Radiation Scatter: Protecting Your Staff, Health, and Career
By Mohammad Sahebjahal, MD
In medical settings, ionizing radiation can harm the body of practicing physician and staff silently, invisibly, and with devastating severity. Those who use its power to diagnose, and treat patients, must understand the dangers, as well as the best practices and technology to minimize its risks. This is especially true of less-familiar scatter radiation, which bounces off the imaging site, and into the treatment suite where it can harm the healthcare team. It’s a particular concern in my cardiac catheterization lab, and anywhere a fluoroscope or other radiation emitter is used, such as in nuclear oncology. The threat is alive in the room every time the emitter is powered up and in use.
A 2016 study showed that interventional cardiology and cardiac electrophysiology doctors and staff suffered increased rates of skin lesions, cataracts, cancer, and orthopedic damage versus their unexposed colleagues. Even though they observed official radiation dose limits, these health problems increased along with the time spent conducting interventions.1
In general, depending on its intensity and duration, radiation can cause four main effects: direct, as from a high dose beam; stochastic, accumulating over time; genetic, affecting DNA; and fetal/embryonic, affecting development in the womb. Additional injuries can include cognitive degradation, thyroid, and cardiovascular diseases, abnormalities in developing fetuses, and death.
Scatter radiation is stochastic, so symptoms will appear much later than with an acute overdose. Not seeing or hearing the threat makes it easier to ignore until the damage is done, and this can include harm to DNA deep within cellular nuclei. As the body attempts to repair this broken genetic code, a damaged section may be replaced incorrectly with a mutated sequence. While no specific cancers are linked solely to radiation, exposure increases chromosomal damage, and this raises the chance of a bad repair leading to cancerous mistakes.
Additional and common effects of utilizing protective measures against radiation scatter, is the pain and fatigue caused by wearing traditional personal protective gear, that is, heavy lead garments. I’ve known colleagues who had to retire early due to debilitating skeletal damage from this strain, so it is much more than an inconvenience. Fortunately, lighter shielding alternatives are becoming available, along with radiation-blocking systems that protect everyone in the room without adding any weight.
The guiding principle for safe radiation use is ALARA, a mnemonic for “as low as reasonably achievable.” Whenever it’s possible to lower the intensity or duration of exposure without compromising results, we should do so, whether by adjusting machine settings, using new technology, or adding more shielding between the radiation source and the people in the room.
Radiation safety happens by minimizing exposure time, maximizing distance, adding shielding, and continuous dose monitoring. In other words, minimize time spent operating the fluoroscope, maximize your distance from it (exposure drops by half just 6 feet from the table), use ample radiation shielding panels or garments, and track your exposure with a personal dosimeter.
Educating staff about scatter radiation’s dangers is mandatory, along with the policies, practices, and technologies in place to defeat it. Something as simple as a radiation safety gear checklist can help staff remember to use all necessary protective equipment. It’s also important while conducting procedures for colleagues to continually check each other for safety lapses, so they can be quickly corrected.
When a fluoroscopic image is noisy or cluttered, it can be tempting to raise the power level to improve image quality, but this can also increase scatter throughout the room. Whenever possible, use the fluoroscope’s lowest settings for power, magnification, and frame rate, and be sure that the automatic brightness control is not overriding your commands. Low power has been shown to produce excellent images though slightly less sharp, with no practical reduction in diagnostic value.2
Overexposure can also be minimized by placing lead drapes around the X-ray source under the patient’s table, moving the X-ray detector as close as possible to the patient, and using tubing extensions to stay two steps away from the table. Ultimately, you should avoid using the fluoroscope if the job can be done by a non-radiological imaging device such as ultrasound, MRI, OCT, intravascular ultrasound, or transesophageal echo.
Blocking the source
From the beginning, the focus of radiation protection was largely on the patient receiving the direct dose of radiation for diagnosis or treatment. The much smaller but repeated exposures of medical staff were largely overlooked, until the telltale health effects of radiation toxicity began to appear. It became clear that staff safety had to be prioritized along with patient safety, or we wouldn’t have any staff left to conduct procedures.
For a long time, the only way to effectively reduce the risk was with lead shielding panels and heavy garments. But in recent years, the trend has been toward developing lighter, lead-free shielding alternatives for individuals along with more comprehensive systems designed to block radiation, and even newer technologies that aim to proactively block radiation at its source. These are typically attached to the table or C-arm of the fluoroscope, and use protective drapes or dynamic shielding panels to block scatter to just the operator, or to everyone in the room.
When recently upgrading the scatter radiation protection where I work, the consensus among interventional suite staff was for convenient, full-room protection without adding weight. We chose the system from Radiaction Medical to address those needs, and we’re pleased with the safety and workflow improvement.
Fully addressing the dangers of scatter radiation in interventional suites requires a fresh understanding of the risks and a commitment to fully adhere to safety protocols, as well as using the latest, most effective radiation blocking technology suited to your application. Current knowledge, appropriate equipment, and consistent safety behavior are the keys to a healthy staff and a long career using radiation to help heal our patients.
- Grazia Andreassi M, Piccaluga E, Guagliumi G, et al. Occupational Health Risks in Cardiac Catheterization Laboratory Workers. Circulation Cardiovascular Interventions. 2016; e003273 9 4, doi:10.1161/CIRCINTERVENTIONS.115.003273
- Shekhar S, Ajay A, Agrawal A, et al. Radiation Reduction in a Modern Catheterization Laboratory: A Single-Center Experience. Catheter Cardiovasc Interventions. 2022 Oct;100(4):575-584. doi: 10.1002/ccd.30396. Epub 2022 Sep 7. PMID: 36073017.