Medical Fluoroscopy:

A Guide for Safe Usage

Paul H. Brown, Ph.D.

Charles R. Wilson, Ph.D.
Daniel J. Miron
Marcum D. Martz, CHP

Contents

I Introduction
II Basic Radiation Physics
III Units of Radiation Exposure and
Absorbed Dose
IV Fluoroscopy Exposure, Factors
Influencing Exposure Rate
V Sources of Radiation Exposure
VI Radiation Protection
VII Basic Radiation Biology
VIII Regulatory Exposure Limits
I. INTRODUCTION

The State of Wisconsin, Department of Health and Family Services (DHFS), revised and published
a new set of Radiation Protection regulations, effective July 1, 2002. In these regulations, the
following is stated:

HFS 157.74 (2) RADIATION SAFETY REQUIREMENTS. (a) Each individual who
operates x–ray equipment shall be instructed in the safe operating procedures for each
specific device and be competent in the safe use of the equipment as determined by the
registrant.

In the regulation above, “registrant” means any facility that registers medical x-ray equipment with
DHFS, such as hospitals and medical clinics. Froedtert Memorial Lutheran Hospital (FMLH), the
Medical College of Wisconsin (MCW) and Community Memorial Hospital (CMH) are all
registrants of medical x-ray equipment and subject to this requirement. To comply with this
requirement, x-ray operators must be trained and pass an examination to demonstrate competency
with the equipment. FMLH, MCW and CMH accept the training and certification of physicians
and technologists whose specialty boards include training and examination in x-ray radiation
safety:

• Board certified radiologists

• Board certified radiation oncologists
• Board certified interventional cardiologists
• Registered Radiologic Technologists

This requirement applies to all diagnostic x-ray equipment, but from a practical standpoint, all
radiographic or CT diagnostic equipment is operated by radiologic technologists; fluoroscopes are
the only x-ray equipment routinely operated by physicians. As a matter of policy, FMLH accepts
the training in x-ray use and safety received by physicians who are board-certified in the above
mentioned specialties. Other physicians (such as urologists, orthopedists, etc.) applying for fluoro
operator privileges must complete this training and pass the associated exam.

II. BASIC RADIATION PHYSICS

X-Ray Production

X-rays are produced when electrons are accelerated through a high voltage in the range of 50,000
to 150,000 volts, (50 to 150 kVp) and allowed to crash into a target composed of a high atomic
number material, such as the tungsten target in an x-ray tube. Electrons are released from an
electrically heated filament in an x-ray tube and accelerated to the target by the high voltage. The
flow of electrons from the filament to the target is referred to as the tube current and is given in
milliamperes (mA). Fluoroscopy is usually performed using 2 to 6 milliamperes (mA) and an
accelerating voltage of 75 to 125 kVp.
The amount of x-rays produced by an x-ray tube is determined by the tube current (mA) and the
high voltage (kVp). X-ray production is directly proportional to the tube current and doubling the
tube current doubles the number of x-rays produced at a particular kVp. However, x-ray
production increases more rapidly with kVp than mA and increasing the kVp by 15% is equivalent
to doubling the mA. Higher kVp values also provide a more penetrating x-ray beam.

Figure 1. A Simple X-Ray Tube Configuration.

III. UNITS OF RADIATION EXPOSURE AND ABSORBED DOSE

Three quantities and their units and are important to the following concepts and will be defined
here. These are exposure, absorbed dose, and effective dose equivalent:

Exposure

Exposure is defined as the quantity of x-rays or gamma radiation required to produce an amount of
ionization (electric charge) in air at standard temperature and pressure. The traditional unit of
exposure is the Roentgen (R) and is defined as 1 R = 2.58 × 10-4 C/kg. The SI unit of exposure is
defined in units of coulombs/kilogram (C/kg). Frequently, ionization measurements are made of
exposure rate, i.e., the amount of exposure per unit of time. Radiation safety survey meters
generally read out in units of Roentgen per hour (R/hr) or milliRoentgen per hour (mR/hr). A
medical physicist making measurements of fluoroscopic x-ray machines would most often measure
the “fluoro output” in R per minute (R/min).

Absorbed Dose

Absorbed dose is defined as the amount of ionizing radiation energy absorbed per unit mass. The
traditional unit of absorbed dose is the rad (Radiation Absorbed Dose), 1 rad = 100 ergs/gram. The
SI unit of absorbed dose is the Gray (Gy), 1 Gy = 100 rad. For x-rays used in fluoroscopy an
exposure of 1 R results in an absorbed dose of approximately 1 rad.

Dose Equivalent and Effective Dose Equivalent

Dose equivalent is used in radiation safety to account for differences in the biological effectiveness
of different types ionizing radiation. Dose equivalent is defined as the absorbed dose times a
radiation quality factor specific the type of radiation to which an ind ividual is exposed. The
traditional unit for dose equivalent is the rem (Roentgen Equivalent in Man); the SI unit is the
Sievert (Sv), 1 Sv = 100 rem. For diagnostic medical x-rays, the quality factor is one, so an
absorbed dose of 1 rad is equal to a dose equivalent of 1 rem.

The risk of potential health effects when only part of the body is irradiated is smaller than when the
whole body is exposed. For example, if a single organ receives a dose equivalent of 300 rem (3
Sv), the resulting health effect to the individual will not be the same as what would be caused by a
300 rem (3 Sv) dose equivalent to the whole body. To account for these differences, the quantity
effective dose equivalent (EDE) is used. EDE is defined as the sum of the absorbed dose to
tissue(s) or an organ(s) times a weighting factor, and is also expressed in the units of rem or
Sieverts. The EDE is a calculation of risk to an individual posed by partial body irradiation as
compared to total body irradiation. The EDE is used estimate the equivalent whole body exposure
for fluoroscopy staff wearing protective aprons for comparison to annual personnel dose limits for
radiation exposure.

IV. FLUOROSCOPY EXPOSURE, FACTORS INFLUENCING EXPOSURE RATE

Modern fluoroscopy machines produce images with an image intensifier (II) which brightens the
image level sufficiently so that the image can be displayed on a TV screen. Fluoroscopy units are
usually operated in an automatic brightness control (ABC) mode.

In the automatic brightness cont rol mode, or automatic exposure control (AEC) mode, a sensor in
the image intensifier monitors the image brightness. Machine factors are then automatically
adjusted to bring the brightness to a proper level. When there is inadequate brightness, the ABC
generally increases the kVp first, to increase x-ray penetration through the patient, and then adjusts
the mA to increase the brightness. Exposure to a thick patient will be greater than to a thin patient,
and abdominal fluoro will require a greater exposure than fluoro in the chest because of the
increased thickness and tissue density in the abdomen. The following are recommendations to
optimize image quality while reducing patient and operator exposure.

Recommendation #1: The image intensifier input should be positioned as close to the patient
as practicable. This results in a lower patient dose and sharper image.

With the II input located far from the patient, the ABC automatically increases the mA to provide
the required brightness and increases the patient radiation dose. Keeping the II input, also produces
another benefit: a sharper image due to less blurring due to of the x-ray tube focal spot.
 Figure 2.

Recommendation #2: Use the exposure pedal as sparingly as possible.

Radiation exposure during fluoroscopy is also directly proportional to the length of time the unit is
activated by the foot pedal switch. The fluoro time is an important determinant of patient and staff
radiation dose. Depression of the foot switch determines the length of the exposure. Fluoroscopy
machines are usually equipped with a timer and an alarm that sounds at the end of 5 minutes. The
alarm serves as a reminder of the elapsed time.

Recommendation #3: Use last-image-hold and pulsed fluoro whenever possible.

Most modern fluoro units are also equipped with "last- image-hold", which stores the last fluoro
image and allows viewing of the image without having to again expose the patient. Many fluoro
units also offer a "pulsed fluoro mode", in which the x-ray beam is pulsed rapidly on/off, resulting
in a lower radiation dose without significantly degrading the appearance of the image on the TV
display.

Recommendation #4: Use the smallest field of view practicable.

Radiation exposure also depends on x-ray field size and keeping the x-ray field as small as possible
(by using the collimators) will decrease the dose to BOTH the patient and the staff in the fluoro
room. Restricting the field size offers a double bonus of not only decreasing radiation dose, but it
also produces a better image! The contrast in the image between various tissue types will be greater
for the smallest field of view that encompasses the desired anatomy.

Recommendation #5: High dose or detail modes should be used only when necessary.
Many fluoro units will have various dose modes, perhaps a low dose, medium dose, and high dose
mode. For example, the modes may be identified as:

R R R
It is important to recognize that fluoroscopic image quality can be adversely affected by too few x-
rays in the image; images are sometimes noisy for low dose. More tissue contrast is produced by
the high dose modes, thus improving image quality at the expense of increased patient dose.
Sometimes the high dose mode is labeled as “detail mode”.

Recommenda tion # 6: Magnification should be used only when necessary.

Most fluoroscopy units are capable of using different magnification modes. Image resolution is
improved with magnification but field size is reduced and patient radiation dose is increased.
Patient dose is minimized by using the lowest magnification (largest field size) appropriate for the
imaging procedure being performed.

Recommendation # 7: For C-arm type fluoroscopy units the patient should be position
as far from the x-ray tube as practicable to minimize patient entrance dose. To reduce
personnel exposure the x-ray tube should be position beneath the patient cart.

In conventional under-table x-ray tube fluoroscopic units (Figure 2), the x-ray tube is located at
fixed distance from the patient’s skin. In C-arm fluoroscopy (in which the distance between the x-
ray tube and the image intensifier is fixed) the patient can be positioned in close proximity to the x-
ray tube thereby increasing the entrance dose and reducing image sharpness.

Figure 3.
It is preferable to locate the C-arm x-ray tube underneath the patient. Since the radiation transmitted
through the patient is typically only 5-10% of the entrance dose, inadvertent exposure to the
operator hand on the exit side of the patient will results in a smaller dose compared to the dose to
the hand on the entrance side of the patient. Also the amount of scatter radiation the operator is
exposed to on the beam exit side of the patient is significantly less than on the beam entrance side.

V. SOURCES OF RADIATION EXPOSURE

Direct Exposure

Entrance skin exposure (ESE) rates in fluoroscopy (meaning exposure in the x-ray beam where it
enters the patient) are limited to less than 10 R/minute. At the maximum allowed ESE rate, 30
minutes of fluoroscopy can therefore deliver 300 R in skin exposure. ESE rates for typical
fluoroscopy procedures are usually less that 5 R/minute.

Fluoroscopy ESE rates can be higher than 10 R/minute under certain circumstances. The
regulatory limits for fluoro exposure rates are listed below (adapted from HFS 157.76):

Fluoroscopic equipment may not be operable at any tube potential (kVp) and current (mA)
that will result in an exposure rate in excess of 11.5 R/min at the point where the center of
the useful beam enters the patient, except under either of the following conditions:

(a) During the recording of images from an x–ray image intensifier tube using
photographic film or a video camera when an x–ray source is operated in pulse
mode.

(b) When an optional high–level control is activated, the equipment may not be
operable at any combination of tube potential (kVp) and current (mA) that will
result in an exposure rate in excess of 23 R/min at the point where the center of the
useful beam enters the patient. Special means of activation of the high–level controls
shall be required. The high–level control shall only be operable when the operator
provides continuous manual activation. A continuous signal, audible to the
fluoroscopist, shall indicate that the high–level control is being employed.

The output of each fluoroscope must be checked annually or after any maintenance that may affect
x-ray dose parameters. Note that the dose to the patient is not regulated; only the maximum dose
rate of the fluoroscopy unit is regulated.

Scatter Exposure to Personnel

The majority of the radiation exposure received by the operator or other personnel in the
fluoroscopy suite during a procedure is due to scattered radiation from the patient. In general, the
operator will be exposed at dose rate of approximately one one-thousandth (1/1000) of the ESE rate
at a distance of 1 meter from the center of the fluoroscopy field. Several factors can increase the
dose from scattered radiation, including:

1. Large patients cause the ABC to adjust the kVp and mA to higher values, which therefore
generate a greater amount of scattered radiation.
2. A large x-ray field, a result of not restricting the field size will also increase scatter
radiation.
3. The length of time during with the fluoroscope is on. Complex interventional cases require
greater procedure time, increasing the dose to both the patient and the fluoroscopist.

A small percentage of the radiation received by the operator during fluoroscopy is due to leakage
radiation through the x-ray tube housing. Radiation exposure to the operators from an under-the-
table x-ray tube is negligible. C-arm operators, however, should be aware that the shielding built in
to a “fixed” fluoroscope is not available for protection against backscatter under the table. This is
of greater concern if the C-arm is rotated out of the normal vertical plane.

VI. RADIATION PROTECTION

The three most productive means of reducing radiation dose to fluoroscope operators and other
staff in the room during fluoroscopy are listed below:

Time

Minimization of time spent in a radiation field is one of the first principles of radiation safety and
exposure reduction. In the case of fluoroscopy, this corresponds to how much time the fluoroscope
is producing x-rays. An important balance must be reached between the productive clinical use of
x-rays and minimizing fluoroscopy time. The operator needs to produce an image with the
necessary information to treat the patient, yet not linger needlessly. The use of last-image-hold and
pulsed fluoro features are technical advantages in reducing the total amount of time during which
x-rays are produced.

Distance

Radiation dose rates increase or decrease according to the inverse square of the distance from the
source. As mentio ned previously, the main source of radiation exposure to fluoroscopic staff is
scattered radiation from the patient, not from the x-ray tube. An example demonstrates the use of
the inverse square law and dose rates at varying distances from the patient:

The intensity (I1 ) of the radiation at one meter (d1 ) from the patient is approximately 1/1000th of the
patient entrance skin exposure. If the patient dose rate is 5 R/minute, then I1 = 5 mR/minute.
According to the inverse square law, the dose rate (I2 ) at some new distance (d2 ) is calculated as
follows:

2
d1
I 1 d 1 = I 2 d 2 or I 2 = I 1
2 2

d 22
Using two different distances for d2 , the change in dose rate is dramatically demonstrated. In the
first case, the fluoroscopist (or other staff member) moves from 1 meter from the patient to 2
meters away, doubling the distance.

12
I 2 = (5) = 1.25 mR/minute
22

Notice that by increasing the distance from the source by a factor of 2, the dose rate decreases by a
factor of 22 , or 4. But when the distance from the source is decreased, such as when the
fluoroscopist moves closer to the patient, the dose increases by the same exponential function:

12
I 2 = (5) 2 = 20 mR/minute
0.5

In this second example, the distance was decreased to one-half meter, and the dose increased by a
factor of 22 , or 4.

Figure 4. Graphical Representation of the Inverse Square Law.

The positioning of staff during fluoroscopy is critical to radiation protection. In many cases, the
physician must be in close proximity to the patient during a fluoro exam. All non-essential
personnel should be removed from the room, or at least be placed outside of a six- foot radius
during x-ray use. Any personnel within six feet of an operating medical fluoroscope must wear
lead (or lead equivalent) protective aprons, according to the regulations. This brings us to the next
major dose reduction method, shielding.

Shielding

Lead garments, lead gloves, thyroid shields, leaded eyeglasses, lead drapes and clear leaded glass
barriers between the patient and the operator all reduce exposure to medical personnel from
scattered radiation. State regulations require that all persons, including staff or other patients, must
be at least 2 meters from the tube head, direct beam, or the exposed area of the patient’s body, or
protected by shielding of thickness equivalent to 0.25 mm of lead (Pb). Furthermore, gonadal
shielding of at least 0.5 mm Pb-equivalent shielding must be used for patients who have not passed
reproductive age for radiographic procedures. Since staff aprons are frequently utilized for this
function, it is recommended that all lead or lead-equivalent aprons be of 0.5 mm Pb-equivalence.

Dose Monitoring

Even when radiation protection techniques and engineering controls are in place to reduce
personnel exposure, dose monitoring of individuals is required. Dosimeters come in several
shapes, sizes and types:

Film Badges – As the name implies, these dosimeters employ film, similar to 35 mm camera film,
that is sensitive to radiation. The film is contained in a paper/foil wrapper that must not be allowed
to be damaged by heat or moisture. The film is loaded into a plastic holder that contains a system
of filters (strips of copper, aluminum, lead, etc.) that allow the dosimeter reader to correctly
identify the type of radiation the badge was exposed to. As such, the film and holder are an integral
system, and must be loaded correctly.

Thermoluminescent Dosimeters (TLDs) – This dosimeter material is composed of small chips of

LiF or CaF crystals that can be used to measure radiation dose. The small size of the TLD chips
make them ideal for extremity monitoring, loaded into plastic rings that may be worn on fingers.
TLD rings may be cold sterilized using a liquid sterilizing solution, but are extremely heat-
sensitive, and may not be sterilized by heat sterilization.

Optically-Stimulated Luminescent (OSL) Dosimeters – Some dosimeter badges use a technology

that records radiation exposure and is read by laser light. These badges can be used in place of film
badges. Generally, the OSL badge comes as a packaged unit that attaches to a plastic holder.
Unlike film badges, OSL badges holders do not incorporate filters, which are contained within the
badge package itself.

Wisconsin Administrative Coded HFS 157.25 requires that any individual (other than the patient)
working within 6 feet of an operating medical fluoroscope must be monitored for radiation
exposure. General requirements for dosimeters are as follows:

• When a dosimeter is assigned, it is assigned to a single individual, and must not be shared.

• Dosimeters designed to measure dose to the whole body (torso, including head) must be worn at
the collar, OUTSIDE any shielded apron.

• Ring badges should be worn inside gloves.

• Dosimeters may be assigned to monitor a period of up to one quarter year (3 months), but if
exposures reach 10% of any of the limits (see Section VIII, Regulatory Exposure Limits), they
must be exchanged on a monthly basis.

Dosimeters (unless otherwise authorized) are to be worn at the collar level, OUTSIDE of the
protective apron.
In some cases, where daily fluoroscopic use is anticipated, two dosimeters will be assigned. When
two dosimeters are in use, one badge is to be worn at the collar outside the apron in the standard
position; the second is to be worn at the waist level UNDER the apron. Dosimeters assigned in this
manner will be color-coded, to prevent the user from inadvertently wearing a badge in the wrong
position. This two-badge method of dose monitoring is used to calculate the individual’s effective
dose equivalent (EDE), taking into account the protective factor of the lead apron. When two
dosimeters are assigned, they must not be confused and worn in the incorrect position.

Dosimeters, when assigned, are to be worn when performing fluoroscopy procedures. A dosimeter
assigned to a fluoroscopy user will be expected to show some radiation exposure above zero, or
minimal readings. Abnormally low dosimeter results will be investigated by Radiation Safety for
compliance with the requirements listed above. Failure to properly wear a dosimeter could result
in disciplinary action, including the revocation or suspension of the user’s fluoroscopy
credential.

Dosimeters wearers must promptly turn in and exchange badges each month or quarter, whatever
the monitoring period. Chronically late badge users will be referred to the Radiation Safety
Committee for action.

The State of Wisconsin occupational radiation dose limits apply to an individual, even when
radiation dose is received at more than one facility. To comply with the dose monitoring
requirements, all monitored radiation doses must be added together. Fluoroscopy users who are
monitored at more than one facility must make arrangements for the sharing of dose information
with all facilities where they have been monitored during the current calendar year, or where they
are still currently monitored. The dosimeter application contains a section authorizing the release
of personal dosimetry records to FMLH/MCW. In the case of resident physicians who rotate to
other hospitals frequently, an FMLH/MCW dosimeter will be assigned to be worn at all locations.

If a dosimeter is damaged, lost or exposed in error (such as being left inside the fluoroscopy suite),
a report must be made immediately to Radiation Safety. Dosimeters are susceptible to heat and
moisture damage; store them in a cool, dry place, away from any sources of radiation. Do not take
a dosimeter home, or travel on an airplane with a dosimeter.

VII. BASIC RADIATION BIOLOGY

Direct Cellular Effects: Skin Injury

X-rays from fluoroscopy interact with biological material by transferring their energy to an
electron, which subsequently interacts with the target molecule (DNA, RNA, or protein) to produce
an ion or free radical. Radiosensitivity is a function of the cell cycle, with late S phase being the
most radio-resistant, and the G1, G2 phases and mitosis being more radiosensitive. According to
the law of Bergonie-Tribondeau, radiosensitivity is highest in undifferentiated and actively
proliferating cells, proportionate to the amount of mitotic and developmental activity which they
must undergo. Cells can sustain a variable amount of radiation and still repair themselves from sub-
lethal damage. Continuous high intensity radiation, howeve r, produces greater damage than an
equivalent, fractionated (multiple smaller) dose, since fractionation allows time for cellular repair.

The total dose, dose rate, fractionation scheme, volume of irradiated tissue and inherent tissue
radiation sensitivity all affect a given organ’s response to radiation. Generally, a large total dose (as
possible in fluoroscopy), a high dose rate (as in fluoroscopy), small fractionation schedule (as in
fluoroscopy), and large irradiated volumes (hopefully not in fluoroscopy) cause a greater degree of
damage.

A major concern from fluoroscopy is the possibility of acute, direct or deterministic, radiation
damage which manifests as skin injury. The severity of the skin injury is dose-dependent; more
dose means more severe symptoms. The FDA guidelines list the following skin injury effects from
radiation exposure. Remember that typical fluoro unit output may be as high as 10 R/min in normal
mode and 20 R/min in high dose or detail mode. Note that the time to expression of symptoms is
long enough that the patient may very likely no longer be in the hospital when symptoms appear.
The physician performing the fluoroscopy cannot discern the damage by observing the patient
immediately after fluoroscopy.

FDA Specification of Radiation-Induced Skin Injuries

Threshold Dose Typical Fluoro-On Time in

Minutes

Skin Effect rem Sv Normal High Dose Time to

Mode @ 10 Mode @ 20 Onset
R/min R/min

Early 200 2 20 minutes 10 minutes Hours

Transient
Erythema

Temporary 300 3 30 minutes 15 minutes 20 days

Epilation

Basal Cell 600 6 60 minutes 30 minutes 10 days

Erythema

Permanent 700 7 70 minutes 35 minutes 20 days

Epilation

Dry 1000 10 100 minutes 50 minutes 30 days

Desquamation

These threshold doses to cause an effect cannot be consid ered exact since there are many variables
involved, including individual biological response, age and characteristics of the person exposed,
and the area of skin exposed. Often, a patient may exceed the threshold dose or typical threshold
fluoro-on times in the table above without showing any symptoms, owing to at least two reasons:
the fluoro x-ray beam is often not necessarily concentrated on a single area of skin for the entire
time, and secondly because 10 R/minute or 20 R/minute are maximum outputs for very thick
patients. Nevertheless, users of fluoro units should be aware of the thresholds listed above and
should attempt to maintain exposures below these symptomatic levels. Thirty minutes of fluoro
time is often suggested as a target time for a “safe” or “benign” fluoro procedure. Thirty minutes
of fluoroscopy is often suggested for a threshold to counsel patients concerning probable radiation
induced skin injury effects. Of course, the medical need for any procedure must always take
precedence over other concerns, and a “safe” fluoro time clearly depends on the x-ray machine
operating parameters.

It should also be noted that the skin injury dose thresholds above, generally in the hundreds of rem,
are for exposure to only a localized area of the body. Exposure of the entire body to such levels of
radiation would cause severe radiation damage known as acute radiation syndrome. The LD50/30
(Lethal Dose that would kill 50% of the exposed persons within 30 days) for an acute radiation
dose without medical care is about 400 rem. Exposure of the gonads should be avoided since this
tissue is very radiosensitive. Just a few minutes of gonadal fluoroscopy could induce temporary
sterility in males; with permanent sterility in either males or females is likely for doses the range of
a few hundreds of rem.

Stochastic Effects: Cancer

Late effects due to low doses of radiation, specifically radiation- induced cancer, may remain
dormant and then become evident 10-50 years after the original exposure. It is often difficult, if not
impossible, to establish a direct connection with the earlier radiation event. Furthermore, radiation
does not often produce specific “radiation- induced” cancer types, but simply increases the
incidence of other already naturally-occur ring cancers. This type of radiation effect is called a
stochastic effect. The incidence of cancer induction is dose dependent (more dose means more
cancers), but the severity of the induced effect is not dose dependent. There is considerable
scientific controversy in specifying stochastic radiation risk estimates, but the prevailing scientific
opinion is that there is no dose threshold for cancer induction, and that the cancer risk is linear with
the absorbed dose. According to the Linear No-Threshold (LNT) dose-response model, no level of
radiation is too small to produce some risk, and doubling the absorbed dose will double the cancer
risk. This is unlike deterministic skin injury effects, where there is generally no risk below some
dose threshold.

A group from the National Council on Radiation Protection and Measurements (NCRP) issued a
report that specifies the latest risk estimates (NCRP Report #115, see references). The total
detriment (excess cancer deaths and severe hereditary disorders) from low- level, low dose-rate
exposure to radiation is between 4 and 8 × 10-2 Sv-1 . This applies to whole body irradiation, and
these risk estimates are: based on human populations that were generally exposed to high doses of
radiation delivered at very high dose rates, such as Japanese atomic bomb survivors. These risk
estimates therefore have wide error bars, and must be interpreted accordingly. A typical calculation
with such risk estimates might involve a scenario in which 10,000 persons are exposed to 1 rem of
whole body radiation. This would lead to an estimate of between 4 and 8 radiation- induced cancer
deaths in this group of 10,000 people. The natural incidence of cancer death is about 22%, so about
2,200 people would die naturally of cancer, and the radiation- induced additional 4-8 cancer deaths
would not be easily detectable. This type of analysis is fraught with assumptions, perhaps akin to
using the risk estimates for jumping off a very high building to calculate the risk for jumping off a
one foot high log. In diagnostic radiology, the patients are not exposed to whole body radiation (to
which these cancer estimates apply), but there is also considerable data in NCRP #115 for
particular organ cancer types. Also, as occupationally exposed radiation workers, our dose rate is
quite low (presuming we utilize appropriate protective techniques), and using the above cancer risk
estimates may be akin to comparing the risk from consuming 100 aspirin all at once to the risk of
consuming one aspirin per day for 100 days. These risks are different, and radiation effects exhibit
similar dependencies on dose and dose rate. Nevertheless, based on the very large volume of
scientific data available to us today, we can fairly confidently conclude that: these potentially late
cancer responses to “low dose radiation” are a prime reason for judicious use of fluoroscopy during
medical procedures. We cannot very exactly specify the number of cancers caused by use of
fluoroscopy in our patients or in ourselves as health care workers. The number of cancers is
scientifically likely to be small, but not zero, and the number of cancers we cause is increased as we
give more absorbed dose to our patients.

Genetic Effects

Low dose radiation can cause chromosomal damage which may be “repaired” with an incorrect
sequence and subsequently be passed on to the next generation. Radiation does not cause new types
of mutations per se, but simply increases the incidence of certain mutations above their natural rate
of occurrence. A gonadal dose of 250 cGy (250 rad) will cause temporary sterility, while 500 cGy
(500 rad) will induce permanent sterility in males. Sterilizing doses in females may require greater
than 625 cGy (625 rad), particularly in younger individuals. Controlled studies of genetic effects
are only available from animal models and must therefore be interpreted with considerable caution
for implications in humans. The 7 million mice, “Megamouse” project revealed the following five
conclusions:

1. Different mutations differ significantly in the rate at which they are produced by a given
radiation dose.
2. There is a substantial dose-rate effect with no threshold for mutation production.
3. The male was more radiosensitive than the female. Most of the radiation- included genetic
burden was carried by the males.
4. The genetic consequences of a radiation dose can be greatly reduced by extending the time
interval between irradiation and conception. Six months to a year is recommended.
5. The amount of radiation required to double the natural and spontaneous mutation rate is
between 20 to 200 cGy.

NCRP #115 suggests that the quantitative risk of severe hereditary risks is 4-8 times lower than the
cancer risks specified above. While these late effect genetic risks appear less frequent than cancer
risks, they nevertheless suggest prudence in irradiating our patients and ourselves.

Embryo and Fetus

There are three general effects from irradiation in utero which are dependent upon the dose and
stage of fetal development:

• Lethality
• Congenital abnormalities at birth
• Delayed effects, not visible at birth, but manifested later in life.

250 cGy (250 rad) or more delivered to a human embryo before 2 to 3 weeks of gestation will
likely result in prenatal death. Those infants with irradiation in the 1st 2-3 weeks who survive to
term generally do not exhibit congenital abnormalities. Irradiation of the human fetus somewhat
later, between 4 to 11 weeks of gestation, may cause multiple severe abnormalities of many organs.
Irradiation during the 8th to 15th week of gestation may result in mental retardation and
microcephaly. NCRP #115 suggests that the quantitative risk of mental retardation from irradiation
during the 8th-15th week is similar in magnitude to the cancer risks mentioned above. The fetus is
therefore considered more radiosensitive in its early stages. After the 20th week, the human fetus is
more radio-resistant but functional defects may be observed. In addition, a low incidence (one in
2000) of leukemia induction has been observed in individuals who received prenatal radiation.

It seems clear that irradiation of the fetus should be avoided without clear medical justification
relating to the medical condition of fetus or mother.

VIII. REGULATORY EXPOSURE LIMITS

The occupational exposure limits concept utilizes an assumption that radiation doses below the
stated levels are an acceptable risk for occupationally exposed personnel and the general population
within the lifetime of the exposed individual. These acceptable risk levels have been set based on
comparisons to other risks in our society: other occupational hazards in other safe industries,
environmental hazards, etc. There are no regulatory limits for patient exposures, but FDA
guidelines and our professional understanding of radiation effects dictate minimizing patient
exposures. And, of course, minimizing patient exposure also minimizes hospital personnel
exposures.

Occupational Annual Dose Limit (mrem)

Whole Body, Effective Dose Equivalent 5,000

Skin, Individual Organs, Extremities 50,000

Lens of the Eye 15,000

Members of the Public 100

Embryo/Fetus* 500
 * The embryo/fetus of an occupationally exposed declared pregnant woman. See the
FMLH/MCW Policy on Embryo/Fetus Monitoring.

ALARA, As Low As Reasonably Achievable

The Radiation Safety Program has as a core principle the ALARA concept. ALARA means that
every reasonable effort, whether through procedural or engineering controls, will be made to reduce
radiation exposures.

The FMLH/MCW Radiation Safety Committee oversees the Radiation Safety Program. FMLH
and MCW are committed to the ALARA program and will do whatever is reasonable to minimize
radiation levels to patients and hospital personnel. Employees should conduct themselves
whenever possible to obtain less than 10% of the maximum permissible occupational radiation
exposure. Full attainment of this goal is not possible without the cooperation of all medical users
of radiation-producing machines.

FOR MORE INFORMATION

FMLH Office of Radiation Safety (414) 805-6540

ORS Website www.mcw.edu/radsafe

Department of Radiology, Medical Physics (414) 805-3790

Radiation-Induced Skin Injuries from Fluoroscopy http://www.fda.gov/cdrh/rsnaii.html

Food and Drug Administration website

REFERENCES

1. Bushberg, J., Seibert, A., Leidholdt, E., et al., The Essential Physics of Medical Imaging,
Williams & Wilkins, Baltimore, MD, 1994.
2. Bushong, S., Radiologic Science for Technologists – Physics, Biology, and Protection, 7th
Edition, Mosby, St. Louis, MO, 2001.
3. Hall, E., Radiobiology for the Radiologist, 5th Edition, Lippincott, Williams & Wilkins,
Philadelphia, PA, 2000.
4. NCRP Report No. 115, Risk Estimates for Radiation Protection, National Council on
Radiation Protection and Measurements, Bethesda, MD, 1993.
5. NCRP Report No. 116, Limitation of Exposure to Ionizing Radiation, National Council on
Radiation Protection and Measurements, Bethesda, MD, 1993.
6. The Radiation Information Network, http://www.physics.isu.edu/radinf/, Idaho State
University.