What to do if the surgical team forgets to take protective measures during an operation using Fluoroscopy (fluoroscopic imaging) and X-Ray on a patient with Myocardial Infarction (MI)?

Immediate Action: Stop X-Ray Exposure Until All Personnel Are Properly Protected

When the radiologist notices unprotected surgical team members during fluoroscopy, the physician operator has a responsibility to immediately stop operating the x-ray system until all personnel working close to the patient are properly shielded. 1

Rationale for Immediate Cessation

The ACC/HRS/NASCI/SCAI/SCCT expert consensus explicitly states that when circulating personnel need to approach close to the patient, the physician operator has a responsibility to not operate the x-ray system. 1 This principle applies equally when personnel are already close to the radiation source without appropriate protection.

Critical Protection Requirements

All medical personnel working in an x-ray procedure room should wear:

• 0.25- or 0.5-mm lead-equivalent aprons 1
• Neck thyroid shields (reduces effective dose by approximately one-half) 1
• Humeral shields 1
• Leaded eye protection with side shields for personnel working close to the x-ray source 1

The thyroid collar is particularly critical because it shields the thyroid and cervical bone marrow—two highly radiosensitive structures in an area of high radiation scatter. 1

Why Partial Solutions Are Inadequate

Option B (asking only the main surgeon to wear protection) is insufficient because:

• All personnel working close to the x-ray source require protection, not just the primary surgeon 1
• The inverse square law means that anyone close to the radiation source receives significant exposure 1
• Scattered radiation affects the entire surgical team in proximity to the patient 1

Option C (only protecting those within 1 meter) is also inadequate because:

• The guideline does not specify a precise distance cutoff; rather, it emphasizes that "medical personnel working close to the x-ray source" should wear protection 1
• Circulating personnel should be positioned remotely from the x-ray source, but when they need to approach the patient, x-ray operation should cease 1
• The focus should be on ensuring all personnel in the procedure room have appropriate protection before any x-ray exposure occurs 1

Proper Implementation Protocol

The correct sequence is:

1. Immediately halt all fluoroscopy and x-ray imaging 1
2. Ensure all surgical team members don appropriate protective equipment (lead aprons, thyroid shields, eye protection) 1
3. Verify proper use of ceiling-mounted shields (reduces operator eye exposure by a factor of 19) 1
4. Confirm under-table mounted shielding is in place to intercept backscatter 1
5. Resume imaging only after all protective measures are confirmed 1

Additional Safety Considerations

Optimize positioning to minimize exposure:

• Maximize distance between the x-ray tube and patient 1, 2
• Position the image detector as close to the patient as possible 1, 2
• Use proper collimation to minimize the exposed field size 1, 2

The ALARA principle (as low as reasonably achievable) must be maintained, though shielding and distance—the two most effective protective measures—are challenging to implement in an operating room setting. 1 This makes proper use of personal protective equipment absolutely essential before any radiation exposure occurs.

Common Pitfall to Avoid

Never continue the procedure without proper protection, even briefly, as cumulative radiation exposure to unshielded personnel poses significant long-term health risks including increased cancer risk and potential left-sided brain tumors in interventional operators. 1 The brief delay to properly shield all personnel is far less consequential than the occupational radiation exposure to the surgical team.