A tipping point to improve radiation safety in orthopaedics?

By Hannah Sevenoaks
Specialty Registrar in T&O, North West Deanery (East)

Corresponding author email: [email protected]

Published 13th April, 2023

My tipping point surprisingly occurred one quiet evening nursing my baby during maternity leave. Scrolling on my phone, I was researching precautions I should take with respect to radiation exposure as a breast feeding mother returning to work. Baby was fast asleep in my arms by the time I had emerged from my PubMed rabbit hole, slightly alarmed by some of the papers I had read, and determined to do something about it.

I have subsequently spent much of the past year immersed in the literature and legislation around occupational radiation protection, working with some inspirational colleagues, and supported by the BOA to better understand and then start to improve the issues of breast radiation protection specifically, but critically recognising its place within the broader context of improving radiation safety for all in orthopaedics.

I headed back to work after maternity leave, armed with all this knowledge, and a new pre-occupation about radiation safety. And very quickly my radiation 'Spidey Sense' started tingling… hard! As much as I strongly believe that women in particular deserve better from their PPE, PPE is only the final link in the chain. I saw with new eyes, how far we need to come as a profession to improve our attitude towards, and behaviours around radiation. We all have a responsibility to do this and I firmly believe orthopaedic surgeons must lead this. It is our actions and requests during fluoroscopy cases that affect everyone else’s radiation exposure in theatre. And it is critical to appreciate that our actions and attitude towards this hidden danger impress upon the next generation of surgeons, and other allied health professionals. We must lead by example.

After finding my feet back to work, I started to gently challenge things I would have not noticed or felt empowered to call out before, reminding colleagues to wear their thyroid shield or step back from the beam. “Do we really need a true lateral view of the femoral head? 70 degrees would do instead and reduce all our radiation exposure” I would offer, or “I’m happy this fixation is stable on flexion and extension views. I don’t think we need to live screen”. 

Weeks later, a core trainee tells me he has started wearing a thyroid guard all the time now since we spoke during our last case together… Win!

I watch the junior clinical fellow take care to select a vest and keep her arms down during a later case after I spoke with her about protecting her breasts… Another win!

I tell the new FY1 in theatre about the work on breast protection work we are doing… ”Wow, that’s great. When I have come to theatre recently, I felt pretty vulnerable in the gowns actually. They don’t cover me well”. Another win!

When you use this equipment every day, you take it for granted and don’t question it’s appropriateness or efficacy. Similarly, the screening techniques, C-Arm and surgeon positions you use become a habit. Stick with what you have always done, use the gown that you always use or feels most comfortable. But this isn’t serving us well. The Radiation in Orthopaedics Study from St George’s Hospital in 2021 highlighted nationwide poor radiation safety knowledge and practises amongst orthopaedic surgeons1. As the use of fluoroscopy continues to grow in trauma and elective orthopaedics, in order to keep safe we must acknowledge these short comings and start to use this technology more judiciously.

The critical eyes of that FY1, newly exposed to our normal work and behaviours, is how we need to look upon our PPE and our practises in order to effect change. How can I reduce my dose exposure, the dose to the patient and my colleagues by changing my techniques? Does my PPE fit well, does it cover all of my torso and down to our knees, and is the lead weighting appropriate?

Along with colleagues in the North West Orthopaedic Research Collaborative we have set about evaluating the current radiation PPE provision in trauma theatres in our region and how this correlates with the requirements of the orthopaedic workforce. The International Atomic Energy Agency recommends a wrap-around style gown (i.e. no open sides)2, yet we have found that open sided tabard gowns, inappropriate for surgeon use, make up two thirds of our trauma theatre provision regionally. In the trusts that do have wrap around provision, these may be few in number and in limited sizes, often catering to only a subset of the workforce and leaving many colleagues, that FY1 included, in ill-fitting and less effective PPE.  From speaking with colleagues in other regions, many report similar inappropriate provision in their hospitals. In the coming months we hope to expand this study out nationally, providing integrated audit tools to help colleagues and trusts better understand the PPE requirements of their workforce. 

This, and the work supported by the BOA to improve breast protection highlights the tangible and easily measurable improvements we can make to radiation safety in orthopaedics with physical interventions.

Ultimately, however it is the more subtle, arguably mundane and probably more elusive changes in behaviour, attitude and culture that will protect everyone more than any amount of shiny new PPE. Hopefully by starting this conversation about radiation safety, we can generate a tipping point for the profession as a whole.

  1. Raza M, Geleit R, Houston J, Williams R, Trompeter A. Radiation in orthopaedics (RIO) study: a national survey of UK orthopaedic surgeons. BJR. 2021 Sep 1;94(1125):20210736.
  2. Radiation protection of medical staff in orthopedic surgery | IAEA [Internet]. [cited 2022 9th Nov]. Available from: www.iaea.org/resources/rpop/health-professionals/other-specialities-and-imaging-modalities/orthopedic-surgery/staff#5.