Top 20 Practical Top 20 Practical Tips for Tips for

Radiography in the Radiography in the Operating Theatre Operating Theatre

Prepared by

V.G.Wimalasena

Ref. Article by F.J.Mullar Wikiradiography

IntroductionIntroduction

The operating theatre (OT) can be a The operating theatre (OT) can be a confronting new environment for confronting new environment for student radiographers. The best student radiographers. The best strategy for dealing with this problem is strategy for dealing with this problem is to take every possible opportunity to to take every possible opportunity to practise your operating theatre practise your operating theatre techniques. To help you along the way, techniques. To help you along the way, here are 20 tips that you may find here are 20 tips that you may find useful. Not all of these tips will be useful. Not all of these tips will be applicable to all theatre situations.applicable to all theatre situations.

Tip 1. Get to Know Your Tip 1. Get to Know Your Operating Theatre StaffOperating Theatre Staff

This is placed at number one for This is placed at number one for good reason. You are in their good reason. You are in their turfturf and you may have goals that conflict and you may have goals that conflict with theirs. For example, your goal with theirs. For example, your goal to produce the best possible images to produce the best possible images may conflict with the scrub nurse's may conflict with the scrub nurse's goal of keeping a sterile field intact!goal of keeping a sterile field intact!

Tip 1. Get to Know Your Tip 1. Get to Know Your Operating Theatre Staff Operating Theatre Staff

Look at this theatre Look at this theatre team..... they look like team..... they look like a team. You would be a team. You would be confident as a patient confident as a patient in their hands. This is in their hands. This is how you should view how you should view your role in the your role in the operating theatre. You operating theatre. You are joining a team of are joining a team of skilled people in the skilled people in the interest of a good interest of a good surgical outcome for surgical outcome for the patient.the patient.

These people can make your theatre These people can make your theatre experience very pleasant or very experience very pleasant or very difficult. Engendering yourself to them difficult. Engendering yourself to them (winning their hearts) can involve such (winning their hearts) can involve such things asthings as learning their names learning their names learning their roles learning their roles learning their rules. learning their rules. helping with patient transferhelping with patient transfer

Be a good communicator with the Be a good communicator with the theatre staff theatre staff

Tip 2. Know The Operating Tip 2. Know The Operating Theatre RulesTheatre Rules

There's a good chance that the operating theatre will There's a good chance that the operating theatre will have several folders of protocols. These could cover have several folders of protocols. These could cover aspects of theatre procedures such as attire, aspects of theatre procedures such as attire, infection control, Occupational Health and Safety, infection control, Occupational Health and Safety, patient safety etc. You will probably not be expected patient safety etc. You will probably not be expected to study these protocols, but the few that affect you to study these protocols, but the few that affect you will need to be known.will need to be known.

Apart from the written rules, there are the matters of Apart from the written rules, there are the matters of theatre theatre cultureculture. These are the rules that are not . These are the rules that are not written down, but the staff tend to follow them- they written down, but the staff tend to follow them- they are common understandings. It could cover such are common understandings. It could cover such matters as how rules are followed, how they are matters as how rules are followed, how they are policed, and how you get around them when policed, and how you get around them when required. required.

Tip 3. Assume Everything Tip 3. Assume Everything and Everyone is Sterileand Everyone is Sterile

Once the surgeon breaks the patient's skin, the Once the surgeon breaks the patient's skin, the patient is at risk of acquiring infection. One of the patient is at risk of acquiring infection. One of the goals of the operating theatre staff is to prevent the goals of the operating theatre staff is to prevent the patient developing a significant post-op infection. patient developing a significant post-op infection.

You should be seen to be sharing in this goal. This You should be seen to be sharing in this goal. This will mean that you should take care not to touch will mean that you should take care not to touch anything or anyone that is sterile. This will mean anything or anyone that is sterile. This will mean not standing too close to a staff member who is not standing too close to a staff member who is gowned and gloved. It will also require you to point gowned and gloved. It will also require you to point out to others in the operating theatre when they out to others in the operating theatre when they are at risk of breaching a sterile field, or indeed, are at risk of breaching a sterile field, or indeed, when they have breached a sterile field.when they have breached a sterile field.

Be particularly careful when you push Be particularly careful when you push the image intensifier over a patient- the image intensifier over a patient- ensure that you do not touch the sterile ensure that you do not touch the sterile handle attached to the operating light. handle attached to the operating light.

Tip 4. Know Your Image Tip 4. Know Your Image IntensifierIntensifier

I am assuming that I am assuming that the majority of the the majority of the imaging procedures imaging procedures in the operating in the operating theatre utilise the theatre utilise the image intensifier. This image intensifier. This machine's operation machine's operation you will need to be you will need to be understood very well. understood very well. Modern digital image Modern digital image intensifiers have a intensifiers have a number of pre and number of pre and post-processing post-processing features. features.

It is very embarrassing if you don't know how to It is very embarrassing if you don't know how to perform a task on the image intensifier. This is perform a task on the image intensifier. This is particularly so when the surgeon knows that other particularly so when the surgeon knows that other radiographers have performed the task.radiographers have performed the task.

A surgeon will probably forgive you for not being A surgeon will probably forgive you for not being familiar with a surgical procedure, but will be less familiar with a surgical procedure, but will be less forgiving if you are struggling to use the image forgiving if you are struggling to use the image intensifier.intensifier.

If you are unfamiliar with a procedure, there can be If you are unfamiliar with a procedure, there can be much to be said for introducing yourself to the surgeon much to be said for introducing yourself to the surgeon and advising him/her that you know how to use the and advising him/her that you know how to use the image intensifier, but will need guidance with the image intensifier, but will need guidance with the procedure. Questions like... procedure. Questions like...

"which side would you like me to come in from?" "which side would you like me to come in from?" oror "do you want the image intensifier to go under the "do you want the image intensifier to go under the

table or over the table for the lateral"table or over the table for the lateral"

Good communication will suggest to the surgeon that Good communication will suggest to the surgeon that you deserve his/her confidence in your abilities. you deserve his/her confidence in your abilities.

Tip 5. Know Your Tip 5. Know Your ProceduresProcedures

There will be a variety There will be a variety of procedures that of procedures that you will be expected you will be expected to assist with. The to assist with. The surgeon will look to surgeon will look to you for signs of you for signs of confident and confident and competent operation competent operation of the equipment. This of the equipment. This will be very difficult if will be very difficult if you are unfamiliar you are unfamiliar with a procedure.with a procedure.

If you are unfamiliar with a If you are unfamiliar with a procedure, let the surgeon know. procedure, let the surgeon know. Better to let the surgeon know up Better to let the surgeon know up front, than for the surgeon to find out front, than for the surgeon to find out during the procedure.during the procedure.

Also, if you know you have never seen Also, if you know you have never seen a procedure that you have been called a procedure that you have been called to do, ask another radiographer to to do, ask another radiographer to come with you to help explain what is come with you to help explain what is happening. happening.

Tip 6. Cover/Drape Your Tip 6. Cover/Drape Your Image IntensifierImage Intensifier

It is better to spend It is better to spend 5 minutes at the 5 minutes at the beginning of an beginning of an operation covering operation covering your image your image intensifier than to intensifier than to spend 20 minutes at spend 20 minutes at the end of an the end of an operation cleaning operation cleaning off blood and off blood and betadine betadine

Tip 7. Face the Monitor Tip 7. Face the Monitor Cart Panel Towards Where Cart Panel Towards Where

you are Standing you are Standing Set up the monitor Set up the monitor

cart so that the cart so that the control panel is control panel is facing you. If you facing you. If you need to manipulate need to manipulate the image, you do the image, you do not want to be not want to be wasting time wasting time walking around the walking around the cart. This will not cart. This will not apply to all image apply to all image intensifiers. intensifiers.

Tip 8. Identify Your Tip 8. Identify Your PatientPatient

This might seem self-evident, but can be This might seem self-evident, but can be remarkably difficult in reality. You can't ask the remarkably difficult in reality. You can't ask the patient what their name is. The most common patient what their name is. The most common method for identifying then patient is from the method for identifying then patient is from the name on the paperwork in the theatre. Bear in name on the paperwork in the theatre. Bear in mind that sometimes patient notes are swapped or mind that sometimes patient notes are swapped or there may be patient notes in theatre left from a there may be patient notes in theatre left from a previous patient. previous patient.

Check age and sex Check age and sex Check name on old imagingCheck name on old imaging Check that there are not two sets of paperwork on Check that there are not two sets of paperwork on

different patientsdifferent patients

Beware.... Beware....

Tip 9. Secure your PlugTip 9. Secure your Plug Securing the mains cord Securing the mains cord

to the boom with a self to the boom with a self tightening knot has two tightening knot has two advantages. advantages.

Firstly, if someone trips Firstly, if someone trips over the cord, they will over the cord, they will not rip the cord out of its not rip the cord out of its socket (they may break socket (they may break their neck, but you’re their neck, but you’re machine is OK!). If the machine is OK!). If the plug is pulled out of the plug is pulled out of the socket, it could cause socket, it could cause damage to your image damage to your image intensifier, or you could intensifier, or you could lose images. Also, the lose images. Also, the surgical procedure will surgical procedure will be delayed while you re-be delayed while you re-boot the image boot the image intensifier. intensifier.

Secondly, when there are multiple sockets Secondly, when there are multiple sockets with multiple plugs, you will recognize with multiple plugs, you will recognize your plug immediately.... it’s the one with your plug immediately.... it’s the one with the fancy knot (I have pulled out the the fancy knot (I have pulled out the patient’s ventilator plug by mistake). Any patient’s ventilator plug by mistake). Any knot that tightens as you pull on it would knot that tightens as you pull on it would be suitable.be suitable.

Many image intensifiers have a built in Many image intensifiers have a built in uninterruptible power supply (UPS)- if the uninterruptible power supply (UPS)- if the power cord is accidentally pulled out of power cord is accidentally pulled out of the socket, replacing it quickly may cause the socket, replacing it quickly may cause no harm. no harm.

10. Go to the Toilet Before 10. Go to the Toilet Before you Start you Start

You can never be You can never be sure how long an sure how long an operation will take. operation will take. It is hard to imagine It is hard to imagine what would be more what would be more painful- the ever painful- the ever increasing size of increasing size of your bladder, or the your bladder, or the pain of pain of embarrassment embarrassment when you ask to stop when you ask to stop the operation while the operation while you go to the toilet. you go to the toilet.

Tip 11. Check Hard-Drive Tip 11. Check Hard-Drive Space Before Starting a Space Before Starting a

New Procedure New Procedure If you are using an image If you are using an image

intensifier with a hard intensifier with a hard drive, check that you have drive, check that you have plenty of hard drive space plenty of hard drive space left before you start. It left before you start. It can be very awkward to can be very awkward to stop a theatre case while stop a theatre case while you you free upfree up some hard some hard drive space on your image drive space on your image intensifier.intensifier.

Obviously, if you are using Obviously, if you are using a non-digital image a non-digital image intensifier, this will not be intensifier, this will not be an issue. an issue.

Tip 12. Check That the Tip 12. Check That the Surgeon is Operating on Surgeon is Operating on

the Correct Side the Correct Side It is sound practice to It is sound practice to

have a good look at have a good look at the patient's old the patient's old imaging. You can imaging. You can often pick up points often pick up points that will help during that will help during the operation. The the operation. The operation may also operation may also make more sense to make more sense to you if you understand you if you understand the patient's history the patient's history and the nature of and the nature of their injuries their injuries

Importantly, check that the surgeon is Importantly, check that the surgeon is operating on the correct side of the operating on the correct side of the patient. Once the scrub nurse has patient. Once the scrub nurse has prepared one side of the patient for prepared one side of the patient for surgery, the surgeon will tend to surgery, the surgeon will tend to assume that is the affected side.assume that is the affected side.

In short, the surgical team should aim In short, the surgical team should aim to perform the correct operation, on to perform the correct operation, on the correct side of the patient, on the the correct side of the patient, on the correct patient.correct patient.

Beware, errors are made. Beware, errors are made.

Tip 13. Watch the Tip 13. Watch the Surgeon's Eyes When Surgeon's Eyes When

Screening Screening This is not a matter of This is not a matter of

romance- it's a radiation romance- it's a radiation protection issue. If it is protection issue. If it is normal procedure for normal procedure for the radiographer to the radiographer to initiate fluoroscopy, or initiate fluoroscopy, or if the surgeon has the if the surgeon has the fluoro' peddle, this is fluoro' peddle, this is still good practice (this still good practice (this is a debatable point- is a debatable point- researchers have researchers have reported conflicting reported conflicting findings). findings).

What you are trying to minimise is the time What you are trying to minimise is the time that the surgeon spends screening when he/she that the surgeon spends screening when he/she is not looking at the image. It is not uncommon is not looking at the image. It is not uncommon for the surgeon to ask you to initiate for the surgeon to ask you to initiate fluoroscopy but not tell you to stop. They are fluoroscopy but not tell you to stop. They are simply concentrating on what they are doing simply concentrating on what they are doing and forget that they have initiated fluoroscopy.and forget that they have initiated fluoroscopy.

It helps if you understand what they are doing It helps if you understand what they are doing at every stage of the operation. This will help at every stage of the operation. This will help you to decide whether the surgeon has averted you to decide whether the surgeon has averted their eyes momentarily from the image (and their eyes momentarily from the image (and wants you to keep screening) or whether they wants you to keep screening) or whether they have simply forgotten to tell you to stop have simply forgotten to tell you to stop screening. screening.

Tip 14. Use a Sequence Tip 14. Use a Sequence Acquisition When Acquisition When

Appropriate Appropriate Modern mobile digital Modern mobile digital

Image Intensifiers are Image Intensifiers are able to store images in a able to store images in a run or sequence. You run or sequence. You set the relevant set the relevant parameters such as parameters such as capture rate, and the capture rate, and the images will be stored in images will be stored in a sequence (it's a bit a sequence (it's a bit like an animated GIF). like an animated GIF).

I see this as having I see this as having several advantages. several advantages.

Firstly, my understanding is that the Image Firstly, my understanding is that the Image Intensifier is performing screen capture and there Intensifier is performing screen capture and there is no cost in terms of increased radiation dose to is no cost in terms of increased radiation dose to the patient.the patient.

Secondly, you are able to record dynamic Secondly, you are able to record dynamic information. This can be particularly useful in information. This can be particularly useful in cases such as ERCP or Laparoscopic cases such as ERCP or Laparoscopic Cholangiogram. If there appears to be a stone in Cholangiogram. If there appears to be a stone in the CBD you can play the sequence back to the the CBD you can play the sequence back to the surgeon and see if the stone acts more like an air surgeon and see if the stone acts more like an air bubble or a stone. bubble or a stone. does it deform in shape does it deform in shape does it divide in two when it reaches the hepatic ducts does it divide in two when it reaches the hepatic ducts does it float up hill or down hill does it float up hill or down hill

Another less obvious use is when the surgeon Another less obvious use is when the surgeon wants to assess the stability of a joint following wants to assess the stability of a joint following ORIF. ORIF.

Tip 15. Be Careful When Tip 15. Be Careful When Moving the C-arm Moving the C-arm

It is possible to do harm when you are moving the C-It is possible to do harm when you are moving the C-arm.arm.

When you are assisting with a hip operation, the When you are assisting with a hip operation, the surgeon will usually want to see that anatomy in the surgeon will usually want to see that anatomy in the lateral projection. The image intensifier is usually set lateral projection. The image intensifier is usually set up to roll under the operating table for the lateral up to roll under the operating table for the lateral projection. The first time you roll the C-arm into the projection. The first time you roll the C-arm into the lateral projection be very careful. Go slowly and ask lateral projection be very careful. Go slowly and ask the surgeon if everything is " Ok over there". the surgeon if everything is " Ok over there".

Similarly, you can fracture a patient's pelvis when Similarly, you can fracture a patient's pelvis when lowering the C-arm. Also watch the anaesthetist who lowering the C-arm. Also watch the anaesthetist who is raising or lowering the operating table when the C-is raising or lowering the operating table when the C-arm is in place. arm is in place.

Tip 16. You are Responsible Tip 16. You are Responsible for your Students for your Students

Qualified Qualified radiographers will radiographers will generally be held generally be held accountable for the accountable for the students under their students under their instruction. I have instruction. I have seen a scrub nurse seen a scrub nurse drop a pair of drop a pair of forceps- the forceps- the radiography student radiography student picked them up and picked them up and put them back on the put them back on the sterile tray for her. sterile tray for her.

It is worth emphasizing to a student It is worth emphasizing to a student radiographer who is entering the operating radiographer who is entering the operating theatre for the first time the following three theatre for the first time the following three points. points. Assume everything and everyone is sterile- touch Assume everything and everyone is sterile- touch

nothing and you can't go wrongnothing and you can't go wrong If you feel unwell, leave the theatre immediatelyIf you feel unwell, leave the theatre immediately If you feel faint, back up to a wall and slide down it If you feel faint, back up to a wall and slide down it

until you are sitting on the flooruntil you are sitting on the floor I was once told that the true measure of a I was once told that the true measure of a

surgeon's ability to train a student lies in their surgeon's ability to train a student lies in their preparedness to let that student operate on preparedness to let that student operate on them. We should think of student them. We should think of student radiographers in the same way- we train them radiographers in the same way- we train them to a level that we would be confident to be to a level that we would be confident to be their patient. their patient.

Tip 17. Use Equipotential Tip 17. Use Equipotential Earthing for Cardiac Cases Earthing for Cardiac Cases

You may have wondered why You may have wondered why your image intensifier has a your image intensifier has a separate earth lead when it separate earth lead when it is earthed through the plug. is earthed through the plug. This extra earthing wire can This extra earthing wire can be used during cardiac cases be used during cardiac cases (pacing wires, defibrillator (pacing wires, defibrillator insertion, ablation etc) when insertion, ablation etc) when equipotential earthingequipotential earthing is is required. If all of the required. If all of the equipment in the operating equipment in the operating theatre is earthed to the theatre is earthed to the same earth point, the same earth point, the grounding of the equipment grounding of the equipment will be identical. This can will be identical. This can assist with electrical safety assist with electrical safety and avoid static discharge and avoid static discharge during surgery. during surgery.

Tip 18. Don't Clean the Tip 18. Don't Clean the Image Intensifier During Image Intensifier During

Open Surgery Open Surgery It can be tempting to do a little bit It can be tempting to do a little bit of cleaning of the image intensifier of cleaning of the image intensifier during the operation. This is during the operation. This is inadvisable. If you are using a spray inadvisable. If you are using a spray bottle, the aerosol will potentially bottle, the aerosol will potentially enter an open wound and cause enter an open wound and cause infection.infection.

This is not to suggest that the image This is not to suggest that the image intensifier does not need cleaning intensifier does not need cleaning between cases. If you want to see between cases. If you want to see what the theatre staff look like when what the theatre staff look like when they are upset, try wheeling a blood they are upset, try wheeling a blood covered image intensifier into an covered image intensifier into an operation.operation.

Cleaning the image intensifier can Cleaning the image intensifier can be more difficult and time be more difficult and time consuming than it looks. There can consuming than it looks. There can be devices that are hard to access. be devices that are hard to access. Also, you will need to turn the c-arm Also, you will need to turn the c-arm upside down to be sure that the upside down to be sure that the image intensifier is completely image intensifier is completely clean. clean.

Tip 19. Distance, Tip 19. Distance, Shielding, Time Shielding, Time

The three basic The three basic principles of principles of radiation radiation protection areprotection are distance, distance, shielding shielding time. time.

Distance is often overlooked as a radiation Distance is often overlooked as a radiation protection technique. This is possibly related to protection technique. This is possibly related to a notion that if you are wearing a lead gown, a notion that if you are wearing a lead gown, you are receiving no ionising radiation. Of you are receiving no ionising radiation. Of course, the lead gown is not covering your course, the lead gown is not covering your entire body. In keeping with the ALARA entire body. In keeping with the ALARA principle, it is good practice, where principle, it is good practice, where appropriate, to move away from the image appropriate, to move away from the image intensifier as far as possible.intensifier as far as possible.

It is also worthwhile considering other It is also worthwhile considering other radiation protection issues. eg.radiation protection issues. eg.

When should you use overcouch techniques and When should you use overcouch techniques and when should you use undercouch techniques? when should you use undercouch techniques?

What is the shape of the radiation scatter cloud What is the shape of the radiation scatter cloud from an image intensifier- where is it safest to from an image intensifier- where is it safest to stand? stand?

Tip 20. What if I feel like I Tip 20. What if I feel like I am About to Faint? am About to Faint?

Fainting doesn't have to be a drama!Fainting doesn't have to be a drama!

If you feel like you are going to faint, back up If you feel like you are going to faint, back up to a wall and slide down it. You are not the first to a wall and slide down it. You are not the first person to faint in an operating theatre and you person to faint in an operating theatre and you will not be the last. Even a hardened will not be the last. Even a hardened radiographer can feel faint in certain radiographer can feel faint in certain circumstances- e.g.circumstances- e.g. if you are dehydrated if you are dehydrated if the operative theatre is very hot if the operative theatre is very hot if the operation is very long if the operation is very long if you are standing for a long period wearing a lead if you are standing for a long period wearing a lead

gowngown I find it useful during long theatre cases to find I find it useful during long theatre cases to find

a seat and take the weight off my feet. Check a seat and take the weight off my feet. Check with your departmental and theatre rules on with your departmental and theatre rules on this one.this one.

Fainting doesn't have to be a drama!Fainting doesn't have to be a drama!