During surgery for myocardial infarction using fluoroscopy, staff have not donned lead aprons, thyroid collars, and eye protection; what is the appropriate immediate action?

Immediate Action for Unprotected Staff During Fluoroscopy

The procedure must be stopped immediately and all personnel in the room must don complete protective equipment—including 0.25-0.5 mm lead-equivalent aprons, thyroid shields, and leaded eye protection with side shields—before any further radiation exposure occurs. 1, 2

Why Stopping the Procedure is Non-Negotiable

• The American College of Cardiology 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 until proper protection is in place; this principle applies to all personnel in the radiation field. 1, 2

• All medical personnel working in an x-ray procedure room must wear protective shielding—this is not optional or selective. 1, 2

• Continuing the procedure with unprotected staff violates fundamental radiation safety principles and exposes personnel to preventable harm. 2

Quantifiable Protection Provided by Each Component

• Lead aprons (0.5 mm lead-equivalent) absorb 95% of 70 kVp scatter radiation and 85% of 100 kVp scatter radiation—this represents substantial attenuation that cannot be achieved through distance alone in a procedure room. 1, 2

• Thyroid shields alone reduce the operator's effective dose by approximately 50% by protecting the thyroid gland and cervical bone marrow, two highly radiosensitive structures located in areas of high radiation scatter. 1, 2

• Leaded eye protection with side shields, when combined with ceiling-mounted shields, reduces operator eye exposure by a factor of 19. 1, 2

• Omitting any single component—especially the thyroid collar—substantially increases radiation risk and cumulative occupational exposure. 1, 2

Why Partial Solutions Are Inadequate

• Sending only the main surgeon to don protection while others remain unprotected (Option B) is unacceptable because it violates the requirement that all personnel in the x-ray procedure room require complete shielding. 1, 2

• The inverse square law provides protection with distance, but scatter radiation still reaches all areas of the procedure room; personnel positioned remotely receive lower but not negligible exposure. 1, 2

• Even staff positioned more than 1 meter from the x-ray source must wear protective aprons, thyroid shields, and appropriate eye protection before any radiation exposure occurs. 2

Critical Pitfalls to Avoid

• Do not assume that proximity alone determines who needs protection—all personnel in the room require complete shielding regardless of distance from the radiation source. 1, 2

• Do not prioritize procedural efficiency over radiation safety; the time required to properly shield all staff is negligible compared to the long-term occupational health consequences of unprotected exposure. 2, 3

• Do not rely on ceiling-mounted or table-mounted shields as substitutes for personal protective equipment—these are supplementary devices that augment, not replace, lead aprons and thyroid shields. 1

Correct Implementation Algorithm

1. Immediately cease all fluoroscopy and x-ray imaging. 1, 2

2. Ensure every person in the procedure room dons complete protective equipment: 0.25-0.5 mm lead-equivalent wraparound apron extending to the knees, thyroid shield, and leaded eye protection with side shields for those working close to the x-ray source. 1, 2, 3

3. Verify that all protective equipment is properly positioned with no gaps at the neck or armholes that could expose radiosensitive tissues. 1

4. Resume the procedure only after confirming complete protection for all personnel. 1, 2

Additional Context for This Clinical Scenario

• In a patient with myocardial infarction undergoing fluoroscopy-guided intervention, the urgency of the cardiac procedure does not override radiation safety requirements—the brief pause to don protective equipment does not compromise patient outcomes. 2, 3

• Research demonstrates that inconsistent use of radiation protection shielding is common but unacceptable; protective eyewear was used in only half of endourology centers studied, and this inconsistency resulted in measurable occupational eye-lens doses. 4

• The highest annual eye-lens dose documented (13.5 mSv) occurred in surgeons working without ceiling-suspended screens, demonstrating that inadequate protection has measurable consequences. 4