In this study, a questionnaire survey was conducted to assess radiologists’ compliance with radiation protection practices. Particular areas where compliance needs more attention were identified. Similar to previous reports on use of leaded aprons during various studies among radiologists, cardiologists, and speech-language pathologists (Rahman et al. 2008 ; Warren-Forward et al. 2008 ; Kim et al. 2010 ; Lynskey et al. 2013 ; Zivile et al. 2016), almost all radiologists in this study always wore leaded aprons during x-ray-guided procedures. In contrast, compliance with thyroid protection practices was poorer than that reported for radiologists, cardiologists, and speech-language pathologists: only 21% of radiologists in this study wore leaded collars compared to 94% of radiologists, 54–94% of cardiologists, and 76% of speech and language pathologists in previous reports (Rahman et al. 2008 ; Warren-Forward et al. 2008 ; Kim et al. 2010 ; Lynskey et al. 2013 ; Zivile et al. 2016). The annual maximum permissible dose to the thyroid is 500 mSv (NCRP 1993), whereas equivalent dose to the neck can be anywhere between 0.03 and 1.2 mSv per x-ray-guided study (Kim et al. 2012). Effective dose can be reduced by approximately 50% by the use of a thyroid shield (Niklason et al. 1994) because the shield protects the underlying skin, esophagus, bone, and bone marrow as well as the thyroid gland (Kim et al. 2012).
In contrast, most radiologists reported never using leaded eyeglasses. Compliance with eye protection practices was previously reported as 32–54% among radiologists, cardiologists, and urologists (Rahman et al. 2008 ; Lynskey et al. 2013 ; Zivile et al. 2016). Recently, the International Commission on Radiological Protection (ICRP) recommended reducing the equivalent dose limit for the lens of the eye from 150 to 20 mSv in a year (Stewart et al. 2012) in response to evolving evidence that the risk of eye cataract is substantially higher than previously thought (Kleiman 2012). Depending on the applied working practice, eye lens doses per procedure range from 0.01 to 2.8 mSv (IAEA 2013). In a study on fellow and consultant radiologists, the annual equivalent dose to eye lens ranged from 4 to 45 mSv (O’Connor et al. 2015). These data highlight the importance of using eye protection during x-ray-guided procedures. In fact, protective eyewear can reduce ocular exposure by a factor of up to 10 times, depending on the type of eyewear and head orientation in relation to the x-ray source and imaged area (van Rooijen et al. 2014).
Although radiologists in this study reported using exposure-reduction strategies such as reduction of exposure time, unnecessary exposures, and exposure by primary radiation, only approximately half of the radiologists reported constant compliance with these practices. Limiting x-ray tube activation time, using tailored frame rate and stored last-image-hold, and minimizing the number of fluoroscopic runs are direct strategies to reduce dose (Detorie et al. 2007 ; Miller et al. 2010). Comparable to this study, only 58% of cardiologists reported reducing fluoroscopic frame rate in a study by Valuckiene and colleagues in Lithuania (Zivile et al. 2016). Radiologist should also stay as far from the x-ray beam as possible and use tools such as needle holders and power injectors to avoid placing their hands in the x-ray field (Detorie et al. 2007).
In compliance with the Jordanian Energy and Minerals Regulatory Commission (EMRC) regulations (Energy and Minerals Regulatory Commission 2015), reading of individual monitoring results must generally be arranged on a monthly basis. This allows adequate time to identify factors that may lead to high radiation exposure. It is, therefore, important to wear personal monitoring devices constantly and correctly in order to obtain accurate personal exposure readings. Radiologists in this study always wore their personal dosimeters. This is better than previously reported compliance among cardiologists in Pakistan (7%) and Lithuania (87%) and speech-language pathologists in Australia (60%) (Rahman et al. 2008 ; Warren-Forward et al. 2008 ; Zivile et al. 2016). The ICRP recommends the use of dual personal monitoring during x-ray-guided examinations, one at collar level over the apron and one on the trunk under the apron (Valentin 2000). However, this practice is not a regulatory requirement and is limited (Ciraj-Bjelac et al. 2011 ; Martin 2011 ; Khelassi-Toutaoui et al. 2016). Jordanian EMRC regulations are in line with ICRP recommendations (Energy and Minerals Regulatory Commission 2007). Most radiologists in this study used one dosimeter at neck level over the collar during x-ray-guided examinations, and the rest wore their dosimeters incorrectly at neck level under the collar. Other studies in the United Kingdom, Eastern Europe, and Algeria showed that wearing a single dosimeter under the apron is the common practice (Ciraj-Bjelac et al. 2011 ; Martin 2011 ; Khelassi-Toutaoui et al. 2016). This method provides a measure of penetrating exposure to sensitive organs in the trunk but omits exposure to unprotected organs, especially the head. Using a single dosimeter at neck level over the collar will do the opposite. Therefore, using dual monitoring is recommended in order to obtain accurate measurements of personal radiation dose.
The current study has limitations. An inherent limitation for self-reporting questionnaire studies is that the results may be biased by social desirability, i.e., the tendency of participants to respond in a manner that will be viewed favorably by others. This may cause radiologists to overreport good behavior or underreport bad. However, the anonymity of this study is expected to reduce this bias. Also, sample size and method of sampling may reduce the accuracy of generalizability. Moreover, radiologists who chose to participate may have had more confidence in their compliance than radiologists who chose not to participate. In addition, other factors that may have affected the level of compliance (such as attitude, comfort, physical strain, availability, ease of use, and supervision) may have been overlooked. Therefore, these factors warrant further investigation.
Therefore, future compliance improvement strategies for radiologists in Jordan should focus on the use of thyroid shields and leaded eyeglasses and on the use of exposure-reduction techniques during fluoroscopic operations.
The authors would like to thank Jordan University of Science and Technology for funding this study (grant no. 20150042).
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