This on-demand teaching session is relevant to medical professionals and focuses on the ionizing radiation regulations and its protection of patients from radiation. The discussion will cover topics such as the risks of ionizing radiation; the three main international principles of radiation protection; the Ionizing Radiation Medical Exposures Regulations (IRMER); and how to ensure compliance with the legislation. The discussion will also cover topics related to radiation safety of the staff as well as the patient's journey through the exposure process. Join us to learn more about ionizing radiation safety and its regulations!
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Learning objectives

Learning objectives: 1. Learn the main international principles of radiation protection 2. Understand the difference between deterministic and stochastic radiation effects and their thresholds 3. Become familiar with the key pieces of legislation which protect patient's from radiation 4. Comprehend the roles and requirements of duty holders and medical experts within exposure 5. Familiarize oneself with the patient journey before and after radiation exposure
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everybody. Can you hear me if someone in the chat just say yes. Can anybody hear us? Hey guys, we're going to start shortly. Can you just let me know if you can hear us? Lovely. Ok, thank you. Uh Welcome everybody. My name is Jasmine. I'm one of the junior doctors in Leicester and I work with our juniors with the education team. Uh Today we're joined by our lovely team. So we've got Ash with us. Uh We've got Doctor Lizzie Davies who's the head of radiation safety at UHL and we've got Andy Bridges who is a medical physics expert. Um Today is part of Ira Bites 2.0 which is an education series brought to you by our juniors. This lovely team is going to tell us more about the ionizing radiation, medical exposure, radiation as regulations. Um If you have questions, please feel free to put them in the chat. We usually kind of address these at the end. Obviously, if there's any technical problems you can't hear. Well, we'll try and address as as soon as possible. But um I'm going to hand over to Lizzie and Andy. Thanks guys. Okay. So Thank you for joining us. Um So were both physicists and we're going to take you through the key piece of legislation that protects patient's from radiation. So we're gonna talk about why we control ionizing radiation. What the risks are, we're going to go through the main international principles of radiation protection. Then we'll go through the basics of Irma and the basics of protecting yourself and then we'll do a little bit about culture. So, um when you're working in the hospital, you may have seen some rooms that have signs such as the one on the slide and they may say something like X ray controlled area, no unauthorized entry. And the reason for that is because ionizing radiation is associated with certain risks and they're mainly divided into two separate types of risks, tissue or deterministic effects and sarcastic or random effects. Um Now the deterministic effects or tissue effects, they have a threshold dose below which you won't see that effect and above which the severity of the effect increases with dose. And so they are things like skin erythema, hair loss sterility, that sort of thing. We don't ever expect to see those effects in members of staff, but you may see them in patient's, for example, in interventional radiology, if it's a long complex procedure and or if the patient is quite large, you can see a skin erythema. So, and it's important that the patient is aware of that beforehand, if it is a potential risk. Um You can also see effects on the foetus of any pregnant individuals. But the threshold for that is quite high and it's around 100 milligray. And it's things like reduction in M I Q um of the actual fetus. And it depends, the thresholds depend and the effects depend on the point in the pregnancy at which they were exposed. And then the other type of effect are stochastic or random effects. So they have no threshold dose. So we believe that there's no safe dose of ionizing radiation. And as you increase the dose, you increase the probability of seeing one of those effects. So those effects are things like leukemia and cancer induction and induction of hereditary defects in the offspring of the exposed individual. So that's things like one I being a different color to the other. And although we, we've proved that hereditary defects do occur in animal models and we've not been able to definitively prove that they occur in humans. So the risk is very small for that. Um in the middle, we have cataracts and glaucoma. So originally, they were thought to be tissue effects with the threshold dose and now they thought they may maybe quasi use sarcastic. So they may not have a threshold dose. So um as we progress in our understanding of how radiation in tracks with the body things do change. Um So because of the fact that radiation has an effect on the body. And when I'm talking about ionizing radiation, I'm talking about things like C T X ray fluoroscopy and nuclear medicine. Um MRI does not use ionizing radiation. So the risk that we're talking about here and not to do with the MRI. Um So because we know that there are risks associated with it and there are three main principles that we used to protect from radiation. The first is justification. So we should never use radiation unless the benefits outweigh the risks and that can be to the individual themselves or society at large. The risk can depend on age sex and the scan. And so when you're justifying the exposure, you have to take that into account. And the benefits obviously depend on the actual um presentation of the patient and their patient pathway. Um So for where we may expect larger benefits, we may accept also larger risks associated with the exposure. The next principle is optimization. And that's that if we say that we need that X ray or that CT we need to keep the dose as low as reasonably practicable, consistent with the intended use. So we wanna, if we have to do a chest X ray, we want to do a chest X ray with the smallest dose possible while still having a usable chest X ray. And then finally, we have limitations. This is mainly where there's no benefits to the individual. So for example, staff and the public are given dose limits, which should never be exceeded. And that's why I said at the beginning, I um staff, you should never see erythema because it's the dose limits are set so that they are so much lower than the threshold for that um actual effect. Um So those three principles are the core principles of radiation safety and they're the foundation on which Irma's base now, Irma or the ionizing radiation medical exposures regulations, which is a bit of a mouthful. So I'll say Irma from now on, I'll set down to protect the patient. There is another piece of legislation which is called the ionizing radiation regulations, which concentrates on how we protect the staff and the public. So those who don't directly benefit from the exposure and, and we're gonna concentrate mainly on Irma for this presentation. But at the end, I couldn't resist putting in a little bit of safety safety for you guys as well. So I just want to talk about within legislation, it identifies individuals who are part of the uh the exposure about the process of taking exposure uh and uh referral. So um sorry, go for the duty holders. We've got the employer. Uh So the employee need to provide a framework for how mental exposures occur uh within the, within the organization. They need to provide us with procedures and protocols on how we do that and to ensure that there's assurance that the quality of what we're producing is sufficient. Uh And they also have to entitle the other duty holders within um the from the legislation. So the Referrer is the person who must be a registered healthcare professional and there has to be entitled to request as individual requires an exposure to radiation as part of their clinical care. And that's generally a doctor, maybe uh an outpatient doctor or might be a GP. But we also get nonmedical refers so we can have nurses and physiotherapists. Anybody who's registered can be Referrer. But there's sometimes a difference in the training that's required. Um The practitioner, um their role is to justify the exposure and justification needs to be ensuring that there's a benefit. Um And it has to be weighed up against the risk from that person receiving that exposure and that's generally a radiologist, but there can be a raid offers who work within that role. Um The operator, the next one. So they're involved in the practical aspects of the exposure. Uh um And they're generally looking at optimizing the exposure. Uh And they also do authorization uh where they authorized exposure and check identity, identity, uh prostate of things like that. Um And also if you are evaluating uh an image also classed as an operator, so we put down a radar for there. But if we're sort of saying in potentially interventional radiology, you may have a radiologist who acts in as referral practitioner and operator. Um It very much can be sort of a mix of the roles dependent on how it works and it's very much dependent on your local procedures within your organization. Um Last duty holder is the medical visit expert and medical experts have the knowledge experience uh to assist with helping the compliance with legislation looking optimization and all the other sort of physics based um aspects of the radiation exposure. Okay. So just gonna touch on the training side of things. Um this um comes from the fact that there's quite a lot of emphasis within legislation about this and they actually provide a curriculum for both operators and practitioners. Um And it's quite specific in what, what's required. So they provide both generic and specialty uh curriculum. Uh and the sort of generic sort of topics sort of look at that sort of basic understanding of what radiation is uh and how it sort of interacts um then sort of looks at the risk aspects of it. So the operator practitioner, you need to understand about the hazard, uh that sort of things and also about radiation dose. Um and how that relates to that sort of risk and that sort of things, um how you sort of manage um and protect the individual being exposed, optimization side of things. Um and other sort of areas like we're special interests, it looks at sort of pregnant, you need to understand about pregnant, pregnant patient's in what aspect in what situations can maybe exposed not exposed and sort of linking it to very much with justification. Uh and the aspects around that. And then the last bit, it sort of touched on some which is very, is a bit with the ionizing radiation regulations, the status of things is about radiation protection uh of the patient and, and you and yourselves really. Um then with this sort of speciality stuff that is very much dependent on the area that you're working in. Uh and very much sure, basic training within area will cover all these sort of aspects within the requirements, legislation. Also, it is very specific in what it requires, things like that, all the records and the quality assurance side of things. So it needs all the dates to be, there, needs to have what the training and nature training is all outside of it, all needs to be um there and present if you're, if the organization is ever expected to make certain that anybody doing exposures or any part person involved in the process of exposing the patient is appropriately trained. Um Another bit of the training is that as we've spoken about, we have procedures. So procedures uh within the employees crates and that is another part of the training that you need to go through those and to be fully aware of how that works. Uh And if you are duty holder, you have a legal responsibility to follow those procedures. Um Okay, so I'm gonna move on to the, how's your pathway? Uh So the patient journey uh from um uh what the process is before having a metal exposure and then afterwards. So starting off with the referral for um and if the patient requires imaging, the Referrer X has to do sort of look at what they are asking for, what is the clinical question they need to be answered. And within that referral name to make sure that there is appropriate and adequate in clinical history so that the examination can be justified. Um And uh quite a nice resource is I refer, which is uh um online. Uh I think most of the NHS can get access to it. Uh And when you're putting what you're the question asking for into it, you can sort of see the different modalities that may be useful uh for looking at the clinical question um and the risks and benefits with, with them, which is quite a nice resource. Um Also, it's sort of specify, you have to refer, might have to specify specifically for um if there's non medical reason, uh non medical imaging reason for it such as a migration um chest exposure for to look at T B. Um And also the refer might need to sort of comment about is the patient pregnant or not. Uh within that say when her for has done that and they're fill then goes over to the practitioner and the practitioner carries out a justification to compare ways up the risk and benefit and if there's a net benefit approves it, um also, it's not always, the pract practitioner doesn't always um justify every exposure. Uh If there is a common examination with common, common clinical questions and the department's. Right. Right. What we call authorization guidelines and these written protocol specify that this x these exposures are justified um for these particular reasons. And that means that the operator can authorize it under these guidelines. Uh And so you can sort of streamline the process for very common examinations. And then uh that when I was done, then passed on to the operator, uh he's kind of practical aspects. They need to sort of check his equipment safe to use. Uh Has the equipment been quality control tested? Is it working appropriately? Um Yes. Is the operator trained? Um And there's other sort of aspects of that sort of uh exposure sort of thinking about, is it a research exposure? And as it's come from the practitioner or from the uh the correct route that is justified and authorized? Uh And when they do the exposure, they need to be thinking about the protocol uh that they've selected for it, they need to think about optimizing the exposure. So, is it appropriate column eight, is the patient correctly centered within the image? And when they've taken exposure, need to think about recording the exposure parameters, the dose that's been delivered and then compare and then comparing them to the diagnostic reference levels which will touch on them later say and then um yeah, and uh sort of part of it is all exposures must be reported in a timely fashion. And really if the if we aren't reporting the exposure, then the exposure hasn't, then there is hasn't been really a reason for the exposure. And in essence, that is an incidence. So making certain that clinical evaluations occur uh for all exposures is very important. Now, throughout this process, instants can occur where patient's can get unintended exposures or accidental exposures. And if an incident occurs, um we need to make certain that the situation is safe. We need to make certain that the incident reported and that the appropriate people are informed of the incident. So the patient, the Referrer practitioner all need to be informed. Uh and they also need to inform that the outcome of when you investigated and the really important bits around learning from the mistakes and share in that learning. Okay. So um one of the sort of things that was being brought in by the society raid offers was around patient um around reducing risks and in improving that sort of process uh and reducing the incidence. And this uh meant that they came up this idea, pause and check. So it's a checklist of sort of the key safety questions. That's the operator or in this case, the referral needs to think about before they are uh, sending off the referral or actually carrying out the exposure. Um, and it's sort of, um, quite a and it sort of important sort of thing to sort of highlight to make certain that people are, uh, know what they need to be looking at and making certain that, uh, process has been followed. But this doesn't really take away from the fact that you still need to read the area procedures and understand how locally um systems work. Okay. So, one of the biggest incidents that you tend to get is incorrect patient referrals and they're really difficult to, you actually capture a later stage. So if you are referring on a referral system and you select the incorrect patient, but you click type in the correct clinical history unless that clinical history visibly doesn't match the patient arrives, it's very difficult for it to be picked up before it goes through to imaging. And if it's above a certain level of exposure, then we have to report it to the C Q C and do a full investigation. One of the other requirements of um which is a new requirement in 2017 is that we have to provide wherever practicable, adequate information to the patient before the exposure about the benefits and the risks associated with it. Now, this is quite a challenging thing to do. I don't expect everyone to know the risk levels associated with every exam particularly because there's quite a wide range and it depends on the age and the sex of the individual. It's not as straightforward as a single number that we can give you, that you can communicate to the patient. So what I always advise, but you have to look at your local Irma procedure is a graded approach to informing patient's of the risk. So for plain film x rays where the majority are really quite low risk compared to the um the natural risk of cancer, which is at one and two. Um The risk is one in 10,000 and, and that's the highest plain film risk. Most of them are more like one in a million. You know, that's it. That's the range. So I would say the Referrer should introduce the risk and maybe provide leaflets and around um the risk or posters which I'll show you later and, and then the radiography should check that the patient's happy to proceed, but it should be informed, implied consent rather than detailed written consent. For CT and diagnostic nuclear medicine studies. There's a slightly higher risk and the patient through um flow doesn't require consent already. So I would say that at that point, we moved to documented verbal consent. Um So just documenting that the patient is happy to proceed. And then for interventional radiology and cardiology, the risks are higher, but the patient is also usually having uh informed written consent anyway. So the radiation risk should be formed part of that consent process and it should include any potential tissue effect. Um So if you find that when you go into interventional radiology or cardiology, that the consent form doesn't contain those things, every hospital will have a medical physics expert like us and should be able to provide that information so that you can add it to the consent form because it's a relatively new requirement. There are some places that are still playing catch up with and what what needs to be done. Um So to try and make it easier for you guys, um the best way I think to introduce the risk to the patient. And we've done a lot of work around looking at what patients' actually require from us. Um is I would say introduce use that you're going to refer them for an X ray or whatever. And we believe that the test may be linked with a small increase in the risk of cancer later in life, but that risk is much smaller than the natural risk of cancer. And without it, you would not be able to what diagnose whatever condition you think or determine the best method of treating them. It's also really key that you emphasize that an imaging specialist will check that request before it goes ahead and only allow it to proceed if the benefits to you are greater than the risk. So we did a really large survey of uh members of the public and we found that that key sentence actually was what made most people happy to continue. Some people will want more detail and, and if they do, there is a U K H has a leaflet which you can access all the links are in the slides at the end as well. Um But it gives broad ranges of risks and you can see they're very broad rate bands of risk categories. Um And, and there's also some posters available from the RCR which go in uh some detail about the levels of risk. Um The best um source of information is the UK hitch say. Um so we have to inform people of the risk and we know that risk varies with age and sex. Um the younger you are and the more time there is to express that council risk. And in pregnancy, we see this um risk increasing further because it's a time of rapid cell turnover. So the risk associated with exposure and pregnancy is greater than that for the rest of the general public. That's why the referral should detail pregnancy status on the request form. But the radiographer will also check it at the point of exposure. One key point to this, which has recently come up from the professional groups is that you cannot assume that patient's that are male or present as male are not pregnant. Um And there have been a few incidents that have shown that this is more than just a theoretical risk. It is a real world risk. Um So provide as much information on pregnancy status as you can on that slide. I've given you um some examples of the higher dose exams, um the additional risk of childhood cancer. And you can see for a ct of the pelvis and that sort of thing exposures of the cities of the area around the foetus. And you can get an approximate doubling of the natural childhood risk of cancer. So from one in 500 to 2, approximately one in um 1001 in 200. Um So uh the next group that we need to be concerned about our people called comforters and carers. Now, this is a really specific term under the legislation and it's individuals who are knowingly and willingly expose themselves to radiation in supporting another individual. This is not a nurse who comes with the patient and helps to hold them in position there. Remember staff and that is covered by I R R and a separate piece of legislation. This is say a, a parent who comes and and stands in the X ray room by the by the child in order to keep them calm for the X ray. Now they will be exposed, they must understand the risks to them and those risks must be justified and they shouldn't really be pregnant or Children. Um But you can get the risks of these types of people justified by a practitioner. So most trusts will have an authorization under protocol for carers and comforters that a radiologist has signed one as the practitioner. And usually it will say something like if it's required in plain film. And then as long as they haven't supported a patient X, number of times in the past, they're not pregnant and they're not a child, it can go ahead and as I say, you can then go to a radiologist and get additional justification if it's outside of those constraints. Okay. So within the legislation, a key aspect of it is quality assurance. Um and as with most organizations, quality assurance is a key part of, of how they work. Uh And um I can see from straight from the legislation, all those planned and systematic actions necessary to provide adequate assurance uh that the structure system component or procedural form satisfactory. Um And that's the main principle of quality assurance. And I think that within legislation, it very much picks out sort of three different areas that we need to think about regarding quality assurance, uh the written procedures uh that employers uh procedures that we spoke about and that very much is sort of reviewed using audit that are specifically looking at those procedures. Uh We have equipment which has to come under Quality Assurance program. Uh This is generally the testing equipment using doing quality control testing. So this is looking at the sort of radiation exposures it delivers uh the image quality of the of the equipment is the are both of those within the expected ranges that we expect? And are they delivering a sort of optimized uh images uh for your for clinical evaluation? And then we have protocols so that is very much around um they're looking at sort of optimization and diagnostic reference levels. Um equipment very much coming on comes in checking that the quality control testing is okay also comes and optimization. But we're very much look at sort of uh sort of protocols that optimization side of things. Uh And as you can see from the audit spiral by continuing uh continuing auditing by sort of looking at standard uh reviewing it and implement an in theaters problem that implement change your sort of going through that uh audit cycle. And that very much sort of improves assurance and blue least for improvements within the what you've what's delivered. So um optimization um so this is the uh let's see, you mentioned earlier. Optimization is very much about um if you're having to do something, you have to make certain that you are delivering the intended purpose uh from the dose as low as reasonably practicable. So a lot of principle um and it is essential to optimize each radiation exposure for patient. And a key aspect of that is understanding the clinical uh question or need being asked. And the as a different clinical questions can necessitate different image energy requirements. And that's why we have the practitioner there to evaluate the clinical question and to decide what is the best practice uh to deliver the the answer to that clinical question. Now with the operator and they're aspect of optimization, they have a key aspect in the sort of practical side of that optimization. Uh especially in interventional radiology with floss equipment ct slightly different. We need to make certain that the optimization looks at like the practical aspects that the operator is very much thinking about patient positioning. Um So you can see for that diagram to the right having the patient close to the imaging detector. So bringing the imaging tests are close to the patient is important because that reduces the dose. The dose is two the patient, we need to think about the correct protocol be selected. So are the is the frame rate um low low is the doses set too low or it depends on the situation. What what protocol is required we need to think about column ated images wherever possible because that also introduces the amount of scatter uh and also the direct dose of the patient when you think about only using magnified views where necessary. Uh there's some equipment has particular settings to actually do a digital magnification and therefore know dose uh aspect to that and use of specialist features within the equipment. So things like recursive filtering and last image hold can lead to improved inequality uh or no radiation dose for same things like last image hold. So, but the key thing to sort of think about with restriction within especially arthroscopy is that optimizing, optimizing the patient dose reduces a dose that you will receive as the operator of in there. Uh and impact on that. Uh So it's always key to sort of optimize transport. Now, another eight to that optimization uh is very much of around the call insurance side of things. And that is very much about how do we use, verify that we're not over exposing our patient's. So we get a dose end of a procedure. How do we know that that's an acceptable dose? So um as you can see on there, all the doses that we deliver from each procedure are supposed to be recorded. And this allows for us to do dose audit and to analyze those doses. Um For the for the comparison side of things, we have these legislation induces concept of diagnostic reference levels. So these are dose levels for typical examinations based on sunset patient's and equipment. Um And that allows us to have a compare something to compare against uh and between procedures. So after the procedure, we compare the dose can compare the dose of the data is preferable or we can compare data record levels to dose orders that we carry out. Um And I'm going to show you an example of some results from a dose audit. Um So this is just from uh Pelvis X ray, uh X rays that are carried out in the rooms that the displayed on the bottom and the dose is on the, the Y axis. Uh And um we've got two lines over a dotted line which is the reference medium dose, which is the dynastic reference level that we previously had. Uh And then we have the current medium dose, which is the dose that's been delivered in the time period that's been looked at. So we can still see that between when the DRL was produced and now that the doses have dropped uh on average across the equipment, so that's good. Um But at the same time though, we've got a number of rooms where the doses are above, not just above the current median but also above the previous DRL. And so this sort of um indicates that all what's going on there, we need to think about what we're doing uh does something need to change. And so if an area of concern is identified, we have to investigate it and we investigated by using a sort of multidisciplinary team approach, so called image optimization teams. And that's generally a radiographer, a radiologist and uh medical physics expert or clinical scientist. And very much we sort of review the sort of equipment side of things is the equipment, the sort of the reason why the higher, is it the general practice within the room or is it patient demographics Um So we can sort of look at those different aspects and sort of determine, is there a particular reason uh for it or capital? Do we need to do some optimization? Do we need to be changing the equipment settings? Do we need to be asking um looking operators? And are they doing something which is um not best practice? And can we um make learning bombs encode learning to improve that practice and reduce the overall doses? Uh And all this sort of aspect to sort of look at medical exposures and also relation is very much covered by medical exposures committees which will generally have at most large hospitals. Um And uh I would encourage you to uh get involved if, if you can. So another sort of area that sort of picked up by legislation is looking at research uh and sort of biomedical research. And when we spoke about justification earlier, it was looking at uh the the the exposure he's justified as being an individual, the net benefit to that individual, the expense and that's them, that's what happens the majority of time. But there are certain times when exposures occur, which there is no, there isn't a net benefit to that patient. And how do we make certain that that exposure has sufficient ethical benefit? So when we have research exposures, we need to make certain that the research to the has been designed correctly to make. And that ethically the reason for the exposure is justified. And so the research will be reviewed by Research Ethics Committee. And there, there'll be a statement from medical expert and clinical radiation expert, generally radiologist. And they will give the statement saying that should be justified. Um But that's very much a national scale on local level. The employer must have a procedure that looks at reviewing that original study and to see if locally we can meet the requirements. Uh And also so that can we meet dose constraints. And if we are carrying out locally, are we how we're identifying patients who are undergoing research exposures and how local authorization might occur? Things like that. We certainly think about this, of the process for research and when things break down such as not identifying a patient as a research, uh patient experience space for research uh incidence occur. And the legislation has specific requirements um for instance, involving metal exposures. And the main reason for the sort of requirements within the legislation is to ensure that when this happens that everybody informed of it. So we're thinking about the referral and practitioner to sort of aid. Um uh and they operated to sort of inform learning, but also with patient's to ensure that with the individual exposed is being informed of what happened and what has been learned from it. Uh And that's very much around and duty of candor. Uh And to emphasize the sort of learning aspects of uh from the incident really and to improve practice. Um Another part of it um in legislation is that if we have incidents which occur, which go over certain thresholds, we have to inform Seiki. See. Uh and that happens if the dose is much greater intended or which is uh when a patient might have it uh exposure, uh that might be done on the wrong modality or for that uh or an accidental exposure where the patient should have received an exposure at all. And are you around like misidentification, patient's that sort of sort of things? Um And the this aids, this sort of notification aids, the secreting looking at trends with incidents nationally and they produce an annual report which includes uh this sort of these trends and sort of guides nationally, how we can improve practice uh within departments. Okay. So that was a whistle stop tour of Irma, which I think is a really elegant piece of legislation um allowing us to have a framework for safely exposing patient's to radiation. Um Now we're just going to talk a little bit about your safety. Um So if you enter a controlled area, so where, where those signs are on the door and it should be very obvious when you're entering a controlled area and you must read and signed to say that you've read the local rules and, and you must comply, apply with those local rules. So this is if you're remaining say, for example, within a CT room during exposure, you should have read the local rules and said that you're comply with them. The radiographer within that domain is the individual who's looking after everyone's safety. They've had additional training and safety around radiation and they're trying to help everyone to work safely. Um, so if they ask you to do something, usually it isn't because they're just trying to show their power or anything like that. It's to make sure that you're working safely. Um If you work with radiation and you enter a controlled area, you'll be subject to a risk assessment which will say whether you need to be monitored for your personal dose of radiation. If you were issued with the dosimeter, you need to wear it and you need to return it when you're told to return it. If you failed to do so, you can be held responsible as well as the trust if something goes wrong. So there was a doctor who was fine 10,000 lbs personally because he didn't return his dosimetry. And when he did, they found that he had exceeded a dose limit. You also have irresponsibility to do any training that's required by your trust and where P P M as instructed. So here is the good, the bad and the ugly of PPE wearing. So you can see in the first corner and the individuals wearing a lovely vest crossed over to provide double protection at the top next to that we have an individual who may be wearing slightly too small vest and it's not quite closing. That closure is um the way that we ensure that there's adequate protection. So you need to make sure that you can fully do all to the vest. And you see underneath the armpit of this individual, there is a gap. Um and there are um the breast tissue is very sensitive to radiation, but there's also increasing evidence that the cardiovascular system, particularly the heart um is radiosensitive as well at quite low doses. And so you need to make sure that that armpit is fitting quite snuggly underneath and particularly if you're standing side onto the actual source of scatter. Next, we have the skirts, the leads leads skirt. Um So in the bad, it's the same, you need to make sure all that Velcro's covered up and also that there's no gaps down the side. Um And, and then finally, thyroid protection, your thyroid is particularly radio sensitive. So if you're given a thyroid shield and asked to wear it, please wear it up tight close to your neck, not like a necklace hanging down and then there's the unforgivable and it might sound stupid, but we see this all the time where someone in a, in a theater is wearing a lead apron. So everybody stands behind that one person and they're not gonna be predicted behind that person. So please ensure if you see that happening, don't be one of those people, you either leave the room while they're screening if you can't put on a lead apron or put on a lead apron because it's for your safety and then finally protect your eyes and we don't want you getting cataracts. Um, and so more recently, um, lead glasses and lead visors, but particularly for people who wear glasses already have started to become more normal practice. And this is because of the evidence about cataracts, not having such a high threshold for, for being caused by radiation. Originally, they thought and that was proved by several papers looking at radiologists and the incidents of cataracts within them. So if you're issued with them and asked to wear them, please wear them, please make sure that you're looking after them because they are quite expensive. And if you have a ceiling mounted screen that should be placed as close to the operator as possible in order to give you the maximum protection. And next, this is a little bit more about the patient, but along the same vein, and it used to be quite common practice for patient's to be offered what we call contact shielding. So gonad shields or lead aprons when they were having x rays. Now with modern practice and modern equipment, actually, the amount of scatter outside of the field is very small and we can column it down to the point where we're only really looking at the area that we want to see. Okay. So the most recent guidance says that in almost every case, contact shielding is not required. Um And, and that also includes pregnant patient's. Um the operator will optimize the scan to reduce the dose as much as possible. But please, as a Referrer don't tell a patient that they will get given a lead apron or going at shields because then when they arrive in radiology and aren't given those things, they begin to question whether they should have been. And sometimes um that puts doubt in their mind about the practice of the radiographers, even though they're showing they're following best practice at the moment. And so one thing I want to finish on is um the standard that we will walk past is the one that we accept. So if you see potentially more senior individuals not wearing red glasses, when they should, please feel that, that you can challenge them because it's for their safety and we should all be doing our best to ensure that we're all safe. So hopefully today, you've learned the principles of justification, optimization and limitation, the lovely piece of legislation called Irma and how it implements those requirements of the international community by defining roles and responsibilities requirements around provision of information to patient's assessing the risk, patient, to pregnant patient's optimization of exposures and research and then how we deal with incidents. And hopefully, you have also learned the real basics of looking after yourself in the radiology environment. But please, when you go back to your areas, make sure that you know, your local procedures and your local training to make sure that you are doing what's needed locally. And finally, and the importance of radiation safety culture. So that's the end of our talk. Sorry. Does anyone have any questions? Um Yeah, so there's one in the chat from Beverly. Um So uh the unforgivable sometimes happens in theater where staff will just form a line behind the screen for protection. At other times, I climb geography scrub slash sterile person goes to the furthest corner in the theater that can't go out of the room. Is that, is that acceptable? And what is the minimum distance? So this is going to sound like a copout. It really depends on your local rules because a risk assessment will have been done for that exact situation and it will tell you how large the controlled areas. So in some trucks, they control a certain distance around the actual equipment and in others, they control the entire room and it just depends on your set up. So you really need to know what's in those local rules because that will be for your specific area. I would say the main things that you need to know if you want to protect yourself as well, the time distance and shielding if you can step back as far away as possible, doubling your distance quarters, you does. Um, So taking a step back is good, but you shouldn't be in an area where they're exposing. If it says in your local rules that that area is not safe, even if you're wearing a lead apron, it's best practice. Take a step back anyway, so lead aprons contain about 0.25 mils of lead. Um Some go up to 0.35. but any screen that's in the, in the room. So the the big control areas they tend to have between 1.5 mills and two mills of lead. So if you can get behind those screens, that's always going to be better than a lead apron. Um but yeah, a lead apron reduces your dose if I about 1/10. But as I say, if you double your distance, you quarter your dose. So if you take that into account, that should help. Does anyone else have any questions? I think we're good. Um Please if you could off fill in the feedback form for the end and that will allow you to get your certificate of attendance and thank everybody for attending and joining us um for this session. And um next week are are bites is doing a session on interventional oncology and I posted the link in the chat. So if you're free join us, then again, um otherwise have a lovely rest of the day and to take everybody. Bye. Mhm. It's going to make us