When Improved Patient Care Comes at a Cost for Hospital Staff: The Double-Edged Sword of X-ray Advancements in the Cath Lab

By Avishag Laish-Farkash, MD, PhD

When I first started conducting procedures in a coronary catheterization lab and an electrophysiology lab decades ago, two prominent details seem wildly out of place today. First, I was a woman at a time when female cardiologists were not commonplace. Second, even though interventional cardiologists and support staff were exposed daily to the scatter radiation emitted from our X-ray machines, our protective equipment and protocols were outdated even then.

While I’ve seen a modest increase in female colleagues conducting fluoroscopic procedures on patients with cardiac problems over the years, I’ve also seen the number, complexity, and hours required to complete these life-saving tasks grow during this time. As new technology has enabled increasingly ambitious procedures, we experienced more, longer, and more powerful radiation exposures than ever before. Unfortunately, better ways to protect interventional team members have not kept pace with this rise in cath lab scatter radiation. We only started to notice the problem when these highly skilled caregivers began to suffer serious health effects.

Looking back, I wish we had addressed this problem earlier, but the emphasis at the time was on the patient, and doctor and staff safety was factored in less often. We predominantly relied on our heavy lead aprons to protect us. In looking ahead, I am heartened by the growing awareness of this problem among caregivers and healthcare administrators, but more need to know about the dangers of scatter radiation and the new approaches to protection that reduce risk with minimal inconvenience.

More Radiation, Same Old Protection?
Those in our field cheered as new X-ray technology and capabilities became available, empowering us to help more patients and save more lives. But in all the excitement, we lost focus on the growing risk to the people delivering patient care. Doctors, nurses, technicians, and other cath lab staff have been increasingly exposed to scatter radiation, but many still use the same outdated heavy-lead apparel they always have. Thankfully, this is beginning to improve as the medical device industry responds to the growing call for more and better caregiver protection.

Better patient care should not harm doctors and staff
Ultimately, despite our best intentions, we live in a world where money matters, and most things are still subject to a cost/benefit analysis. These pressures force us to consider efficiency and economy in our decisions. Still, cutting corners at the expense of patients or staff or delivering the bare minimum of medical care for the cheapest possible price must be avoided.

Most of us struggle with these issues on a small scale daily: what can we afford, and is it worth the cost? But in healthcare and most other industries, these decisions can make or break an organization’s long-term viability so they can be gravely serious. Still, the tensions remain: how much can we get for our investment?

For decades, the trend had been toward avoiding hefty expenses and letting healthcare workers bear the brunt of scatter radiation’s effects. Of course, this was short-sighted and permitted safety conditions in cath labs to degrade to the point where staff were getting ill, injured, dying, or retiring early to avoid those possibilities. Cancer, cataracts, cardiac and fetal abnormalities, cognitive impairment, orthopedic problems, and other related problems were rising along with the number and duration of interventional procedures. Medical students began to think long and hard before choosing a cardiology career, and I believe many talented young women doctors in particular went with safer alternatives.

This was unsustainable, but perceptions had to change before improvements could be made. This is happening now, and the change in attitude is palpable and positive but incomplete. Those of us who are plugged into this issue are obligated to get the radiation hygiene message out in every forum possible. Talking about it is the first step toward fixing this problem.

The morality of the situation is obvious: as medical professionals, we are sworn to protect the health of all people, even each other. Nevertheless, it always helps when the path to a sustainable solution is cost-effective, too. In this case, the costs for a comprehensive medical radiation safety overhaul are minimal compared to treating staff radiation injuries and losing the experience, expertise, and people who deliver the high-tech healthcare our world has come to depend upon.

Solutions
Where I work at Samson Assuta Ashdod Hospital, Israel, we are fortunate that the administration gets it: they understand that radiation protection is a critical investment. As a result, we’ve been using and evaluating several recent radiation-blocking technologies.

The Zero-Gravity device (Biotronik) is designed to protect the fluoroscope operator. Essentially, it is a long lead apron, open at the top and bottom. But rather than being worn by the operator, it is suspended from the ceiling by a rail system and magnetically attached to a vest worn by the user. This permits the operator to move freely in the workspace without bearing the heavy load of traditional lead shielding.

The EggNest (Egg Medical) is a system of shields that attaches to the table and is flipped up into place manually when needed for procedures. It surrounds the patient with radiation-blocking panels, preventing most scatter radiation from exiting and protecting everyone in the room.

The technology I’ve been studying clinically is the Radiaction system (Radiaction Medical). Unlike manually operated systems, Radiaction’s device is attached to the C-arm and robotically deploys radiation-blocking panels at the press of a button, so all staff are protected.

I led the team that conducted the first Radiaction system bench testing and performance in a live clinical environment in 2022. We found it to reduce overall radiation in the room by up to 93% and reduce exposure to the treating physician’s head, neck, and face by up to 97%.¹ As someone who has friends who developed a cataract at a relatively young age, I find this compelling.

Users felt the device was intuitive and simple. During CIED implantations, it did not increase the duration of procedures, and it offered good image quality and accuracy when using 3-D mapping in the EP lab. No anxiety was evident in patients due to the apparatus, which was highly integrated into the clinical workflow. It is recommended, however, to maintain existing standard shielding unless additional clinical data indicates a reduced need for personal protective clothing.²

We are currently using the Radiaction system as a protective control measure in a DNA study of interventional team members to look for radiation damage at the genetic level.

Conclusion
This type of foundational knowledge will help us better confront these dangers and ensure that no doctor is dissuaded from interventional cardiology due to health concerns. This will likely attract and retain more diverse staff who bring rich experiences and valuable perspectives to the profession. The cost savings from reduced staff turnover and unneeded radiation injury treatments could be significant. Of course, more study data is needed to help us increase awareness, address these problems in meaningful ways, and move toward a brighter, safer future.

Avishag Laish-Farkash, MD, PhD is the head of Electrophysiology Unit, Cardiology Department, at Samson Assuta Ashdod Hospital in Ashdod, Israel.

Reference
1. Laish-Farkash A, Harari E, Finkelstein A, et al. A novel robotic radiation shielding device for interventional cardiology procedures. EuroIntervention. 2022;18(3):262-266. doi: 10.4244/EIJ-D-21-00577. PMID: 35094972; PMCID: PMC9912971.

2. Laish-Farkash A, Harari E, Rahkovich M, et al. A novel robotic radiation shielding device for electrophysiologic procedures: A prospective study. Am Heart J. 2023;261:127-136. doi: 10.1016/j.ahj.2023.03.009. PMID: 37225386.