blood vessels, and assisting in cutting and suturing tissue. CERTIFIED SURGICAL TECHNOLOGIST A CST is a health professional who prepares the OR by supplying it with the appropriate supplies and instruments. Other CST respon- sibilities include preparing the patient for surgery and helping connect surgical equipment and monitoring devices. During surgery, CSTs have the primary responsibility for maintaining the sterile field. CIRCULATOR A circulator is a nonsterile CST or RN who assists in the OR by responding to the needs of scrubbed members in the sterile field before, during, and after the surgical procedure. Duties may include Fig. 15.87 Scrub preparing and maintaining sterile surgical field. recording of pertinent information, retrieval of additionally needed items, and connecting nonsterile surgical equipment. SCRUB A scrub is a CST or RN who prepares the sterile field scrubs, gowns the members of the surgical team, and prepares and sterilizes the instruments before the surgical procedure is begun (Fig. 15.87). NOTE: During OR cases, the radiologic technologist receives instructions from a physician (surgeon, anesthesiologist). 15  596 C H A P T E R 15 TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY Surgical Radiography Imaging Equipment The technologist must be familiar with the location of power outlets to be used for a procedure. Ideally, all imaging equipment should be in place and checked for correct operation before the procedure is begun. Although most surgical equipment remains in the surgical area, it must be cleaned and checked frequently for correct opera- tion. Once the procedure has begun, there is no time to troubleshoot equipment or fix problems. Daily, weekly, and monthly quality control protocols should be followed for all surgical radiographic equipment. Even a small problem such as a frayed electrical cord must be addressed before it results in an equipment failure. CLEANING Mobile (portable) units and C-arm equipment should be cleaned before and after use in the surgical area. An approved antiseptic cleaner should be used to wipe down the equipment. A liquid-type cleaner rather than an aerosol is recommended to prevent the introduction of airborne contaminants into the surgical area. The technologist must wear gloves when cleaning equipment, especially if blood or other body fluids are present. Equipment permanently stored in the surgical area must be cleaned weekly or as needed. IRs and grids must be inspected for contamination and cleaned weekly. Fig. 15.88 OEC 9800. (Courtesy GE Healthcare.) OPERATIONAL CHECK Before imaging equipment is used, an operational check should be performed. A log of any problems and failures should be maintained and monitored. TV monitors and Image intensifier tower control cart PROPER EQUIPMENT LOCATION The technologist must be familiar with the location of power outlets (and data ports for uploading images to a picture archiving and communications system [PACS]) to be used for a procedure. Ideally, all imaging equipment should be in place and checked for correct operation before the procedure. If C-arm fluoro units are being used, place monitors in clear vision of the surgeon. Make sure that placement of the C-arm or portable unit is not interfering with normal foot traffic. Adjustable C-arm MOBILE C-ARM DIGITAL FLUOROSCOPY SYSTEMS Head end of Another type of mobile imaging equipment is the C-arm mobile Surgical bed fluoroscopy system. The term C-arm is descriptive of a basic design X-ray tube of a mobile fluoroscopy unit, which forms a large C shape with the x-ray tube located at one end of the C-arm and the image intensifier Fig. 15.89 Philips BV29 C-arm with image processor and display tower at the other (Fig. 15.88). stand, demonstrating setup for PA projections for surgical and Familiarity with the C-arm, monitor, and image controls is essen- interventional cases. (Courtesy Philips Healthcare, Andover, Mass.) tial for the technologist who is performing ER or OR procedures, during which these systems are most commonly used. One also must become familiar with the various types of special beds or carts used with the C-arm. For example, a surgical bed used for operative cholangiography may not accommodate the C-arm x-ray tube under the table in the abdominal area because of the base supports unless the patient’s head is placed at the correct end of the bed or cart (Fig. 15.89). 15  TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY C HA PTE R 15 597 Maneuverability Additional optional modes available on some equipment that The equipment is designed to be very maneuverable. The C-arm allow more complicated procedures include subtraction (digital itself is attached to a beam located on the base of the C-arm that subtraction) and roadmapping. Subtraction is a technique in which can be raised, lowered, or extended as needed. The base of the an initial image is recorded during continuous fluoroscopy. The C-arm and the supporting beam provide a much-needed counter- initial image then is used as a filter for the next fluoroscopic images. balance to the C-arm portion. This counterbalance stabilizes the Essentially, the C-arm subtracts the initial image from all the other machine during any needed rotation, tilt (cephalic or caudal angles), images produced. All stationary structures are removed (subtracted) or horizontal-beam, cross-table projection (Fig. 15.90). The C-arm from the image, and only moving (or new/different) structures are can also be rotated 180° to place the tube on top and the intensifier imaged. When fluoroscopy ends, the C-arm resets back to normal on the bottom. However, this is not recommended because of the mode. For example, subtraction is sometimes used for operative increase in OID, which decreases image resolution and increases cholangiography. Use of subtraction will eliminate the stationary scatter radiation. The tube-on-top position also results in a significant ribs, spine, and surrounding soft tissues, leaving only the moving increase in exposure to the eyes, head, and neck areas of the injected contrast medium to be imaged. Therefore, the final images surgeon or radiologist because of the exposure pattern of the C-arm show the contrast-filled biliary system free from superimposition of in this orientation (see Fig. 15.97). the surrounding structures. Overall, the unit is flexible to use. The technologist must be Roadmapping is a method of image display wherein a specific familiar with a variety of built-in joints, extensions, and adjustments. fluoro image is held on the screen in combination with continuous With its three-wheel base, steerable rear wheels, and a swiveling fluoro. It is similar to subtraction in that it removes stationary nose wheel, the operator can easily maneuver the unit into almost structures from the viewing screen. This is especially useful in any possible configuration, with reasonable space. interventional procedures that require the placement of catheters. Display Monitors and Control Cart Two monitors are generally used, so the active image can be dis- played on one monitor while the second monitor can be used to hold an image for reference purposes. Generally, the active monitor is on the technologist’s left and the hold monitor is on the right. Images also can be rotated or flipped as needed for preferred viewing by the surgeon and/or radiologist. Uses of C-Arm The technologist will use the C-arm unit with various types of procedures in which mobile fluoroscopy and/or still frame imaging is needed. Common surgical procedures may include cholangiog- raphy, open or closed reductions of fractures, and hip pinnings. Images can be stored temporarily by video memory or on hard disks. With the advancement and popularity of the PACS, images can be directly uploaded to a PACS with the appropriate data connection. Optional hard copy printers are also available for Fig. 15.90 Horizontal setup for lateral hip. printouts. Cine loop capability, wherein images are recorded in rapid succession while contrast medium is injected and then displayed as a moving (or cine) image, is possible. As with other types of digital imaging, image enhancement and manipulation are possible, including overall brightness and contrast controls, magnification, edge enhancement, masking, and digital subtraction studies. These manipulations can be made during fluoroscopy or for postimage processing, depending on the manufacturer. Controls and Operation Modes The digital C-arm fluoroscopy systems include a variety of operating mode control options with which the technologist must be familiar. These control panels may be located on the display monitor control cart, on the C-arm unit itself (Fig. 15.91), or on an attached or detached remote control. The magnification mode is the ability of a system to magnify the image for better visualization of structures because surgeons frequently need to view the image at a specified distance from the Fig. 15.91 Control panels of OEC 9600 series C-arm. (Courtesy GE monitor. OEC Medical Systems, Salt Lake City, Utah.) The pulse mode is used to create an x-ray beam that pulsates at timed increments to reduce exposure. The snapshot or digital spot mode activates a digital spot, which results in a higher quality computer-enhanced image as compared with a held fluoro image. Auto/manual exposure control allows for exposure by the opera- 15 tor if desired, or the use of automatic exposure control (AEC).  598 C H A P T E R 15 TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY Foot Pedal or more over the diagnostic x-ray energy range, is recommended.15 The foot pedal allows the physician or other operator to have A wraparound apron is necessary if the person’s back is repeatedly hands-free operation of the C-arm. A fully equipped foot pedal has turned toward the patient. In addition, staff members should always multiple controls for various functions, as shown in Fig. 15.92. move away from the patient during x-ray beam activation if their immediate presence is not required. Extra care must be taken to Image Orientation ensure that all personnel are conscientious about the location of The flexibility of the C-arm for imaging a variety of anatomic struc- the C-arm and each adjusts their position appropriately so that the tures at almost any conceivable angle from any side or direction lead shield remains between themselves and the C-arm. In addi- requires correct image orientation each time it is set up for use. tion, the operator, even if wearing a lead apron, should always stand This should be completed during setup time before the initial image a minimum of 6 feet (2 m) from the x-ray tube during all is obtained to avoid needless exposure to the patient and exposures. personnel. Because of the variety of policies and procedures reported in various hospitals and medical centers, technologists must develop their own methods of achieving correct image orientation before the patient is imaged. One method is to bring the C-arm into the room in the same position and orientation that will be used for the procedure. Place an R lead marker on the flat surface of the x-ray tube collimator, oriented in the same way the patient will be ori- ented. The top of the letter R should be to the head end, indicating the patient’s right side, to appear anatomically correct on the monitor to the viewer’s left. (This is the same orientation as for viewing radiographs—that is, the patient’s right to the viewer’s left.) At this point, the image can be flipped or rotated as needed to produce the correct orientation necessary for the procedure. An exposure can be provided during this setup with an apron or other shielding covering the C-arm to shield other personnel in the room. Correctly viewing and orienting the test image of the R on the monitor is an important preparation for the procedure. Fig. 15.92 Foot pedal controls. O-ARM The O-arm is a new type of surgical imaging equipment that a radiologic technologist may operate during select procedures (Fig. 15.93). The O-arm imaging system is a mobile x-ray system designed for 2D fluoroscopic and 3D imaging and is intended to be used where a physician benefits from 2D and 3D information of anatomic structures and objects with high x-ray attenuation such as bony anatomy and metallic objects. The O-arm imaging system is compatible with certain image-guided surgery systems.14 The O-arm is an example of new technology that can be oper- ated in the surgical setting by a radiologic technologist; however, the C-arm continues to be the primary imaging equipment with fluoroscopic capabilities used, and therefore, the C-arm is the focus of this section. Radiation Protection in Surgical Radiography Conscientious radiation protection practices are especially important in mobile radiography and surgery suites in which fixed protective barriers do not provide a shielded place to stand during exposures. This is true with all mobile x-ray examinations, but even more so Fig. 15.93 O-arm imaging system. (Reprinted with the permission with C-arm mobile fluoroscopy, which potentially results in consid- of Medtronic, Inc. © 2017.) erably more scatter radiation to the immediate area over a longer time. The technologist must continually be aware of the three important cardinal rules of radiation protection—time, distance, and shielding. STAFF RADIATION EXPOSURE The primary source of radiation exposure to the fluoroscopy staff is from scattered radiation from the patient. Scattered x-rays originate from the volume of tissue irradiated by the x-ray beam (structures within the field of view). Nearby radiation levels depend on C-arm orientation, technique factors, and patient size, but decrease rapidly with distance from the patient. 15 The operator and all persons who remain in the room during the exposure should always wear a lead apron. A 0.5-mm lead equivalent apron, which reduces the exposure by a factor of 50%  TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY C HA PTE R 15 599 C-ARM ORIENTATION AND EXPOSURE PATTERNS Summary of Radiation Protection in Vertical Posteroanterior Projection CR Surgical Radiography If it is assumed that the patient is supine, keeping the C-arm Sound radiation protection practices are important for protection of posteroanterior (PA; the fluoroscopy tube is located below the all personnel during mobile imaging as already described. A patient, and the image intensifier is located above the patient) and summary of what this includes in the surgical setting is as follows. directly perpendicular to the floor minimizes exposure to the neck and facial region (Fig. 15.94). If the C-arm is tilted as much as 30°, TIME as shown in Fig. 15.95, the configuration of the exposure fields Use of Intermittent Fluoroscopy changes to increase exposure significantly to the upper body and Single-exposure capacity can greatly reduce fluoroscopy time. facial region not shielded by the lead apron. Studies have shown The image hold feature allows the last image to remain on the that even a 30° C-arm tilt will increase the dose to the face monitor. and neck region of an operator of average height who stands next to the C-arm by a factor of 4. Minimize Boost Exposures The boost feature on most C-arms provides an improved and Horizontal Projection CR brighter image for the patient with a large body habitus, or thick The configuration of the exposure fields with a horizontal beam is anatomy. However, this feature increases radiation, primarily mA, demonstrated in Fig. 15.96. Note that the exposure region on the which also increases exposure to the patient and surrounding surgi- x-ray tube side of the patient is significantly larger than that in cal team by a factor of three to four times compared with standard the region near the intensifier tower. This should be an important fluoroscopy. Use the boost feature only when no other alternative consideration for the surgeon or other operator who may need to or adjustment will improve the image. stay near the patient. DISTANCE Vertical AP Projection CR Vertical Alignment Occasionally, the technologist may be asked to reverse the C-arm, Place the vertical alignment of the C-arm so the x-ray tube is away tube on top and image intensifier on bottom. This may provide the from the operator’s head and neck region. This is achieved by surgeon more room for manipulation; however, this is not recom- placing the x-ray tube beneath the OR table, thus reducing the dose mended due to a significant increase in exposure to the opera- to the head and neck region of the surgical team. (See p. 600 for tor, as shown in Fig. 15.97 (up to 100 times higher dose to the details of C-arm orientation and exposure patterns.) eyes of the operator). Minimize Distance Between Anatomy and Image Receptor Patient Dose Reducing the distance between the anatomy and the image intensi- Modern fluoroscopic units produce images with an image intensifier fier creates a brighter, sharper, and less magnified image, with a (or flat panel detector) that captures the x-rays exiting the patient. reduction in radiation to the immediate area. The detector converts the time sequence of incident x-rays to a series of images displayed on the monitor. With manual technique, SHIELDING the image quality and brightness are adversely affected when the Protective Lead Aprons operator pans across tissues of different thickness and composition. Provide aprons for all personnel. For this reason, fluoroscopy is almost exclusively performed using Wear a thyroid collar. automatic brightness control (ABC). Technical factors (e.g., kV, mA, Secure aprons tightly to prevent them from touching the sterile filtration, and/or pulse length) are then adjusted automatically to field or sterile personnel. maintain image brightness at a constant, proper level. Clean aprons weekly or as needed with a liquid-type cleaner. The exposure rate depends on operational mode, field size, Intermittently check aprons for cracks in the lead lining. patient size, tissue composition, and ABC design. Attenuation of x-rays along the beam path influences the number of x-rays reach- COMMUNICATION ing the detector. The ABC compensates brightness loss caused by Coordination of Exposure With Surgical Team lower transmission of x-rays through the patient by generating more Coordinate exposures among the anesthesiologist, surgeon, and x-rays and/or producing more penetrating x-rays (reducing image surgical team. For studies such as operative cholangiography, injec- contrast). The maximum exposure rate at 30 cm from the image tion of contrast media, suspension of patient breathing, and x-ray receptor (IR) cannot exceed an air kerma rate of 88 mGy/min, exposure must be closely coordinated among team members. which equals an exposure rate of 10 R/min. In high-level fluoros- The technologist should clearly announce “x-ray” or “x-ray on” copy (HLF) mode, the maximum exposure rate at the same refer- before initiating an exposure to enable nonessential staff to leave ence point cannot exceed 20 R/min, corresponding to an air kerma the area or get behind lead shields. Announcing “x-ray off” com- rate of 176 mGy/min. Generally, the entrance exposure rate to the municates to nonessential staff that it is safe to return to the area. patient is 1 to 3 R/min, but the ABC can boost the exposure rate to maximum for large patients. Monitor Personal Dosimetry Report Digital spot film acquires a single, static radiographic image of Technologists who frequently perform C-arm procedures should the structures of interest with a low radiation dose. This is an closely monitor their personal dosimetry. If they discover excessively excellent dose reduction method to evaluate static spatial relation- high levels, they may have to modify their work habits and discuss ships or document the proper location of a device. strategies to reduce dose levels with the department radiation Gonadal shielding should be applied when the x-ray beam is safety officer. directed toward the abdomen and pelvis if the presence of such shielding does not interfere with the examination. 15  600 C H A P T E R 15 TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY mR/hr 4 F A ! 300 E B 100-500 3 C 50-100 D D 25-50 2 C E 10-25 Inten. B F " 10 1 A 0 Tube Inten. scale (ft.) D C B A mR/hr F E A ! 300 Tube B 100-500 C 50-100 D 25-50 scale (ft.) E 10-25 6 5 4 3 2 1 0 F " 10 Fig. 15.94 Exposure levels—CR vertical, PA projection, intensifier on Fig. 15.96 Exposure patterns and levels—CR horizontal (least top (least exposure to operator). exposure at intensifier side). (Adapted from Technical reference, Salt Lake City, Utah, 1996, OEC Medical Systems; and Geise RA, Hunter DW: Personnel exposure during fluoroscopy procedures, Postgrad Radiol 8:162–173, 1988.) mR/hr F E A ! 300 D C B 100-500 B C 50-100 A Tube D 25-50 E 10-25 Int en F " 10. A B C mR/hr D Inten. E A ! 300 F Tu B 100-500 be C 50-100 D 25-50 E 10-25 F " 10 scale (ft.) 6 5 4 3 2 1 0 scale (ft.) 4 3 2 1 0 Fig. 15.95 Exposure levels—CR 30° from vertical (CR angle increases Fig. 15.97 Exposure levels, AP projection (tube on top) (not exposure to operator). (Adapted from Technical reference, Salt Lake recommended). (Adapted from Technical reference, Salt Lake City, City, Utah, 1996, OEC Medical Systems; and Geise RA, Hunter DW: Utah, 1996, OEC Medical Systems; and Geise RA, Hunter DW: Personnel exposure during fluoroscopy procedures, Postgrad Radiol Personnel exposure during fluoroscopy procedures, Postgrad Radiol 8:162–173, 1988.) 8:162–173, 1988.) 15  TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY C HA PTE R 15 601 Surgical Asepsis Principles cover, called a snap cover, has a band that makes a snapping sound Unfortunately, it is impossible to remove all infectious organisms when it is released into position (Fig. 15.100). These types of from the OR. Surgical asepsis consists of the practice and proce- covers also make it possible for the technologist (with guidance dures used to minimize the levels of infectious agents present from the surgeon) to position the image intensifier precisely as in the surgical environment. Through the use of safe practices, needed over the sterile surgical site for correct centering. wearing proper surgical attire, and ensuring that care is taken around the surgical incision, the patient’s exposure to these infec- tious agents is greatly minimized. This requires a clear separation of sterile items and areas from nonsterile areas in the surgical suite (Fig. 15.98). To reduce the risk for infection of the patient during surgery, the following principles of surgical asepsis must be followed: 1. Only sterile items are allowed within the sterile field. 2. If the sterility of an object is in doubt, it must be considered nonsterile. 3. If a sterile drape or cover is touched by a nonsterile object or person, it must be considered contaminated. 4. Nonsterile personnel must not come into contact with a sterile barrier, drape, surgical instrument, or sterile personnel. 5. Any contaminated sterile drape or cover must be reported and replaced by sterile personnel. 6. Sterile gowns are considered sterile from the shoulder to the level of the sterile field, and at the sleeve from the cuff to just Fig. 15.98 Surgical asepsis—separation of sterile and nonsterile above the elbow. areas. 7. OR tables are considered sterile only at the level of the tabletop. 8. Only sterile personnel can touch sterile items. Surgical Suite Environment The typical surgical suite has two general regions known as sterile and nonsterile areas. The sterile area includes the patient, surgical field, surgeon and surgical assistants, surgical equipment, tables, and carts. (In some facilities, the sterile area includes the area surrounding the sterile field, up to 1 foot wide.) Often, most of the sterile area is located to one side of the room, leaving the other side of the room available for necessary nonsterile personnel. The technologist and the imaging equipment must not violate the sterile area. Student technologists new to the OR must have a clear understanding of the differences between sterile and nonsterile areas. When in doubt, ask the radiologic technologist, CST, or circulator for clarifica- tion. If the sterile area is violated, which may contaminate the instruments used for the procedure, the technologist must report this event immediately. Because the violation may have not been Fig. 15.99 Draping the C-arm with sterile plastic C-arm cover. noticed by the surgical team, the technologist has a critical respon- sibility to report it. In most cases, additional sterile drapes or a new set of sterile instruments can be used to create a safe and sterile environment again. The nonsterile area is where the technologist, as well as other nonsterile surgical personnel such as the anesthesiologist and the circulator, is located. The technologist can safely stand and operate imaging equipment within this area. For select procedures, a plastic drape or shower curtain may be erected to indicate the dividing point between sterile and nonsterile areas. IMAGING EQUIPMENT/PERSONNEL AND STERILE FIELDS C-arm C-arm use in surgical settings requires special attention in maintain- ing sterile fields. Vertical alignment with the intensifier on top often causes it to be placed over open incisions. The following three basic approaches are commonly used to maintain a sterile field. The first (and most commonly used) method involves draping the image intensifier, x-ray tube, and C-arm with a sterile cloth and/ 15 or bags, with a tension band or adhesive tape holding the cloth or Fig. 15.100 Draping the C-arm and intensifier with snap cover. plastic cover in place (Fig. 15.99). Another type of image intensifier (Courtesy Philips Healthcare, Andover, Mass.)  602 C H A P T E R 15 TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY A second approach is to drape the patient (or surgery site) temporarily with an additional sterile cloth before the undraped C-arm is positioned over the anatomy. Once a satisfactory image has been obtained and the C-arm removed, the sterile cloth (or drape) is then removed from the patient and discarded. This process is repeated with a new (unused) sterile cloth if it becomes necessary to use the C-arm again. This approach is used in cases in which the physician does not need to interact with the surgical site during fluoro or when snap covers are not available. The third method of maintaining a sterile area uses a shower curtain. Hip pinnings or femoral roddings require frequent manipu- lation of the C-arm between PA and lateral projections to the surgical incision, making these procedures ideal for the shower curtain. A long horizontal metal bar attached to two vertical suspending rods is placed along the lateral longitudinal axis of the affected side (Fig. 15.101). A large, sterile, clear plastic sheet (called a shower curtain) Fig. 15.101 Shower curtain, view from the technologist’s (nonsterile) is suspended from the horizontal bar, which is positioned about 3 perspective. feet above the patient. A special opening in the middle of the plastic is attached with a second adhesive strip to the lateral aspect of the hip–proximal femur and is used for access to the incision. The curtain forms a sterile barrier between the physician and patient as the C-arm is positioned for a standard PA and horizontal beam lateral hip from the nonaffected side of the patient (Fig. 15.102). IMAGE RECEPTORS When an image receptor must be used within the sterile field, it must be placed in a sterile plastic cover. Keep in mind that only the outer surface of the cover is sterile. The inner surface of the cover is nonsterile and comes in contact with the IR. The procedure for placing and removing an IR in a sterile cover is as follows: 1. Sterile surgical personnel hold the plastic cover open, with the top cover folded over to maintain sterility of the outer surface and their gloved hands. Fig. 15.102 Shower curtain, view from the surgeon’s (sterile) 2. The technologist carefully slips the IR into the cover, ensuring perspective. that the IR touches only the inner surface of the plastic cover (Fig. 15.103). 3. Surgical personnel wrap the top of the cover over and secure it. 4. The surgical staff, with verbal directions from the radiologic technologist, places the covered IR in the necessary location and the exposure is taken. 5. Once the exposure has been taken, the surgical staff removes the covered IR and hands it to the radiologic technologist. 6. The technologist removes the IR from the plastic cover by sliding the IR onto a nonsterile table or surface, with care taken not to transfer any possible body fluids from the outer cover of the plastic bag, to dispose of the IR cover in the appropriate recep- tacle, and to remove gloves (Fig. 15.104). 7. The image is processed. NOTE: The technologist must wear nonsterile gloves when handling the Fig. 15.103 Procedure for placing IR into sterile cover. cover because of possible blood or other body fluid exposure. 15 Fig. 15.104 Removing IR from sterile cover.  TRAUMA, MOBILE, AND SURGICAL RADIOGRAPHY C HA PTE R 15 603 Surgical Attire NONSTERILE GLOVES The technologist must change from normal work dress into the When handling contaminated IR cassettes or soiled IR covers, or appropriate surgical attire before entering the OR. Because when cleaning equipment after procedures have been performed, the technologist’s typical uniform may pose a health concern for the technologist must wear nonsterile gloves. Once the gloves are the operative patient, proper surgical attire must be worn in all removed, the hands must be washed. restricted and nonrestricted areas in surgery (Fig. 15.105). Proper surgical attire includes the following. SCRUBS Even if surgical scrubs are normally worn in the general radiology department, the radiologic technologist must change into approved surgical scrubs. Surgical scrubs should be made of a low lint- producing material, which minimizes bacterial shedding. Two-piece scrubs should fit properly, with the top tucked in at the waist. The pant legs of the scrub bottoms must not drag on the floor. In some facilities, scrub jackets are also available. Surgical scrubs must be changed following the procedure and laundered by the hospital. If soiled with blood, perspiration, or food, scrubs must be changed before the wearer reenters the surgical suite. SCRUB COVER Scrub covers are button-up or snapped covers worn by the tech- nologist between procedures. They are designed to prevent soiling or cross-contamination of the scrubs while the technologist is outside the surgical suite. Scrub covers must be removed before the technologist enters the surgical suite. Fig. 15.105 Surgical attire—scrubs, mask, shoe covers, head cover, nonsterile gloves, and protective apron. HEAD COVER A proper-fitting head cover must be worn before entry into a surgical area. The bouffant and hood types of covers are preferred because they cover the head best. All hair must be tucked inside the head covers. The hood type of cover must be worn by the technologist with a beard or other facial hair. Head covers must be discarded immediately after use and changed for each procedure. SHOE COVERS Shoe covers are designed to keep the shoes clean and decrease the quantity of soil and bacteria tracked into the surgical suite. They must be changed if they become soiled or torn. They should be worn even in the presurgical and recovery areas. SHOES Because of the volume of fluid and presence of sharps in the OR, soft cloth shoes should not be worn. A durable shoe with plenty of support and closed hard toe and heel will minimize injuries caused by falling objects, needles, and cassettes. MASKS A surgical mask must be worn to reduce the dispersal of microbial droplets from the technologist during surgery. Masks also will reduce the risk that pathogenic organisms present in the surgical suite may be inhaled by the technologist. A single high-filtration mask is recommended for most procedures. This mask has a pliable nose stripe and two sets of ties to secure it. The nose stripe provides a contoured fit for the wearer and helps prevent fogging for eyeglass wearers. Masks must be changed between proce- dures or when moisture is detected on the outside of the mask. PROTECTIVE EYEWEAR If the technologist is present during a procedure in which blood, body fluids, or tissue debris may strike the eye region, Occupational Safety and Health Administration (OSHA)-approved protective eyewear must be worn. However, this equipment will not be neces- sary for most of the radiographic procedures performed in surgery. 15 In the angiography suite, specialized lead eyewear is sometimes worn to protect the eyes of the wearer from long-term exposure to the x-ray field.