Transcript Top 20 Practical Tips for Radiography in the Operating Theatre

Top 20 Practical Tips for
Radiography in the
Operating Theatre
Prepared by
V.G.Wimalasena
Ref. Article by F.J.Mullar
Wikiradiography
Introduction
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The operating theatre (OT) can be a confronting
new environment for student radiographers. The
best strategy for dealing with this problem is to
take every possible opportunity to practise your
operating theatre techniques. To help you along
the way, here are 20 tips that you may find
useful. Not all of these tips will be applicable to
all theatre situations.
Tip 1. Get to Know Your Operating
Theatre Staff
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This is placed at number one for good reason.
You are in their turf and you may have goals that
conflict with theirs. For example, your goal to
produce the best possible images may conflict
with the scrub nurse's goal of keeping a sterile
field intact!
Tip 1. Get to Know Your Operating
Theatre Staff
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Look at this theatre team.....
they look like a team. You
would be confident as a
patient in their hands. This is
how you should view your
role in the operating theatre.
You are joining a team of
skilled people in the interest
of a good surgical outcome
for the patient.
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These people can make your theatre experience
very pleasant or very difficult. Engendering
yourself to them (winning their hearts) can
involve such things as
learning their names
 learning their roles
 learning their rules.
 helping with patient transfer
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Be a good communicator with the theatre staff
Tip 2. Know The Operating Theatre
Rules

There's a good chance that the operating theatre will have several
folders of protocols. These could cover aspects of theatre
procedures such as attire, infection control, Occupational Health
and Safety, patient safety etc. You will probably not be expected
to study these protocols, but the few that affect you will need to
be known.
Apart from the written rules, there are the matters of theatre
culture. These are the rules that are not written down, but the
staff tend to follow them- they are common understandings. It
could cover such matters as how rules are followed, how they are
policed, and how you get around them when required.
Tip 3. Assume Everything and
Everyone is Sterile

Once the surgeon breaks the patient's skin, the patient is at risk
of acquiring infection. One of the goals of the operating theatre
staff is to prevent the patient developing a significant post-op
infection.
You should be seen to be sharing in this goal. This will mean
that you should take care not to touch anything or anyone that is
sterile. This will mean not standing too close to a staff member
who is gowned and gloved. It will also require you to point out
to others in the operating theatre when they are at risk of
breaching a sterile field, or indeed, when they have breached a
sterile field.

Be particularly careful when you push the image
intensifier over a patient- ensure that you do not
touch the sterile handle attached to the
operating light.
Tip 4. Know Your Image Intensifier

I am assuming that the
majority of the imaging
procedures in the
operating theatre utilise
the image intensifier.
This machine's operation
you will need to be
understood very well.
Modern digital image
intensifiers have a
number of pre and postprocessing features.
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It is very embarrassing if you don't know how to perform a task
on the image intensifier. This is particularly so when the surgeon
knows that other radiographers have performed the task.
A surgeon will probably forgive you for not being familiar with a
surgical procedure, but will be less forgiving if you are struggling
to use the image intensifier.
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If you are unfamiliar with a procedure, there can be much to be
said for introducing yourself to the surgeon and advising
him/her that you know how to use the image intensifier, but will
need guidance with the procedure. Questions like...
"which side would you like me to come in from?"
or
"do you want the image intensifier to go under the table or
over the table for the lateral"
Good communication will suggest to the surgeon that you
deserve his/her confidence in your abilities.
Tip 5. Know Your Procedures

There will be a variety of
procedures that you will
be expected to assist with.
The surgeon will look to
you for signs of confident
and competent operation
of the equipment. This
will be very difficult if you
are unfamiliar with a
procedure.

If you are unfamiliar with a procedure, let the
surgeon know. Better to let the surgeon know up
front, than for the surgeon to find out during
the procedure.
Also, if you know you have never seen a
procedure that you have been called to do, ask
another radiographer to come with you to help
explain what is happening.
Tip 6. Cover/Drape Your Image
Intensifier
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It is better to spend 5
minutes at the beginning
of an operation covering
your image intensifier
than to spend 20 minutes
at the end of an operation
cleaning off blood and
betadine
Tip 7. Face the Monitor Cart Panel
Towards Where you are Standing

Set up the monitor cart
so that the control panel
is facing you. If you need
to manipulate the image,
you do not want to be
wasting time walking
around the cart. This will
not apply to all image
intensifiers.
Tip 8. Identify Your Patient
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This might seem self-evident, but can be remarkably difficult in
reality. You can't ask the patient what their name is. The most
common method for identifying then patient is from the name
on the paperwork in the theatre. Bear in mind that sometimes
patient notes are swapped or there may be patient notes in
theatre left from a previous patient.
Check age and sex
Check name on old imaging
Check that there are not two sets of paperwork on different
patients
Beware....
Tip 9. Secure your Plug

Securing the mains cord to
the boom with a self
tightening knot has two
advantages.
Firstly, if someone trips over
the cord, they will not rip the
cord out of its socket (they
may break their neck, but
you’re machine is OK!). If
the plug is pulled out of the
socket, it could cause damage
to your image intensifier, or
you could lose images. Also,
the surgical procedure will be
delayed while you re-boot the
image intensifier.

Secondly, when there are multiple sockets with
multiple plugs, you will recognize your plug
immediately.... it’s the one with the fancy knot (I
have pulled out the patient’s ventilator plug by
mistake). Any knot that tightens as you pull on it
would be suitable.
Many image intensifiers have a built in
uninterruptible power supply (UPS)- if the
power cord is accidentally pulled out of the
socket, replacing it quickly may cause no harm.
10. Go to the Toilet Before you Start

You can never be sure
how long an operation
will take. It is hard to
imagine what would be
more painful- the ever
increasing size of your
bladder, or the pain of
embarrassment when
you ask to stop the
operation while you go
to the toilet.
Tip 11. Check Hard-Drive Space
Before Starting a New Procedure

If you are using an image
intensifier with a hard drive,
check that you have plenty of
hard drive space left before
you start. It can be very
awkward to stop a theatre
case while you free up some
hard drive space on your
image intensifier.
Obviously, if you are using a
non-digital image intensifier,
this will not be an issue.
Tip 12. Check That the Surgeon is
Operating on the Correct Side

It is sound practice to
have a good look at the
patient's old imaging.
You can often pick up
points that will help
during the operation.
The operation may also
make more sense to you
if you understand the
patient's history and the
nature of their injuries
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Importantly, check that the surgeon is operating
on the correct side of the patient. Once the
scrub nurse has prepared one side of the patient
for surgery, the surgeon will tend to assume that
is the affected side.
In short, the surgical team should aim to
perform the correct operation, on the correct
side of the patient, on the correct patient.
Beware, errors are made.
Tip 13. Watch the Surgeon's Eyes
When Screening

This is not a matter of
romance- it's a radiation
protection issue. If it is
normal procedure for the
radiographer to initiate
fluoroscopy, or if the
surgeon has the fluoro'
peddle, this is still good
practice (this is a debatable
point- researchers have
reported conflicting
findings).
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What you are trying to minimise is the time that the
surgeon spends screening when he/she is not looking
at the image. It is not uncommon for the surgeon to
ask you to initiate fluoroscopy but not tell you to stop.
They are simply concentrating on what they are doing
and forget that they have initiated fluoroscopy.
It helps if you understand what they are doing at every
stage of the operation. This will help you to decide
whether the surgeon has averted their eyes momentarily
from the image (and wants you to keep screening) or
whether they have simply forgotten to tell you to stop
screening.
Tip 14. Use a Sequence Acquisition
When Appropriate

Modern mobile digital Image
Intensifiers are able to store
images in a run or sequence.
You set the relevant
parameters such as capture
rate, and the images will be
stored in a sequence (it's a bit
like an animated GIF).
I see this as having several
advantages.
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Firstly, my understanding is that the Image Intensifier is
performing screen capture and there is no cost in terms
of increased radiation dose to the patient.
Secondly, you are able to record dynamic information.
This can be particularly useful in cases such as ERCP or
Laparoscopic Cholangiogram. If there appears to be a
stone in the CBD you can play the sequence back to the
surgeon and see if the stone acts more like an air
bubble or a stone.
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does it deform in shape
does it divide in two when it reaches the hepatic ducts
does it float up hill or down hill
Another less obvious use is when the surgeon wants to
assess the stability of a joint following ORIF.
Tip 15. Be Careful When Moving the
C-arm
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It is possible to do harm when you are moving the C-arm.
When you are assisting with a hip operation, the surgeon will
usually want to see that anatomy in the lateral projection. The
image intensifier is usually set up to roll under the operating table
for the lateral projection. The first time you roll the C-arm into
the lateral projection be very careful. Go slowly and ask the
surgeon if everything is " Ok over there".
Similarly, you can fracture a patient's pelvis when lowering the Carm. Also watch the anaesthetist who is raising or lowering the
operating table when the C-arm is in place.
Tip 16. You are Responsible for your
Students

Qualified radiographers
will generally be held
accountable for the
students under their
instruction. I have seen a
scrub nurse drop a pair
of forceps- the
radiography student
picked them up and put
them back on the sterile
tray for her.
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It is worth emphasizing to a student radiographer who
is entering the operating theatre for the first time the
following three points.
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Assume everything and everyone is sterile- touch nothing and
you can't go wrong
If you feel unwell, leave the theatre immediately
If you feel faint, back up to a wall and slide down it until you
are sitting on the floor
I was once told that the true measure of a surgeon's
ability to train a student lies in their preparedness to let
that student operate on them. We should think of
student radiographers in the same way- we train them
to a level that we would be confident to be their patient.
Tip 17. Use Equipotential Earthing
for Cardiac Cases

You may have wondered why your
image intensifier has a separate earth
lead when it is earthed through the
plug. This extra earthing wire can be
used during cardiac cases (pacing
wires, defibrillator insertion, ablation
etc) when equipotential earthing is
required. If all of the equipment in
the operating theatre is earthed to
the same earth point, the grounding
of the equipment will be identical.
This can assist with electrical safety
and avoid static discharge during
surgery.
Tip 18. Don't Clean the Image
Intensifier During Open Surgery

It can be tempting to do a little bit of
cleaning of the image intensifier during the
operation. This is inadvisable. If you are
using a spray bottle, the aerosol will
potentially enter an open wound and cause
infection.
This is not to suggest that the image
intensifier does not need cleaning between
cases. If you want to see what the theatre
staff look like when they are upset, try
wheeling a blood covered image intensifier
into an operation.
Cleaning the image intensifier can be more
difficult and time consuming than it looks.
There can be devices that are hard to
access. Also, you will need to turn the c-arm
upside down to be sure that the image
intensifier is completely clean.
Tip 19. Distance, Shielding, Time
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The three basic
principles of radiation
protection are
distance,
 shielding
 time.
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Distance is often overlooked as a radiation protection
technique. This is possibly related to a notion that if
you are wearing a lead gown, you are receiving no
ionising radiation. Of course, the lead gown is not
covering your entire body. In keeping with the ALARA
principle, it is good practice, where appropriate, to
move away from the image intensifier as far as possible.
It is also worthwhile considering other radiation
protection issues. eg.
When should you use overcouch techniques and when
should you use undercouch techniques?
What is the shape of the radiation scatter cloud from
an image intensifier- where is it safest to stand?
Tip 20. What if I feel like I am About
to Faint?
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Fainting doesn't have to be a drama!
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If you feel like you are going to faint, back up to a wall
and slide down it. You are not the first person to faint
in an operating theatre and you will not be the last.
Even a hardened radiographer can feel faint in certain
circumstances- e.g.
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if
if
if
if
you are dehydrated
the operative theatre is very hot
the operation is very long
you are standing for a long period wearing a lead gown
I find it useful during long theatre cases to find a seat
and take the weight off my feet. Check with your
departmental and theatre rules on this one.
Fainting doesn't have to be a drama!