Doctors drop use of lead X-ray aprons
NEW HAVEN — Even the doctors see it as “monumental shift.”
Those heavy lead aprons we’ve always worn during an X-ray are being phased out at some hospitals in the state and experts say it’s for health reasons.
The lead aprons are no longer are being used at Yale New Haven Hospital, a change in longstanding practice accelerated by the COVID-19 pandemic.
Bridgeport Hospital also is ending their use, and the other Yale New Haven Health hospitals, including Greenwich Hospital, will end the practice.
“We are one of the first, if not the first in Connecticut, and there’s only a handful of hospitals nation
wide” to discontinue use of the lead shields, said David Facchini, diagnostic imaging manager at Yale New Haven Hospital. “We are a pretty big innovator in terms of this practice change.”
Radiologists and doctors have long talked about whether the shields, used primarily to block radiation from the ovaries and testes, really do any good, especially given the low amounts of radiation used in modern X-rays.
There is evidence that they actually can increase the amount of radiation a person receives, especially if they block a portion of the scan and it needs to be done a second time.
“This is a monumental shift in what has been standard practice in radiology for 50-plus years,” said Dr. Jay Pahade, radiology medical director for quality and safety at Yale New Haven Health. “They were taught over and over again to shield, to shield, to shield … to protect the patient.”
However, research has found that the lead shielding not only does little if anything to protect the gonads from radiation that might cause genetic defects or cancer, but that it may result in an increase, said Adel Mustafa, chief of diagnostic radiology physics, radiology and biomedical imaging at the Yale School of Medicine.
Medical professionals in the past had “the mistaken idea that they are going to protect the gonads from scattered radiation,” he said. “If one is to look at the amount of external radiation, it is insignificant compared to the internal scatter.”
Another issue is that modern X-ray machines use an “auto-exposure control device” to measure how much radiation to emit. If the lead shield is detected by the machinery, “it will actually be seen … as if it is a large person” and increase the amount of radiation, Mustafa said.
Facchini said, “it actually increases the dose and that has been going on for a long time.”
When preparing an Xray, radiologists follow a standard called ALARA: as low as reasonably achievable, Pahade said.
“That is kind of our gospel in radiology when it comes to exposure to the patient,” he said. Radiologists use “the least exposure possible to answer the diagnostic question,” such as where there may be a pelvic fracture.
“We want to use enough radiation to get a goodquality image … We want to use the least amount possible,” he said.
Another issue is the risk that an X-ray will have to be repeated, resulting in twice the dose of radiation.
“Sometimes the shield was used and not placed in the right place by the tech. It may block things we need to see,” Pahade said.
Mustafa added that there is “a bit of guessing where that ovary is in the patient” and also that “patients move during exposure.”
The change in practice has been discussed for a decade, Mustafa said, with members of the medical physics community asking, “Why are we doing this?” The American Association of Physicists in Medicine recommended in April 2019 that lead shields be discontinued.
The shields became standard in the 1950s out of concern that radiation could cause genetic defects in ova and sperm. There is also a small risk of radiation causing cancer in internal organs. Radiation levels at that time “were about 10 times higher than what we are using now,” Mustafa said.
The risks now are “extremely low to the point where no one can quantify it.”
Facchini said we are continually bombarded with radiation. “You get so much radiation from the sun when you’re outside” so as to make the additional exposure from an X-ray insignificant.
“It’s hard for a lay person to understand it,” Pahade said. “We just essentially know that the risk is so low from a regular X-ray that it’s not even worth talking about.”
The amount of ionizing radiation we receive varies, depending on the part of the body. According to radiologyinfo.org, a chest X-ray will deliver as much as 10 days of background exposure, a mammography similar to seven weeks and a scan of a hand or foot about three hours.
Pahade said Yale New Haven had planned to change its practice in July, but when COVID-19 hit, it became more urgent. Cleaning the aprons took additional time and there was an increased risk of infection from the coronavirus.
Staff asked, “Can we make this change quicker?” he said. “It really made sense for us during the pandemic to flip the switch.”
They made the change March 28 at Yale New Haven Hospital and will do so at Yale New Haven Health’s four other hospitals.
Dr. Ian Karol, chairman of radiology at Bridgeport Hospital, said in an email, “Following our colleagues at Yale, here at Bridgeport Hospital we will be immediately following a new protocol of no longer considering gonadal shielding as a gold standard of radiology care. ... We would like to keep the public informed of this current change of practice as we continue to adjust in order to maintain the best diagnostic care for our community.”
The shields still will be available if patients ask for them, but they will be told why they aren’t really necessary. Also, technologists who may be exposed to repeated doses of radiation will continue to wear protective gear.
Nuvance Health, which includes Norwalk, Danbury and New Milford hospitals, is “currently evaluating this practice,” according to spokeswoman Andrea Rynn.