Radiation exposure is one of the main concerns keeping gifted, qualified women from entering fields like interventional radiology in greater numbers. With time and education, we should see this trend shift; “the future is female,” as some say. For would-be proceduralists and surgeons who worry about radiation exposure related to using fluoroscopy (flouro), I’ve put together a brief guide on radiation protection in interventional radiology.

This is the first of two educational posts on radiation protection. What better way to address the leaky pipeline of women interested in procedural fields that use x-ray?

My partner in radiation protection

I’m thrilled to announce a new partnership, which I’ve been cultivating for some time. Why, you may ask? There’s a lot of care and maintenance that goes into a site like this, and it’s been a labor of love for two years. With the help of my partnership with RADPAD, I can reach more women aspiring to the male-dominated fields of medicine and surgery. I want the message of empowerment in this blog to grow and flourish. With support, I can continue to make that happen!

In RADPAD, I could not have found a company more aligned with my goals and mission. Heck, they’ve become a part of my daily life in the angio suite. That’s because RADPAD makes protective shielding that I can place directly on my patients to absorb scatter radiation I would have potentially received without it.

For those of you who haven’t yet studied radiation physics, here’s the issue in a nutshell. After the x-ray beam penetrates the patient’s tissue to make the image on the screen, it can scatter out toward you, the operator. This is actually the chief source of radiation exposure to operators in IR, interventional cardiology, vascular surgery, orthopaedics, and the like. That’s why, as my patients get larger and sicker, I’ve begun using RADPAD protective shields every day. 

Radiation physics … zzz…

I’ve never been a great sleeper, but one page of a dense radiation physics text could put me into a deep slumber. Luckily, I passed my esoteric physics boards– by the skin of my teeth. Fortunately, you don’t need to be a physics wiz to protect yourself from the harmful effects of scatter radiation. I’ll share some of the ways I protect myself in my daily work. 

Use all the personal protective equipment available to you

Lead apron

Commonly referred to as “lead,” these protective garments used to be made with actual lead; it made them pretty heavy. Luckily, smart folks have since developed lead equivalents, making these garments easier and more comfortable to wear when you’re working with fluoroscopy.

The best kind of lead to get (or borrow, depending on your stage) is a two-piece suit consisting of a wrap-around kilt and a vest. The wrapping in the front doubles the protection as you face the source of radiation. This design is also easier on your body, since it off-loads much of the weight of the garment from the shoulders and back to the hips.

Lead Glasses

I wear prescription leaded glasses for every case requiring the use of x-ray. Not only do they protect my eyes from splashes that can occur when working with body fluids and wires, but they block harmful x-rays from scattering into the eye, where over time, they can produce cataracts. These are a must.

Many trainees don’t have their own lead glasses, and they can be expensive. If you plan on working in a field that uses fluoroscopy, I recommend getting a pair of leaded glasses or goggles of your own. They run a few hundred dollars or more, depending on whether you need a prescription. Some training programs have a loaner pair of leaded goggles which can be used by those rotating through IR or fluoro-heavy rotations. If your program doesn’t why don’t you suggest it?

Cap

A radiation protection cap is great for longer cases, or those requiring the use of hand-runs, like fistulagrams. A “hand run” refers to a digital subtraction angiogram you do without leaving the room (as opposed to stepping out of the room for a power-injector run). Hand runs expose the operator to a significant amount of radiation. That’s why when I do these, I also use adjunctive methods like a ceiling-mounted shield.

Though the brain is relatively insensitive to radiation (compared to other cellular beds), there’s a known increased incidence of neoplasia in operators who use fluoro. So it makes sense to use a protective cap if you’re expecting significant radiation exposure.

Badge & quarterly reports

Everyone in the fluoroscopy suite must wear dosimetry badges to track their radiation dose. It’s important to wear these badges as instructed by your radiation safety officer. Doing so will ensure an accurate reading. Make sure no one borrows your lead with your badges attached. That’s a surefire way to artificially increase the dose on your quarterly dose report.

With the usual protective measures, your dose each quarter should remain well below the regulatory limits put forth by the Nuclear Regulatory Commission (NRC).

Time, distance, shielding

These are principles you will come to know and use as you work with radiation in your work. They are great ways to minimize your dose during procedures.

• Minimize the time fluoroscopy is on
• Increase your distance from the source
• Use the various shielding devices available

Follow the principles of ALARA

ALARA is an acronym which stands for “as low as reasonably achievable.” Since there is no known safe level of radiation exposure, this rule, well… rules. It’s an axiom to use for pediatric patients, for pregnant patients, for adults, and for you. The radiation dose should be as low as it possibly can be, and making that happen is up to you!

Be aware of these factors that affect your radiation exposure: 

Air gap

The distance between the patient and the image intensifier (“II”), the imaging panel over the patient’s body, affects the amount of scatter. Always minimize the air gap (without actually touching the patient!). I try to keep the II within a couple centimeters of the body part I’m imaging.

Collimation

Fluoro machines have shutters on the 4 sides of the imaging field. You can use these to reduce the area you’re visualizing on screen. Narrowing your field of view to just that which you actually need to see improves image quality and significantly reduces your dose.

Frame Rate

Frame rate refers to the number of fluoro images you’re seeing per second. When you reduce the frame rate, you decrease the radiation dose (for everyone). When the frame rate is too low, the imaging can look delayed, or like it’s skipping. But if you’re working on a difficult vessel select, reducing the frame rate to the degree you can tolerate is a smart move.

Obese patients

As the population becomes more obese over time, you’re exposed to more scatter radiation. Obese patients can provide up to eight times as much scatter radiation as a patient of normal BMI.

Density of the body part imaged

It’s important to know that the thicker and/ or denser the body part you’re imaging, the more radiation scatter results. This means that imaging the arm is less radiation intensive than imaging the chest. And the chest requires less radiation to penetrate than the abdomen, a denser area. You can take this concept into account as you use your various radiation protection measures.

Training the whole team in radiation safety practices

I am always training new techs, and a key part of this training is learning about radiation protection. I make sure they are aware of these concepts, and reinforce them throughout our cases. In this way, the practices become healthy habits which benefit everyone in the room.

Adjunctive maneuvers

Face the table when fluoro is active

As I mentioned above, lead suits are designed with the greatest protection in the front. Whether you wear the wrap-around kilt and vest or a single piece apron, stay protected by facing the table when fluoro is on.

RADPAD

In most of my interventional cases, I place a RADPAD Shield on the patient to protect me from scatter radiation. I am especially diligent to place a shield on my larger patients because of the sheer volume of scatter that comes from their bodies (up to 8x as much on larger BMI patients). For example, if I’m embolizing the splenic artery of a large patient, I can place the pad on the patient’s right flank, where it will block and absorb any scatter from the abdomen, without encroaching into my field of view. 

In a paper by Kohlbrenner et al in the Journal of Vascular & Interventional Radiology, operators using a radiation protection pad reduced dose to the operator by 56 percent.

As you can see, there are many different ways you can protect yourself as a fluoroscopy user. Some measures, like wearing your lead, are mandatory in every case. Adjunctive measures like using a RADPAD can help tailor your protection to the particular case you’re doing. 

With time, training, and experience, these measures become second-nature. So, like anything new, don’t let it overwhelm you. But for those of us who work with radiation daily, it never hurts to remind ourselves of all the methods at our disposal. They can help bring our dose to “near-zero” levels.

In the coming months, you’ll see RADPAD images on the site. These will be linked to helpful information so you can continue to learn more about radiation protection!

Stay tuned for part 2 of this series on radiation protection: protecting yourself in pregnancy. It’s not as hard as it sounds.

Take care and stay safe. Leave any advice on your own strategies in lowering your dose in the comments below!