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Editorial |
1 From the Department of Radiology, University of Texas—Houston Medical School, 6431 Fannin St, Houston, TX 77030. Received March 21, 2000; accepted March 24. Address correspondence to the author (e-mail: Louis.K.Wagner@uth.tmc.edu).
Index terms: Computed tomography (CT), guidance, 70.12119 • Computed tomography (CT), radiation exposure, 70.12119 • Editorials • Fluoroscopy • Phantoms • Radiations, exposure to patients and personnel, 70.12119 • Radiations, measurement, 70.12119 • Radiations, protective and therapeutic agents and devices, 70.12119
Here is a quiz: With regard to radiation-induced skin effects, name the person who said the following and the occasion on which it was said, "I hope that we will soon be able to prevent these injuries . . . , so beginners will not have the same misfortune." This statement is relevant today, even though it was spoken by Mihran Krikor Kassabian at the 1903 meeting of the American Roentgen Ray Society (1). It was about 1910 when Dr Kassabian lost two fingers because of radiation effects and died of radiation-induced cancer.
Before you disregard this message as sensationalism or irrelevant advice for today's practice, consider that more than 65 cases of fluoroscopically induced injuries to the skin of patients and practitioners have been reported since 1994, and additional cases are known to exist (eg, see references 2–11). Some injuries have been severely debilitating. Several patients were injured during transjugular intrahepatic portosystemic shunt procedures; many more were injured during cardiac interventions. (This finding is probably a reflection of the proportion of cardiology versus transjugular intrahepatic portosystemic shunt procedures that are performed each year.)
Consider also that, since 1995, several incidences of radiation-induced cataract and skin effects in the legs and hands of interventionalists have been reported in the literature or are known to this author (9,12). For example, I have witnessed dermal atrophy, epidermal degeneration, brown fingernails, and scarring in the hands of interventionalists, all due to inappropriate use of the fluoroscope. As the 21st century begins, I sense a vicarious déjà vu with the experiences of those, like Dr Kassabian, who ushered in the 20th century at the dawn of radiology.
The increase in radiation-related injuries is directly linked to the long exposure times and high doses sometimes experienced in our highly technologic interventional work. We have been able to venture into realms of medicine that were previously inaccessible only because of our advanced digital imaging techniques that include the use of delicate, sophisticated, minimally invasive medical devices and high-output but phenomenally durable x-ray tubes. Along with these advances comes the increasing use of ionizing x-rays in quantities unfamiliar in diagnostic imaging. No longer are we simply concerned about the nebulous risk of radiation-induced cancer from small doses of x rays. Now, we face the very real risk of injury to ourselves and our patients, injuries that can be severe and intractable to treatment (7,9–11).
As we commence the new millennium, we venture into an era of computed tomographic (CT) fluoroscopy made possible by those same developments in x-ray tube technology and digital imaging and by the more recent development of continuously rotating CT x-ray systems. The physician now enters the scanner room for dynamic real-time interventional imaging, while the x-ray tube circles the patient, repeatedly exposing the same skin area. The potential for a radiation response in the patient and physician exists. Only by learning how to properly complete the exposure with dose-saving techniques and proper radiation protection will we "prevent these injuries . . . , so beginners will not have the same misfortune" (1).
In this issue of Radiology, Nawfel and co-authors (13) discuss their research into the issue of radiation dose and exposure during CT fluoroscopy–guided interventions. We are well advised to familiarize ourselves with the relationship between CT technique factors and doses to patients and to ourselves. Dose rates to the skin of patients are on the order of 2–10 mGy/sec (specific to their equipment) for tube currents that are typically much reduced from those used with standard imaging techniques.
While these dose rates will not likely result in serious injury to a patient during a 90-second imaging procedure, dose levels in excess of those required to produce transient erythema are possible. And, by extrapolating from the tube current, procedures performed with standard imaging techniques would lead to very high doses that would be of concern during a prolonged procedure. The authors recommend an evaluation of technique factors for appropriate dose-limited completion of a procedure. They also establish protocols for monitoring the use of radiation during prolonged procedures. This level of awareness is necessary to keep radiation use in check and is well advised.
The authors also recommend the use of lead drapes to reduce scatter to the hands and bodies of personnel. Such lead drapes appear to be easy to use and will be effective in the substantial reduction of the dose when personnel work in close proximity to the area of interest. (Of course, the physician must make every effort to keep his or her hands out of the primary imaging field.) To avoid the accumulation of high doses that could lead to deterministic effects during the career of an interventionalist, such a simple application of protective material is warranted. Nawfel and his co-authors give us a reasonable perspective on the radiation management issues in CT fluoroscopy and recommend simple solutions for an ever-present problem.
The development of good radiation management practices for all radiologic work, and especially for interventional radiologic work, should be high on the agenda for our academic facilities, where new generations of interventionalists will incorporate the attitudes of their mentors toward radiation protection and management. Practices that demonstrate a professional respect for radiation will serve them well because this will "prevent these injuries . . . , so beginners will not have the same misfortune"(1).
FOOTNOTES
See also the article by Nawfel et al (pp 180–184 ) in this issue.
REFERENCES
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