Is the equipment designed to protect healthcare workers in cath labs doing more harm than good?

For years, concerns about clinicians working in fluoroscopy labs have centered on the long-term dangers of radiation exposure. Now a new multisociety statement points to a second underrecognized threat: a growing burden of orthopedic injury caused by protective equipment.

The statement was developed by a think tank made up of diverse representatives — including catheterization lab staff, radiation physicists, and advocacy groups — that was convened to address these overlapping hazards.

The resulting joint statement, “ALARA+: Summit on Radiation and Orthopedic Risks in Fluoroscopic Laboratories,” published in the Journal of the Society for Cardiovascular Angiography & Interventions and simultaneously in Heart Rhythm, the Journal of Vascular and Interventional Radiology, and the Journal of Vascular Surgery-Vascular Insights, identified several compelling trends shaping occupational risk. 

Current Equipment and Radiation Levels

The statement cites several studies that showed a clear association between occupational radiation exposure and increased risk for cataracts, atherosclerosis, brain and neck tumors, and breast cancer. DNA damage from radiation has also been linked to increased risk for cancer.

Furthermore, the statement noted that, “increased frequency of minimally invasive procedures, longer procedural duration, extreme gantry angles, and the need for alternative vascular access approaches” increase operator exposure during fluoroscopy-guided interventions.

In one survey of interventional cardiologists, for example, 6.1% reported having cancer, while many stated they knew colleagues with tumors. The problem arises, the statement says, because current equipment does not fully block radiation and leaves some body parts exposed.

The Hidden Epidemic: Orthopedic Injury

Traditionally, clinicians have used lead or lead-equivalent protection garments, with additional equipment including lead caps, goggles, ceiling-mounted shields, and table-mounted lead skirts underneath the patient table.

Lead aprons, which have been the mainstay for radiation protection in cath labs, are heavy and associated with high rates of orthopedic injuries.

The think tank pointed to studies showing 66% of cardiologists report musculoskeletal pain, while 79% say colleagues have experienced similar injuries. Reported issues included chronic back and neck pain and nerve damage, with some cases requiring surgical intervention. These problems come from standing for hours in a cath lab, leaning forward or craning the neck, and wearing heavy gear.

“Unfortunately, this finding, that two-thirds of interventional cardiologists report musculoskeletal pain, did not surprise me,” said Andrew J. Einstein, MD, PhD, professor of medicine (radiology) and the director of nuclear cardiology, cardiac CT, and cardiac MRI at Columbia University Irving Medical Center/New York-Presbyterian Hospital in New York City. “Anecdotally, we hear this complaint all the time, and even worse, many cases of severe spine pathology, surgery, and disability.”

Targeted Groups: Women and Support Staff

The statement highlights disparities among groups. Women, who make up roughly 50% of medical school graduates, are underrepresented in interventional fields.

This is often because of fear of radiation (especially if pregnant or planning a pregnancy), physical demands, and a lack of supportive policies. Beyond the shared risks for radiation and orthopedic injury, women have concerns related to reproductive health, career advancement, and navigating a demanding medical culture, note the think tank authors.

Another important note: Medical trainees, nurses, and imaging staff often receive higher radiation exposure than physicians, placing them at increased risk for radiation-related and orthopedic injury.

What’s the Solution?

The authors propose a new framework, which they define as “low (radiation) AND as light (physical burden) as reasonably achievable,” or ALARA+, which expands the traditional radiation safety protocols to include physical burden.

For example, newer, enhanced radiation protection devices reduce radiation without requiring heavy wearable lead. These include ceiling-mounted shields, mobile barrier systems, radiation-shielded workstations, and robotic systems that can both reduce radiation risk and cut down or eliminate the need for heavy gear. 

And, while the costs of implementing these new protocols might seem cost-prohibitive ($150,000-$200,000 per system), the authors argue that the cost of not fixing the problem is even greater.

Arash Salavitabar, MD, director of cardiac catheterization & interventional therapies at Nationwide Children’s Hospital in Columbus, Ohio, and an author of the joint statement. He believes these investments are critical.

“Specialties relying on fluoroscopy have continued to depend on largely unchanged technologies for many years, rather than more broadly adopting and developing innovations designed to better safeguard healthcare workers from these risks,” he said.

Costs associated with exposure to interventional fluoroscopy average about $9 million per case of fatal cancer, $200,000 per case of nonfatal cancer, and between $12,000 and $45,000 per case for musculoskeletal disorders. The authors also argue that staffing shortages in interventional medicine are already severe, and losing trained physicians costs $500,000 to $1 million to replace.

Finally, the think tank authors believe the solutions should include regulatory change for these safety implementations (like laws for airbags in cars and needlestick safety). 

“It is crucial for all of us to continue to advocate both for existing enhanced radiation protection devices to be implemented in fluoroscopic laboratories and for more advanced protection devices to be developed for procedural environments that currently do not have ideal options,” Salavitabar said.

Salavitabar and Einstein reported having no relevant financial relationships. 

Lois Anzelowitz Levine is a lifestyle and medical journalist in Dallas.