Rising Awareness of Radiation Safety Trickles Down to Fellows

 

 When Celina Mei Yong, MD, MSc, MBA, was pregnant with her first child, she spent countless hours thinking about something that most soon-to-be mothers do not—how exposure to cath lab radiation might affect her developing baby.

Then taking a year to conduct research after her general cardiology fellowship, she would check in on procedures “for fun” but was not required to be in the cath lab on a daily basis, if at all. “The thought of wearing heavy lead when you're 8 months pregnant is terrible,” Dr. Yong, currently an interventional cardiology fellow at Stanford University Medical Center (Palo Alto, CA), told TCTMD in a telephone interview.

 Radiation safety has always been at the core of interventional cardiology practice, she said, but “the reason why there has been more attention on it [among] the current generation of fellows is that there are more and more women who are coming through the cardiology program… mostly of childbearing age, and that issue becomes more important when you are thinking about family planning.” 

As one of 2 interventional fellows in her 1-year program, Dr. Yong says she often fields radiation safety questions from both male and female general cardiology fellows related to pregnancy and fertility. Yet she feels she has limited resources from which to answer them. “That's [not] the current focus of radiation safety training,” she said. “The fact that some people have come to me asking questions… means that we’re not getting the information that we should be getting.”

Pregnancy vs Practicality

In addition to designing the radiation safety course for incoming fellows at Columbia University Medical Center (New York, NY), medical physicist Stephen Balter, PhD, told TCTMD in a telephone interview that he leads long discussions with women who have officially declared pregnancy while working in the cath lab as operators, nurses, technicians, and fellows.

“So much of this is individualized. The book answer is that as long as the radiation levels are monitored and they are appropriately low, there is no problem,” he said. “There are practicalities when you are trying to complete a fellowship—you have to get a log book done.”

Dr. Balter added that he has no authority to prohibit anyone from entering a cath lab, but if a fellow decides to take time away from operating while pregnant, the question then becomes: “What are you willing to do in order to complete your [fellowship] objectives?”

From another perspective, S. Hinan Ahmed, MD, associate program director of the interventional cardiology fellowship program at the University of Texas Health Science Center (San Antonio, TX), said that his program does not allow fellows to rotate through the cath lab “during certain periods of their pregnancy.”

“We just make it clear to them that there are some risks involved even with all the protection and gear, so it's probably a better and safer idea to just do the rotation at a later date,” he explained in a telephone interview with TCTMD.

In a 2011 consensus statement, the Society for Cardiovascular Angiography and Interventions (SCAI) advised that “concerns over radiation exposure should not be a barrier to choice in pursuing a career in invasive or interventional cardiology, nor should they arbitrarily limit an existing operator’s choices on work environments during pregnancy.”

As for questions about fertility, Dr. Balter said fellows should rest easy. Based on data acquired from the Hiroshima and Nagasaki nuclear bombing survivors, radiation has “no known genetic effects on humans,” he reported.

Reducing Radiation With Practice Changes

Beyond the risks associated with radiation exposure during pregnancy, countless reports have been published about brain tumors, back and neck problems, cataracts, and other hazards of a lifetime spent working in the cath lab.

Radiation exposure can be substantially higher for fellows, who typically stand at the head of the operating table, closest to the x-ray beam, reported Shikhar Agarwal, MD, MPH, an interventional cardiology fellow at the Cleveland Clinic (Cleveland, OH).

Dr. Agarwal was part of a team that lead a twofold initiative at his institution in 2013 to reduce exposure by lowering the default fluoroscopy setting from 10 to 7.5 frames per second and by installing a second footplate for low-dose acquisition that captures images using one-third of the amount radiation than is used normally.

“We reduced our radiation significantly—almost 30% for percutaneous coronary interventions—and there was absolutely no difference in our outcomes,” he told TCTMD in a telephone interview.

“People are getting more and more in tune with radiation safety,” Dr. Agarwal continued, adding that there are still many fellows going into practice who do not understand the exact science behind radiation dosimetry. “It's not just about wearing lead. You have to understand how procedurally you can cut the radiation down because that is more sustainable.”

The online modules and one-on-one trainings that incoming fellows go through annually are good but do not always provide enough specific advice, he said. Simple radiation practices like using low-resolution imaging, keeping the table height low, and placing the imaging equipment close to the patient go hand in hand with remembering to wear protective equipment like lead aprons, glasses, and caps, Dr. Agarwal noted.

Dr. Balter agreed, adding, “The danger is if people don’t get the training, they can either hurt themselves or their patients, which is why we do it and why we do it as early in the training program as we can.”

Call for Consistency in Education

According to Dr. Ahmed, best practices for radiation safety are not difficult to follow, but most interventionalists do not prioritize them. “You're dealing with a lot of issues going on at the same time, and most important is the well-being of the patient,” he said.

To help minimize the occupational hazards even further, many of the sources contacted by TCTMD advocated for a standardized, nationwide radiation safety course, perhaps developed by the American College of Cardiology, American Heart Association, Heart Rhythm Society, or  SCAI, which together penned the 2004 fluoroscopy clinical competence statement.

A simple yet comprehensive slide presentation created collaboratively by interventional cardiologists and radiation safety officers would do the trick, according to Dr. Yong. The goal would not be to add to the demands of already overtaxed physicians, she added, but rather to make information more readily available.

If professional societies and fellowship programs do not step up to this task, Dr. Balter said, the government may be required to introduce new regulations and red tape.

Older generations of interventionalists have roles to fill in ridding complacency from the cath lab as well as in adopting and teaching new technologies and equipment that have been built with radiation safety in mind, Dr. Agarwal noted. “If it’s just a software upgrade and then you can start using low-dose acquisition, that is complete value for money,” he said. “Not everything is super expensive.”

‘Like Wearing Sunscreen’

Today, Dr. Yong is considering how she might balance work in the cath lab with a potential future pregnancy. “If I transitioned to a faculty position, I'd think differently because then I’m supposed to be completing my obligations at work and it's not just a matter of preference,” she said.

Dr. Yong acknowledged that she does not always prioritize the more commonplace issues of radiation safety. “Radiation exposure is something that happens over a lifetime. [Worrying] about a lifetime of exposure on a day-to-day basis just doesn't seem as acute as the guy who is having a heart attack in front of you,” she said.

While saying the cumulative risk scares her in an abstract way, she also admitted to not wearing her lead glasses when in a rush. “It’s kind of like wearing sunscreen for skin cancer protection,” Dr. Yong observed. “I can't say I always do, and I know it's good for me, but what can I say? Sometimes the worst patients are doctors.”