The next issue of Trauma MedEd will be sent out to subscribers at the end of the week, and will cover a whole bunch of what I call Potpourri. These are some tidbits that I find fascinating and sometimes odd.
Topics will include:
Trauma and the gut microbiome
“Single look trauma laparotomy” (as opposed to damage control laparotomy) and postop complications
Pneumothorax: how big is too big?
The best prehospital stretchers for rapid extraction in MCIs
I’ve pushed the solid organ injury update issue out to next month. There’s a lot of stuff to cover, and quite a few changes have occurred over the years.
Okay, so you’ve seen “other people” wearing perfectly good lead aprons lifting them up to their chin during portable x-rays in the trauma bay. Is that really necessary, or is it just an urban legend?
After hitting the medical radiation physics books (really light reading, I must say), I’ve finally got an answer. Let’s say that the xray is taken in the “usual fashion”:
Tube is approximately 5 feet above the xray plate
Typical chest settings of 85kVp, 2mAs, 3mm Al filtration
Xray plate is 35x43cm
The calculated exposure to the patient is 52 microGrays. Most of the radiation goes through the patient onto the plate. A very small amount reflects off their bones and the table itself. This is the scatter we worry about.
So let’s assume that the closest person to the patient is 3 feet away. Remember that radiation intensity diminishes as the square of the distance. So if the distance doubles, the intensity decreases to one fourth. By calculating the intensity of the small amount of scatter at 3 feet from the patient, we come up with a whopping 0.2 microGrays. Since most people are even further away, the dose is much, much less for them.
Let’s put it perspective now. The background radiation we are exposed to every day (from cosmic rays, brick buildings, etc) amounts to about 2400 microGrays per year. So 0.2 microGrays from chest x-ray scatter is less than the radiation we are exposed to naturally every hour!
The bottom line: unless you need to work out you shoulders and pecs, you probably don’t bother to lift your lead apron every time the portable x-ray unit beeps. It’s a waste of time and effort! Just stand back and enjoy!
Trauma Team members typically wear a lead gown under their personal protective equipment so they don’t have to run out of the room when x-rays are taken. How often do you see people do this?
Is it really necessary? Or is it just a way to exercise your pecs and biceps? Tomorrow I’ll talk about how much radiation team members are really exposed to so you can decide if this is really necessary.
You’re hooked! You are thinking back to a number of cases that you think might have done better with a hybrid room. And now let’s assume you already have one in your OR suite. Now what do you do?
The key is to avoid jumping right in and sending your next eligible patient straight to that room. You absolutely must take some time to develop policies and guidelines to make sure things go smoothly.
Here are some important things to think about:
Identify which specific patients are eligible so you don’t squander this resource
Who calls the OR to secure the room (surgeon, resident, other)?
Who calls the interventional radiologist?
What if another case (TEVAR, etc) is already on the table?
What if another case is getting ready to use the OR? How are conflicts resolved?
Develop an initial in-room report process so all the teams know the game plan
Assign an extra circulator to the room. You’ll need them!
Make sure all retractor systems (abdomen, head) fit the table! Remember that little asterisk in the previous section? Some retraction systems may need adaptors to work with your table. Don’t find this out at the last minute!
What about lithotomy position? How will this work with your hybrid table? They don’t have sections that break away.
Ensure radiation protection for all, including thyroid shields.
Bag the bottom x-ray detector, otherwise it will get very, very gross!
Create an external fixator equipment cart that can be moved into the hybrid room.
Create an embolization cart with appropriate wires, catheters, coils, etc. This stuff may not be stocked normally in the hybrid room
And I’m sure there are more details that I haven’t thought of. If you have some helpful suggestions, policies, or protocols, please share them with me!
The key to answering this question is to look at the resources that a hybrid OR brings to bear, and then determine what types of patients can take full advantage of them. Sadly, we have no guidance from the trauma literature, so we need to let our imaginations run free.
The basic concept for hybrid room use is this:
“My patient needs interventional radiology plus at least one other surgical specialty procedure”
The additional procedures don’t necessarily need to benefit from or utilize the IR capabilities. But they do need to be of an emergent nature. For example, a patient with a pelvic fracture can undergo angio-embolization and pelvic external fixation, while the gynecologic surgeons repair a vaginal laceration. Simultaneous, but not related to the embolization.
Here’s my list of possibilities. It is by no means complete or exhaustive. It’s just a start. All include the interventional radiologist for some part of it:
Pelvic fractures with angioembolization plus:
Perineal / gynecologic repair
Liver angioembolization plus laparotomy
Thoracic aortic injury plus laparotomy
Angiographic assistance for management of vascular extremity injury
Any of the previous procedures plus craniotomy*
And don’t forget to toss REBOA in with this!
Plus some other stuff I’m sure you will think up
Tomorrow, some details to think about while setting up your own hybrid OR!
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