Flu­o­roscopy puts providers at ra­di­a­tion risk

Modern Healthcare - - NEWS - By Steven Ross John­son

The growth of flu­o­ro­scopic imag­ing in car­dio­vas­cu­lar and or­tho­pe­dic in­ter­ven­tional pro­ce­dures is rais­ing fears that in­sti­tu­tional safety pro­to­cols are not ad­e­quate to pro­tect med­i­cal staff from in­creased health risks re­sult­ing from ra­di­a­tion ex­po­sure.

Emerg­ing tech­no­log­i­cal so­lu­tions are re­duc­ing those risks, but most are in early stages of devel­op­ment and not yet in wide­spread use, at least partly be­cause of their costs.

Flu­o­roscopy, which uses X-ray beams, gives car­di­ol­o­gists, or­tho­pe­dists and in­ter­ven­tional ra­di­ol­o­gists a less-in­va­sive way to per­form pro­ce­dures such as catheter in­ser­tions through the blood ves­sels, an­giograms, stent place­ments and or­tho­pe­dic surgery.

But ex­perts say the long-term ef­fects of fre­quent low-dose ra­di­a­tion ex­po­sure on med­i­cal staff who per­form such pro­ce­dures has never been fully ex­am­ined. “We kind of take our safety for granted when we get into this pro­fes­sion as in­ter­ven­tion­al­ists,” said Dr. Charles Cham­bers, a pro­fes­sor of medicine and ra­di­ol­ogy at Penn State Mil­ton S. Her­shey Med­i­cal Cen­ter. “We know there are ra­di­a­tion is­sues.”

In the nat­u­ral en­vi­ron­ment, peo­ple are ex­posed to an av­er­age of 3 siev­erts, or units of ra­di­a­tion ab­sorp­tion, a year. But pa­tients un­der­go­ing bar­ium flu­o­roscopy can be ex­posed to the same amount of siev­erts in two min­utes. Over a 20-year ca­reer, an in­ter­ven­tional car­di­ol­o­gist can be ex­posed to up to 1,000 siev­erts to the head and 100 siev­erts to the lower body, ac­cord­ing to es­ti­mates by the In­ter­na­tional Atomic En­ergy Agency.

A Fe­bru­ary re­port by the Or­ga­ni­za­tion for Oc­cu­pa­tional Ra­di­a­tion Safety in In­ter­ven­tional Flu­o­roscopy found ev­i­dence of a link be­tween in­ter­ven­tional imag­ing pro­ce­dures and ad­verse health ef­fects on med­i­cal staff. It re­ported height­ened risk for cataracts, tu­mors, re­duced sperm pro­duc­tion and birth de­fects. A 2013 study in the Amer­i­can Jour­nal of Car­di­ol­ogy found 22 cases of physi­cians who de­vel­oped brain tu­mors on the left side of their head, which the re­searchers said was linked to pro­longed ex­po­sure to ion­iz­ing ra­di­a­tion in the in­ter­ven­tional lab­o­ra­tory.

Stan­dard prac­tices to pro­tect staff in in­ter­ven­tional labs in­clude lim­it­ing their length of ex­po­sure and in­creas­ing the dis­tance be­tween staffers and the ra­di­a­tion source. An­other is wear­ing heavy lead shields dur­ing flu­o­roscopy.

But some say lead protective gear does not of­fer staffers full-body pro­tec­tion, leav­ing the head, neck and limbs ex­posed. And the use of heavy lead gear has dis­cour­aged some young doc­tors from go­ing into imag­ing-re­lated spe­cial­ties out of fear that regular use of the heavy gear over many years will cause mus­cu­loskele­tal prob­lems.

“A large num­ber of peo­ple were dis­suaded from go­ing into the field be­cause of the phys­i­cal labors,” said Dr. Lloyd Klein, an in­ter­ven­tional car­di­ol­o­gist at Rush Uni­ver­sity Med­i­cal Cen­ter in Chicago.

Klein was the lead au­thor of a re­port pub­lished in the April is­sue of the jour­nal Catheter­i­za­tion and Car­dio­vas­cu­lar In­ter­ven­tions, which found that 49% of 314 sur­veyed in­ter­ven­tional car­di­ol­o­gists re­ported hav­ing at least one work-re­lated or­tho­pe­dic con­di­tion. Nearly 7% of catheter­i­za­tion lab­o­ra­tory op­er­a­tors said they limited the num­ber of pro­ce­dures they per­formed be­cause of ad­verse health ef­fects from ra­di­a­tion ex­po­sure, and 9% of cath lab op­er­a­tors re­ported the need to take a health-re­lated leave of ab­sence.

“Many physi­cians are very pa­tien­to­ri­ented and just don’t see—or don’t want to see—the long-term ef­fects of what they’re do­ing,” Klein said.

Dr. Anne Roberts, chief of vas­cu­lar and in­ter­ven­tional ra­di­ol­ogy at the Uni­ver­sity of Cal­i­for­nia San Diego Health Sys­tem, said she and her staff limit the num­ber of per­son­nel in the lab dur­ing flu­o­roscopy pro­ce­dures. Doc­tors also are in­structed to use a com­mon fea­ture of newer flu­o­ro­scopes called “last im­age hold,” in which the last im­age on a mon­i­tor is dig­i­tally frozen af­ter the ra­di­a­tion flow has ended. That al­lows doc­tors to con­tinue look­ing at the im­age with­out ex­pos­ing them­selves or pa­tients to ad­di­tional ra­di­a­tion.

“There’s no rea­son to keep your foot on the flu­o­roscopy pedal when you have that im­age there,” Roberts said. In her view, peo­ple are “much more care­ful” about ra­di­a­tion ex­po­sure than they were 15 years ago, and the ra­di­a­tion ex­po­sure that in­ter­ven­tional ra­di­ol­o­gists face now is “a lot less.”

In­no­va­tions such as robot­i­cas­sisted sys­tems that al­low a physi­cian to per­form in­ter­ven­tions by re­mote con­trol at a safe dis­tance could help with the ra­di­a­tion-ex­po­sure prob­lem. There also are mo­bile protective shields that can be low­ered into place from the ceil­ing of the in­ter­ven­tional lab, or that can be rolled up in wheeled stands.

But Klein said those types of so­lu­tions can be cost-pro­hib­i­tive for many hos­pi­tals. In ad­di­tion, they dis­tance the doc­tor from the pa­tient and doc­tors don’t nec­es­sar­ily like that. Hos­pi­tals and surgery cen­ters, he said, should re­think how flu­o­roscopy ta­bles and labs are de­signed to im­prove staff and pa­tient safety. “Physi­cians ought not to be wear­ing their pro­tec­tion,” Klein said. “Their pro­tec­tion should be sur­round­ing them.”

Doc­tors may not want to face what they

know about risks of ra­di­a­tion ex­po­sure.

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