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PORTABLE MOBILE EQUIP

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PORTABLE MOBILE EQUIP – PowerPoint PPT presentation

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Title: PORTABLE MOBILE EQUIP


1
PORTABLE MOBILE EQUIP APPLICATIONS
  • IN SURGERY
  • OR (OPERATING ROOM)
  • RTEC 124
  • Rev SPRING 2009

2
PORTABLE RADIOGRAPHY SURGERYOR (OPERATING
ROOM)CAUTION SOME IMAGES MAY BE
DISTURBINGBUT AS HEALTHCARE PROFESSIONALS THIS
IS WHAT YOU MAY EXPERIENCE Merrills Vol.3
Ch. 30
3
Who are these people?
4
Importance of maintaininga sterile field. Your
role as an RT
5
STERILE IN OR
  • MUST CHANGE CLOTHING
  • WEAR A COVER GOWN WHEN LEAVING
  • MASKS, HAIR COVER, SHOE COVERS
  • CHANGE WHEN YOU LEAVE THE OR ROOM
  • DO NOT TAKE HOSP SCRUBS HOME!!

6
The O.R. Team
7
What to expect
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From your point of viewdo not touch sterile field
10
Surgical Radiography
  • Imaging is commonly used in surgical procedures
    in the operating room (OR).
  • One might think there would be no need to see
    inside the body during surgery, because the
    surgeon is already there.
  • That is not always the case.

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  • MUST COVER EQUIPMENT IN STERILE DRAPES WHEN IT
    MAY COME IN CONTACT WITH PATIENT, INSTRUMENTS OR
    SURGONS HANDS

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Sterile trays
21
  • Radiographer leaning over the sterile field while
    positioning the x-ray tube.
  • WITH CAUTION!
  • The sterile incision site over which the
    radiographer works is properly covered to
    maintain a sterile field.
  • Note the sterile instruments in the foreground
    (arrow).
  • The radiographer should never move radiographic
    equipment over uncovered sterile instruments or
    an uncovered surgical site.

22
Radiographer and CST exchange the IR into the
sterile drape
23
  • Radiographer correctly removes the IR from the
    now contaminated bag
  • to a clean table
  • being careful not to brush contaminants from bag
    onto self or others.

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SURGERY
  • JUST ANOTHER TYPE OF PORTABLE
  • EXCEPT
  • STERILE PROCEDURES MUST BE FOLLOWED - NEVER
    CONTAMINATE THE SURGICAL SITE
  • DONT TOUCH ANYTHING GREEN OR BLUE !!!
  • Be careful not to run into trays, etc

26
IMAGING IN THE OR
  • MOBILE RADIOGRAPHIC
  • MOBILE C-ARM FLUOROSCOPIC
  • DEDICATED RAD ROOM IN OR (CYSTO)

27
BATTERY POWERED vs plug in
aka _________________
  • May have unit for OR use only
  • Or share unit from the dept.
  • Clean equipment before taking into the OR suite

28
  • UNLIKE PORTABLE EXAMS ON THE UNITS
  • EQUIPMENT IN THE OR MUST BE COVERED
  • TO PROTECT THE PATIENT
  • Prevent
  • CONTAMINATION OF STERILE INSTRUMENTS

29
C- ARM Mobile Fluoro
30
  • C-ARM MONITORS IN THE OR
  • FLUORO
  • VIDEO REVIEW
  • STILL SHOT
  • PRINT TO HARD COPY
  • 21 8X10 CASSETTES

31
  • CAN ROTATE C-ARM 360
  • SIDE TO SIDE
  • AND 90
  • TOP TO BOTTOM

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Hand surgery tableshould never allow Dr to use
IR as table
35
  • SOME OR TABLES HAVE A GAP TO PLACE CASSETTE

WITHOUT CONTAMINATION OF STERILE FIELD
36
Slide cassette in at top of tablewith help from
Anesthiologist
37
Set up room in advance if possible
38
Considerations before procedure
  • Find out where Dr wants you to go
  • BE CAREFUL NOT TO RUN INTO
  • STERILE SET UP ? ? ? ? ?
  • Plug in C-arm - test it
  • Guard FOOT Switch ( why?)
  • Marker check on II if possible
  • Park portable equipment in corner out of the way

39
Orientate anatomy to c-arm - fluoro your
MARKER and adust the Position on the screen
(Surgeon does not want to look at the Anatomy
sideways or upside down
40
Considerations
  • If called in while surgery is going on
  • Before entering, park machine outside of room
  • Survey room to get lay-out
  • Rearrange equipment/furniture if necessary -
    remember to put it back when done!
  • Place cassette in a STERILE WRAP

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USING C-ARM vs PORTABLE
  • C-ARM
  • FASTER INSTANT IMAGE
  • MORE RADIATION?
  • --SMALLER FIELD OF VIEW
  • IMAGE /FILM
  • ACCURATE TECHNIQUE
  • PROCESSING NEEDED
  • LONGER TIME
  • LARGER AREA OF VIEW

POST OP IMAGES TAKEN IN RECOVERY ROOM
43
TYPES OF IMAGINGPROCEDURESIN THE OR
  • SEE Merrills Vol 3 pg 264 for list

44
POSITIONING APPLICATIONS
  • Same as other exams
  • Much more challenging
  • Patient is covered in sterile drapes
  • Try to maintain C/R - to IR
  • DONT TOUCH ANYTHING BLUE/GREEN
  • IF YOU DO TELL SOMEONE!!!

45
DEDICATED UNIT- CYSTO RM
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PERCUTANEOUS NEPHROLITHOTOMY
49
POSITIONING APPLICATIONS
  • AP CHEST OR ABD (?FB check?)
  • FLUORO STUDIES PINNINGS
  • CHOLANGIO / ARTERIOGRAM
  • BRONCHOGRAM / CATHETER PLACEMENT
  • PELVIS WITH X TABLE LAT OF HIP
  • EXTREMITIES 2 VIEWS - 90
  • SPINE USUALLY C.SP OR L. SP
  • X-TABLE (LAT)
  • IN OR or POST OP

50
You may want to wait outside the door while the
patient is prepped cauterized.
Why?
51
Note, radiographer positioned the fluoroscopic
image intensifier (arrows) carefully to avoid
hitting laparoscopic instruments protruding from
the patient's abdomen.
  • C-arm in correct position for an abdominal
    cholangiogram.
  • Assistant surgeon checks syringe for air bubbles
    prior to handing to surgeon for injection.

52
Lap chole
53
  • Surgeon standing behind a sterile draped lead
    shield injecting contrast media for an operative
    cholangiogram.

54
Operative cholangiogram
55
Op CHOLEDigital can reverse images
56
OP CHOLANGIO
  • WHICH DUCT IS THE ARROW POINTING TO?
  • WHAT PROBLEM COULD OCCUR FROM THIS?

57
Hickman catheter placement
Introduction of the catheter begins in the upper
thorax and is completed with the catheter in the
heart.
58
Catheter in jugular
59
Upper Ext Arteriogram
60
Using fluoro for tube positioning- beam on ONLY
when Surgeon is looking at the monitor
61
CERVICAL SPINE
  • SOMEONE MAY PULL DOWN ON SHOULDER TO SEE C-7 T-1
  • BOOST MODE
  • MAG MODE
  • HIGHER DOSE

62
  • SCOUT FILM
  • CHECKS PLACMENT
  • SEQUENTIAL FILMING
  • WATCHES PLACEMENT OF SCREWS, PINS
  • FINAL IMAGE FOR
  • DOCUMENTATION
  • PRINT A HARD COPY

63
Lateral projection of the cervical spine with
patient supine. Done to verify the correct
position of instruments before continuing
surgery. Often a spinal needle is placed in the
disc space to show position.
USE OF PORTABLE CROSS TABLE LATERAL C.SPINE
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disectomy
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LAT LUMBAR
DRAPE C-ARM WITH STERILE PLASTIC COVER PROTECTS
PATIENT AND EQUIPMENT
68
PA LUMBAR
  • MAY HAVE TO ROTATE
  • C-ARM 90 FOR PA TO LAT
  • CAUTION NOT TO HIT EQUIPMENT OR PATIENT
  • KEEP STERILE
  • KNOW YOUR LOCKS BEFORE ATTEMPTING THIS IN OR
  • PRACTICE WITH CI, RTS

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X-TABLE LAT L.SP
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Challenges ? Positioning CR ?
73
HIP PINNING
74
PATIENT CONSIDERATIONSDURING SURGERY
  • PT MY NOT ALWAYS BE UNCONSCIOUS
  • TWILIGHT SEDATION
  • SPINALS
  • ALWAYS TREAT WITH RESPECT AND COURTSEY THEY MAY
    BE HEARING EVERYTHING THAT IS BEING SAID!
  • REMEMBER MOVIE THE DOCTOR

75
LATERAL OF HIP
  • MAY HAVE TO ROTATE
  • C-ARM 90 FOR PA TO LAT
  • CAUTION NOT TO HIT EQUIPMENT OR PATIENT
  • KEEP STERILE
  • PRACTICE

76
Orthopedic tools
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NOTE THAT FIELD OF VIEW IS SMALLER WITH C-ARM II
DETERMINES SIZE
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85
ROD PLACEMENTIN FEMUR
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89
C-arm positioned for tibial nailing. Note
radiographer positioned the fluoroscopic image
intensifier to be parallel with the long axis of
the leg.
90
  • Image of tibial nail screw holes in incorrect
    alignment and oblong in shape.

Image of tibial nail screw holes perfectly round,
and magnified to assist proper alignment.
91
  • Image of tibial nail screw holes in incorrect
    alignment and oblong in shape.

Image of tibial nail screw holes perfectly round,
and magnified to assist proper alignment.
92
What exam is this? Look closely at anatomy
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DR may cover area to prevent dirt/dust to enter
surgical site Clear cover or blue sterile
towel..
95
NOTE THE POSITION OF THE II AND TUBE
KEEP II CLOSE TO PATIENT KEEP TUBE AS FAR AWAY
AS POSSIBLE MUST BE AT LEAST ________ INCHES
FROM PT
96
SUBTRACTION TECH
  • REMOVES UNWANTED ANATOMY
  • SEE VESSELLS WITH CONTRAST
  • SPECIAL USE WITH C-ARM
  • MASK - EXPOSURE

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DIGITAL SUBTRACTION
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fluoroscan
101
More Surgical Radiography
102
SURGERY - Common Procedures
  • Ortho (Bone) Work
  • Pinning/ Rod / Screw placement
  • Fracture realignment
  • Organs / Vessels with contrast
  • Arteries / Veins in the extremities
  • Cholangiograms ducts
  • Urography
  • Pacemaker and Line Placements etc

103
SURGICAL RADIOGRAPHY
  • The area being treated may extend beyond the
    incision.
  • For example, a rod made of surgical steel may be
    placed down the center of a leg bone, well past
    the area where the leg is broken.
  • Radiography or fluoroscopy are required to assess
    the placement of the rod.
  • On other occasions a surgical instrument may be
    used to probe beyond what is visible, and imaging
    is required to guide the way.

104
TECHNIQUE CONSIDERATIONS
  • SAME RULES APPLY AS IN RAD ROOM
  • AP CHEST SCREEN OR GRID
  • (REMEMBER 4x LESS FOR SCREENS)
  • BODY PARTS OVER 12 CM GRID
  • SID VERY IMPORTANT TO MEASURE
  • CHEST USUALLY DONE AT 62 72
  • ALL OTHER DONE AT 40 when possible
  • SEE MERRILLS BEGINNING AT PG 212

105
RAD PROTECTION in the O.R.
  • Its your duty to protect the patient, yourself
    and others (healthcare professional)
  • Politely ask whoever can, to move back from the
    area
  • Provide aprons to those who cannot leave
  • Announce your intent to make an exposure and
    give time for others to move back
  • IF personnel are in sterile drape may not be
    able to put on apron

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What the surgeons eyes Light on the
scope For viewing images on the monitor
Keep Beam ON time to A MINIMUM ALARA !
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Bypass Surgery
112
MOBILE FLUOROSCOPY
  • C-ARM UNIT - Carltons pg 547
  • Tube at one end - I.I. at other end
  • TV Monitor control cart separate from unit
  • Uses Digital Fluoroscopy
  • Last Image Hold, Image Enhancement
  • Save for hard copies from disk, Video
  • Photographic Magnification, Subtraction
  • Static (pulsed) and continuous fluoro
  • Maneuverable and Versatile

113
RAD PROTECTION in the OR
  • C-ARM HIGHER DOSE
  • STAND BEHIND C-ARM UNIT WHEN POSSIBLE

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RAD PROTECTIONRULES OF GOOD PRACTICE
  • Never place your hand or other body part in
    primary beam
  • Provide gonadal protection for the patient if
    possible
  • FOR C-ARM IF BEAM FROM BELOW PLACE APRON ON
    TABLE BEFORE PATIENT IS ON TABLE
  • Achieve maximum distance from the patient and
    tube (stand 90 from the patient)
  • Minimum 6 foot exposure cord for radiography
  • Label and handle cassettes carefully

118
RADIATION PROTECTIONRemember the Cardinal
Rules
  • RADIOGRAPHIC
  • 6 exposure cord
  • Minimum source to skin distance 12
  • Preferred SID of 40to 72 (? mag ? detail)
  • ? Distance from tube and patient
  • At least .25mm lead apron
  • FLUOROSCOPIC
  • Minimum source to skin distance 12
  • Preferred SSD OF 18
  • ? Distance from tube and patient
  • 5 min Audible Alarm
  • At least .25mm lead apron to be worn
  • 5 R/min - 10 R/min

119
POST OPTAKEN IN THE RECOVERY ROOM
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Open fracture
communited
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What pathology do you see?

126
What pathology do you see?

127
What pathology do you see? Why?

128
All hardware must be included in the image

129
Pre-op Post-OP
How were these images taken?
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The Recovery Roomuse good radiation protection
practicesPatient? Equipment Positioning?Other
Patients/Staff?
132
Post Bypass Surgery
133
Same imaging principlesCR to part alignmentPt
may or may not be able to cooperate
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O.R. - SURGERY COMPETENCIES
  • FOR PORTABLE WORK
  • YOU MUST ALWAYS HAVE SUPERVISION
  • EVEN AFTER COMPETENCY IS DONE per JRCERT
  • DO NOT PUT YOURSELF IN A SITUATION WHERE
  • YOU DO NOT HAVE APPROIATE SUPERVISION !

137
OR / PORT COMPS
  • STILL NEED DIRECT SUPERVISION EVEN AFTER YOU
    HAVE COMPED AN EXAM
  • CANNOT DO PORTABLE OR O.R. WITHOUT AN RT
    DIRECTLY SUPERVISING OR WITHIN EARSHOT

138
PORTABLE C- ARM COMPETENCIES
  • Must do a Pre-Portable check off first
  • C- Arm check off
  • Must do more than 3 exams of each area portable
    before attempting competency

139
PORTABLE COMPETENCIES
  • COMPETENCIES
  • CHEST 2 PORT CHEST ABDOMEN
    EXTREMITY
  • C-arm -
  • LOG WHAT SPECIFIC EXAM YOU DO
  • PORT CHEST / ABD/ PELVIS /EXTREMITY (which part)
  • OR for what procedure ????

140
SURGERY C-ARM
  • LIST WHAT TYPE OF EXAM MUST DO SEVERAL
    DIFFERENT KINDS TO GET A COMP EX
  • PICC LINE
  • PACEMAKER
  • HIP
  • FEMUR PINNING
  • PAIN MANAGEMENT .etc

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OTHER O.R. COMPS
  • OP CHOLANGIOGRAM
  • RETROGRADE UROGRAPHY

143
Medical errors Foreign BodiesHow to avoid
them
144
Medical errors imaging
  • IT STARTS
  • WITH YOU
  • CORRECT MARKER
  • ON THE CORRECT SIDE OF THE
  • PATIENTS BODY

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There are many Opportunities For mistakes And
safeguards to Prevent medical errors
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SCREW THROUGH PT IN PAIN
The X-ray shows a screw can clearly be seen
protruding from the acetabulum through the thin
wall of her pelvis, into her abdominal cavity.
"It felt like 100 hot pokers going through your
leg and up into your hip," said the patient
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  • About 1,500 people get objects left inside them
    after surgery every year in the United States.
  • In context, the problem is relatively rare given
    that about 28.4 million inpatient operations are
    performed in the United States each year. Yet
    this is no consolation for the people who've had
    it happen to them.

151
  • Surgical sponges like these are the most common
    object left inside patients. During surgery, the
    sponges fill up with blood and can resemble parts
    of the body.

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154
Common medical devices left inside patients
  • Eyebrow Tweezer
  • Tissue expander
  • Retractor
  • Syringe
  • Purple Latex Gloves
  • Sharpie
  • Speculum
  • Mouth gag,
  • Hemostat
  • Chest Spreader

155
  • Self-insertion of foreign bodies into the urethra
    is a phenomenon encountered in both general
    medical and urologic practice. Cases involving
    urethral foreign bodies occur frequently and have
    been reported since the earliest days of the
    medical literature. Diagnosis is based largely on
    the history and physical examination however,
    radiographic or cystoscopic studies may be
    required to confirm the diagnosis and to
    determine appropriate treatment

156
Rasor blade
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159
Fish hook
160
Ball point peninserted 2months ago
161
Nail in femoral artery
162
Sewing needle
163
  • Pt with diabetic neuropathy
  • Unaware of nail in toe

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Chicken bone
166
Did you lose something?
167
A few more examples of OR
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Drove himself to hospital
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179
EEL inserted into rectum OUCH
perforating bowel
180
GSW TO ABD
181
QSWMARKING ENTRANCE /EXIT WOUNDS
182
Airport body scanners
183
backscatter x-ray machines
TONED DOWN FOR MEDIA The Real images are so
highly detailed that they can actually see the
pores on your skin! If that isn't enough, every
image that is taken of everyone who passes
through these x-ray scanners will create a
biometric digital image of your body and map it
just as they do with digital biometric face
scans. Your biometric "digital thumb print" of
your body will then be entered into a federal
database where it will be added to your record
and stored permanently. Do you mind having your
naked body photographed and digitally stored by
the government
184
Female concealed weapon
185
Peds images
  • www.hawaii.edu/medicine/pediatrics

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What technique would you use for this patient?
188
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