What to do if doctors forget to take protective measures during a procedure using fluoroscopy (fluoroscopic imaging) and X-ray (radiography) on a patient with myocardial infarction (MI)?

Immediate Action Required: Stop the Procedure

The procedure must be stopped immediately to ensure all medical personnel in the x-ray procedure room don complete protective equipment before resuming fluoroscopy. 1, 2

Why Complete Cessation Is Mandatory

All medical personnel working in an x-ray procedure room must wear 0.25- or 0.5-mm lead-equivalent aprons, thyroid shields, and leaded eye protection (for those near the source) before any fluoroscopic imaging begins or continues. 1, 2 This is not negotiable—the American College of Cardiology explicitly states this requirement applies to everyone in the room during active fluoroscopy. 1

Critical Protection Standards

• Lead-equivalent aprons (0.5 mm) absorb 95% of 70 kVp x-ray and 85% of 100 kVp scattered radiation—this level of protection cannot be compromised for any personnel present during the procedure. 1, 2

• Thyroid collars alone decrease the effective dose to operators by approximately 50% by shielding the thyroid and cervical bone marrow, two highly radiosensitive structures in high-scatter areas. 1, 2 This protection is particularly critical and cannot be omitted. 2

• Leaded eye protection with side shields is required for personnel working close to the x-ray source, as proper use of ceiling-mounted shields combined with eye protection reduces operator eye exposure by a factor of 19. 1, 2

The Correct Response Algorithm

Step 1: Immediate Cessation

Stop all fluoroscopic imaging immediately upon recognition that personnel lack protective equipment. 2 The physician operator has explicit responsibility to not operate the x-ray system when personnel approach the patient without proper protection. 1

Step 2: Universal Protection Requirement

All personnel remaining in the procedure room must don complete protective equipment:

• 0.25- or 0.5-mm lead-equivalent aprons 1, 2
• Thyroid shields 1, 2
• Leaded eye protection with side shields for those working close to the x-ray source 1, 2
• Humeral shields as augmentation 1

Step 3: Personnel Positioning Optimization

• Circulating personnel should be repositioned remotely from the x-ray source (ideally >8 feet away) where they receive negligible exposure, though they still require protective aprons if remaining in the room. 1, 2
• Apply the inverse square law principle: X-ray intensity decreases as the square of the distance from the source, making operator positioning crucial for exposure magnitude. 1

Step 4: Resume Only When Fully Protected

Resume the procedure only after confirming all personnel are properly shielded. 2

Why Option C (1-meter rule) Is Incorrect

The guideline does not support a 1-meter threshold for protection requirements. 1, 2 The American College of Cardiology states that "medical personnel working in an x-ray procedure room" require protection—this is a room-based requirement, not distance-based. 1 While scatter radiation follows the inverse square law and proximity increases exposure, all personnel in the room during active fluoroscopy require protective equipment regardless of distance. 1, 2

Why Option B (Only Main Surgeon Leaves) Is Dangerous

Allowing only the main surgeon to leave while others remain unprotected violates fundamental radiation safety principles. 2 This approach:

• Leaves other personnel exposed to scatter radiation without protection 1, 2
• Contradicts the explicit requirement that "all medical personnel working in an x-ray procedure room" must wear protective equipment 1
• Ignores the operator's responsibility to ensure all nearby personnel are protected before operating the x-ray system 1

Critical Pitfall to Avoid

Never assume that personnel not directly operating the fluoroscopy equipment can remain unprotected. 2 Ancillary personnel (anesthesiologists, surgeons, perfusionists, nurses) may not be knowledgeable about radiation protection and require explicit instruction and enforcement of protective measures. 2 The scatter radiation field affects everyone in the room, though exposure magnitude varies with distance. 1, 2

Special Consideration for MI Patients

While this patient has an MI requiring urgent intervention, the brief pause to don protective equipment (typically 1-2 minutes) does not compromise patient outcomes and is mandatory for personnel safety. 1 The physician operator's responsibility to minimize healthcare worker occupational exposure is particularly important given that these workers are typically young and more susceptible to radiation effects, with potential for substantial cumulative exposure over extended careers. 1