High-dose fluoroscopy: the administrator's responsibilities

During the past 15 years, developments in x-ray technologies have substantially improved the ability of practitioners to treat patients using fluoroscopically guided interventional techniques. Many of these procedures require a greater use of fluoroscopy and serial imaging (cine). This has increased the potential for radiation-induced dermatitis, epilation and severe radiation-induced burns to patients. Radiology administrators must realize that these high-dose procedures increase the risk for radiation injury and radiation-induced cancer in personnel as well as in patients. This article discusses particular clinical cases and describes positive, pro-active steps that practitioners and administrators can take to help prevent such injuries in their facilities. Unfortunately, with the exception of radiologists, a large proportion of physicians who use fluoroscopy have effectively no training or credentials in management of radiation or the biological effects associated with its use. In 1994, an FDA advisory warned that training of physicians for modern-day use of the fluoroscope was for the most part insufficient and needed to be expanded. Many prominent medical organizations such as the American College of Cardiology (14) and the American Heart Association (15) have published strongly worded position papers agreeing that there is an urgent need for such training. The consensus is that "rubber-stamp" privileges (16,17) to perform fluoroscopic procedures should no longer be granted. At present, the JCAHO is considering the implementation of a statement regarding JCAHO standards and privileges for practitioners to use fluoroscopic x-ray equipment. Whether or not the JCAHO becomes involved, it is becoming increasingly clear that all practitioners who use fluoroscopic radiation should be required to complete focused training in radiation physics, radiation biology and radiation safety. Training should include the pertinent aspects of radiation management in the clinical setting so that these physicians will be able to acceptably control risks to patients and personnel. The task of securing these materials and lecturers and documenting everything may fall on the shoulders of the radiology administrator or radiation safety staff. Completion of an approved educational program (with appropriate testing) provides the evidence needed by the facility to approve the practitioner's qualifications. In summary, it will take a concerted effort on the part of professional medical organizations and regulatory agencies to insure that the wealth of preventative information now available is disseminated to and put to use by these physicians who may fail to fully appreciate the potential for imparting serious injury to their patients. Even one radiation injury caused by lack of education is unacceptable.