Problem-Solving: Balancing ALARA in radiology with data collection

Question

I’m relatively new to conducting pediatric MBS studies. The pediatric MBS is also a relatively new service provided at our facility. The pediatric radiologist seems extremely conservative in how many swallows/seconds he will allow for an MBS study (10 seconds/swallows total). I was trained at another facility and in talking with my peers, this is not enough swallows to get an accurate picture of an infant’s swallowing (especially if also looking at fatigue, position changes, thickeners).
I’ve been looking for research to support the amount of radiation intensity (continuous) and time (around 60 seconds total) that my peers tend to use, however there seems to be minimal literature that specifically addresses this topic.
Can you advise me as to how to advocate for a more complete study, even though this means more radiation exposure?
Thanks

 

Answer:

Rads are the ones who manage and minimize radiation exposure for patients and us too . So his caution is an attempt to protect us.

ALARA – as little as reasonably achievable – is the mantra. Work with the rad from a perspective of recognizing that and finding a common ground for gathering good data but assuring optimal protection (shielding well, time, distance all matter). Have some conversations outside of the “moment in radiology” to problem-solve.

When I teach my pediatric swallow study seminars across the US, I always survey attendees for average exposure times they use as guides, and they are typically <2 minutes for infants , and < 5 minutes for children.

This allow typically for enough data to objectify physiology and interventions usually.

If I need to watch a bit longer to complete my differential, I let the rad know and ask if we can watch just briefly and he knows I really need to see that but that I am careful to watch exposure time.

Our aim is the least dose, so if I use about more time it is only after careful thinking and when it is crucial data that is needed.

Our tech can tell us at any time the exposure time up to that point, so we know how we ear doing as we go along. Tech tells us total exposure time at the end, and I always ask myself is there anything I might have done differently to lessen the exposure time.

Usually there is not but I always try to consider that question so can become a better clinician.

Rads usually pulse the beam, we use 30 frames per second but not every hospital radiology team does. Studies have shown that less frames/sec results in less useful data and 30 fps is optimal.

If the rad pulses the beam, and he starts the beam when you say “on” , and you plan what you are going to observe to objectify physiology, carefully select interventions to objectify so you minimize radiation, then these exposure time guidelines work well.

Feeding off line for fatigue while eating/drinking materials impregnated with barium will not use up that exposure time, just the brief re-imaging post fatigue feeding , to see if there are traces in the airway , larynx, nasal airway, etc. that suggest bolus mis-direction and or residue when infant/child was feeding off line, simulating fatigue factor.

Try this approach and see if it works. It does for me.  I developed it with input from our rads, who problem-solve with us as a team and we learn from each other from a place of mutual respect for the perspectives we each bring. The rads  recognize we too will do all we can to assure safety and focus on  ALARA.

I hope this is helpful.

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