Occupational Hazards in the Cath Lab — Physician, Protect Thyself!

In this issue of the Journal of Invasive Cardiology, Sciahbasi et al¹ publish data demonstrating high pelvic radiation exposure levels compared to thoracic radiation exposure, independent of access site. The measured nine-fold increase in pelvic exposure is primarily attributed to the proximity of the operator’s pelvis to the radiation source. Since the operator’s pelvis is at table level or slightly higher, this exposure is predominantly related to scatter, most of which could be reduced by proper shield placement. The fact that such high levels of radiation were measured despite the use of antiradiation patient drapes, and was observed with both radial and femoral access, re-emphasizes the need to use proper technique and barrier protection more effectively. Moreover, the necessity of reconsidering the design of the cath lab suite remains an unresolved problem without much voice in our community, despite increasing recognition of radiation-induced illness and orthopedic issues.^2-5

The proper practice of shielding in the cath lab has been described.² Current shielding available in every laboratory offers >90% reduction at the pelvic level. Above-table and below-table shielding should be positioned close to the operator, not the patient as commonly done, and the ceiling-mounted above-table shield placed close to the table-attached shielding. The findings of Sciahbasi et al offer contemporary proof that operators continue to either disregard radiation safety precautions or don’t care to take the time to protect themselves and others in their environment. Table 1 offers a number of reasons why physicians refuse to take this matter seriously. Unfortunately, since radiation cannot be seen, felt, or heard, and because others in the laboratory have been taught not to express concern in the presence of the patient, it is easy for operators to deviate from standard protective measures. 

Clearly, unless our national professional societies and local laboratory directors change course and begin to insist on a culture of self-protection, it simply is never going to happen, and those who “complain” will often soon be working elsewhere. The proper use of lead garments, decreasing frame counts, increased use of collimation, shallower imaging angles, and strict radiation monitoring need to be made a constant and required practice, not one dependent on the operator’s cooperation. Minimizing the distance between the x-ray source and patient to decrease scatter radiation exposure and maximizing the distance between the operator and radiation source should be kept in mind during every case. Radiation exposure follows the inverse-square law: the amount of radiation varies inversely with the square of the distance to the source. Thus, exposure standing 2 feet away from the radiation source will be one-fourth of the exposure when standing 1 foot away. Maximizing distance from the radiation source has been made more difficult with the trend toward transradial over transfemoral access. While the radial approach has multiple well-established benefits – enhanced patient comfort, economic benefits, decreased vascular complications – it may come at the cost of operator safety. Shah et al⁶ demonstrated that among experienced operators, cases performed via transradial access was associated with higher radiation exposure as compared to transfemoral access, with an increase in dose-area product (DAP) and fluoroscopy time (FT). Lange and von Boetticher⁷ demonstrated that pelvic lead shielding reduced radiation dose from 20.9 ± 13.8 uSv to 9.0 ± 5.4 uSV (P<.001) when performing catheterization from the radial position; however, the overall radiation exposure still remained higher compared to the femoral position. This raises the question of whether interventional cardiologists ought to be more selective with the use of the radial approach. Finally, there have been some promising advances in safety equipment,⁸ including “zero-gravity” lead suits, light-weight aprons designed with bismuth instead of lead, and radiation badges that offer “real-time” monitoring of radiation exposure. While these new tools show potential, their wide-spread use remains limited and their long-term impact on reducing the health-care risks of working in the cath lab remains unknown.

Moreover, there are many systemic reasons why the occupational hazards posed by the cath lab have not been taken seriously. The lack of economic value in protecting cheap and replaceable labor has been discussed previously.⁵ Without any doubt, the realities of labor management as well as the potential intrusion of increased upfront costs into profitability lead the rationale for the absence of change. 

Despite these facts, however, the truth remains that physicians don’t express their concern for proper radiation protection^3-5 and one critical reason is fear that those who employ us are primarily profit motivated. Management-level issues that stem from the lack of a strong and well-organized professional position has strongly affected the response to the occupational hazards faced by interventional cardiologists. The changing employment dynamic between hospital systems and physicians is contributory. In the 1970s and 1980s, the majority of clinicians worked in private practice and a successful private practitioner would have little financial incentive to demand changes from hospital administration. In the 1990s, there were increased efforts to integrate hospitals and physicians through joint ventures and purchases of physician groups by hospitals, but many of these partnerships dissolved by the end of the decade. Over the past 5-10 years, there has been a major shift away from private practice toward hospital employment, with only 35% of United States physicians in 2014 independently employed as compared to 62% in 2008.⁹ The changing nature of physician employment underscores the difficulty in creating a meaningful, doctor-driven push to improving occupational hazards in the cath lab. 

In interventional cardiology, the safety of the men and women who work in the cath lab must keep pace with a rapidly growing field. The onus remains with physicians to minimize workplace hazards, but administrative and organizational roadblocks need to be negotiated in order to address the rising health-related costs of working in the cath lab. New insights at the level of hospital administration are essential to revise labor practices and prioritize investments in updated safety technologies. Increasing hospital employment may give physician organizations the opportunity to effectively advocate for new guidelines that uphold higher levels of safety and awareness of occupational hazards in the cath lab. Our profession only stands to benefit from meaningful change in this respect. 

References

1.    Sciahbasi A, Piccaluga E, Sarandrea A, et al. Operator pelvic radiation exposure during percutaneous coronary procedures. J Invasive Cardiol. 2017 Dec 15 (Epub ahead of print).

2.    Klein LW, Maroney J. Optimizing operator protection by proper radiation shield positioning in the interventional cardiology suite. JACC Cardiovasc Interv. 2011;4:1140-1141.

3.    Klein LW, Miller DL, Balter S, et al; on behalf of the members of the Joint Inter-Society Task Force on Occupational Hazards in the Interventional Laboratory. Occupational health hazards in the interventional laboratory: time for a safer environment. Catheter Cardiovasc Interv. 2009;73:432-436.

4.    Klein LW, Miller DL, Goldstein J, et al; on behalf of the members of the Multispecialty Occupational Health Group. The catheterization laboratory and interventional vascular suite of the future: anticipating innovations in design and function. Catheter Cardiovasc Interv. 2011;77:447-455.

5.    Klein LW, Bazavan M. The economic imperatives underlying the occupational health hazards of the cardiac catheterization laboratory. (Editorial). Circ Cardiovasc Interv. 2016;9:e003742.

6.    Shah B, Bangalore S, Feit F, et al. Radiation exposure during coronary angiography via transradial or transfemoral approaches when performed by experienced operators. Am Heart J. 2013;165:286-292.

7.    Lange HW, Boetticher HV. Reduction of operator radiation dose by a pelvic lead shield during cardiac catheterization by radial access. JACC Cardiovasc Interv. 2012;5:445-449.

8.    Fornell D. Technologies to reduce cath lab radiation exposure. Diagnostic and Interventional Cardiology | DAIC. https://www.dicardiology.com/article/5-technologies-reduce-cath-lab-radiation-exposure. Published September 6, 2016. Accessed September 4, 2017.

9.    Health Care Reform and the Decline of Physician Private Practice: A White Paper Examining the Effects of The Patient Protection and Affordable Care Act On Physician Practices in the United States. 2010.https://www.physiciansfoundation.org/uploads/default/Health_Reform_and_the_Decline_of_Physician_Private_Practice.pdf. Accessed August 29, 2017.

From the Advocate Illinois Masonic Medical Center and Rush Medical College, Chicago, Illinois. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Address for correspondence: Lloyd W. Klein, MD, Specialty Services Clinic Advocate Illinois Masonic Medical Center, Fourth Floor, Chicago, IL 60657. Email: lloydklein@comcast.net