PowerPoint Slides

for

RADIOGRAPHY
IN THE

DIGITAL AGE
4th Edition
1
SERIES

2
CHAPTER 42

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4
 Understanding Table 42-1
 Distributed skin exposure is not the exposure
delivered to any particular section of tissue, because
it may be spread out by different projections to
different portions of the skin, nor is it the
scientifically ascertained dose to the patient , which
would be measured in milligray

 Distributed skin exposure is defined as a summed

total of the entrance exposures, representative of the
radiographic procedure

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 Understanding Table 42-1
 Exposures listed assume that the patient is of
average thickness and therefore average
radiographic techniques are used

 It should be remembered that listed exposures are

partial body, not whole-body, exposures

 Exposures listed were averaged from the Biological Effects of

Ionizing Raditation (BEIR) Report, BERT (Background
Equivalent Radiation Time) by Cameron, Hendee & Bushong,
and an independent ion chamber survey by a medical physicist

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7
 Notes on Table 42-1
 The 2-view chest study delivers about 4-5 times the exposure of a
single PA chest – This agrees with proportional anatomy (Chap.
26), which lists the lateral technique at 3-4 times the PA view

 A single abdomen exposure is approximately equal to an entire

5-view cervical spine series, the annual natural background
exposure, and the typical annual occupational exposure for
radiographers – all of these are about 5 times the 2-view chest

 The “bone” procedure producing the highest exposure is the

lumbar spine series, which can generate as much as 50 mGy for
3 views or 70 mGy for 5 views

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 Notes on Table 42-1
 The IVU series can deliver from 35 mGy for 7 views to 60 mGy for
12 views

 Overall exposure levels listed for BEs and UGIs are conservative
estimates based on 24 mGy/min for fluoroscopy and 3 mGy per
overhead view. These can vary widely depending on the number of
overhead and “spot” views taken and the condition of the
fluoroscopic unit

 Risk comparisons with such things as cigarettes smoked or miles

driven in a car are inherently difficult to make with high scientific
accuracy, and must be interpreted with some reservation –
nonetheless, they can be very useful in providing perspective

 By using intermittent fluoroscopy and by employing the minimum

number of views necessary, exposure can be lessened significantly

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 Notes on Gonadal Exposure: Table 42-2
 For most radiographic views, projected at some distance from
the gonads, gonadal exposure is due to scatter radiation and
very roughly averages about 1/1000th of the entrance skin
exposure (ESE) within the beam

 For procedures in which the collimated field comes close to the

gonads, gonadal exposure is very roughly 1/100th of the ESE in
the beam

 For procedures on female patients which include the ovaries

within the primary x-ray beam , the ovarian dose is
approximately 1/3 of the ESE, due to beam filtration by tissues

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11
 Optimizing Radiographic Technique
 1. mAs and kVp: High-kVp, low-mAs techniques are generally
recommended. With digital equipment, increases in technique
should generally be made using kVp, while decreases should
generally be made using mAs
 mAs = directly proportional to patient exposure

 Suppose it is desired to reduce mottle appearing in the image by

increasing exposure at the detector:
-If the mAs is doubled, the patient’s ESD increases 100%
-A 15% increase in kVp accomplishes the same thing at the
detector. From 80 to 92 kVp, the increase in patient
ESD is (92/80) 2 = 1.32 times more ESD, or a 32%
increase
-This is 2/3 less increase than when using mAs
-Patient dose can be spared by using kVp rather than mAs to increase

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 Optimizing Radiographic Technique
 2. Generators and Filtration: High-powered generators bring a
net savings in patient exposure for equivalent techniques.
Patient exposure could be significantly reduced for mobile
procedures using CPG units by reducing mAs rather than kVp
relative to techniques used on fixed equipment in the
department

 Slab filters should never be removed from the collimator or tube

13
 Optimizing Radiographic Technique
 3. Field Size Limitation: Inclusion of nearby organs within the
primary beam makes a 100-fold difference in dose to these
organs

 Repeats caused by over-collimation clipping off anatomy of

interest effectively double exposure for the view
 Proper collimation is the most effective means the radiographer
can use to limit radiation exposure to patients

 4. Patient Status: Thicker body parts require higher exposures.

Compression can reduce the fluoroscopic exposure needed

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 Optimizing Radiographic Technique
 5. Grids and Image Receptors: The minimum grid ratio should
be used which provides sufficient clean-up of scatter radiation

 Materials used for the front panels of imaging plates should be

as radiolucent as feasible
 The greater the overall efficiency of the image receptor system,
the less technique is required, and the more patient exposure is
saved

 Default digital processing allows lower grid ratios to be used

and more procedures to be done non-grid. Virtual grid software
eliminates the need for grids for many procedures, reducing
patient dose by 67-75% through technique reductions

15
 Optimizing Radiographic Technique
 6. Digital Processing Speed Class: The highest speed class
which does not present an unacceptable level of mottle
should be selected. Some procedures allow for more mottle

 The Deviation Index (or exposure indicator) should be

regularly monitored to help prevent dose creep from
excessive radiographic techniques

 7. Radiographic Positioning: Repeating exposures for minor

positioning corrections must be discouraged. Exposure to
some critical organs can be minimized by doing certain
procedures PA instead of AP (see textbook)

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 Optimizing Radiographic Technique
 8. Increasing SID to Reduce Patient Dose:
Increasing SID reduces patient ESD somewhat even after
increasing mAs to compensate for the inverse square law. This is
because when the SID in increased by a particular amount, the SSD
is changed by a greater ratio than the SID, because the SSD is
smaller to begin with.
Demonstrated mathematically in Chapter 22, the technique
compensation for the SID is slightly less than the savings in patient
dose from increased SSD, for a net reduction in patient dose

-Several manufacturers now produce x-ray units with default

tabletop SIDs at 110 or 115 cm. Advantages include:
1. Reduced patient ESD
2. Increased spatial resolution (sharpness)
3. Decreased magnification
4. Increased field-of-view (next slide)

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 Increasing SID to Expand Field-of-View
Increasing SID adds appx. 2 cm to the lengthwise field-of-view
for every 25 cm (10”) added SID. This allows more anatomy to be
included within the area of the image receptor

Courtesy, Digital Radiography Solutions

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 Increasing SID to Expand Field-of-View
Increasing SID from 100 cm (40”, left) to 180 cm (72”, right) adds
more than 7 cm to the lengthwise field-of-view, enough to include
an entire additional vertebra within this AP lumbar spine projection.
To take advantage, do the procedure at the upright bucky at 180 cm

Courtesy, Digital Radiography Solutions

19
 Increasing SID to Save Patient Dose
Because of the increased exposure latitude for digital
processing, an increase in SID of up to 25 cm can be
executed without compensating the mAs at all for an
even greater savings in patient dose.
-Unacceptable mottle may result from too great an
uncompensated increase in SID, especially combined with a large
patient or other factors that reduce exposure reaching the IR

Courtesy, Digital Radiography Solutions

20
 Optimizing Radiographic Technique
 8. Radiographic Technique and AEC: A systematic approach
including the regular use of technique charts should be adopted

 AEC still requires the application of certain optimum technique

factors. Proper collimation and accurate positioning over
correctly-selected detector cells is essential. Some situations
require the use of manual technique to minimize retakes

 9. Quality Control and HVL: Quality control programs help

detect trends toward poor images or excessive patient exposure,
before these results actually come about.
 In particular, the HVL must be routinely monitored, because poor
penetration results in higher absorbed dose to the patient

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22
Patient Shielding
Types of Shields:
1. Most shields are contact shields, including “lap” or “half-
shields,” lead aprons, and leaded-rubber cut-outs, placed
directly on patient
2. Shadow shields:
Extension arm attaches
to collimator, allowing
sterile fields to be
maintained in surgery

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 Patient Shielding
 Generally: “The patient’s gonads must be shielded any
time they lie within 5 cm (2") of the edge of a properly
collimated beam,” provided diagnosis is not compromised*
 *See next slide

 A good example is a femur procedure on a male patient. The

gonads are easily shielded without risking occlusion of the
proximal femur, and otherwise could be in the primary beam

 Leaded rubber sheets can be used as a back-up to

collimated field edges, which are frequently inaccurate

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 2019 Update: Patient Shielding of
Abdominal and Pelvic Procedures
 After decades of studying the frequency with which
abdominal/pelvic shielding has interfered with diagnosis, in 2019
the American Association of Physicists in Medicine (AAPM)
recommended that the practice be generally discontinued
 This policy was soon endorsed by both the American College of
Radiology (ACR) and the National Council on Radiation
Protection (NCRP)
 The policy does not apply to procedures outside the abdomen and
pelvis – Gonadal shielding should still be appropriately used any
time the x-ray beam is close to the gonads for such procedures
 Example: An upper extremity with the patient seated up against
the x-ray table, arm extended onto the table and lap close to the
side of the table

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 2019 Update: Patient Shielding of
Abdominal and Pelvic Procedures
 Rationale given for this change in policy:

 1. Genetic effects are lower than previously estimated

 2. Improvements in technology have reduced gonadal dose
 3. Shields can interfere with automatic exposure control
(AEC) and with digital processing
 4. Gonadal shielding may obscure important diagnostic findings
 5. For certain exams, it is difficult to accurately shield the gonads
 6. A significant portion of dose to the gonads (especially for
female patients) is from internally scattered x-rays that cannot
be blocked by shielding

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Examples of Common ALARA Violations
 ALARA: As Low as Reasonably Achievable

 AP Chest on female patient in a wheelchair:

 Female ovaries are only a few cm below the level of the iliac
crests
 There can never be any reason for the collimated x-ray field to
extend below the iliac crests

 Hand or wrist with patient seated and IR placed in lap

 Hand, wrist, forearm or elbow at edge of table with field
spilling over into seated patient’s lap below

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Patient Shielding
 Lead Aprons or Leaded Rubber Sheets:

 General Effectiveness = approx. 85%

-Range is from 66% - 99%, depending on lead thickness and

kVp level

-0.5 mm of lead is 88% effective at 75 kVp

(12% of primary beam gets through)

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Policies Regarding Pregnant Patients
 Provision of patient education materials strongly
recommended, e.g. brochures, videotapes in waiting areas,
etc.

 Ask all child-bearing age females if they could be pregnant

-Notify radiologist or supervising tech

 For non-urgent procedures, a policy of elective scheduling

can be used: Have x-ray procedures done within 10 days
following the onset of mensus

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Patient Pregnancy Policies
 When a radiation exposure has occurred to a developing embryo
due to a pregnancy unknown at the time or to an emergency
procedure, the embryo dose can be reasonably estimated at 1/3
of the mother’s typical ESE for that projection

 Abortion should never be counseled by medical personnel if

estimated embryo/fetal dose is less than 100 mGy, covering
most situations in diagnostic imaging

 Although fetal exposures above 250 mGy pose a substantial

increase in risk for congenital defects, such a level of exposure,
(requiring an ESE of 750 mGy) are very rare for diagnostic
procedures

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Guidelines for Equipment
 1. All exposure switches
including the fluoroscopy
foot-switch, and drive
switches on mobile units
shall be of “dead-man”
type, which requires
continuous pressure to
remain energized

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Guidelines for Equipment
 2. A fluoroscope routinely operated above 90 kVp
should have at least 3 mm of aluminum-equivalent
filtration . [2.5 mm minimum for overhead units capable
of operating at > 70 kVp; 1.5 mm for mammography
and other units operating at < 70 kVp,

 3. Devices connected to the collimator ensure that the

Tube-Tabletop Distance shall not be less than:
-Fixed Unit: 38 cm (15")
-Mobile Unit: 30 cm (12“)

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 Plastic “cones” (left) or metal rails (right) typically installed on
smaller collimators prevent the x-ray tube target on a mobile
unit from being brought closer to the patient than 30 cm (12”)

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Guidelines for Equipment
 4. During fluoroscopy, a 5-minute cumulative timer
must emit an audible signal at 5 minutes
accumulated beam-on time
 Radiographers should not impede the function of this
timer – They can reset it immediately when it sounds

 5. Fluoroscopic collimator shutters shall be visible on

the TV monitor at all times fluoroscopy is engaged

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Guidelines for Equipment
 6. Fluoroscopic exposure at the tabletop shall not exceed
100 mGy/minute nor 21 mGy / min. / mA
 -should not exceed 50 mGy/min.

Typical Fluoroscopy Exposure: “Best Case” Scenarios:

= 20 mGy/min. @ 5 min. Fluoro OR

40 mGy/min. @ 2½ min. Fluoro

= approximately 100 mGy ESE

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Fluoroscope Technology
-Normal, high-contrast, recorded, pulsed or digital
fluoroscopy all produce different exposure levels.

-Most conventional fluoroscopes average an ESE of about

50 mGy/minute

-Limits of 10 mA and 100 mGy/minute exposure were set

on conventional fluoroscopy units “except during
recording of the fluoro image” where no limit was set to
allow unlimited spot-filming

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High-Contrast/Enhanced Imaging
Fluoroscopes (“Boost image/contrast”)
-Euphemisms for units using higher levels of radiation
output to produce improved images

-Can operate at from 20 to 300 mA (10 mA, 100 mGy/min limit

not applied) and can pose a significant hazard to patients

-Only newer machines have dose rate limit imposed: “100

mGy/min for first position, 200 mGy/min for second [lateral]”

-Some have louder signal that sounds at 10 minutes cumulative

fluoroscopic beam-on time

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With Pulsed Digital Fluoroscopes
USE:

-Short pulse widths and reduced frame rates reduce patient dose
(Chapter 37). Pulse widths can often be cut in half.
-Maximum source-to-skin distance (SSD)
-Minimum object-image distance (OID)
-Large field-of-view (FOV) or least magnification
- Dose quadruples when the FOV is halved
-Proper collimation for the anatomy
- Note that over-collimation (too tight) can surge the ABC (automatic
brightness control), causing excessive patient dose
-“Last image hold” or “fluoro save” to minimize beam-on time
- Can save as much as 10 times patient dose (90% reduction)
-Last held fluoro image in place of overheads

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Pulsed Mode Fluoroscopy
-Pulse width = exposure time for each pulse, e.g. 6 msec or 3 msec
-In continuous mode, radiation between frames is wasted

-3 msec can be selected by the radiographer. Still using 20 mA, this

will cut patient exposure in half.

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 Pulsed Digital Fluoroscopes
FOR SMALL PEDIATRIC PATIENTS (<28 kg or 5 years old or less):

-Removing the grid can reduce radiation dose by a factor of 2 or

more
- “Changing from continuous fluoroscopy to pulsed fluoroscopy at
7.5 frames per second and removing the grid can reduce
entrance dose by 87% for a 1-year old child”

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Fluoro Procedure Dose Affected By:
1. “Mode” used = input phosphor diameter: 15, 23, 30, or
40 cm.
2. Selected mA
3. Operation in continuous mA mode Vs. pulsed mode
4. Actual source-skin distance
-Rolling the patient into lateral position reduces SSD
5. Cumulative beam-on time of fluoroscopy
6. Number of digital “spot” exposures taken

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Pulsed Mode Fluorocopes
 Fluoroscopes can emit from 20 to 100 mGy per minute; C-arm
units can emit still higher exposure rates

 Example Dose Calculation:

 Assuming a conservative exposure rate of 40 mGy/minute:

 At 10 minutes beam-on time, 400 mGy could be delivered to a

localized portion of the patient’s body
 Recall that 250 mGy whole-body dose can cause a drop in blood
count

 Doses as high as 800-1000 mGy are becoming commonplace

among C-Arm procedures. (3000 mGy will burn the skin.)

42
C-Arm Units in Surgery
-Severe radiation burns have occurred with modern C-arm units

Example Physicist’s Estimation:

- Taking ion chamber measurements, an exposure rate of 30-40

mGy/min. was measured at a distance of 75 cm from the x-ray
tube. But, to allow for a sterile field, if the image intensifier is
moved higher above the patient , bringing the x-ray tube 30 cm
from the patient: The ESE is estimated at 180 mGy/min.

-It has been recommended that surgeons adopt a

target maximum exposure to the patient between
200 and 400 mGy even for urgent situations

43
Current Issues
-In the late 1990’s, a study conducted by an FDA task force
came to the following conclusion:

-“In cardiovascular interventional radiology, angiography

and pain management procedures, new techniques
requiring longer exposure times and higher dose rates to
image smaller objects (emboli, etc.) are now resulting
again in severe burns & lesions.”

44
Current Issues
Safe Medical Devices Act of 1990 requires reporting to
the FDA of serious radiation injury or death.

-The FDA task force identified a list of high-risk procedures,

all of which present the “possibility of exceeding 100
minutes fluoro time at 20 - 50 mGy/min using 13 cm or 18
cm mode”

-At 4 R/min, 100 minutes of fluoro time would deliver an

ESE to the patient of 4 Gray

45
Identified High-Risk Procedures (FDA)
1. PTCA -percutaneous transhepatic cholangiography
-Case study showed an average of 51 minutes of
fluoroscopic beam-on time [compared to 7.1
minutes for a typical angiogram]
-At 4 R/minute, 51 minutes would deliver an ESE to the
patient of 2.04 Gray

2. RFAB -radio frequency ablation

3. STEN -stent placement

46
Current Issues
-The FDA task force recommended the following for
such high-risk radiation procedures:

1. Recording in patient’s chart the field size, body part,

technique, and estimate of dose received
2. Informed consent from the patient on possible
radiation effects
3. Customized protocol delineating when use of “high-level”
fluoroscopy will be allowed
4. Maximum allowable cumulative fluoro time
5. Credentialing of all fluoroscopists (including MD’s)

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Current Issues: CT
-The FDA also identified adolescent and pediatric CT scans
as an area of concern, due to inappropriate and excessive
referrals by physicians (particularly in the ED) for CT scans
when routine diagnostic radiographs would suffice

ACR Appropriateness Criteria

Continuing reports from the American College of Radiology
suggest the most appropriate imaging modality to referring
physicians for various clinical conditions. Over 200 entries
include numerical appropriateness ratings for each case

48
Current Issues: CT
-A second cause the FDA identified for adolescent and
pediatric CT scans as an area of concern is failure of CT
radiographers to reduce the mA used for adult patients
downward appropriate to patient size and weight, and to
the anatomical part. They recommended:
1. Reducing tube current according to weight, size and anatomy
2. Establishing technique charts based on part weight and size
-Most CT units now have built-in charts
3. Increasing the table increment or pitch to reduce the number
of “slices” taken
-An estimated 33% reduction results without loss of
diagnostic information

49
Current Issues
-The radiographer is frequently the person present with
the most expertise in radiation protection

-Radiographers and their organizations must take a

more active role, and show more leadership in
preventing unnecessary excessive exposure

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51
Personnel Monitoring
-Required if it is likely that individual will receive >1/4 the
occupational DEL (~1 mSv/month) at any time

-Federal regulations require that any monitor be worn on the

portion of the body likely to receive the greatest radiation
exposure.

-Wear at the collar level OUTSIDE of any lead apron

or shield – This gives an indication of eye lens dose

-A control monitor must be placed to acquire background

exposure for comparison to obtain accurate report

52
Personnel Monitoring
-The unprotected head and neck (including the eye lens and
the thyroid gland) generally receive about 10 times the
torso dose when the torso is covered with a lead apron

-Devices for personal monitoring:

1. OSLD
2. TLD
3. Film badge
4. Pocket dosimeter (for very short-term checks, not
recommended for monthly monitoring)
-Described in Chapter 39

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Personnel Monitoring Reports
Must include:

 Proper identification
 Current period dose
 Cumulative quarterly dose
 Cumulative annual dose
 Cumulative total exposure (for duration of service)
 Unused portion of the cumulative lifetime DEL

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Personnel Monitoring Reports
NOTES:

 “M” = “minimal exposure”

 “N” = “negligible exposure”
 (<100 μGy for film badge, <50 μGy for OSLD or TLD)

 “Penetrating” or “deep” Vs. “Shallow” dose columns are

primarily for nuclear industry workers to discriminate
between alpha, beta and gamma exposure, and are not of
much consequence for radiographers receiving only x-ray
exposure

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56
Personnel Monitoring Reports
NOTES:

-Several companies continue to use millirem (mrem) in

personnel reports. To convert mrem to microsieverts (μSv),
simply add a zero (multiply by 10)

-Maximum reporting period = quarterly (every 3 months)

-Employers must make reports accessible to each employee

-When leaving a job, the radiographer should receive a

summary report of cumulative exposure, and present it to
new employer. Ultimately, it is the radiographer’s
responsibility to ensure this happens

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The Cardinal Principles:
 The main source of radiation exposure to the radiographer
is scatter radiation from the patient

 Time: Exposure is directly proportional

 Distance: Exposure is inversely proportional to the

square of the distance (inverse square law)

 Shielding: Exposure is inversely exponential

58
Using Distance for Protection
 NCRP Report #116: “Whenever possible, all personnel
should stand at least 2 meters from the x-ray tube and
patient”
 Scatter exposure at 1 meter from patient is about
1/1000th patient’s in-beam exposure

 Scenarios:

1. Radiographer 1 meter from table with lead apron on

= ~1/10,000th patient’s in-beam exposure
2. Standing behind radiologist at 2 meters both with
aprons on = < 1/500,000th patient’s in-beam exposure

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On a topographical map, lines represent areas of
equal elevation - closer lines indicate steeper
terrain where the elevation drops more rapidly

60
Iso-Exposure
Curves
Lines represent
positions of
equal radiation
exposure in the
room at about
waist height -
Closer lines
indicate areas
where the
exposure drops
more rapidly

61
 Iso-exposure curves indicate that the least
exposure to personnel is to the SIDE of the table

 Generally, avoid standing at the head or foot of the

x-ray table unless it is necessary for the procedure
or for patient care

 Radiation exposure to personnel is always least at

right angles to the central ray of the x-ray beam

 Backscatter is more intense than forward scatter

 Always place the I.I. of a C-arm unit above the patient

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C-Arm Fluoroscopy Protection
-Scatter exposure to personnel is significantly reduced by
placing the fluoro tube under the patient with the image
intensifier over the patient:

-Dallas study on C-Arm Scatter Radiation to Technologist:

Tube Under Table Tube Over Table

Eye/Thyroid: 120 μGy 600 μGy
Gonads: 270 μGy 250 μGy

Conclusion: “Backscatter is more intense than forward scatter”

-Higher kVp increases percentage of forward scatter.

63
Personnel Shielding Requirements
 from NCRP Report #102:

 Only persons whose presence is necessary shall be in the

diagnostic .. x-ray room during exposure. All such persons
shall be protected with (lead) aprons … Regulations also
state that during lengthy fluoroscopic procedures … the
leaded apron shall always be worn … Operators of mobile
equipment should wear lead aprons. Apron and gloves
should be worn when holding a patient or when closer than
2 meters (6 ft) from the beam

64
Personnel Shielding Requirements
 Lead aprons must be worn by any one whose
exposure may exceed 50 μGy / hr

 Lead thickness of 0.5 mm is required if machine is

routinely operated above 100 kVp (All R&F)
 For non-fluoroscopic and low-kVp units,
0.25 mm required, but 0.5 mm recommended

 Fluoroscope aprons once each year to check for

cracks

65
Leaded Gloves
 0.25 mm lead required – flexibility needed

 Lead-impregnated gloves are appx. 20-30% effective, but

can lead to a false sense of security because on the
fluoro screen the operator sees the effect of 2
thicknesses whereas the actual protection is only 1
thickness

 Worse, the presence of lead gloves in the field causes the

Automatic Brightness Control to increase dose rate to
compensate, affecting the patient. Lead gloves must be
used with careful deliberation

66
Effectiveness of Leaded Garments
 Effectiveness of lead aprons depends on the
amount of lead content and the kVp used

 General Effectiveness = approx. 85%

-Range = 66% - 99%
-e.g., 0.5 mm Pb is 88% effective at 75 kVp)

-For a fixed level of filtration and kVp, the HVL

becomes a measure of shielding effectiveness – the
lower the HVL, the more effective the material

67
Tenth-Value Layer (TVL)
 HVL, an appropriate unit for beam filtration,
becomes an unwieldy unit for shielding materials
such as lead, copper or steel

 A more appropriate unit for shielding effectivenss is

the tenth-value layer (TVL), defined as that amount
of material required to reduce the intensity of the x-
ray beam to one-tenth the original

68
-Graph showing the effect of stacking lead aprons or sheets:
Each successive apron attenuates about 85% of the beam,
leaving 15% penetration of the previous amount, leaving 15%
after the first apron, 2.25% after the second, 0.3% after the
third, and so in exponential fashion

69
Effectiveness of Leaded Garments
 More accurately, since there is a hardening effect
on the x-ray beam from each successive layer of
lead, each apron is a bit less effective than the
previous one
 e.g., 1st = 85%, 2nd = 75%, 3rd = 65%, and so on

 Standard materials in walls and doors do not

provide adequate shielding from scattered x-rays.
Two lead aprons should be kept with each mobile x-
ray unit

70
Other Minimum Lead Thicknesses
1. Fluoro tower: Required equivalent shielding of
2 mm lead (= primary barrier)

2. Bucky Slot Cover = 0.25 mm lead must move into

place when bucky is moved to foot of table

3. Fluoro curtain = 0.25 mm lead required for

overlapping slats

71
Related Guidelines
 Fluoroscopy must not be capable of operating with the
fluoro tower in “park” position (behind the table)

 Exposure cords on mobile units are required to be

extendable to at least 2 meters (6 ft) from the x-ray machine
to allow the operator to stand back at this distance

 Any person within 2 meters (6 ft) of the x-ray tube who

cannot leave the area must be provided with a lead apron

 For ALARA protection, radiographers should always

maximize both shielding and distance during exposure

72
Slats on both the fluoro curtain (upper arrow) and the
bucky slot cover (lower arrow) must have 0.25 mm lead

73
Policies for Personnel Protection
 Holding imaging plates or patients:
1st choice: Mechanical device
2nd choice: Adult relative/friend of pt
3rd choice: Health worker (non-RT)
4th choice: Non-reproductive RT

Guiding principles:
1. Minimize exposure when possible
2. Distribute radiation exposure among the general
population rather than RTs
3. Minimize exposure to the reproductive population

74
Policies for Personnel Protection

1. For fixed unit, the exposure cord must be too short to allow
operator out of control booth

2. The control booth must be so constructed that radiation can

only reach operator after 2 scattering events

Rule of Thumb: Each scattering event

reduces radiation intensity to approx. 1/1000th

75
By constructing the control booth such that radiation can only
reach the operator after 2 scattering events, intensity levels are
reduced to about 1 millionth of the patient’s ESE – This is in
addition to the effects of distance by the inverse square law

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Policies for Technologist Pregnancy
 Recommended:

 1. Encourage, but not require, reporting of

pregnancy at earliest possible time
2. A 2nd monitor worn at waist level under any lead
apron, to more directly indicate fetal dose
3. Limit radiographer from high-dose procedures
4. Document instruction on DEL and ALARA
guidelines/practices

-Involuntary leave NOT necessary

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Additional Guidelines for Equipment
 1. Leakage radiation is defined as that emitted
through the x-ray tube housing in any direction
other than the port. At 1 meter from tube, leakage
from the tube housing must not exceed 1 mGy/hr

 2. Generally, tube housing must have minimum of

2mm lead throughout

 3. All units required to emit an audible or visible

signal to indicate any time beam is on

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79
Fixed Barrier Shielding
 Primary barrier = Primary beam strikes in normal use
 Secondary barrier = Usually only scatter radiation
strikes
 Control booth is always considered a
secondary barrier

Thickness Guidelines:

 Primary barrier must be 1.5 mm lead equiv. (1/16")

 Secondary barrier should be 0.8 mm lead eq. (1/32")

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-Lead in wall barriers need only extend to 2.2 m (7 ft) high

-Leaded Joints must overlap at least 1 cm, or double the lead

thickness, whichever is greater

81
 Alternative Shielding Materials
 Specially Leaded Glass (yellow):
-6.4 mm (1/4") = equivalent to about 2 mm sheet lead
-“Use 4 X recommended sheet lead thickness”
e.g.: Control booth (secondary barrier): 0.8 mm X 4 =
3.2 mm leaded glass

 Regular Glass = similar to concrete:

- 10 cm (4“) of concrete = approx. 1.5 mm (1/16“) of lead
-NCRP: “Should only use concrete for minimal needed
protection” because of air pockets

 Masonry: Generally 10 cm = 1.5 cm lead

 Gypsum board = 6.25 cm can form adequate secondary
barrier

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Factors for Adequacy of Barriers
 For a specific wall in a particular room, additional
lead may be required based on the formula:

W x U x O x E
D
 where:
 1. W is the maximum workload in mA-minutes per wk
 2. U is the use factor
 3. O is the occupancy factor
 4. E is the kVp capacity (energy) for the machine
 5. D is the distance from the machine to the wall

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Averaging Workload in mA-minutes
= Beam-on time for 5-day week X average mA.
 Simplified Example:
Room A does 3 barium enemas and 6 C-Spine series per day.
X 5 day week = 15 BE’s and 30 C-Spines
C-Spines = 5 overheads each = 150 overheads
Typical overhead exposure time = 0.1 seconds
Typical mA = 200
150 X 200 X 0.1 = 3000 mA-seconds/60 = 50 mA-min.
 BE’s = 6 overheads, 6 spot-films, 4 minutes of fluoro each
= 180 overhead/spots AND 60 minutes fluoro
Overheads & Spot Films:
Typical exposure time = 0.1 seconds
Typical mA = 200
180 X 200 X 0.1 = 3600 mA-seconds/60 = 60 mA-m
ADD: Typical Fluoro = 5 mA X 60 minutes = 300 mA-min.
 TOTAL FOR ROOM A = 50 + 60 + 300 = 410 mA-minutes per week.

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Use Factor
= Ratio of 8-hour day shift that primary beam is
directed toward the specific wall or floor.

 Standard Use Factors are:

Floor = 1
Wall w/ Chest Board = 1
Other Walls = 1/4
Ceiling = <1/4

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Occupancy
= Ratio of 8-hour day shift that the public occupy
adjoining rooms.

Standard Occupancy Factors are:

1 X-ray rooms, reading rooms, waiting rooms,
nursing stations, offices = “full”
1/2 Exam or treatment rooms
1/5 Corridors, patient rooms, staff lounges
1/20 Public toilets, storage, patient holding, seated
outdoor
1/40 Stairs, elevators, parking lots, outdoor areas

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Distance and Energy
Distance = Average distance from the x-ray tube
to each wall/barrier

Energy = Maximum kVp the unit is capable of, i.e.,

penetration capability through walls

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DELs supercede barrier guideines
The previous formula and guidelines provide
prospective guidance in planning facilities.
Overriding them all, the DEL’s for the public in
adjoining rooms and for radiographers are not to be
exceeded.

However, these actual radiation levels in adjoining

rooms cannot be measured until after the
construction is completed. At that time, a medical
physicist may use TLDs for long-term measurements
or ion chambers to check for leakage from walls.

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 Types of Radiation Areas
 “Controlled Area:”
-Occupied primarily by radiation workers; The occupancy
must be known, the working conditions must be
supervised, and the radiation equipment must be
inspected regularly.

-Barriers must be sufficient to keep exposure rate below

100 μGy / week (5 mGy / yr)


89
Types of Radiation Areas

 “Uncontrolled Area:” Any one can occupy area

-Barriers must be sufficient to keep exposure rate below

20 μGy / week (1 mGy / yr)

90
Posted Warnings Required
 “Caution - Radiation Area” sign required:
-If exposure could feasibly exceed 1 milligray in 5
days OR 50 microgray in 1 hour

 “Caution - High Radiation Area” required:

-If exposure could feasibly exceed 1 milligray in
any 1 hour

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Warning signs may use red,
maroon or black symbols on
a yellow background

Signs must be posted near

all entryways to a radiation
facility

92
Radiation warning tags for
nuclear medicine materials
(below) and for radioactive
patients (right)

93
Radiation Safety Advisory Groups
 NCRP: National Council on Radiation Protection and
Measurements

 ICRP: International Commission on Radiological Protection

 NAS / NRC : Ntnl Academy of Sciences / Ntnl Research

Council: Jointly published the BEIR (Biological Effects of
Ionizing Radiation) Report

 UNSCEAR: United Nations Scientific Committee on the

Effects of Atomic Radiation

 FDA / EPA / RSNA / ACR/AMA / ASRT

94
Reports from the NCRP

95
Regulatory Agencies
 NRC: Nuclear Regulatory Commission: Defines
“Agreement” Vs. “Non-agreement” states
-Non-agreement states must meet federal guidelines
-Agreement states have more stringent guidelines

 BRH: U.S. Bureau of Radiological Health: Published the

NEXT (Nationwide Evaluation of X-Ray Trends) study

 EPA / FDA: Environmental Protection Agency / Food and

Drug Administration

 State Health Departments

 OSHA: Equipment specifications

96
 Radiography Standard of Practice
 The standard of practice for all personnel working
around radiation is ALARA (As Low As Reasonably
Achievable). Legally, it is not sufficient to show that
exposure levels are within the maximum permissible
limits (DELs) – Rather, it must be shown that all
reasonable precautions have been taken to keep
exposure to patient and personnel as low as possible,
remembering that the effects of radiation are
cumulative over long periods of time

97
 A final word
 Every radiographer should have an active role in
continuously educating not only himself or herself in
radiation safety, but also other health care workers
with whom we must collaborate. NCRP guidelines
state that “technologists shall be aware of the
approximate amount of radiation received by their
patients,” and understand the “typical occupational
doses for their assignment.” Our skills and knowledge
must be continuously updated in medical imaging

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