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Just because you can't smell it, see it, or feel it doesn't mean it isn't serious; in fact, the lack of such stimuli may make it even more serious. Take radiation, for example. The use of radiation is most certainly serious business. However, you may not pay much attention to it. After all, everyone is aware of the government regulations that manufacturers of radiographic equipment are required to meet. Also, such equipment is subject to periodic safety inspections by qualified physicists. Therefore, you pretty much take it for granted that radiation equipment is safe to be around and safe to use.
True, federal and state regulations and requirements have made the use of radiation relatively safe, but there are limits. No amount or manner of regulations and requirements can repeal the laws of physics. Too much radiation is still too much radiation. And you can still give too much radiation if you are not mindful of the basic time-and-dose relationship. No matter how safe the use of radiation has been made by various regulations and requirements, you can still deliver an excessive dose of radiation to a patient if you don't pay attention to the total time of fluoroscopy performed during the course of a procedure.
In fact, in this issue, radiation skin injury from fluoroscopic procedures is well chronicled in informative reviews by Koenig et al. [1, 2], who describe the pathophysiology of radiation injury and graphically depict injuries from various procedures. In addition, this issue contains an article by Berlin [3] that describes the legal consequences of radiation injury.
Now admittedly, certain interventional procedures performed under fluoroscopic control require considerable skill on the part of the operator and may be complex, arduous, and time-consuming. And that which is being done is obviously important to the patient. And there are recognized risks involved in undertaking such difficult procedures. But rarely should the risk be radiation injury to the patient. For the most part, paying strict attention to the use of fluoroscopy by using it only when necessary should significantly reduce, if not prevent, such injuries. This can be accomplished, but you "gotta wanta," as one of my coaches from long ago used to say. You can do it if you want to. You can reduce fluoroscopy time if you are committed to doing so.
The operator must be aware of the amount of radiation used during a procedure. Cavalier attitudes about fluoro time, failure to record the time, and conscious avoidance of steps that minimize exposure are to be condemned and discouraged. Using intermittent flouro, pulsed fluoro, simply taking your foot off the flouro pedal, reviewing the previous run on video rather than repeating it—there are many ways to reduce exposure without compromising a procedure, but you must recognize the need to do so. Some physicians, unfortunately, don't. As a result, some operators and their patients are needlessly overexposed. You can learn to do with less. It is all a matter of making a conscious effort to do so. You "gotta wanta"!
When it comes to radiation safety and protection, there are two ways to learn: formal study (assigned reading, scheduled lectures, and tests) or OJT (on the job training, learn as you go).
It has been a long while since all residents in radiology could learn the effects of radiation on the job. Approximately 35 years ago, in the mid 1960s, the field of radiology was split into two separate disciplines: diagnosis and therapy. Before that, every resident in radiology was required to have spent a minimum of 9 months in radiation therapy, treating patients with orthovoltage machines and handling radium needles and applicators for the treatment of various malignancies. The effects of radiation and its potential dangers were then up close and personal. Radiation effects were immediately obvious. They could not be overlooked. Treating cancer patients with orthovoltage equipment meant every patient had a skin injury, or reaction, as it was euphemistically called. You could watch the reaction blossom during the course of therapy and for some time thereafter, with the reaction becoming so severe toward the end of the course of radiation therapy that the resultant skin injury itself required treatment and in following up patients who had undergone treatment, you would see the characteristic skin atrophy and scarring in the treatment portal.
Even if you weren't a radiologist, but instead were a medical student or trainee in other disciplines, it was easy to become familiar with the signs and effects of radiation injury. It was knowledge obtained on the job, not in the classroom, because the teaching of radiation safety and protection to medical students and trainees in nonradiology disciplines, then as now, was rare. Evidence of radiation skin injury was regularly encountered when you worked up patients with a history of radiation therapy for cancer.
But times have changed. Diagnostic radiologists are no longer required to train in radiation therapy, and higher energy machines with improved beam penetration have replaced orthovoltage equipment, sparing the skin from injury. As a result, radiation skin injury is quite rare these days, and there is little opportunity for medical trainees to see firsthand the effects of radiation injury. OJT, in this regard, is no more.
So if you are going to learn about radiation injury and the effects of irradiation, you must do so by a course of formal study. Such knowledge is not intuitive; thus, we have the formal requirements of the Diagnostic Radiology Residency Review Committee (RRC) and the American Board of Radiology (ABR) for diagnostic radiologists.
But other disciplines that may use fluoroscopy are left to their own devices. It is wrong to be allowed to obtain credentials at weekend courses where they hand out filigreed, gilded certificates simply for attendance. Such impressive documents may then be handed with a wink to friendly chairpersons of medical staff credentials committees in order to secure privileges to perform fluoroscopy. Paying lip service to the requirements for knowledge of radiation is to be deplored.
Radiation safety is not a given. If you use radiation, you must respect it. You must be informed and believe. Radiation safety is serious business.
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