As an interventional cardiologist, I specialize in complex cardiac and vascular interventions. I’ve been in the field since the mid-1980s and spent a lot of that time performing procedures in rooms where scatter X-ray radiation was a constant, ever-present threat, one that we accept without thinking about it. I now know that such “blind acceptance” is a mistake!
During those decades on the job, I’ve learned a lot – through my own experience and that of many of my colleagues about the costs we’ve been paying by exposing ourselves and our staff to radiation scatter in the cath lab, not to mention tolerating the burden of wearing antiquated, heavy lead protective equipment to shield us from it. The toll these have taken on all healthcare workers who utilize ionizing radiation for diagnosis and procedural guidance has been astonishing and concerning.
Scatter radiation is an important driver of morbidity and mortality among the doctors and staff who work with it daily. Long-term exposure can cause skin damage, cataracts of the eye, cancer, and chromosomal abnormalities. It is a silent killer – I’ve had colleagues die from leukemia and other cancers, almost certainly resulting from years of ongoing exposure to scatter radiation on the job.
Even more prevalent than radiation damage are the orthopedic injuries resulting from continually wearing heavy lead during lengthy procedures throughout their career. Shouldering twenty-five to thirty-five pounds of lead every day, often for hours at a time, is a serious occupational hazard.
Despite my background as an athlete and a person who exercises regularly, I still developed orthopedic issues like so many of my colleagues. After years of pain, followed by two back surgeries and ongoing physical therapy, I’ve regained most of my functional capabilities. That said, the MRIs showing compression throughout my lumbosacral spine are a testament to the long-term effects of donning lead aprons. The whole saga has been a close-up experience of waste and loss: lost time treating patients, wasted days suffering acute pain, and the loss of confidence that I’ll be able to stay active in the profession I love until I am ready to retire. Indeed, a substantial number of my colleagues have retired specifically because of the dangers of radiation and the orthopedic injuries they have sustained. It is clear that we need new ways to protect all staff in the cath lab without loading them down with obtrusive, injury-causing wearable lead aprons.
How did we get to this point of crisis? Two of the usual suspects stand out: 1) Good doctors prioritize their patients’ well-being over their own — sacrificing one’s comfort, free time, and even health is often accepted as part of the job. Like firefighters, we run full speed into the house on fire in order to carry out our mission of helping fellow human beings. Though subconsciously aware of the liabilities, we ignore them at the moment. The fact that the risks are latent rather than immediate makes it even easier to ignore them; 2) Hospitals and other large healthcare facilities have failed to acknowledge these occupational risks and consequently have yet to embrace the potential solutions. They suffer from institutional inertia, often sticking with partially effective systems and delaying investment in new technology. The issue of cost and value always comes up, but it is time to place a higher value on the well-being of our medical staff. Indeed, if one thinks logically, investment in the staff will increase productivity and staff retention while reducing the epidemic of debilitating health effects faced by our frontline caregivers. The facts are now undeniable: the orthopedic issues are of epidemic proportion. Well over 50% of interventionalists have either had surgery or experienced back or neck issues. Physicians and cath lab staff should no longer be required to bear the burden of radiation protection. And institutions can no longer be passive and look the other way. Instead, hospitals must embrace the recent cadre of paradigm-shifting technologies that are beginning to offer real, sustainable solutions never before available.
These novel solutions include various methods to protect the operators and other staff in the room to varying degrees. The systems available can substantially reduce exposure to scatter radiation; if used properly, they can minimize exposure enough to enable operators to abandon lead aprons. I have had the opportunity to utilize some of the devices.
The approach that I favor is that taken by Radiaction Medical. While other systems on the market utilize complex arrangements of shielding around the X-ray table to block the scatter, Radiaction aims to block scatter radiation at the source. This is accomplished by seamlessly integrating an arrangement of shutters with the fluoroscope’s C-arm. There is no interference with C-arm performance, maneuverability, or imaging quality. The shutters, attached to the image intensifier above and the X-ray tube below, deploy automatically at the touch of a button and “hug” the patient from above and below. It requires minimal set-up time and 2-3 seconds for deployment and retraction. The sophisticated sensor-based technology ensures that the shutters are positioned precisely in relation to the patient, providing immediate patient access and effectively blocking radiation before it scatters around the room. By containing the radiation at its very source, the system protects everyone working in the room: doctors, nurses, technicians, and others who may be present, such as imagers or anesthesiologists. This is currently the only system that enables such global protection. By reliably blocking scatter at the source, Radiaction allows cath lab physicians and staff to significantly lighten their load of wearable lead garments without sacrificing safety. Orthopedic injuries like mine may become a relic of days gone by. In the future, I envision big iron companies incorporating and integrating the Radiaction shield system into their “build” of the C-arm architecture so that it functions seamlessly and without even having to think about it. Imagine full radiation protection for everyone in the room, with no need to wear heavy lead or set up all kinds of unwieldy shielding systems.
We are now at a crossroads. In the coming months and years, more creative technologies like Radiaction will be approved for use, and options for effective, sustainable radiation protection will proliferate. This surge in innovation is being matched by growing demands from a new generation of interventional medicine professionals who are increasingly aware of the occupational hazards they face —they will not be placated with half-measures anymore, especially if excellent protective solutions are available if these forces can merge with new understanding among hospital administrators and others with institutional purchasing power. I believe the future of cath lab radiation protection is on the right track toward a positive outcome. We owe it to our patients, our colleagues, and ourselves to keep it there.
Kenneth Rosenfield, MD, MHCDS, is the Section Head for Vascular Medicine and Intervention. He specializes in complex cardiac and vascular interventions and directs the program for treating acute myocardial infarction (STEMI) in the cardiac catheterization laboratories. He has spearheaded the development of less-invasive therapies for patients with coronary and vascular disease, both at MGH and nationally, including treatment of Carotid, Kidney, and Leg artery narrowing using stents and other novel devices.