yearly radiation dose

[TIVAndy]

ASC xray tech came to me and said my radiation level is through the roof (whatver that means. i have to check the mrem on the dosimeter)
and this is only at ASC - excluding in office dosimetry.

are you guys concerned about yearly dosimeter readings and what are you guys doing to lower the dose?
i've been more concerned about lateral views especially - cervical RFAs i work right next to it

i'm trying to think of ways to lower the overall dose. minimize live, use pulse/ low dose, minimize lateral. etc.

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[RoloTomassi]

Depends how many and what type of ASC procedures a month. Anyone else wearing your lead or hanging in room?

I take one step back between shots especially laterals, stand with the tube in front of me on laterals, only go live on kypho and even then for spurts, collimate, ii close to pt

 

[Doctodd]

not concerned at all....but i dont do 30 procedures a day anymore. Reminder.... dont use lead gloves because it only forces the c-arm to increase the radiation.

 

[SSdoc33]

dont get laterals on TFESIs.

place multiple needles at once and do multiple adjustments prior to taking another shot.

dont futz around for the absolute perfect picture or arthrogram, if you are reasonably sure where you need to go, inject and move on

i cannot tell you how many times i have seen a fellow take a flouro pic, think about when he/she sees, then take another flouro pic without actually doing anything or placing any needle.

most of this is common sense. i do 2x the flouro injections compared to my colleagues, yet half half the radiation. just dont have as heavy of a foot

 

[willabeast]

Depends if this is a one time reading that is high or if it happens every year. One time figure your badge got left near a CT scanner or something. Every year then make sure your shielding is intact and the flouro unit is putting out what it is supposed to put out. Technique?

 

[PinchandBurn]

dont get laterals on TFESIs.

place multiple needles at once and do multiple adjustments prior to taking another shot.

dont futz around for the absolute perfect picture or arthrogram, if you are reasonably sure where you need to go, inject and move on

i cannot tell you how many times i have seen a fellow take a flouro pic, think about when he/she sees, then take another flouro pic without actually doing anything or placing any needle.

most of this is common sense. i do 2x the flouro injections compared to my colleagues, yet half half the radiation. just dont have as heavy of a foot

How are you getting away with no laterals?
For medicare you need 2 views saved

 

[SSdoc33]

How are you getting away with no laterals?
For medicare you need 2 views saved

ap and oblique.

no medicare agents been around in the last 15 years. unless they were covert spies disguising themselves as an LOL in NAD

 

[lobelsteve]

I will have a vignette to share with you all shortly. It involves lack of saved images and bad outcomes.

Please, please, please save your contrast injected AP/CLO or laterals.

 

[pastafan]

Use a rolling screen to step behind on laterals.

 

[PinchandBurn]

I will have a vignette to share with you all shortly. It involves lack of saved images and bad outcomes.

Please, please, please save your contrast injected AP/CLO or laterals.

Please share

 

[Painologist]

I think about this often as well. I do laterals for all epidurals still. Try to minimize shots otherwise. Anyone have a mobile x-ray shield they recommend?

 

[lobelsteve]

Please share

Can't do that yet. Private forum soon.

 

[Ducttape]

low dose
pulsed
collimate
dont "go live" for more than a couple of seconds.

have the rad tech run the c-arm. i know, this is controversial, but we tend to focus just on the procedure and we dont take our foot off the pedal quickly enough.

 

[Baron Samedi]

Great tips so far, a few more:

- Avoid instrumentation in the field
- Make sure target structure is centered in the field
- Don't drape the patient in lead
- In lateral views, stand directly behind the X-Ray source
- Optimally position the patient before taking any pictures
- Use extension tubing
- Use static images instead of live fluoro if you can. Perfect example is joint injections where you are not worried about vascular uptake
- Avoid using fluoro at all if you don't have to. Learning some ultrasound skills can really cut down on exposure

 

[lobelsteve]

low dose
pulsed
collimate
dont "go live" for more than a couple of seconds.

have the rad tech run the c-arm. i know, this is controversial, but we tend to focus just on the procedure and we dont take our foot off the pedal quickly enough.

Agree with all of this except the tech running the machine. Use the pedal. You are always ready for the shot when you take it. You will use less Xray than the tech.

 

[Baron Samedi]

A lot of techs try to guess when you want new images (such as every time you take your hands off the needle or look at the screen) and end up taking a lot of extra shots.

 

[SSdoc33]

have the rad tech run the c-arm. i know, this is controversial, but we tend to focus just on the procedure and we dont take our foot off the pedal quickly enough.

GOD NO!!!

that is like letting your wife drive the car on a family vacation

 

[hyperalgesia]

I use a pedal except for lateral images. The pedal is a few feet back so I have to back up to shoot. For laterals, I stand at the foot of the table and get the tech to shoot.

 

[Ducttape]

Agree with all of this except the tech running the machine. Use the pedal. You are always ready for the shot when you take it. You will use less Xray than the tech.

thats debatable

we tend to press on the pedal for much longer than necessary. and can accidentally press twice. and can accidentally press continuous rather than intermittent.....

https://www.painphysicianjournal.com/current/pdf?article=MjAxMQ==&journal=78

issues with study - observational and not a true comparative study.
they made multiple changes that reduced radiation exposure. in particular, no continuous fluoro and using intermittent pulsed, and rad tech pressing instead of physician foot petal.

maybe the entire effect was due to other factors. but...

100 times decrease in mrem numbers...

 

[lobelsteve]

thats debatable

we tend to press on the pedal for much longer than necessary. and can accidentally press twice. and can accidentally press continuous rather than intermittent.....

https://www.painphysicianjournal.com/current/pdf?article=MjAxMQ==&journal=78

issues with study - observational and not a true comparative study.
they made multiple changes that reduced radiation exposure. in particular, no continuous fluoro and using intermittent pulsed, and rad tech pressing instead of physician foot petal.

maybe the entire effect was due to other factors. but...

100 times decrease in mrem numbers...

I guess I meant I’m much better at limiting the fluoro.

 

[pastafan]

I think about this often as well. I do laterals for all epidurals still. Try to minimize shots otherwise. Anyone have a mobile x-ray shield they recommend?

I bought one like this used on Ebay: Half Acrylic Mobile Barrier

This looks ideal. I remember seeing a version that attached to the table side rails: My Shield

 

[cowboydoc]

GOD NO!!!

that is like letting your wife drive the car on a family vacation

3 disagreements with duct in as many weeks. The apocalypse must be near!


The only other idea to reduce rads dose I can think of comes from Dr. Milton Landers (RIP). He was teaching a SIS course, and his slide showed him sitting at the head of the table with the c-arm wrapped around him and a student asked him about his radiation dose. He quickly quipped "Damn near zero...of course I leave the badge sitting on my desk in the office next door.

 

[pastafan]

3 disagreements with duct in as many weeks. The apocalypse must be near!


The only other idea to reduce rads dose I can think of comes from Dr. Milton Landers (RIP). He was teaching a SIS course, and his slide showed him sitting at the head of the table with the c-arm wrapped around him and a student asked him about his radiation dose. He quickly quipped "Damn near zero...of course I leave the badge sitting on my desk in the office next door.

I fondly remember Milton's response to an SIS cadaver lab question regarding radiation exposure. He replied "if you're worried about radiation exposure you should have gone into pediatrics!"

 

[SSdoc33]

I fondly remember Milton's response to an SIS cadaver lab question regarding radiation exposure. He replied "if you're worried about radiation exposure you should have gone into pediatrics!"

Didn’t he die of pancreatic cancer? Not exactly a ringing endorsement

 

[TIVAndy]

i do what i can to minimize but still ways to go.
hi volume interventions weekly.

1. i don't do lateral on tfesi
2. i use pulse/low dose when i do live (scs/drg/kypho)

I do have a tendency to try to get perfect pictures. slight blurring or off few degrees on AP image annoys me so sometimes i correct that quite often.

i'm thinking of doing all images on low dose as default. one of my in office machine is an older one and doesn't have low dose mode

 

[Ducttape]

GOD NO!!!

that is like letting your wife drive the car on a family vacation

it does reduce the number of comments such as "arent you following too closely".

 

[Sig123]

I’ve used a lead table skirt for many years and it cut my radiation numbers in half.

 

[Ducttape]

i'm thinking of doing all images on low dose as default. one of my in office machine is an older one and doesn't have low dose mode

all your images should be low dose with pulse on and collimated.....

time to get rid of the old machine.

 

[PinchandBurn]

Can't do that yet. Private forum soon.

Where is it?

 

[oreosandsake]

Do everything that’s reasonable and safe with US
All peripheral joints.

SIJ
Yes, SIJ. Same efficacy

If we could bill them you can do C and L spine mbb and facets IA with US in most BMI 30’and under.

But fluoro pays more

 

[Baron Samedi]

Do everything that’s reasonable and safe with US
All peripheral joints.

SIJ
Yes, SIJ. Same efficacy

If we could bill them you can do C and L spine mbb and facets IA with US in most BMI 30’and under.

But fluoro pays more

My understanding is that US SIJ is billed as a trigger point injection?

Really a shame since I far prefer an US approach.

 

[MitchLevi]

Post the vignette here...No reason for private.

I won't do lateral on TFESI. Not happening bc there's no reason.

 

[RoloTomassi]

Post the vignette here...No reason for private.

I won't do lateral on TFESI. Not happening bc there's no reason.

This is why I do laterals. Like to know I'm in the anterior half for better ventral spread.

Epidural Contrast Flow Patterns of Transforaminal Epidural Steroid Injections Stratified by Commonly Used Final Needle-Tip Position

Abstract. Objective. To evaluate the relationship between commonly used final needle-tip positions and subsequent contrast flow and patient-reported pain r

academic.oup.com

 

[CleanUp]

Ultrasound SIJs don’t count for someone wanting a RFA