Where do I get Lead Glasses??

[KluverBucy]

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I'm not lookin for prescription lenses or those nerdy lookin lead-coated glasses for the OR. It's all about style...where do i pick up a pair of those lead-coated shades that have a mirror look and they look like a pair of Oakleys? thanks...

 

[ThinkFast007]

dumb q here,but are you looking for lead glasses in order to protect your eyes from Xrays during surgeries?

I've never heard of anyone, nor have I seen anyone doing this. Going to mk me think twice now, whenever i walk into a room that's going to have a patient in need of xrays,etc. 😱

 

[KluverBucy]

dumb q here,but are you looking for lead glasses in order to protect your eyes from Xrays during surgeries?

I've never heard of anyone, nor have I seen anyone doing this. Going to mk me think twice now, whenever i walk into a room that's going to have a patient in need of xrays,etc. 😱

let me educate you... the top 3 tissues that are most sensitive to radiation are the gonads, thyroid, and yes, the EYES (cataracts)....hence the original question. and i've seen this on several occasions, although not really common practice. but then again, some docs don't even wear lead aprons. now anyone know of a good website??

 

[ThinkFast007]

nice

never knew that.

 

[Epidural]

I'm not lookin for prescription lenses or those nerdy lookin lead-coated glasses for the OR. It's all about style...where do i pick up a pair of those lead-coated shades that have a mirror look and they look like a pair of Oakleys? thanks...

Try a pair of the MicroLite lead glasses with XL Croakies. Mention discount code MP7 for $100 off.

 

[undecided05]

too lazy to dig out the radiology study, but after puberty, the thyroid ain't affected. no need to wear the necklace.

 

[VolatileAgent]

too lazy to dig out the radiology study, but after puberty, the thyroid ain't affected. no need to wear the necklace.

ummm... you're confusing the thyroid with the thymus, dude. wear the necklace.

 

[stephend7799]

too lazy to dig out the radiology study, but after puberty, the thyroid ain't affected. no need to wear the necklace.

is that true?

 

[ThinkFast007]

is that true?

just did a pubmed search...couldnt pull anything up.............

 

[btmed772]

is that true?

nope

 

[GasEmDee]

I'm not lookin for prescription lenses or those nerdy lookin lead-coated glasses for the OR. It's all about style...where do i pick up a pair of those lead-coated shades that have a mirror look and they look like a pair of Oakleys? thanks...

This has a large selection:

http://www.medicalsafetyglasses.com/

 

[KluverBucy]

This has a large selection:

http://www.medicalsafetyglasses.com/

trust me, you should wear the collar and if you're gonna be doin ortho or pain, you should get eyewear too ( http://www.hps.org/publicinformation/ate/q5316.html ).
thanks for all those posting websites...keep 'em comin if you know of any more (lead-filled though). lookin for some pimp a$$ shades, but trying to compare all the prices cuz i'm not loaded............yet 😉

 

[Idiopathic]

too lazy to dig out the radiology study, but after puberty, the thyroid ain't affected. no need to wear the necklace.

Oh goodness. Maybe you should go ahead and dig out that study anyway.

 

[Idiopathic]

trust me, you should wear the collar and if you're gonna be doin ortho or pain, you should get eyewear too ( http://www.hps.org/publicinformation/ate/q5316.html ).
thanks for all those posting websites...keep 'em comin if you know of any more (lead-filled though). lookin for some pimp a$$ shades, but trying to compare all the prices cuz i'm not loaded............yet 😉

I think I may buy used books and buy some lead glasses also with my book fund.

 

[lobelsteve]

I wear the barrieronline microlites without Rx lenses. They are nice.
Lots of data to protect yourself.
As an aside- don't wear leaded gloves with an auto power machine. THe machine will just crank up the radiation to get better penetration increasing the scatter. Don't listen and risk losing your fingernails in 20 years.

 

[Doctodd]

I wear the barrieronline microlites without Rx lenses. They are nice.
Lots of data to protect yourself.
As an aside- don't wear leaded gloves with an auto power machine. THe machine will just crank up the radiation to get better penetration increasing the scatter. Don't listen and risk losing your fingernails in 20 years.

Absolutley.....but wear the lead gloves if your hand is just out of the screen or just on the edge of the screen. If you notice the machine will crank it up to penetrate the gloves. I saw Bogduk wearing long lead gloves up to his elbow.....nails and arm hair were already looking bad though.

T

 

[lobelsteve]

Absolutley.....but wear the lead gloves if your hand is just out of the screen or just on the edge of the screen. If you notice the machine will crank it up to penetrate the gloves. I saw Bogduk wearing long lead gloves up to his elbow.....nails and arm hair were already looking bad though.

T

Niks arms are more likely a product of the smoking than the radiation.

 

[stonemountain]

Looking good is one factor. However, being able to see with them should be the biggest factor.
I just got some Microlite's about 3 months ago (Barrier Technologies) that was listed earlier. They look very snazzy, like Oakleys.

However, they are very heavy (not too bad if I rest the glasses on the face mask), but hurts when on bare skin. Also, the oblique angle of the lenses make them look a little different than my normal glasses. I gave them the exact same prescription as my normal glasses. The view is super sharp. However, the sides look a little different than my normal glasses. Unfortunately the effect is similar to when you get new glasses that are a little different prescription than your old glasses (slight dizziness and headache for about an hour while the eyes adjust). This is OK since my eyes adjust after an hour. However, I have to go through the same problem each time I initially put on the leaded glasses. Unfortunately they are too heavy for me to wear all the time. 🙁

Next time, when I need new glasses, I am going to buy an extra frame and find someone who can put leaded lenses in them. I hope this method will work better. 🙄

 

[Doctodd]

Well that's a fine example...lol.

T

 

[KluverBucy]

wow, didn't know that the machine cranks up the juice if you have leaded gloves in the field of xray. makes sense though. just trying to live the dream without paying the price by comin down with some CA down the road.

thanks by the way guys for your help on the leaded glasses...will def look into barrier technologies. looks as if i'll be droppin' 2 to 3 bills on a pair. i might have to use Idiopathic's idea of using some of the book fund towards some equipment. strong work.

 

[TofuBalls]

too lazy to dig out the radiology study, but after puberty, the thyroid ain't affected. no need to wear the necklace.

This is... BS

 

[KluverBucy]

too lazy to dig out the radiology study, but after puberty, the thyroid ain't affected. no need to wear the necklace.

This is... BS

BS? are u kidding me? yea well i'm too lazy to dig out another radiology study that i found..i think it says it's impossible to get CA from x-rays, and that there's no need to wear any lead at all. can anyone confirm this? 🙄

 

[lobelsteve]

The only reason everybody in the readiology department and in any office that takes Xray or uses fluoro is required to wear a detector badge is becasue of a large government conspiracy. THe "rad badge" profit scheme generates the finances to: 1. Build a wall between the US and Mexico, 2. Nuke Iran, 3. Pay for all Senate ethics legal bills.

Or I could be mistaken and since Marie Curie and folks realized there were potential dangers from this new energy source/waveform there have been thousands of papers published on radiation safety. Anybody ever look into the small text by Lennard? A whole chapter on radiation.

 

[thepainguy]

Check out protecheyewear.com thay have some cool ones that look like oakleys.

 

[lmb13903]

Try burlington medical or TZ medical. Both have very nice products- light weight, styish but they do protect you. Most of the new styles are 50-80 grams. Not too bad. They come with a strap that keeps them secure and takes the weight off your face. Nothing like the weight of the old styles. I work in a cath lab and always wear my lead, thyroid collar and glasses. Only you can keep yourself safe. Personally I do not want to deal with cancer or cataracts. Most hospitals have contract and can get you a better price. Go by and meet the cath lab director and team. They should be able to help you.

 

[wonthurtabit1]

Read this article from RSNA

http://www.shieldingintl.com/eyeweararticle.htm

Excerpts:
investigators screened 59 practicing interventional radiologists during a medical conference in New York City in November 2003 to evaluate PSC cataract formation caused by ionizing radiation. The physicians were between the ages of 29 and 62. They were questioned as to years in active practice, work circumstances and potential cataractogenic confounders. A special imaging system, the Nidek EAS1000 Scheimpflug and retroillumination camera, was used to document the subject's eyes and cataract status.

The researchers found that nearly half of the interventional radiologists screened had signs of radiation-related lens changes. PSC cataracts were found in five (8 percent) of the 59 radiologists screened, and an additional 22 subjects (37 percent) showed small paracentral dot-like opacities in the PSC region of the lens, which is consistent with early signs of radiation damage. One interventional radiologist had undergone cataract surgery in one eye before being screened in the study.

"This study combined with other research shows that people are developing cataracts at much lower radiation doses than permissible limits allow," says Basil V. Worgul, Ph.D., a professor of radiation biology in ophthalmology and radiology at Columbia University College of Physicians and Surgeons in New York City. Some of that other research includes workers who cleaned up after the Chernobyl nuclear power plant disaster in 1986.

"Currently, radiologists are told they have no risk of cataracts if they stay under 2,000 milligray," says Dr. Worgul. "That reasoning, upon which such a threshold is based, is not biologically sound. We know from animal studies that no radiation dose is completely safe. All of our current limits are based on threshold. The feeling that we are protected if we do not exceed that level is incorrect."

More than a decade ago, Dr. Worgul predicted that astronauts would develop cataracts from their forays into space. Recently, a paper was published reporting that flight path inclination can be correlated to cataract formation in astronauts.

Dr. Worgul says he believes the threshold dose should be reduced to as little as 10 percent of today's current recommendation and that eventually a risk per unit dose will be developed without consideration of a threshold.

The eye lens, along with bone marrow, is highly sensitive to radiation. Because PSC cataracts form in the back of the lens, they decrease contrast sensitivity before they affect visual acuity. This differs from most forms of age-related cataracts, which interfere with visual acuity first.

"One of the most important findings was that the changes observed were found in interventional radiologists in their mid-40s," says Anna Junk, M.D., lead author and ophthalmologist at Albert Einstein College of Medicine. "Even though these small opacities will not yet interfere with the ability to work, they have to be taken seriously because they reflect radiation exposures dating back 10 or more years."

Has anyone gone to the optometrist to check for these early signs of radiation induced damage?

 

[Aether2000]

Interventional radiologists are probably exposed to many times the xray exposure of the typical pain management interventionalist because of the use of cine fluoroscopy and frequently having their eyes close to the primary beam. Also, many of their procedures such as vertebroplasty or vasculoplasty have an extremely high fluoroscopy usage measured in tens of minutes or hours that is in contrast to the seconds of exposure most conservative pain interventionalists receive. It is not a matter of poor technique, but rather an occupational hazard of certain procedures.

 

[tailiglasses]

 

[Substanz P]

Barrier Tech has a nice plair of lead glasses and they allow to try it out for a couple of weeks before you decide to buy it.

About the lead gloves: Does the KVP go up, if you collimate down to keep your hands just off the screen?

 

[Mister Mxyzptlk]

My philosophy about xrays and cataracts is the same as for masturbation. Just do it until you need glasses.

 

[guetzow]

..............

 

[Aether2000]

Regarding lead gloves: depends on the manufacturer of the fluoroscope. Not all fluoroscopes will compensate by increasing the milliamperage when leaded gloves are placed in the field. Some will use contrast/brightness control adjustments instead.

 

[Lizard1]

Try a pair of the MicroLite lead glasses with XL Croakies. Mention discount code MP7 for $100 off.

it says that discount does not exist???

 

[f_w]

Pretty lightweight. About $200. Protection to the sides probably not as good as the models with dedicated side-shields.

http://www.rfdesigninc.com/gallerymore.asp?id=51108&page=4&galleryid=33889

 

[f_w]

Interventional radiologists are probably exposed to many times the xray exposure of the typical pain management interventionalist because of the use of cine fluoroscopy and frequently having their eyes close to the primary beam.

Given the level of ignorance towards radiation protection I had the chance to observe in some of my colleagues in pain management, I am not sure whether this holds true. I wonder whether anyone in the stacks of radiation protection literature ever looked at the exposure of high-volume pain interventionists.

(Btw. If you remain in the room during angio-runs, you didn't listen up during your physics course.)

 

[Aether2000]

There are several published studies using dosimeter readings. The most recent was published in Pain Physician comparing the results of 3 different physicians. Inexplicably, one physician that used the least time for procedures was exposed to the most scatter under the table. This calls into question the methodology used during the study. There are no published real time dose studies. But interventional radiologists have published angio radiation studies that have brought changes in their techniques due to high radiation exposure. The LAO projection gave very high radiation scatter doses, and once reduced exposure in the projection was undertaken, scatter was greatly reduced.

 

[f_w]

one physician that used the least time for procedures was exposed to the most scatter under the table.

-Time
-Distance
-Shielding

If that person kept is body on average only 6in closer to the beam than the other two, he could still incur a larger dose.

Also, as you noted obliquity increases scatter. The volume radiated is another factor (The beam going through air-filled lung in the thorax or a neck will lead to far less scatter than anything penetrating abdomen and L-spine). Work-position in relation to the 'heel' of the anode will also affect your dose. So unless the 3 had exactly the same case-mix there has to be nothing wrong with the methodology.

 

[Aether2000]

The case mixes were similar. One cannot conclude there is nothing wrong with the methodology since the upper body radiation for the physician using the least time was less than other physicians. It is unlikely a person practicing interventional pain has much to do with using fluoroscopy of the lungs so that is a non-issue. What we need are real time data, not the non-sensical averaging one obtains through dosimetry. The exposure to high levels of scatter radiation should be avoided through appropriate shielding, but we really do not know where to shield. Obliquity is important in the lumbar spine or using phantoms, but what about the cervical spine? Different ballgame, different scatter pattern.
Finally technique, esp collimation, will ultimately be the best method to avoid both direct patient radiation and scatter radiation. Using pulsed fluoroscopy while having the hands in the beam is hazardous and foolish since the primary beam is up to 1000-3000mrem/min exposure. Using a hemostat to move ones hands out of the pulsed field still results in significant radiation to the hands. The least radiation is by moving the hands away from the table and using intermittent fluoro exposures.
Low dose is way way underutilized and some fluoro techs do not know it exists on their fluoro machines they have operated for years.

 

[f_w]

> It is unlikely a person practicing interventional pain has
> much to do with using fluoroscopy of the lungs so that is a non-issue.

What do you think you are going through if you get an oblique in the T-spine ? (going through the lungs reduces your dose compared with lets say lumbar, its a good thing).

> What we need are real time data, not the non-sensical averaging
> one obtains through dosimetry.

If you mean the q-month recordings obtained with the regular badges, yes, they are only for surveillance and not a good methodology to evaluate particular techniques. But rather than real-time, you are more likely to get useful results through the use of multiple TLDs on the bodyparts you are interested in and reading them out right after the case. Also, there are excellent simulation software packages out there. (The human body is pretty simple from a scatter standpoint. It contains air, calcium and water in pretty well defined locations and the nice thing about physics is that things follow actual laws).

> The exposure to high levels of scatter radiation should be
> avoided through appropriate shielding, but we really do not know
> where to shield.

You might not know it, the manufacturers of angio rooms do know it. Hence the curtain and the articulated lead-glass shield.

> Finally technique, esp collimation, will ultimately be the best method
> to avoid both direct patient radiation and scatter radiation.

Everything done in combination will avoid undue radiation exposure
- limiting procedures to the patients that need them
- using state of the art equipment
- proper filtration
- collimation
- good technique
- use of lead-glass shields
- personal protective gear suitable for the situation

> Using pulsed fluoroscopy while having the hands in the
> beam is hazardous and foolish since the primary beam is
> up to 1000-3000mrem/min exposure.

I have a couple of people here you should talk to.

> Using a hemostat to move ones hands out of the
> pulsed field still results in significant radiation to the hands.

Some things just have to be done in realtime, for everything else there is the 'tap and move' technique (intermittent fluoro).

> Low dose is way way underutilized and some
> fluoro techs do not know it exists on their fluoro
> machines they have operated for years.

The other day I got a fluoro sheet where one of our orthopods did an entire knee-case on HLF in maximal magnification. When I asked the tech why she didn't tell him that he is giving himself 10x the regular dose I was told that 'this battle has been fought and lost 5 years ago'.

 

[Aether2000]

Thoracic spine work should be rare since the thoracic spine is a rare cause of pain. That is unless you believe the nonsensical study demonstrating a year's response from thoracic medial branch blocks. Of course there is SCS...
It is true body part readings from instant radiation monitors would be useful for each procedure, but the issues are the scatter from the human body is not simple and is not accurately determined via mathematical models. I recently measured scatter in real time and was stunned to find out the published scattergrams by manufacturers are dead wrong.
The vast majority of pain procedures in the US are performed without adequate shielding to the feet, to the head, and to staff that are placed at the head of the table during cervical procedures. Angio suites may be equipped but I have noted numerous interventional radiologists that disregard the leaded glass shields.

Everything done in combination will avoid undue radiation exposure
- limiting procedures to the patients that need them....AGREE
- using state of the art equipment...NOT PROVEN and some modern equipment from one manufacturer may give vastly more radiation scatter than the next manufacturer. Acquisition time is however much more rapid on some of the newer c-arms thereby lowering dose.
- proper filtration...Low end beam filtration is preset using aluminum or copper filters on most fluoroscopes...this is not a variable available on most C-arm fluoroscopy...however there are software filters that can be set
- collimation...Correct....reduction to 1/10 the screen size will reduce radiation scatter by 90%
- good technique...Agree
- use of lead-glass shields...Agree, but these are often cumbersome
- personal protective gear suitable for the situation ....Unless you know the scatter pattern, you do not know the proper gear nor where to wear it. Also, the frequent use of ultralight radiation gowns results in penetration of a significantly increased degree of scatter radiation.
I will add a few more: low dose fluoro use; use of manual mode sub-low dose in which the contrast, mA, kV, and brightness are independently adjustable; use of ultra-low dose with increased signal averaging; avoiding hiring stupid techs that irradiate you when you have your back turned or when you have your hands in the field; attendings stepping in and taking over when the fellow or resident can't keep their hands out of the beam; time limitations for exposure for each patient (if it can't be done in a given timeframe, then either someone else with more grey hair should try, or come back again another day); use of carbon tables where possible for radiolucency; avoid placing heavy metal objects in the field to be used as pointers (such as large hemostats since in older machines this increases mA while in newer machines it causes image washout unless you have the latest greatest machines that compensate for this); movement capabilities of C-arm, X-ray source, image intensifier (easy movement may reduce multiple exposures), using an isocentric position of the patient relative to the fluoroscope reduces overall radiation and scatter, using a smaller I/I size (field of view) reduces lateral scatter, using a low fluoroscopy pulse rate, X-ray photon energy spectra (this is a very wide range on fluoroscopes- perhaps in the future we will have single frequency outputs as does some mammography equipment), software image filters, preventative maintenance and calibration (calibration is checked each year and the beam focus is the most important factor...real time radiation measurement would help to determine any excess leakage due to the beam being knocked out of alignment), patient fatness....fat patients produce far more scatter due to the necessary greater penetration mA and keV, acquisition time (newer fluoroscopes have more rapid image acquisition while older fluoroscopes may require 4-5 sec of fluoroscopy before the first image is visualized and stabilizes), laser pointer??? is useful only if the tech knows what they are aiming for and can see the pointer, having a tech that is aware of the movements of most c-arms to bring into an isocentric position (eg. rotation right oblique usually requires translation right to maintain the field in the center of the screen), keeping the target in the center of the visual field reduces parallex error and therefore increases accuracy of needle placement requiring less fluoro time, etc etc....

I know of no interventional injection or neurodestructive pain procedure that requires real time advancement of a needle with the hand in or near the field. SCS lead advancement is the only time I advance in real time, and only then with collimation and offset of the beam to the thoracic spine.

Your last statement hit the nail on the head....there are no standards for use of fluoroscopy and no repercussions to physicians that insist on using shoddy techniques even though they are increasing radiation risk to everyone in the room.

 

[f_w]

> avoiding hiring stupid techs that irradiate you when you
> have your back turned or when you have your hands in
> the field;

Why would you allow the tech to fluoro for you ? That is what the foot pedal is for.

> time limitations for exposure for each patient (if it can't be
> done in a given timeframe,

Time has only a loose relationship with dose. Cumulative skin entrance dose is a better metric.

> use of carbon tables where possible for radiolucency;

Are there any other tables ?

> movement capabilities of C-arm, X-ray source, image intensifier

Motorized with tableside controls.

> using an isocentric position of the patient relative to
> the fluoroscope reduces overall radiation and scatter,

Sorry, but that is false. You want to have the patient as close to the II (or detector) as possible. Either by moving the entire C-arm, or in better equipment by lowering the II onto the patient.

> using a smaller I/I size (field of view) reduces lateral scatter,

Collimating reduces radiation, switching to magnification mode (smaller FOV) drastically increases dose.

> using a low fluoroscopy pulse rate,

If your equipment supports this.

> X-ray photon energy spectra (this is a very wide range on
> fluoroscopes-

This is a wide range on old c-arms with single-phase generators. The newer HF equipment has less of a problem with that.

> preventative maintenance and calibration (calibration is checked
> each year and the beam focus is the most important factor...

And knowing the telltale signs of an ill-aligned imaging chain.

> patient fatness....fat patients produce far more scatter

Unfortunately I work at the epicenter of the obesity epidemic it seems.

 

[Aether2000]

I thought the indentation in the middle of the US in Indiana was due to the morbid obesity vortex effect- there is such a concentration of obesity here that the topography of the land is slowly sinking, albeit not as low as New Orleans.
Well meaning but not too bright fluoroscopy techs in operating theaters around the country will often try using fluoroscopy to line up the beam for the physician prior to the physician activing the beam with the pedal...when I hear the beep-beep of the fluoroscopy when I have my back turned, I do a slow burn, and instruct yet another in a long line of either uneducated or irresponsible fluoro techs to not cook my buns with their machine. It is also fascinating to me when teaching cadaver courses to see the number of participants that wait for the tech to activate the fluoroscope for them. I yell, Carpe Diem! and tell the docs to take control of the machine.

Time may be loosely correlated, but it is still correlated to dose. Docs that stand on the pedal are delivering far more radiation than those that use spot exposure.

There are non-carbon tables that are less expensive.... see www.oakworksmed.com/FlTablePolyCarb.htm Also, some OR radiolucent tables are not constructed of carbon, but are acrylic.

<Motorized with tableside controls.> Excellent concept, however is relegated to the rich and famous. The new OEC 9900 with motorized controls retails for $270,000....a bit out of the price range for interventional pain medicine.

Using proper "down-the-barrel" techniques, it is not possible to place the I/I very close to the patient. Most C-arms have an isocentric point that is found by elevating the table significantly, then centering the beam. The isocentric point will usually permit entry of a needle under the I/I, but is not too far away from the patient.

Mag does increase dose significantly....I use mag only once in a blue moon. Post image processing can zoom the field of view to permit appropriate visualization if the I/I is too small or collimation is too severe.

Fascinating discussion...

 

[f_w]

> a bit out of the price range for interventional pain medicine.

The technical fees for pain management are a veritable river of gold for the people active in this business. Of course, if you run your 'injectiorama' with some refurbished 10 year old POS, you will have more opportunity to haul your loot to the bank than if you do the work using proper equipment.

> Time may be loosely correlated, but it is still correlated to dose.

No doubt. But as a 'limit' for radiation protection it doesn't work very well. (you can do a neurointerventional case with 2 hrs of fluoro time distributed on multiple views and ports without causing damage. At the same time you can fry a hole into a heavy patients skin if you spend 30min on maximal magnification with high-level fluoro going through the L-spine on the same spot e.g. a TIPS procedure.)

 

[Aether2000]

The average pain medicine interventionalist performs somewhere between 1200 and 2000 procedures a year in addition to assessing chronic pain patients, and engaging in an entire array of patient care issues outside of injections. Given Medicare coverage rates of office fluoroscopy as an average reimbursement (between Medicaid, self pay, Medicare, WC, and insured), then it would take approximately 30 years to pay for a OEC 9900 motorized C-arm when service contracts are included. This would definitely be a poor business decision under the above scenerio.
Prudent business decisions for many interventionalist physicians in private practice often involve the purchase of a refurbished C-arm for a small fraction of the price of a new C-arm.

The difference between interventional radiology time-dose exposures and that of interventional pain is that 99% of pain procedures are anatomically focused on a very small area of the body that does not involve total body survey with radiation. Time and dose are fairly well correlated for interventional pain physicians....

 

[lobelsteve]

In regards to post fluoro magnification, what units support this feature? I have not found it on OEC 9000-9400 or on Siemens Siremobil 2000.

 

[Mister Mxyzptlk]

The average pain medicine interventionalist performs somewhere between 1200 and 2000 procedures a year in addition to assessing chronic pain patients, and engaging in an entire array of patient care issues outside of injections. Given Medicare coverage rates of office fluoroscopy as an average reimbursement (between Medicaid, self pay, Medicare, WC, and insured), then it would take approximately 30 years to pay for a OEC 9900 motorized C-arm when service contracts are included. This would definitely be a poor business decision under the above scenerio.
Prudent business decisions for many interventionalist physicians in private practice often involve the purchase of a refurbished C-arm for a small fraction of the price of a new C-arm.

I don't see how you arrived at 30 years.

Using the Texas Medicare fee schedule for an LESI done at a facility:

76005 with -26 modifier = 30.34
62311 = 86.36

Total = 116.70

In the office:

76005 = 84.12
62311 = 253.17

Total = 337.29

The difference is 220.59 per case.

If you do 1200 Medicare LESI's/year in the office instead of a facility then the difference in gross reimbursement per year is $265,000.

62311 plus 76005 @ Medicare rates is the lowest common denominator scenario. If you assume a mix including WC and commercial insurance cases, cervical procedures, RFTC, TFESI's, facets, etc, the gross revenue goes much higher.

How many new c-arms will that buy?

If you look around you can find a low-end brand-new c-arm with a great picture for under $100K, and with a lease-purchase over 5 years it won't sting at all - the first 10 procedures you do each month will pay for the lease and service contract, the kits, drugs, monitors, staff, rent on the extra room, etc and the next 90 are gravy. If you just pay for it with a lump sum it will pay for itself in a few months, not 30 years.

However, if you are a partner in an ASC you might want to take all your cases to the facility because the returns are usually better and it garners you referrals from your partners.

 

[Aether2000]

The Medicare fluoroscopy fee generated in an office is 84 dollars per case period. The physician fee for performance of procedures has nothing to do with the fluoroscopy fee, that Medicare intermittently balks at paying for no apparent reason. Built into the increased reimbursement for performing procedures in an office is the cost of actually running an office and I guarantee it is not peanuts to run an office. 8% of your earnings will go to process billing and collections expenses (typically 30% or more), 25% will go to staff, 5-10% for facility lease, equipment and supplies will be more....

The situation in an ASC is worse in my area since the physician reimbursement is reduced by 2/3 for most of my cases, and unless you are a principle partner, the amount you receive in income from ownership will not offset the inherently greater expenses of an ASC compared with an office.

You have to run the numbers for your practice and decide on how much outlay you need for pretty pieces of new expensive equipment relative to the projected income, and you absolutely need to do this before you make a decision to have an office based or ASC based practice or before purchasing a $250,000 C-arm.

Also, remember Congress has proposed a 40% reduction in interventional pain physician fees for next year....so one should be cautious about enormous outlays for an office based practice.

Let me lay out the costs of new equipment for a basic office:
C-arm new Phillips Pulsera or OEC9900 $130,000-140,000
New OEC 9900 motorized C $250,000-280,000
Service contracts on C-arms: $2000-6000 per year
New Autoclave $3,500-5000
New RF Unit with 2 probes: $20,000-35,000
New Fluoro table carbon fiber with tilt, height, trendel $15,000-25,000
New Monitors for OR and any recovery area: $3500-6000 each
New Defibrillator: $5000-10,000
New high vac suction $1000-4000
EMR new high quality such as eMD, nextgen, ecw, etc $10,000-50,000
Computers with server new: $6,000-20,000
And the list goes on and on....
A new equipment outfitting of a procedure room in an office can easily run $400,000-500,000.
Some people feel buying all new equipment fits their philosophy better than buying refurb equipment. Given my reimbursement level, it would not be financially plausible to do so.

 

[Mister Mxyzptlk]

There is no $84 Medicare technical fee for fluoro (at least in Texas). $84 is what you get for the whole 76005.

The 76005 code is made up of the professional fee (-26 modifier) and the technical fee (TC modifier). If you do the case in a facility you get 76005-26 (the professional component fee), while the facility gets the 76005-TC fee, (the technical component).

If you do the procedure in the office you get the full 76005 fluoro fee (26 plus TC) because you are providing the c-arm in addition to doing the procedure.

If you're billing 76005 for a procedure done at an ASC instead of the reduced 76005-26 then you are committing Medicare fraud.

I have no idea why you would include the fluoro fees in your calculations but not the professional fee differential. You just said yourself that you get 2/3 less professional fee at a facility. You have to factor that in when you figure office vs facility.

You are also running worst case scenarios with high-end prices. I paid $70K for a new Siemens Iso-C. You can get a new autoclave for less than $2K, and less than $500 if you don't need it to be automatic (I recommend automatic - watching the damn things to be sure the temp stays high enough can be very annoying, and downright scary if you leave it unattended, the pressure gets too high, and the safety valve starts spewing with a horrendous noise).

I agree that you don't need new equipment for everything. Monitors can be bought used on eBay. They measure BP, sat and EKG fine. I had my procedure table built for $500.

Your ASC return will vary depending on your partnership status, but frankly any center that has unequal partners will have tremendous internal strife and it will probably not do as well as if everyone is equal. That is a plain fact of life when you are dealing with doctors.

If you are in an ASC with just other pain docs it may not be as good as doing things in your office because the profit margins may not be there. It will depend a lot on the quality of the facility's contracts. However, ortho, ENT, podiatry and other specialties often have much better profit margins than pain, so what you lose on your own fee differentials you can easily make up on what your partners are generating.

 

[Aether2000]

Siemans would not give us the same deal they gave you, but some of what we deal with in buying C-arms is like looking at apples and oranges. OEC has a couple of low end models without DS for around 80K, but also do not have a rotating anode or post image processing. Some companies will offer "new" C-arms but they are really demos that have a lot of wear and tear from movement and use in cadaver labs where people stand on the fluoro pedal continuously for hours.
You are correct about the 76005 billing and that is why I prefaced the statement with "in the office". Billing in a facility, whether ASC or hospital, generates $28 in my state while the TC component generates approximately $50 for the facility to pay for the C-arm equipment . The code is specifically subdivided into two parts to permit facilities with C-arms to have enough income to pay for the C-arm. Therefore, the combination of the two components for office use is designed by Medicare to pay for the radiology equipment used in addition to a fluoroscopy interpretation fee.
But an office has many other expenses.
My point is that no one needs a $250,000 C-arm in their office unless they love to burn money, or can eliminate staff because of the C-arm. In my case, a motorized C-arm would not eliminate anyone, and it would be a luxury that I certainly would not appreciate, the referring docs would not appreciate, nor the patients would appreciate.
Regarding autoclave prices for new autoclaves, view the following page with autoclaves on sale: http://www.thedrstore.com/category.aspx?categoryID=1
Regarding performance of cases in ASCs: I am a 5% owner in an ASC but would get killed financially if I took my Anthem and Medicare cases there, and in addition would result in grossly overcharging of patients for something that could be done in the office. For instance, it costs Medicare patients $500 for a lumbar TFESI performed in a surgery center but costs only $375 when performed in the office. For a 2 level procedure, the situation is even worse. Out of network insurance patients receive a bill of $1500 from the ASC (paid out of pocket) and an additional physicians fee....
The physician receives a set income from the ASC based on profits that are divided between all partners, some of which may bring zero cases to the ASC. In my case, the income derived from ownership in the ASC plus my physicians fee would result in a net loss to me of approximately $200,000 per year. So in my case it is ludicrous to send patients to an ASC in which a. the patients are being charged more and must pay more and b. results in a significant net loss to my practice. If you own 50% or more of an ASC, the situation would be different, but the overhead is much higher...approximately twice as high as in an office setting.
It may also be beneficial to remain informed regarding Medicare's tinkering with procedures in ASCs. For 2007, it appears Medicare will reverse their current way of thinking in publishing inclusion lists, and will instead publish exclusion lists. If pain procedures are excluded from ASCs, the principle owners will take a bath financially. ASIPP has current updates on this situation under their "news" section on their website.

 

[Mister Mxyzptlk]

I do cases where the carrier pays a fee differential in the office.

Any carrier that pays the same whether office or facility is telling me that they want to pay a facility fee.

I wouldn't know what to do with a $250K c-arm. My old eyes can only see about $100,000 worth of image anyway. With a new prescription maybe I can kick that up to $125,000.

If the patients complain I just tell them that at the facility I get paid $X, whereas at the office I get $X minus the cost of my supplies. I tell them I like them very much but if I have to choose whether they take the hit or I do, they get the short straw. *I didn't buy the insurance policy*.

I also tell them if they don't like it they should complain to their insurer just like I did when I tried to negotiate my contract ("tried" being the operative word here - the usual negotiation process for a solo doc in an urban area is "take it or leave it").

I just bought a new autoclave a few months ago and it was nowhere near those prices. I'll see if I can dig up where I bought it. A lot depends on what you need. I just have a small one for sterilizing RF probes, pointers, and such.

I read somewhere that CMS is expanding the ASC procedure list by almost 50%.

As previously mentioned, whether you can make more money with an ASC depends on how the partnership is structured, their contracts, and some political "intangibles". If you're the only pain guy you can usually count on a lot of volume from your ortho partners. If you bite the hand that feeds you by doing their referrals in the office they might cut you off in favor of a non-partner who supports the facility.

If you're perceived as "dead wood" by the other partners you'll be lucky to leave the partnership meetings with your skin intact and no new excretory orifices. Then the calculation gets really easy because you're just a parasite that can't be purged because of anti-kickback statutes.

They don't teach this stuff in med school. Taking care of the patients is easy compared to the business side.

If you get the opportunity consider a specialty hospital investment because the facility fee differentials are considerable and likely to widen. Also your ortho partners will be doing good margin procedures like total joints and if you have imaging you can refer your Medicare patients to it under the "whole hospital exemption", unlike a freestanding center. Specialty hospitals seem to always be under attack, but these days what isn't?