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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Introduction
Minimizing Risks from Fluoroscopic XX-rays
¬

Brent K. Stewart, PhD, DABMP
Professor, Radiology and Medical Education
Director, Diagnostic Physics
a copy of this lecture may be found at:
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On September 9th, 1994, the FDA issued an advisory for facilities
facilities
that use fluoroscopy for invasive procedures. Recommendations….
¬ Appropriate credentials and training for physicians performing
fluoroscopy
¬ Operators be trained and understand system operation, and
implications of radiation exposure for each mode of operation
¬ Physicians be educated in assessing risks and benefits on a
casecase-byby-case basis for patients
¬ Patients be counseled regarding the symptoms and risks of large
radiation exposures
¬ Physicians justify and limit use of high dose rate modes of
operation
Brent K Stewart, PhD, DABMP
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Who can perform Fluoroscopy

and Associated Radiography?
¬

Most states have regulations regarding the operation of radiation
radiation
producing equipment and these regulations vary from state to state.
state.

¬

In some states, it may be illegal for an untrained person to operate
operate
an xx-ray machine even under the direct orders of a physician.

¬

However, the fact is that many physicians who use fluoroscopy have
have
essentially no training in this area.

Washington State Law
¬

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

WAC 246246-225225-020
¬ Operators shall be adequately instructed in safe operating
procedures and shall be able to demonstrate competence
¬ A medical xx-ray machine operator shall be licensed, certified or
registered by the department as either:
¬ a licensed health care practitioner
¬ a certified diagnostic or therapeutic RT
¬ a registered xx-ray technician

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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

What should an operator know?
¬
¬
¬
¬

¬
¬
¬

What an operator should know

How to operate the machine
How to properly position the patient
How to minimize the use of radiation
How to properly use shielding devices and personnel monitoring
devices
How the radiation is distributed in the room
How to control the factors that optimize image quality (kVp, mA etc.)
How to control factors that reduce radiation levels (collimation)
(collimation)

¬

Two professionals trained in specific aspects of fluoroscopy are the
radiological technologist and medical physicist

¬

Nurses or physician assistants should be trained in its safe and
proper operation if asked to operate xx-ray equipment

¬

Physician is ultimately responsible for assuring that the xx-rays are
safely and properly applied and that appropriate radiation protection
protection
measures are followed

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Potential effects in skin from fluoroscopy

Skin Injuries
¬

During the application of xx-rays, the patient has no sensation of
temperature rise in the skin, even if the patient is fully conscious
conscious and
even for all but the most massive doses of radiation

¬

Small doses from modern equipment might induce cancer, but the
frequency of induction would be too low to detect a direct
relationship with xx-rays

¬

Chronic exposure to low doses can also result in gradual erosion of
tissue

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

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c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays. 1996.

Brent K Stewart, PhD, DABMP
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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Skin Injuries – Case Reports

Skin Injuries – Case Reports
Three weeks post rf cardiac catheter ablation

Ischemic dermal necrosis 5 months post procedure

Exposed to 20 minutes fluoro with elbow 2025 cm from focal spot. Note circular pattern
coinciding with x-ray beamport

Suggesting that the 18 Gy threshold was passed
during the procedure

Deep ulceration with exposure of the humerus at 6.5 months post-procedure

Some radiation ulcers never heal completely, but break down intermittently. Progression
of the ulcer may ensue and can be extensive, exposing deep tissues such as tendons,
muscles or bones.

c.f. Koenig TR, et al. Skin Injuries from Fluoroscopically Guided Procedures:
Part 1, Characteristics of Radiation Injury. AJR 2001, 177, pp. 3-11.

c.f. Koenig TR, et al. Skin Injuries from Fluoroscopically Guided Procedures:
Part 1, Characteristics of Radiation Injury. AJR 2001, 177, pp. 3-11.

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Skin Injuries – Case Reports
Three transjugular intrahepatic portosystemic
shunt placements within a week

Radiation Injuries of the Skin

Injuries that are advanced to this stage require surgical
excision and grafting.

¬
¬

Non-healing deep tissue necrotic ulcer with

exposure of deep tissues, including spinous
processes of vertebra at 22 mos.

At 23 months, musculocutaneous skin grafting was
performed. Disfigurement is permanent.

Many articles in literature about skin injuries (see Koenig manuscript)
manuscript)
Some case reports teach us two important lessons:
¬ Radiation dermatitis is delayed, from weeks to years after the exposure
exposure
¬ Several procedures can result in very high cumulative doses to the
the
same area if the skin
¬ A conscientious effort should be made to avoid prolonged exposure
exposure to
the same area of the skin
¬ Documentation of certain conditions will help physicians if future
future
procedures are needed
¬ A careful record identifying the location of the exposed skin will
will alert
other physicians about the need to avoid irradiation of the same area
¬ A record of the estimated skin dose is also helpful

c.f. Koenig TR, et al. Skin Injuries from Fluoroscopically Guided Procedures:
Part 1, Characteristics of Radiation Injury. AJR 2001, 177, pp. 3-11.
Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP

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Brent K. Stewart, PhD, DABMP

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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Commandment #1:
Patient Size

Controlling Image Quality, Dose and Dose Rate
¬

The following ten factors are the principal determinants of image
image
quality, radiation dose rate and total radiation dose to the patient
patient
and to personnel during fluoroscopy
“the Ten Commandments”
Commandments”
¬ patient size
¬ tube current (mA) and kVp
¬ proximity of the xx-ray tube to the patient

¬ proximity of the II to the patient
¬ image magnification
¬ x-ray field collimation and use of a grid
¬ shielding and position of personnel relative to patient and
equipment
¬ beambeam-on time

¬

Brent K Stewart, PhD, DABMP

Keep in mind that dose rates are greater and dose accumulates
quicker for larger patients

Brent K Stewart, PhD, DABMP
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Commandment #2:
Tube Current (mA)
¬

Commandment #3:
Tube Kilovoltage (kVp)

Keep the tube current as low as possible

¬

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

Keep the kVp as high as possible to achieve the appropriate
compromise between image quality and low patient dose

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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Commandment #4:
Proximity of XX-ray tube to Patient
¬

Commandment #5:
Proximity of the Image Intensifier to the Patient

Keep the xx-ray tube at the maximal “reasonable” distance from the
patient

¬

Brent K Stewart, PhD, DABMP

Keep the image intensifier as close to the patient as possible
¬ To optimize image quality and reduce radiation dose
¬ Optimize image quality ⇒ distortion of anatomy and image blur
decreases
¬ Radiation Dose decrease ⇒ x-ray intensity required to produce a
bright image (automatic brightness control) decreases

Brent K Stewart, PhD, DABMP
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Commandment #6:
Image Magnification

(#6) Magnification
¬

¬

Don’t overuse the magnification mode of operation
¬ Magnification can be achieved in 2 ways:
¬ magnification option on the image intensifier
¬ geometric magnification

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

Magnification options of the image intensifier
¬ This is achieved by making the xx-ray field smaller and displaying
the smaller field over the full viewing area of the monitor
¬ The mode of least magnification (largest field) usually delivers
the lowest dose rate
¬ Sometimes the dose rate does not change with magnification but
frequently, the dose rate increases with magnification
¬ To optimize overall radiation management, use the lowest level
of magnification consistent with the goals of the procedure and
reduce the irradiated volume of the patient by employing narrow
collimation

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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

(#6) Magnification
¬

¬

Commandment #7:
The Grid

Geometric Magnification
¬ Achieved by increasing the distance between the patient and the
image intensifier (contrary to dose reduction method)
¬ Geometric magnification can be used with isocentric systems
¬ Dose typically increases with the square of the magnification
¬ i.e., if magnification increases by 2x, dose rate goes up by 4x
¬ Maximum dose rates in this configuration may exceed 10 R/min
(legal entrance exposure limit)
¬ this is because compliance dose rates are tested under
conditions of least geometric magnification (patient closest to
image intensifier)
Again, the minimum magnification consistent with the goals of the
the
procedure should be used to manage radiation properly

¬

Brent K Stewart, PhD, DABMP

Remove the grid during procedures on small patients, thin body
parts or when the image intensifier cannot be placed close to the
the
patient

Brent K Stewart, PhD, DABMP
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Commandment #8:
X-Ray field Collimation
¬

Commandment #9:
Distance and Shielding

Always use tight collimation

¬

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

Personnel must wear protective aprons, use shielding, monitor their
their
doses, and know how to position themselves and the imaging
equipment for minimum dose

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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

(#9) Shielding and Distance

(#9) Shielding and Distance
¬

The principal source of radiation for the patient is the xx-ray tube

¬

Brent K Stewart, PhD, DABMP

The principal source of radiation for the operator and other
personnel is scatter from the patient

Brent K Stewart, PhD, DABMP
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(#9) Shielding and Distance

(#9) Shielding and Distance
¬

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¬

One of the most important means
by which personnel can reduce
dose to themselves is by using
shielding and properly positioning
themselves relative to the patient
and the fluoroscopic equipment

¬
¬

Lead aprons
¬ lead equivalency: 0.25 mm to 0.50 mm
¬ 0.25 mm: absorbs > 90% of scatter
¬ 0.35 - 0.50 mm: absorbs 95 - 99% of scatter (but heavier)
Lead aprons should be properly stored on a hanger when not in use
use
Aprons should be checked annually for holes, cracks or other forms
forms
of deterioration

x-ray
¬

All personnel who are not
positioned behind a radiation
barrier must wear a lead apron

during a procedure

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Protection of Physician’s Hands

(#9) Shielding and Distance
¬

Aprons do not protect the thyroid gland or the eyes.
¬ Thyroid shields and leaded glass can be used
¬ Leaded glass attenuates 30%30%-70% depending on the
content of lead in glass
¬ Protective gloves of 0.5 mm lead of greater should be worn if
hands are going to be near the primary beam (false sense of

protection)

¬

¬

¬

¬

¬

Dermal atrophy of the forearm and hands were observed in
physician who performed fluoroscopy for years
Convinced some physicians to wear special radiationradiation-attenuating
surgical gloves or hand shields
Such devices are not likely to protect hands if placed fully into
into the
beam
The automatic brightness control (ABC) detect the reduction in
brightness due to the attenuation by the gloves and boost the
radiation output to penetrate the “protective” gear
Protective hand gear can be relied on only to protect against
radiation outside the field of view of the ABC

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Protection of Physician’s Hands
¬

Protection of Physician’s Hands

To protect hands during fluoroscopy, it is recommended:
¬ Keep hands out of and away from the xx-ray field when the beam
is on unless physician control of invasive devices is requires for
for
patient care during fluoroscopy
¬ Work on the exitexit-beam side of the patient whenever possible
¬ x-ray tube should be below table for vertical orientations
¬ for oblique and lateral projections, stand on the side of the
patient where the image intensifier is located
¬ for adult abdomen, exit radiation is only about 1% the
intensity of the entrance radiation
¬ extra care must be exercised in situations where physician
must work on the xx-ray tube side of the patient

¬

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

To protect hands during fluoroscopy, it is recommended to:
¬ wear a ring badge to measure your hand exposure monthly

¬ ring monitors dose only at the base of the finger
¬ dose at the finger tips may be significantly higher

c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays – Supplement 1. 1997.

Brent K Stewart, PhD, DABMP
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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

(#9) Shielding and Distance
¬

¬

¬

(#9) Distance

All personnel who perform
fluoroscopic procedures are
required to wear a radiation
monitoring device, usually a film

badge
¬ Personnel potentially exposed
to 10% of the occupational
annual limit (50 mGy or 5000
mrem) need a radiation badge
It is recommended that personnel
wear their badges anteriorly on
their collar outside of lead apron
Badge readings are monitored by
the radiation safety office (RSO)

¬

Radiation Dose to personnel can be significantly reduced by
increasing their distance from the radiation source

¬

InverseInverse-square law: the dose rate drops significantly as the distance
from the source increases

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Given:
Exposure
Rate at 2 ft
= 90 mR/hr.

(#9) Distance

34

(#9) Radiation at 1 Meter From Patient
About 0.1% of patient entrance radiation exposure reaches 1 meter from
patient
1m

3 ft
2 ft
1 ft
4 ft2

1 ft2 1 ft

2 ft

9 ft2

x-ray

3 ft

2 ft
4 ft

100%

0.1%

6 ft

⎛D ⎞
E2 = E1 ⎜⎜ 1 ⎟⎟
⎝ D2 ⎠

2

The NCRP recommends that personnel stand at least 2 meters
from the x-ray tube, whenever possible. (6 feet = 1.82 m)

Exposure Rate at 4 ft = (90 mR/hr)(2ft/4ft)2 = 22.5 mR/hr.
Exposure Rate at 6 ft = (90

mR/hr)(2ft/6ft)2 =

10 mR/hr.

Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

(#9) CC-Arm FluoroscopyFluoroscopy-Shielding
¬

¬

¬

(#9) The Separator Device (or Spacer Cone)

With the CC-arm oriented vertically, the xx-ray tube should be located
beneath the patient with the II above
In a lateral or oblique orientation, the xx-ray tube should be
positioned opposite the area where the operator and other
personnel are working
In other words, the operator and II should be located on the same
same
side of the patient
¬ This orientation takes advantage of the patient as a protective
shield

¬

¬

¬

¬
¬
¬
¬

Brent K Stewart, PhD, DABMP

The FDA requires that fluoroscopic xx-ray machines be designed so that the
patient’s skin is at least a specified fixed distance from the XX-ray source
The purpose of this regulation is to prevent the dangerous situation
situation in which
the intense beam emerging from the xx-ray source is too close to the
patient’s skin
To provide flexibility for some procedures, the FDA permits machines
machines to be
designed with removable spacers
For Dx procedures, the device is to remain attached to the xx-ray source
For modern machines fixed in room, this distance is 38 cm
For mobile machines, this distance is 30 cm
For “special surgical procedures” the device may be removed and the
minimum distance can be as short as 20 cm (potentially dangerous)
dangerous)

Brent K Stewart, PhD, DABMP
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(#9) The Separator Device (or Spacer Cone)

Commandment #10: Beam OnOn-Time
¬
¬

¬

¬

c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays – Supplement 1. 1997.

Brent K. Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP

Keep beambeam-on time to an absolute minimum! - The Golden Rule
Control over beam onon-time is almost always the most important
aspect of radiation management
It is essential practice to disengage fluoroscopic exposure when the
image on the monitor is not being used
Absentmindedly leaving the xx-rays on while viewing other factors
associated with the procedure, such as direct observation of the
patient or communication with other personnel in the room, must be
strictly avoided

Brent K Stewart, PhD, DABMP
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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Good vs. Bad Geometry: Patient Dose and the
Position of the Fluoroscope

Fluoroscopic Timer
¬

A 5-minute cumulative timer is required on all fluoroscopic units
to remind the operator audibly of each 5-minute time interval
and to allow the technologist to keep track of the total amount of
fluoro time for the exam

the Good
Brent K Stewart, PhD, DABMP
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c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays – Supplement 1. 1997.

Good vs. Bad Geometry: Patient Dose and the

Position of the Fluoroscope

c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays – Supplement 1. 1997.

Brent K. Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Good vs. Bad Geometry: Summary

¬

the Ugly

the Bad

Differences in geometry of as little as a few centimeters can have
have a major
impact on dose to a patient’s skin

even Uglier

Brent K Stewart, PhD, DABMP
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c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays – Supplement 1. 1997.

Brent K Stewart, PhD, DABMP
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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Good vs. Bad Geometry: Patient Dose and
Physician Height

No invasive devices present

c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays – Supplement 1. 1997.

Good vs. Bad Geometry: Patient Dose and
Physician Height

30% dose reduction

Invasive devices present

Brent K Stewart, PhD, DABMP
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Good vs. Bad Geometry: Patient Dose and

Invasive Devices
¬

¬

¬

¬

¬

¬

c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays – Supplement 1. 1997.

Brent K Stewart, PhD, DABMP
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Good vs. Bad Geometry: Invasive Devices and
Personnel Versus Patient Dose

In many invasive procedures, syringes, catheters, or other devices
devices may be
protruding from the patient
With the patient prone on the procedure table, some distance must
must be
maintained between the patient and the image intensifier to provide
provide
adequate working space

In oblique orientations it is necessary to move the image intensifier
intensifier to a
position that avoids collisions with the patient and the invasive
invasive devices
This may place severe constraint on how far the xx-ray tube can be
positioned from the patient
For larger patients, the port of the xx-ray tube may actually come into contact
with the patient’s skin
Extreme caution is advised in these situations to reduce the potential
potential of
inducing skin burns

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

c.f. Wagner and Archer. Minimizing Risks from
Fluoroscopic X-rays – Supplement 1. 1997.

Brent K Stewart, PhD, DABMP
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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Good vs. Bad Geometry: Recommendations on
Managing Risks from Geometry
¬
¬
¬
¬
¬
¬
¬
¬
¬
¬
¬

Good vs. Bad Geometry: Where Do I Stand When
Using a CC-Arm?

Attach the separator cone to the port if at all possible
Move the xx-ray tube away from the skin as far as practicable
Move the image intensifier as close to the patient as possible
Keep the beambeam-on time of the study as short as possible
If the image contrast is not affected, remove the grid
Routinely keep hands away from the imaged area and outside the housing
housing
of the image intensifier
Use collimation to control image quality and reduce scatter
Monitor hand dose
Step back from the patient before engaging fluoroscopy
Use a transparent shield for the head and neck if the xx-ray tube is above the

patient
Have assistants use extra shielding or stand well back from the patient if
tube is above patient

¬

¬

Brent K Stewart, PhD, DABMP

When using lateral and oblique projections, the scatter radiation
radiation and the
primary beam are least intense on the exit beam side (image intensifier
intensifier
side) of the patient
¬ For example, in the lateral orientation scatter is about 3 to 10x
10x greater
on the xx-ray tube side than on the image intensifier side, depending on
patient size and section of body irradiated
In many situations, it is required that the physician work on the
the xx-ray tube
side
¬ For example, cardiologists work in a bibi-plane configuration and stand
next to the laterally projecting xx-ray tube located on the right side of the
patient, left side of cardiologist exposed
¬ lead aprons and ceiling suspended radiation shields should be used
used to
reduce exposure to the head and neck
¬ radiation badge should be worn on the left side

Brent K Stewart, PhD, DABMP
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Thoracic Fluoroscopy in Women
Cataracts
¬

¬
¬

¬

¬

Cataracts are a potential risk for patients undergoing highhigh-dose
interventional procedures in the head
The threshold for radiationradiation-induced cataract is about 1 Gy
To reduce the potential for cataracts:
¬ for lateral orientation of the tube, the eyes can be shielded on the
lateral side by using tight collimation to shield a large portion
portion of
the orbit that is closest to the xx-ray tube
¬ the frontal view should be performed with the xx-ray tube posterior
to the head and the image intensifier anterior. This ensures that
that
the eyes receive only the much reduced exit beam dose and not
the much higher entrance dose

¬

¬

¬

Breast cancer has been induced in women who
underwent thoracic fluoroscopic evaluation for the
treatment of tuberculosis
These women, for the most part, were positioned
with their breasts facing the xx-ray tube
This might occur with today’s procedures if the xx-ray
c-arm is oriented for an oblique view through the
thorax, perhaps to view the spine
¬ breast could get exposed to high xx-ray
intensities
It may be reasonable to turn the cc-arm over so that
the xx-ray tube is above the back of the prone patient
¬ breast would receive only the reduced exit dose
Position the beam so that the breast is not in direct
line with the xx-rays or consider using tape or
bandages to move some of the breast out of the
direct xx-ray beam

/>
/>Brent K Stewart, PhD, DABMP

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

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Minimizing Risks from Fluoroscopic X-rays

Diagnostic Radiology Imaging Physics Course
9 December 2004

Dose Reduction by Heavy Filtration
¬

¬
¬

Other Factors?

Some modern fluoroscopy units now provide options for heavy xx-ray
beam filtration under some conditions (e.g., Philips ‘Spectrabeam’)
‘Spectrabeam’)
¬ this filtration more effectively removes nonnon-penetrating, dosedoseenhancing, lowlow-energy xx-rays than does conventional filtration
¬ this results in reduced patient xx-ray exposure
¬ this heavy filtration typically consists of thin plates of copper
copper
inserted at the window of the xx-ray source
To be effective, the tube current must be set very high
The physician should be aware that the equipment has this special

special
feature and know when it is engaged so that unnecessary concerns
over high tube currents can be avoided

¬

¬
¬

¬
¬

Brent K Stewart, PhD, DABMP

Use modes of operation such as pulsed fluoro (30, 15, 7.5 and 3.75
3.75
pulses per second) which reduce dose dramatically over continuous
continuous
fluoro techniques
Try to avoid long exposure time to same skin area
Try to avoid high skin dose modes of operation such as cine, high
highlevel control if possible
Don’t allow any extraneous body parts in the beam
RealReal-time dose monitoring is now standard on most newer
fluoroscopic/angio/interventional systems

Brent K Stewart, PhD, DABMP
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Conclusions
¬
¬

¬
¬

Be smart about radiation and use common sense
Apply the riskrisk-reducing factors (“the Ten Commandments”)
discussed herein for the patient’s safety as well as your own
Keep the beambeam-on time to a minimum
Consciously and conscientiously practice ALARA

Brent K Stewart, PhD, DABMP
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Brent K. Stewart, PhD, DABMP

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