Wednesday, April 24, 2013

Radiation risks

This is a topic I discussed a while back on Mothers in Medicine, but it came up somehow in the comments on this blog, so I figured I'd turn it into its own entry. (i.e. it's my blog and I'll do what I want to)

It goes back to an experience I had during residency when I was about four months pregnant.

It was generally the resident's job to hold patients' heads during flexion-extension spine films, which would come up maybe every other week or once a month. Most of my attendings immediately insisted that I couldn't be in the way of X-ray beams and would generally do it themselves. So for the first couple of months, this was never an issue.

However, I had one attending (a mother herself) who seemed baffled by why I didn't want to do it. "But you'll be wearing lead," she pointed out.

In any case, she refused to do it for me and made me find another resident willing to do it. (And the first resident I asked was a total jerk about the whole thing, asking what I'd do for him in return even though I'd done tons of favors for him in the past without expecting immediate retribution.)

There are a lot of women out there in medicine who get exposed to radiation in pregnancy. It can be an occupational hazard. In my last month of residency, I was assigned to a rotation doing daily fluoroscopic injections (thanks, chiefs!), but I had absolutely no trouble finding another resident to switch with me since that was a coveted procedure.

People who work with radiation a lot will tell you that the risks are minimal. They wear radiation counters and will tell you that their exposure is practically negligible. And you know what? They're probably right.

But here's the thing:

1) The vast majority of attendings and residents I worked with never even remotely questioned my decision not to be exposed to radiation.

2) There's data but obviously no randomized controlled studies.

3) There's a box on X-ray forms for patients asking if the patient is pregnant. That's for ONE X-ray, not for repeated exposures.

4) When I received a serious injury during pregnancy and needed an X-ray of my ankle (not near my uterus), the doctor was really reluctant to order it due to my pregnancy.

5) I'd feel like a total slimebag if I asked my pregnant resident to do something like that.

6) On another occasion when I went to hold a patient's head and wasn't pregnant, the tech quizzed me on whether there was any chance at all I could be pregnant before he let me in.

7) There are fellows in cardiology programs who are not allowed in the cath lab. Presumably, this decision is made by educated professionals and not Scruffy, the bum who sits outside the hospital.

Clearly doctors are not comfortable saying that this exposure is safe in pregnancy, so I think it's wrong to call me "irrational" for wanting to avoid exposure. I think it's extremely rational and even normal to worry about being exposed to radiation in pregnancy and wanting to avoid it if possible.

However, it seems like women in medicine who have had exposures during pregnancy become absolutely furious when I mention this story. I have no idea why this is, but it's happened to me multiple times. Is it guilt? Is it that pervasive "I did it so you should too" attitude in medicine?

I don't think you're a terrible person if you went into the cath lab while pregnant. But I feel like it should be the pregnant woman's choice to do this. I maintain that I should not have been pressured to walk in front of X-ray beams while pregnant.


  1. I agree. No sense in risking the child.

  2. Fizzy, I wouldn't step in front of x-ray beams either if I were pregnant. And I wouldn't give a shit what people thought of that. I don't know why you tend to post rebuttal blogs after taking heat about something. Who cares what people think of your decision not to expose your baby to even tiny amounts of radiation? If they think you are an idiot, so be it. Especially on this particular issue, their comments say more about them than they do about you.

    1. Well, the people who responded are all medical professionals and all in positions (or will be) to pressure other residents or underlings to expose themselves to radiation during pregnancy. So that's why I think it's worth giving a shit. Not for me, but so others realize they have the right to stand up for themselves.

  3. FYI: These are some of the responses I was alluding to in my post:

    1. But again, who cares what other people think? Someone else pointed out that they wouldn't drink even one sip of alcohol when pregnant, if someone were to mock her for that, why should she care? No matter what any given study "proves" or "disproves" about cigarette smoking, drinking, or radiation or VOC or lead exposure during pregnancy, we believe that the causes of birth defects are complex, sometimes purely genetic, sometimes purely environmental, but often a mix of genes and some sort of environmental trigger. It's possible that up to 99.999% of fetuses will be just fine if mom gets her annual dental x-rays while pregnant while wearing a lead apron, or smokes a couple of cigarettes during pregnancy, or drinks a glass of wine once in a while. But if a mom doesn't want to risk falling into the 0.001%, that is their choice and their right. No one can or should dictate to you what is prudent when it comes to limiting risks for your fetus, and more importantly, WHO CARES if they judge you or if they feel like you are attacking the decisions they made when they were in your shoes. They obviously are insecure about taking the risk. Not your problem.

    2. Not my problem. Just the problem of any pregnant residents/fellows they supervise in the future. Too bad for them, I guess.

  4. Amazing, because the trend now in pediatrics is to avoid ordering xrays and CT scans unless absolutely necessary! And I've had parents argue with me against performing these tests when I feel they are essential. Guess we need evidence based guidelines, pronto!

  5. "5) I'd feel like a total slimebag if I asked my pregnant resident to do something like that."
    Maybe because you care. Apparently there are quite a few "caregivers" that don't.

  6. I think two things are going on:
    1. Some women think that you're judging their choice (to accept what they think is negligible radiation exposure). You're not. I didn't drink alcohol while pregnant. I don't think a woman is awful for having a small glass of wine here and there but I didn't.

    2. They think you're using pregnancy to get out of doing work. Pregnancy doesn't change a woman's personality. There are women who are lazy and dump work on their colleagues. These women often use pregnancy as an excuse if they can. Women who aren't lazy to begin with don't use pregnancy as an excuse. I found that I was very conscious of doing more of the tasks I could do while pregnant to compensate for the fact that the people I work with would not let me do certain things. I've covered for pregnant women (sometimes doing an assay I thought was no big deal) because it's what decent people do.

    Some people are jerks. If you weren't pregnant they'd be jerky about something else.

  7. The radiation risks are negligible, to the point of being irrelevant. Much higher is the risk of litigation. If, God forbid, something happened in your pregnancy or something was wrong with the baby, you could claim it was the radiation you had been exposed to, and the hospital would be facing a million dollar OSHA lawsuit.

  8. It seems that the institutional/floor protocols protecting pregnant nurses hasn't been extended to include the house staff. I remember when working on the nursing staff of a med-surg unit, the nurses really supported each other in exchanging patient assignments to accomodate: no pregnant nurses in cdiff rooms, with patients who had radiological procedures or chemotoxic drugs. The pregnant residents didn't have nearly the same support.

    Even today, during our MS1 Occupational Health lecture, the very first real-life example was of our lecturer during her Peds Hem/Onc sub-intern rotation when she was directed by her attending, without regard for her advanced pregnancy, to draw blood on a patient with a severe disseminated viral skin disease.

  9. I'm very surprised that the attending was so cavalier about the whole thing. I agree that it probably falls under what Anonymous (Sophia) said above.
    I've had a few x-rays done in my life and the radiologists always seem sooo worried about the possible pregnancy thing. There was one time I actually got rather annoyed at the people working in the office because of it. I had signed the form and said I wasn't pregnant, and they kept asking me... They had to have asked me at least 5 times, was I really really sure I wasn't pregnant? It got to the point where I wanted to yell at them "I haven't had sex in 5 years, so unless it's an immaculate conception, I'm definitely not pregnant!" Ugh...

    Back to your point, as far as helping cover you while you're pregnant, for this and other things... I think it's part of American individualism and the me me me thinking. Americans just tend to help themselves and if it doesn't have some immediate obvious benefit for them, don't want to do it. This is bad enough in society in general, but I would think that for medicine, with all the competitive people it attracts, it's even worse.

  10. It seems like there are a lot of safety rules that are expected to be ignored if they might result in someone doing less or different work. Like when medical personelle get sick. It's extremely dangerous for them to be around patients who are often immune compromised, and yet I've known people who were punished (or threatened with firing) for having to go home early when they were clearly infected. We expect doctors to be tough and somehow that translates into invincible. As though there were a toughness level that would make you less likely to pass on germs or have your tisses affected by x-rays. Bizarre. Good for you for sticking to your guns, though.

  11. There are calculators that determine your x-ray radiation risk.

    ex: 30 year old female who gets a coronary angiogram (no fluoro for ESI unfortunately)
    Coronary Angiogram (diagnostic)
    Total Effective Dose: 7 (mSv)
    Additional Cancer Risk: 0.09 (%); 1 in 1071
    Baseline Cancer Risk: 37.5 (%)
    Baseline + Additional Risk: 37.59 (%)

    Comparison Doses
    Natural Background 3.1 mSv/year
    Domestic Pilots 2.2 mSv/year
    Average US Exposure 6.2 mSv/year
    7 Hour Airline Flight 0.02 mSv
    Chest x-ray (2 views) 0.10 mSv
    Chest CT 7.0 mSv

    Wait, there's a 37.5% risk for cancer in a 30 year old? whoa.

    1. That 37.5% risk could be rephrased as your odds of not dying of an MI or CVA plus your odds of recovering from cancer. Not surprising at all.

  12. Informative Article! Good to see somebody who really knows what they are talking about and can additionally produce common sense blog for us the reader. Certainly looking forward to your next article.

  13. My sister in law was given a CT scan and had an operation that removed one of her ovaries--came to find out she was pregnant shortly after the operation. Despite using her birth control medication properly, she had been pregnant before the CT scan of her abdomen. No one gave her a pregnancy test before the CT scan or operation.

    She switched OB/GYNs shortly after her operation. Her baby seems to be okay so far, but has a weird problem with an immune response and his skin. No one else in either family has a problem like it and a biopsy was invonclusive. I know she wonders if the CT scan may have caused it.

  14. Even in my rather sadistic surgical residency (wait, that's redundant), no one ever forced a pregnant resident to by exposed to anything. I think you happened to draw an asshole in residency. As for those who are responding against your position, many senior residents and attendings demonstrate evidence of battered child syndrome. They were beaten as residents by their surrogate parents (their senior residents and attendings) and they don't even realize they are now beating their surrogate children (those junior to them). It's a sad pattern which often seems to repeat. An argument can be made looking at actual radiation doses and exposures but quite honestly, if you're concerned it's easy these days to find someone to cover that sort of procedure while you do something else in return. Being a tall guy, I regularly did arm pulls for lateral c-spines for smaller, typically female residents who couldn't pull hard enough. Had nothing to do with how good doctors they were. There was always some task they could do to make it up to me and no one's training or care suffered.

  15. I had a back problem investigated and was sent for an x-ray. I told the technician there was a possibility I was pregnant as it was the first half of my cycle (I had been having unprotected sex since we were trying to start a family). I was pooh-poohed, you'll have a lead apron, no problem. 5 weeks later I had a classical missed abortion which was terminated fully after about 12 weeks. I had been pregnant - I will never know if it was that x-ray or just coincidental. Had they waited a couple of weeks I'd have known I was pregnant - and the guidelines were not to x-ray in the first trimester unless unavoidable. I wasn't going to die of my back problem - I'd waited 6 months for the appointment anyway.

  16. On the one hand, I think each person can decide what risks to accept--if a female cardiologist doesn't want to miss cath lab time, that's her call--but if each person is deciding, it's hard to have an institutional culture where nonpregnant people are expected to take these duties for those who are pregnant.

  17. I'm not a doctor, nurse, or in any way associated with any medical profession, except as a patient, and yet...I understood what you were saying and why, and agree with you. I have a feeling that those who are being difficult and disagreeable are doing it because they are making it personal. It could be as you said that they either feel guilty about their own radiation exposure (maybe unconsciously) or feel like you are judging them about it. It's the fact that they won't drop it after having their say, and that they are being unnecessarily vicious towards you, sometimes in a passive agressive way. It could also be that they have been reading you for some time and have decided they do not like you and will troll you, point out any "errors", and harass you. It just seemed way over the top to me.

  18. I think you're absolutely right and should not be forced or 'guilted' into be radiated while pregnant. And I'm an x-ray tech. Ultimately as long as someone is making an informed decision on whether or not to be radiated, that's their call. I'm shocked by how many pregnant chicks I actually x-ray. =\ (And when I was pregnant my co-workers were awesome in keeping me out of fluoro/surgery/holding patients)