RE: Medical training war stories

["Huesgen, Jim" <HuesgenJ@health.missouri.edu>]

Until recently I was in charge of Quality Assurance for a large radiology
department.  I was asked to evaluate the complaints of one of the orthopedic
surgeons regarding poor image quality of the C-arm mobile x-ray fluoro
units.  I had the radiological engineers pull the unit out of service and
run a QA inspection on it.  We could find nothing wrong, indeed, it was
resolving 40 lines per inch on the test phantom which is considered quiet
good.   We placed the unit back in service only to received the same
complaints.  This went on for some time, with the unit producing excellent
images in the test environment and degraded images in the operating room.
We were at a loss for an explanation and decided to observe the unit in use.

After the patient was prepped and draped, the surgeon called for the C-arm
fluoro unit to be placed in the operating position.  The receptor was draped
with a sterile shroud and the unit rolled into position with the x-ray tube
under the operating table and receptor above.  The procedure in progress was
the internal fixation of a distal tibia (lower leg).  Sure enough, when the
fluoro was activated, the image was just awful.  Hardly any contrast and
very grainy.  I got down on the floor and crawled under the drapes and OR
table to see what the dickens was in the primary beam and found the patient
was lying on a very thick wooden platform of some sort. The problem was that
the beam was passing through probably several HVLs of oak in the process of
forming the fluoro image.  This hardened the beam causing loss of image
contrast and also produced a large amount of scattered radiation leading to
further degradation.

I tried to explain the source of the problem and was immediately cut down by
the surgeon.  It seems he had "invented" the "fluoro board" so that the
C-arm could have unobstructed movement from the patients pelvis to the foot.
In order to build an operating table with no central pedestal, he had one
built using a 18 inch wide three in thick oak plank that was about six feet
in length.  It was supported by a single counterbalanced pedestal positioned
at one end of the device and resembled some sort of diving board.  Any
attempts to explain half value layers, attenuation, scatter, etc, met with
immediate and hostile rebuff.  To my knowledge, the device is still in use.

So, based on this (and other responses I've read) I'd have to say that the
level of knowledge concerning things relating to radiation use and or
hazards is abysmal at best.  The improper use of radiation producing
devices, particularly the C-arm fluoro units, is becoming more common and
has resulted in injury.
-----Original Message-----
From: Rene Michel [mailto:remichel@ucsd.edu]
Sent: Thursday, July 20, 2000 15:17
To: Multiple recipients of list
Subject: Medical training war stories


Neon and other radsafe members,

I'm interested in hearing some of the "wild war stories" Neon mentioned and
any experiences other radsafe members have had in this area.  If possible,
please, avoid mentioning the names of the individuals and/or institutions
involved in these stories.
I think we all can learn from such "war stories" and they can certainly be
useful in justifying additional training for MDs that lack instruction in
radiation safety.
Thanks!
René
remichel@ucsd.edu

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