X-rays and the evolving standard of care for hospital staff
Click Here to Manage Email Alerts
Key takeaways:
- Ionizing radiation has traditionally posed risks for cardiologists who use X-ray machines.
- Advances in radiation safety have reduced these risks, making working conditions more attractive, especially for women.
It seems long ago now that so much has changed, but just a few decades ago, interventional cardiologists, electrophysiologists and others who work daily with X-ray machines lived in a very different world.
Despite the known risks of fluoroscope-generated ionizing radiation, educating the health care workers who used this equipment was not a universally high priority. Neither was a commitment to workplace safety or employee well-being in institutions where these procedures took place. Speaking as a woman cardiologist, one of the people most at risk, we should have raised the issue earlier and been more insistent.
Thankfully, recent years have seen a change for the better. More and more, those of us in this field gained a better understanding of the risks involved with radiation exposure, and our collective voices have gradually grown louder in demanding more protection. Institutions are also coming around to the idea that unless the risk of radiation is managed upfront early on, we could see a world without enough skilled people to deliver this type of critical care because they’re afraid of the danger. Understanding this evolution in thinking is important to keeping us on track toward safer, healthier radiation environments for everyone using these deadly miraculous devices to save lives.
The old days
I went to medical school at the Karolinska Institute in Stockholm, Sweden, then did my residency at Vanderbilt, and pursued cardiology and electrophysiology (EP) fellowships. I was drawn to the field because it’s a procedure-oriented specialty, and patients who respond well tend to do so dramatically. This is one of the most rewarding aspects of cardiology, along with the rich, long-term connection with patients.
While there was some cursory instruction and a fluoroscope exam to pass, that’s where our formal education ended. Because our focus was on our patients, there just wasn’t much discussion of radiation safety in the cath labs of my youth, and that extended into my years as a faculty member.
For most of that time, there were very few women in cardiology, and radiation risks were not discussed. As the only woman among men, I was often reluctant to “rock the boat,” even if I had concerns. Overall, though, I wasn’t concerned enough. I had a child during my cardiology fellowship and another one during my EP fellowship, and I am grateful that they are happy and healthy to this day. I remember putting the lead on, doing the procedure and hoping for the best. There were no other options, and administrators provided little direction and few resources. It was like a self-imposed taboo, but in the long term, it was not sustainable.
Problems proliferate
Over time, problems began to emerge with this approach. Cardiologists, electrophysiologists, technicians and other staff began to suffer health effects due to scatter radiation and the heavy leaden apparel used to guard against it. In an atmosphere where the topic rarely came up, these problems accumulated due to gaps in knowledge, adherence to unsubstantiated traditional behaviors, and the false sense of security that allowed us to stop worrying about ourselves and tend to our patients. There was little outcry for better solutions, and little was done in this area for quite some time. We had to be happy with our ill-fitting, heavy lead protective gear, and that was it.
Unfortunately, radiation’s insidious damage goes on whether we talk about it or not. As the years ticked by and the number and duration of fluoroscope-guided procedures multiplied, we began to see more and more health problems among cath and EP lab staff, both from the direct effects of the scatter radiation that enters gaps in protective apparel, and its weight, which can exceed 20 lb, leading to painful, career-threatening orthopedic injuries.
Because radiation damage accumulates over time, cath lab veterans were most at risk for breast and brain cancer, cognitive degradation, cataracts, thyroid disease and grave consequences for developing fetuses.
Suddenly, it seemed, we were losing cardiologists and other nuclear medicine professionals in the prime of their careers due to injury, death and early retirement. Worse, young doctors were beginning to gravitate toward other, less dangerous jobs. For all these reasons, we faced an imminent crisis in the field.
Women, pregnancy and reducing the risk
For a pregnant woman working near a fluoroscope, the dangers of scatter radiation extend to both mother and child. In working with and mentoring women cardiologists over the years, I’ve had many conversations about the big decision each of us had to make in medical school, and the big question we had to answer: If I enter this specialty, will it harm my future child?
I used to think of the pregnancy risk as an extra burden that women bear, but I have come to believe that the added motivation we have as women will drive solutions to this challenge going forward. It’s not optional because it’s not just about us. This realization has led me to spend a lot of time recruiting, training and advising female colleagues. Increasing their numbers and amplifying their voices are key to improving radiation safety for everyone involved.
Heartening trends
After all these years, seeing real improvements coming online is gratifying. After all, everyone facing these risks wants the same thing: to feel safe throughout the workday and not come home every evening worrying about the diseases we might get from very long procedures and exposures.
We talk about these things now, which is perhaps the most significant change, but we’re also seeing new technology come to the rescue. You can see lead glasses being worn for eye protection today. This was utterly unknown in the old days. Nobody had head or eye protection, and recently more novel, robotic systems have appeared on the market that have the capability to protect a whole room full of people by blocking radiation at the source. These developments sprang from increased awareness and demand for better protection, which is a function of doing more and longer procedures and getting more radiation exposure.
Beyond better wearable shielding and new high-tech, whole-room solutions, simply using the lowest practical fluoroscope power settings can help reduce scatter radiation, and tracking exposure times with individual dosimeters can minimize overdoses. Notably, an increasing number of procedures now rely on non-radiating imaging devices such as ultrasound or MRI, which was uncommon 20 years ago.
The slow burn of awareness and conversation about cath lab radiation safety has become a crackling bonfire, and we are no longer condemned to suffer in the shadows. Thanks to new thinking among hospital administrators, the latest protective technology is starting to show up where needed, which bodes well for the future of the specialty and patients and doctors alike.
With the latest radiation-blocking technology used in conjunction with modern, well-designed, and appropriately lighter protective apparel, I do not worry about the risk to staff in a typical interventional lab. I think about it, and double-check the safety protocols, but it’s no longer a worry. I hope and expect that as the fear legitimately diminishes, eagerness will increase for young doctors — especially women — to enter this fascinating and rewarding field.
References:
- Jacob S, et al. Intl J Cardiol. 2012;doi:10.1016/j.ijcard.2012.04.124.
- Park S, et al. Korean J Pain. 2022;doi:10.3344/kjp.2022.35.2.129.
- Scheidt S, et al. Z Orthop Unfall. 2022;doi:10.1055/a-1219-8453.
- Venneri L, et al. Am Heart J. 2008;doi:10.1016/j.ahj.2008.08.009.
For more information:
Ulrika Birgersdotter-Green, MD, is a board-certified cardiologist who specializes in diagnosing and treating heart rhythm disorders. She directs the Pacemaker and ICD (Implantable Cardioverter Defibrillator) Service at UC San Diego Health and leads one of the largest lead extraction programs in the western United States. She can be reached at ubgreen@health.ucsd.edu.
Collapse
Click Here to Manage Email Alerts