Chapter 40 Radiation

Protection Procedures
ALARA and Occupational
Exposure
ALARA
ALARA stands for As Low As Reasonably
Achievable. It is the basic principle of radiation
protection procedures.
There is much that we can do to keep exposure
to the patient and the operator as low as
possible.
The chiropractor is unique in the fact that you
can perform radiography and refer your patients
for other types of examinations.
Occupational Exposures
In radiologic technology, 95% of the
occupational exposure comes from
fluoroscopy and mobile radiography.
Neither would be used in your office so the
worst case scenario is that you would
receive 5% of the exposure that a
technologist would receive.

Occupational Exposures
During radiography, the operator should be
behind a protective barrier.
These barriers are usually considered as secondary
barriers so protection would be from tube leakage and
scatter from the patient. The tube should never be
pointed toward this type barrier.
If the barrier can have the tube angled toward the
barrier. It must be a primary barrier.
Staying behind the barrier effectively eliminates the
source of occupational exposure if the shielding is
adequate.
Occupational Exposures
Medical Imaging Exposures
Fluoroscopy: All personnel will wear protective apron.
If extremities get into the beam lead gloves can be
worn.
The radiologist will usually be close to the machine during
fluoroscopy so their exposure will be higher than that the
technologist. Aprons between the Image intensifier and
Bucky Slot covers reduce radiologist exposure.
The technologist should stand as far away from the table as
possible during the exam and move closed only when
necessary.
The radiologist will use short burst of exposure and keep the
exposure time as short as possible. The 5 minute clock timer
will alarm when 5 minutes of fluoroscopy has been used.
Occupational Exposures
Medical Imaging Exposures
Mobile radiography:
The technologist must wear a lead apron during
mobile plain film or fluoroscopy examinations.
An apron must be assigned to each portable
machine.
The exposure cord for portable radiographic
machines must be 2 meters long to maximize
distance from the tube during exposures.
Occupational Exposures
Radiology Ancillary Staff
Assuming the rooms are adequately shielded,
the receptionist, file room and darkroom staff
should not receive any occupational
exposure.
Radiology ancillary staff should not be used to
hold patients during radiography.
Occupational Radiation Monitoring
Occupational Radiation Monitoring is required if there is
any likelihood that an individual will receive more than
1/10 of the recommended dose.
With just plain film radiography, monitoring may not be
required as long as the operator stays in the control
booth during all exposures.
There are some exams such as stress views of the ankle
where the operator would be in the room with the patient.
If this is done, monitoring would be necessary.
If the operator ever holds a patient monitoring would be
necessary.
Occupational Radiation Monitoring
Occupational radiation monitoring offers
no protection against exposure. It merely
records the exposure received.
If needed, find a certified laboratory to
process the dosimeters.
Types of monitors
Film badges
TLD
OSL
Film Badges
Film badges have been used since the 1940s
and are still used today.
Exposures below 10 mR are not measured on
the film.
Filters along with the window in the badge allow
estimation of the energy of the exposure.
The must be worn with the proper side to the
front.
They are typically worn on the collar so they
would remain outside the lead apron.
Film Badges
Advantages
Inexpensive
Easy to handle and process
Reasonably accurate
Disadvantages
Can not be reused
Sensitive to heat and humidity
Must be changes monthly
TLD
TLD has several advantages over film
badges.
Not sensitive to heat or humidity
Measure exposures to 5mR More sensitive
and accurate.
Can be changed quarterly instead of monthly
Disadvantages
Cost but changing badges less frequently
than monthly eliminates cost problem.
Optically Stimulated Luminescence
All of the advantages of the TLD over film
badges plus:
Can be re-read to confirm exposure
More accurate than TLD
Where to wear the monitor
The whole body badge is typically worn at
collar level so it can be outside the lead
apron.
Fetal monitoring badges used during
pregnancy are worn at waist level under
the apron.
Hand or finger TLDs are worn on the
extremity.
Occupational Radiation Monitoring Reports
State and federal regulations require that the
results of the occupational radiation monitoring
program be recorded in a precise fashion and
maintained for review.
Specific information is required to be on the
report including current and cumulative
exposure.
Each site of monitoring must be identified
separately.
There will also be a control monitor to measure
the background exposure during transport,
handling and storage.
Occupational Radiation Monitoring Reports
The supplier of the badges must know the type
of radiation for proper calibration of the
equipment.
The badges are control are shipped back to the
supplier in a timely manner.
For lost or damaged badges, a health physicist
will estimate the exposure.
The annual exposure is discussed with each
worker and receipt of the information is
documented. Monthly reports may be posted but
care must be taken with sensitive information.
Lead apron used for operator or patient
protection must be the equivalent of 0.5mm of
lead.
They must be worn when in a room during the
exposure or during fluoroscopy.
Half aprons are effective means to provide
gonad protection during radiography.
0.25 mm of lead aprons should be avoided as
they only attenuate 66% of the beam at 76 kVp.
Protective Apparel
Aprons used in interventional radiology should
be a wrap around type. Thyroid shields may also
be worn.
Lead gloves can be worn when the hands are in
the beam.
Aprons must be stored on specially designed
racks or laid flat on the floor. They are never
folded.
Aprons are tested annually for cracks or holes in
the lead, usually by fluoroscopy.
Protective Apparel
During fluoroscopy radiologic technologist
should stand as far as possible from the
machine.
Standing behind the radiologist offers added
protection.
If you must be in the room, position your body
as far away from the primary beam as
possible.
Position
Patient holding
Many patients will find the x-ray examination to
be physically demanding. Some may not be
capable of staying in position.
This is a particular challenge for weight-bearing
radiography. Mechanical supportive devices are
limited for erect studies.
If you have a radiographic table, the patient may
be examined recumbent. Sponges may be used
as supportive devices.
Patient holding
Radiology or office staff should never hold a
patient. Family or friends may be called upon to
assist the patient.
The person assisting the patient must wear a
lead apron and if their hands will be in the beam
lead gloves.
Position the person as far away from the primary
beam as possible.
Since the person holding the patient may be a
parent, make sure they are not pregnant.
Reducing Unnecessary Patient
Dose
As a doctor, you have the responsibility to
determine if the radiography is necessary and
justified.
There are more practice guidelines available
every year to assist in determining if the
examination will yield necessary diagnostic
information.
There are many examinations that are
performed knowing that they will yield little
helpful information so they in no way justify the
patient radiation dose.
Reducing Unnecessary Patient
Dose
Check to see if the patient has previous
examinations that may make the new
examination not necessary.
You may be sued if you dont take films
and the treatment plan fails because you
missed something the films would show.
The yield of information must be greater
than the risk of radiation exposure.
Reducing Unnecessary Patient
Dose
Routine x-ray examinations should not be
performed.
Used the most accurate tests to confirm
or rule out your working diagnosis.
Consider using MR instead of CT
Repeat Examinations
One area of unnecessary patient exposure is
repeated x-ray examinations. Past estimates of
frequency has been as high as 10% but they
should normally not exceed 5%.
Most of the retakes are of the lumbar spine,
abdomen and thoracic spine.
Most retake are due to the exposure factors
being incorrect resulting in an over exposed or
under exposed film. Proper measurement are
important.
Repeat Examinations
Positioning errors account for about 25% of
retakes. Proper training and practice is important
to fine tune positioning skills.
Motion causes about 11% of retakes so proper
patient communication during the exam is
important.
But do not be afraid to retake a poor quality
film. If you can not see a problem makes it
likely you will miss it. Poor quality exams are
never justified.
Radiographic Technique
Use as high kVp as possible to get
adequate contrast and reduce patient
exposure.
Collimate the beam to slightly smaller than
film size or the area of interest, whichever
is smaller.
Use the fastest-speed screen-film
combination consistent with the nature of
the examination.
Positioning
When taking films with the patient seated,
do not allow the gonad to be in the primary
beam. Position the patient lateral to the
beam.
For female patients turn the patient PA to
reduce breast and gonad exposures when
possible.
Patient shielding
Some form of patient shielding should be
used on all patients able to reproduce.
All children should have shielding.
Pre-menopausal women should be
shielded except when the shield would
interfere with the examination.
Men should be shielded beyond 50 years.
Patient shielding
Patient shielding includes contact shields
and shadow shields.
Contact shields are placed on the patient
and include aprons, the heart shaped filter
and the bell.
Shadow shields are placed between the
patient and the tube. Here we attach it to
the tube.
Patient shielding
Shielding must be used when the gonads
lie in or near the useful beam and when it
does not interfere with obtaining the
required diagnostic information.
Accurate placement is extremely important.
Repeated examinations can result form
improper placement of the shield.
Proper patient positioning and collimation
should not be relaxed when gonad shields
are in use.
Ten Commandments of ALARA
1. Understand and apply the cardinal principles of
radiation control: time, distance and shielding.
2. Do not allow familiarity to result in a false
security.
3. Never stand in the primary beam.
4. Always wear protective apparel when not
behind a protective barrier.
5. Always wear a radiation monitor and position it
outside the protective apron at collar level.
Ten Commandments of ALARA
6. Never hold a patient during radiographic
examinations. Use mechanical restraining
devices when possible. Otherwise, use
patients or friends to hold the patient.
7. The person holding the patient must wear
protective apron and if possible, gloves.
8. Use gonadal protective on all people of
childbearing age when it will not interfere with
the examination.
Ten Commandments of ALARA
9. Examinations of the pelvis or lower
abdomen of a pregnant patient should be
avoided whenever possible, especially
during the first trimester.
10. Always collimate to the smallest field size
appropriate to the examination.
Chapter 31 Quality Control
Two areas of activity are designed to
ensure the best possible image quality
with the lowest possible exposure and
minimum costs.
Quality Assurance deals with people
Quality Control deals with instrumentation
and equipment.

Chapter 31 Quality Control
Two areas of activity are designed to
ensure the best possible image quality
with the lowest possible exposure and
minimum costs.
Quality Assurance deals with people
Quality Control deals with instrumentation
and equipment.

Ten Step Approach to Quality
Assurance
1. Assign responsibility
2. Delineate scope of care
3. Identify aspects of care
4. Identify outcomes that effect the aspects
of care.
5. Establish limits of the scope of
assessment.
Ten Step Approach to Quality
Assurance
6. Collect and organize data.
7. Evaluate care when outcomes are
reached.
8. Take action to improve care
9. Assess and document actions
10. Communicate information to
organization-wide QA Program
QA Projects
Things that QA can evaluate includes
Scheduling of patients
Instructions given to patients
Wait times in the office
Interpretation of films
Retake analysis
Record accuracy
QA Program
Quality Assurance deals with people and
processes used to complete tasks.
QA involves training and record keeping.
As the owner of the equipment, you will be
responsible for your radiology services.
The State of California Department of
Radiologic Health established the
Standards of Good Practice that is the
foundation of QA and QC in radiography.
QA and QC Requirements
Degree of requirements vary by state.
California and New York have very tight
standards for quality control of the
radiographic and processing equipment.
We are required by statue to teach QA
and QC in the radiology program. It is
covered in detail in 9
th
Quarter. My
textboook covers QC in detail.
Quality Control
An acceptable QC program has three
steps:
1. Acceptance Testing
2. Routine performance monitoring
3. Maintenance
Acceptance Testing
The x-ray machine, cassettes and film
processor or digital system are the largest
capital expense you may experience.
It makes economic sense to make sure
that the equipment meets the performance
standards.
It is recommended that a third party such
as a health physicist do the testing.
Acceptance Testing
Areas that should be tested include on the x-ray
machine:
Shielding of Room
Focal spot size
Calibration of mA, timer or mAs
Calibration of kVp
Linearity of exposure
Beam alignment
Grid centering
Collimation
Filtration (HVL)
Acceptance Testing
Areas that should be tested on the x-ray
cassettes:
Screen contact
Screen speed
Light leaks
Light spectrum matching
Acceptance Testing
Areas that should be tested on the x-ray
film processor:
Developer temperature
Replenishment rates
Travel time
Water flow
Hypo retention
Quality Control
The acceptance testing ensures that the
machine was installed and calibrated
properly.
The performance may drift or deteriorate
over time. Consequently, periodic testing
is required to monitor the performance.
With the exception of film processing most
testing is annual or semiannual.
Quality Control
After a major repair, the machine should be
retested to ensure that it was repaired properly.
When the testing shows that the machine is not
performing properly, service or preventive
maintenance is required.
Manufactures establish recommended
preventive service schedules. When these are
followed many repairs become unnecessary.
Radiographic Quality Control
Areas of concern in x-ray machine
Focal Spot Size will impact spatial resolution
Filtration will impact patient exposure
Collimation will impact patient exposure
kVp calibration will impact image quality and
exposure.
Exposure timer accuracy will impact image
quality and exposure
Radiographic Quality Control
Areas of concern in x-ray machine
Exposure linearity will impact exposure and
image quality
Exposure reproducibility will impact exposure
and image quality.
Alignment of tube and image receptor will
impact exposure and image quality.
Focal Spot Testing
When the machine is installed or the tube
is replaced, the focal spot size should be
measured. Then annually thereafter.
A pin hole camera, star test pattern or line
pair test tool.
As the tube ages, the focal spot tends to
grow and spatial resolution is lost.
Filtration
The filtration is measured but determining
the half value layer of the beam at specific
exposure levels. Minimum filtration is
2.5mm aluminum.
As a tube ages, tungsten will plate the x-
ray port and increase filtration. This can
cause technique problems. Inadequate
filtration will significantly increase patient
exposure.
Collimation
If the collimation is misaligned, intended
anatomy can be missed.
It can be tested in many ways from using
pennies to using test patterns.
Misalignment can not exceed 2% of the
SID.
It is tested semiannually and after the
replacement of the collimator lamp.
kVp Calibration
In diagnostic radiology, any change will
impact patient exposure. A variation of
about 3% will impact contrast and image
density.
Can be tested with filtered ion chambers,
filtered photodiodes or even a cassette
with calibrated filters.
Tested annually.
Exposure Timer Accuracy
The exposure time is the responsibility of
the operator. It will impact the density of
the image and spatial resolution.
Tested with an ion chamber, multi-meter
internally or even a spinning top.
Exposure time must be within 5% for
exposure times greater than 10 ms and
20% less than 10 ms.
Exposure Linearity
Many combinations of mA and time will
produce the same mAs value. The ability
of the machine to produce a constant level
of exposure with various combinations of
mA and time is called exposure linearity.
Can be tested with a step wedge and
densitometer or rate meter.
Should be within 10% for adjacent
stations.
Exposure Reproducibility
Any exposure using the same factors
should produce the same level of density
and contrast on the image.
Sequential exposure should be
reproducible to within 5%
Can be tested with a rate meter or step
wedge and densitometer.
Performance standards for x-ray
equipment
Measurement Frequency Tolerance US Tolerance Ca
Filtration Annually 2.5 mm Al 2.7mm Al
Collimation Semiannually 2% of SID 2% of SID
Focal Spot Annual 50% 50%
kVp Annual 10% 2 kVp between
60 & 100 kVp
Timer Annual 5% > 10 ms
20 % 20 ms
3 phase 5%
1 phase 10%
Linearity Annually 10% 10%
Reproducibility Annual 5% 5%
Darkroom and Processing
The development of the image is
dependent upon the temperature of the
developer, its concentration and how long
the film is in the developer.
The film is sensitive to variations in the
environment and processing from the time
it is manufactured until it is processed.
Darkroom and Processor QC is the key
process of Quality Control.
Processing
Processor densitometry is performed daily
before the first patient is exposed.
A sensitometer is used to produce a step
wedge image on the film that is evaluated
with a densitometer.
The densitometer reads the optical
density of the processed image.
A digital thermometer is used to test the
chemical temperatures in the processor.
Processing
Key densities on the processed film are
measured and then graphed.
Base plus Fog is measured on an area of
unexposed film to check the darkroom
environment.
Speed is tested at the level of exposure that
produces a density of 1.25OD
Contrast is tested at the level that produced a
density of 0.40 OD and one that produced a
density of 2.20.
Processing
By monitoring these densities, problems
with film processing can be detected
before image quality deteriorates.
In 9
th
Quarter we will cover how to perform
processor QC and problem solve.
Waste Records
Since used fixer is classified as a
hazardous waste material, it is important
to maintain accurate records of usage and
disposal.
The extent of records vary by city, county
and state. You are responsible for the
proper disposal of the waste. Some
regions include developer as hazardous
waste.
Silver Recovery
If the silver ions are removed from the
fixer, it may be disposed of in the normal
waste when diluted with water.
There are two primary types of silver
recovery systems.
Metallic replacement uses steel wool and
can recover 95% of the silver in the effluent
Electrolytic recovery passes direct current
through the solution and nearly pure metallic
silver is deposited on the cathode.
Silver Recovery
Old radiographic films and repeated films
are retained for silver recovery. X-ray
images can not be disposed of in normal
trash.
They also can not be used to clean the
processor rollers.
Waste recovery companies will either burn
or chemically remove the silver from the
film.
Performance standards for film
processor and darkroom equipment
Measurement Frequency Tolerance CA Tolerance US
Sensitometry Daily B+F: 0.05
MD: 0.10 OD
Contrast 0.10OD
B+F:0.08 OD
MD 0.15 OD
Contrast 0.15 OD
Safelight Semiannual < 0.05 OD in 2
minutes
n/a
Darkroom temp Monthly 70F 5 n/a
Darkroom
humidity
Monthly 50% 10% n/a
Developer temp Daily 0.5F 2-3
Replenishment Daily 5%
Transport Annual 3% 3%
Accessory QC
The cassettes and screens are the area of
chief concern. Problems with either will
result in artifacts on the images and
increased retakes.
The screens need to be properly cleaned
frequently. Mammography screens are
cleaned daily. California recommends
monthly cleaning.
Accessory QC
Dirty screens produce white artifacts on
the image.
Multiple white artifacts indicate the need to
replace the screens.
Screen contact is tested semiannually. A
problem with screens contact will cause a
loss of resolution.
As screens age, they loose speed so this
is also tested.
Accessory QC
The other important accessory is the
gonad protection devices and lead aprons.
Improper care of the apron can result in
cracks and holes in the lead that reduces
their effectiveness.
Aprons and shields are tested
semiannually. The easiest was to test
them is with video-fluoroscopy but film can
be used.
Performance Standards for
Accessories
Measurement Frequency Tolerance CA Tolerance US
Screen contact Semi annual No problems
detected
No problems
detected
Aprons/shields Annually No holes No holes
Screen
matching
Annually 0.05 OD for all
cassettes used
Screen cleaning Monthly Semimonthly
Record keeping
All electromechanical devices need
periodic service.
There are three types of maintenance.
Scheduled maintenance such as processor
monthly or weekly service. It includes
observing moving parts and lubrication.
Preventive maintenance is planned service
and replacement of parts at regular intervals
before they fail at inopportune times.
Record keeping
Non-scheduled maintenance is the worst
type of service because it impacts patient
service. It may also be very expensive.
With proper scheduled and preventive
maintenance, non-scheduled service can be
minimized.
All service schedules should meet
manufacture recommendations.
All service should be documented as part
of the quality assurance program.
Retake Analysis
Required part of a QA program in
California.
Evaluation includes
View repeated
Cause of the repeat
Rate of retakes should be less than 5%.
Information can be gathered from the log
that the state mandates for patients being
exposed to radiation.
Retake Analysis
Done every three months using a
relatively large sample of data to see
trends in:
Type of examination being repeated.
Reasons for the repeated films.
Determine if additional training or review is
needed.
Determine if equipment service might be
required.
Repeat Analysis
Your patient log can be designed to
capture both films usage and repeated
films.
Data is gathered from log for analysis
Repeated films can be put into two main
categories:
X-ray Personnel Errors
Equipment malfunctions
X-ray Personnel Errors
Failure to measure patient.
Use of improper technical factors (mAs,
kVp or distance)
Incorrect positioning
Improper Collimation
Improper use of accessories such as
cassettes, grids or filters
X-ray Personnel Errors
Improper handling of exposed or
unexposed films.
Failure to clearly communicate to the
patient breathing instructions and to
remain still.
Failure to observe patient during
exposure.
X-ray Equipment and Accessory
Failure or Malfunctions
Inaccurate calibration of kVp and mA.
Inaccurate timer calibration
Dirty or damaged cassettes
Improperly labeled or damaged grids
Malfunctioning collimator
Improper film storage or processor
function.
Reasons for Retake Films
Over or under exposure accounts for over
50% of retakes nationally.
Errors in positioning (25%)
Patient motion 11%
Processing errors 6%
Wrong view, beam alignment,cassette
screen or grid errors and artifacts.
Retake Films by Region
Cervical Spine Exams = 7%
Thoracic Spine Exams = 17%
Lumbar and Abdominal X-rays = 40%
Skull, Chest,Lower Extremities = 15%
Majority or retake results in
unnecessary exposure to gonads or
blood forming organs of the body.
Daily Log Design
Most regulatory agencies
will require a log of
patients having radiation
exposure.
Columns can be added to
capture film usage,
repeats, views repeated
and reason.
This data can be
gathered and analyzed.
Retake Analysis
In this example, most of
the retakes were of the
T-spine. Potential
reasons include:
Improper use of filters
Incorrect
measurements
Faulty technique chart

Retake Analysis
The reason of each
retake is recorded
and percentages are
computed to
determine the overall
rate and rate by
reason.
Less than 5% is ideal.
End of Lecture
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