Radiation and pregnancy

[cartoondoc]

This occurred during my training when I was 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.

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. I've been called "irrational" for not wanting to expose myself to radiation while pregnant.

However, even if the risk is minimal, I feel that it should be the pregnant woman's choice to do this. I maintain that my attending shouldn't have pressured me to walk in front of X-ray beams while pregnant.

What do you think?

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[JediZero]

This occurred during my training when I was 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.

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. I've been called "irrational" for not wanting to expose myself to radiation while pregnant.

However, even if the risk is minimal, I feel that it should be the pregnant woman's choice to do this. I maintain that my attending shouldn't have pressured me to walk in front of X-ray beams while pregnant.

What do you think?

I saw this topic, and immediately thought to link to your blog post on it. So much for that idea... XD

In any case, we all take on some risks when we choose to enter medicine, and radiation exposure is one of them. That said, your child has not been given the opportunity to make that decision, and while lead can reduce the risks it certainly does not eliminate them. I support your right to be the one deciding this, and your attending (and the others) can stuff it.

I mean, honestly, even if the chances of something actually happening are microscopic, if this gives you peace of mind, then it's worth it. Not to be morbid, but if two years down the road your baby develops leukemia, I would think being able to say to yourself "there is nothing I could have done to prevent this" is easier than wondering if it was all your fault.

 

[colbgw02]

I think that she was wrong, and that she has an underdeveloped understanding of the stochastic effects of radiation. I think that the effects from this exposure are negligible, but that she shouldn't exert pressure on you to act as she would. I also think that this apparent one time event should be dropped. There is nothing different to do with respect to your pregnancy, and this doesn't sound like a recurring issue. You're extraordinarily unlikely to get anywhere if you make this an issue.

 

[shopsteward]

Your attending may have had good reason for not wanting to do it herself, just as you had.

Even so, if there is any risk at all she shouldn't have tried to persuade you into it.

 

[colbgw02]

There are rules governing this. As someone exposed to radiation therapy, you should declare your pregnancy in writing (it cannot be verbal). The radiation safety officer at your institution will then get involved and make sure you are being monitored to stay below the allowed amount during pregnancy (I think its 50 mSV or 5 msV per mo) and will be able to guide you as to which procedures to stay away from.

It's supposed to be no greater than 5 mSv to the fetus for the entirety of gestation or no more than 0.5 mSv per month. If they were to consider the presumed math that the fetus will only receive 10% of the exposure as measured at the skin surface, then one need only follow the normal guidelines for any radiation worker. But that's not how the regulations read.

Declaring yourself as a pregnant radiation worker may not be the best strategy. These rules are designed to protect people whose job requires them to be exposed or else they cannot function - nuclear pharmacists, fluoro and NM technologists, IR docs, etc. That doesn't sound like the situation you're in, meaning that your "normal" occupational exposure (scatter radiation from radiographs 1-2/month per OP) is likely well below 0.5 mSv per month.

Paradoxically, the attending in question could potentially use these rules to force push the OP into more exposure, since it is highly unlikely to approach the regulatory limit. "What do you mean you don't want to hold the patient's head? You've only had 0.1 mSv this month!" You may be better off sticking to and citing ALARA principles, which most of your attendings seem to understand, and then using the regulations only if the exposure becomes excessive. You'll have to make a judgment call on how to proceed based on the degree of exposure, the potential backlash from attendings, and the degree of support you can expect from the hospital if you decide to officially declare your pregnancy to the RSO.

 

[Law2Doc]

There are rules governing this. As someone exposed to radiation therapy, you should declare your pregnancy in writing (it cannot be verbal). The radiation safety officer at your institution will then get involved and make sure you are being monitored to stay below the allowed amount during pregnancy (I think its 50 mSV or 5 msV per mo) and will be able to guide you as to which procedures to stay away from.

You will come nowhere close to those thresholds if you are standing in lead next to a patient once a month. The law thresholds were set up for women who work with radiation and want to keep working.

 

[Rendar5]

You will come nowhere close to those thresholds if you are standing in lead next to a patient once a month. The law thresholds were set up for women who work with radiation and want to keep working.

Vacationing in Denver or taking an airplane flight would give you more radiation exposure than being in lead and hlding a pt's head in position. You are nowhere even close to the extremely cautious radiation limits we already place on pregnant women. So while I wouldn't force you to hold a patient in position (and honestly, there are other more serious dangers you face by going to work and seeing patients than that minimal radiation exposure) and think that attending was a little pushy from your description, I also think that your refusal to hold position was not necessary and probably resulted from lack of education on this (and honestly, most docs aren't trained on radiation limits of pregnancy)

 

[reno911]

It's funny how no matter how much knowledge we have or evidence we are aware of, we can still be irrational when it comes to our kids. I don't think that the attending is wrong here, she is just not very nice. Even though her assessment of the risk to your fetus (non-existent) is correct, I would think she would understand that pregnant moms are naturally overprotective and it wouldn't be a big deal to make this small, infrequent accommodation.

 

[inep]

I'm going to side with the attending on this one.

This would be the equivalent of refusing to work with an AIDS patient because even though you know the risk of contracting the disease with proper precautions (gloves, sharp procedures, etc), is negligible, you still don't like the idea of it.

At the end of the day, it's your body and your choice if you want to be around radiation, HIV+ people etc, but it is also your choice to work in this profession! American students and residents have it good where they can choose to not do pretty much whatever they want. There are so many safety measures for us. I have heard stories about students in third world countries being forced to do procedures without gloves because they weren't available. Forget about radiation exposure!

This has been studied extensively and you can look up radiation limits at different points in pregnancy. You can have a CT SCAN done of your head and it would only expose the fetus to fraction of a percent of the normal background radiation it receives during pregnancy. I understand your feelings and sometimes it can be hard to 'practice what we preach.' We all are human, after all.

 

[colbgw02]

It's funny how no matter how much knowledge we have or evidence we are aware of, we can still be irrational when it comes to our kids. I don't think that the attending is wrong here, she is just not very nice. Even though her assessment of the risk to your fetus (non-existent) is correct, I would think she would understand that pregnant moms are naturally overprotective and it wouldn't be a big deal to make this small, infrequent accommodation.

I'm not sure if you're being hyperbolic for effect, but the bolded part is not correct. I agree the risk is fleetingly small, but it's still some number greater than zero.

I'm going to side with the attending on this one.

This would be the equivalent of refusing to work with an AIDS patient because even though you know the risk of contracting the disease with proper precautions (gloves, sharp procedures, etc), is negligible, you still don't like the idea of it.

At the end of the day, it's your body and your choice if you want to be around radiation, HIV+ people etc, but it is also your choice to work in this profession! American students and residents have it good where they can choose to not do pretty much whatever they want. There are so many safety measures for us. I have heard stories about students in third world countries being forced to do procedures without gloves because they weren't available. Forget about radiation exposure!

This has been studied extensively and you can look up radiation limits at different points in pregnancy. You can have a CT SCAN done of your head and it would only expose the fetus to fraction of a percent of the normal background radiation it receives during pregnancy. I understand your feelings and sometimes it can be hard to 'practice what we preach.' We all are human, after all.

The bolded is an inapt analogy. The OP has a condition with a known endpoint that is temporarily altering her behavior - not an objection to a certain task or patient subset that prevents her from functioning long-term.

 

[cartoondoc]

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 on this topic but obviously no randomized controlled studies.

3) There's a box on all 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. That was something *necessary* for my health, not a piece of scut.

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 actually 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. 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. Especially for a piece of scutwork.

 

[colbgw02]

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 on this topic but obviously no randomized controlled studies.

3) There's a box on all 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. That was something *necessary* for my health, not a piece of scut.

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 actually 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. 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. Especially for a piece of scutwork.

These are examples of both an implicit understanding of ALARA principles mixed in with a touch of ignorance. To wit, it's silly to hesitate in ordering indicated ankle radiographs because of pregnancy, and it's unnecessary to avoid fluoro exposure categorically - and in doing so potentially compromise education - without first taking appropriate precautionary and monitoring measures.

The keyword in all of this is "reasonably" (the 'R' in ALARA). If you have to expose yourself for personal health reasons or for urgent/emergent patient care, then that's reasonable. If it can be avoided - as in the OP's example - then it should be.

 

[Law2Doc]

3) There's a box on all 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. That was something *necessary* for my health, not a piece of scut.
...
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.
....

you are mixing and matching unrelated concepts dangerously here. As a medical professional you need to have a Much better grasp on the actual risk of radiation, because you are presumably going to be talking to patients about this. First, there's a HUGE difference between being a patient at whom they are directing radiation and standing next to the patient and wearing lead. You wouldn't be getting direct radiation here, only scatter which will be partially attenuated by the patient and again by the lead. That's VERY different than being the patient. (and bear in mind the patient will still get the study in most cases as the risk is very low compared to the alternative). So to the extent people ask pregnant patients questionaires has nothing to do with your situation. Second, there's a HUGE difference in the amount of radiation used in fluoroscopic procedures in cath lab and the amount of radiation in flexion/extension spine films. It would be the equivalent of you drinking a glass of wine versus downing a fifth of vodka. Yes neither are recommended in pregnancy, but the former isn't really a problem. Cardiac cath workers are often exposed to the highest levels of radiation in the hospital due to the nature of the procedure and the length of time the beam is on. So no you shouldn't be in the cath lab but no there's not really the same kind of risk as you described In your situation.

Bear in mind that I don't really agree with your attending. I have seen plenty of pregnant residents excused from radiologic procedures and I don't think it's enough of an educational opportunity for an attending to make it an issue. But let's not kid anyone here -- the risks are within the legal thresholds for pregnant workers and not particularly significant. Flying on a plane during your pregnancy is more radiation.

 

[Rendar5]

A few points, a cath lab uses fluoro. that is a lot more radiation exposure overall than a c-spine series.

The attending who was reticent to get an ankle x-ray due to your pregnancy is an idiot. That is nowhere near your radiation limits even if you're unshielded. I believe the limits hover around the radiation load of 2 chest CT's or 1 abdominal CT.

As I said, you get more radiation on a flight than a couple xrays that you were shielded from, and they don't try to ban pregnant women from flying. So as law said, I don't agree with your attending for being all crotchety, and I can understand the maternal instinct. But you need to understand that the radiation dose you are concerned about is trivial. Abusive patients pose more risk to you than the radiation. I can't fault you for not knowing that though. There are only a couple fields that are even supposed to be trained on it.

 

[reno911]

I'm not sure if you're being hyperbolic for effect, but the bolded part is not correct. I agree the risk is fleetingly small, but it's still some number greater than zero.

I was rounding to zero. Part hyperbole part casual language usage. Obviously the risk is some extremely low, but non-zero amount. Doesn't change the point being made.

 

[colbgw02]

I was rounding to zero. Part hyperbole part casual language usage. Obviously the risk is some extremely low, but non-zero amount. Doesn't change the point being made.

I guess I just see one as an unreasonable fear of a real threat, almost like a phobia. Whereas the other is a false belief of a nonexistent threat, like a delusion. I understand your point though, as they are both irrational.

 

[Law2Doc]

... I can't fault you for not knowing that though. There are only a couple fields that are even supposed to be trained on it.

actually any field that sends patients for imaging (or really any study) ought to be able to talk halfway intelligently with those patients about the (lack of) risk of that imaging. You don't have to be an expert, but should at least have a very general sense. You are the one the patient is going to ask - for routine imaging they may not ever see another MD before the study.

 

[dpmd]

How are you guys doing your flex-ex films? I have never had to hold the patient's head for for this. The flexion and extension is supposed to be voluntary so there should be a way to accomplish this without having anyone hold the head.

Other than that question I will say that some people feel the need to coddle pregnant women and will do all sorts of stuff for them that they could actually do themselves. If I were the attending and I would have to take extra time to do someone else's job just because they are pregnant I wouldn't be so keen on it, but if it didn't add much hassle then I would help them out (for example, if I have a case that will require fluoro and there is a pregnant scrub tech I will not delay my case or do the case without a scrub tech, but if I don't actually need their hands at the time fluoro will take place I have no issue with them stepping away from the table). Since the OP was able to sucker someone else into doing her work, I don't see what the problem is.

Also, I agree any doc that may be in a position to order imaging in a pregnant patient should be aware of the risks and acceptable exposure limits, as well as be able to have a competent discussion with the patient weighing the risks and benefits of the imaging study. Ankle xray to rule out fracture is a no brainer with appropriate shielding. Heck, sometimes even an abdominal CT is the safer option for a pregnant patient than not getting imaged or getting imaged with an alternative study. Too many docs have this idea that you shouldn't expose any pregnant people (or kids, some docs act like scanning a kid is the same as punching them in the face). I don't know if it is lack of knowledge or just an inability to come to a rational conclusion based on existing information (similar to the OP).

 

[cartoondoc]

When a patient has a fracture and is in a C-collar, we're required to support their neck for their films.

My point is that it's not *irrational* because, while the data may not technically support it, the data is NOT ironclad (no randomized studies), and pretty much every single doctor you come across acts like radiation IS a big risk. It may ultimately be *wrong*, but not irrational to worry.

And if I had gone down to hold the patient's neck, I'm pretty sure (from future experiences) that the tech would have seen my belly and not even allowed me in. They don't want the liability.

 

[colbgw02]

When a patient has a fracture and is in a C-collar, we're required to support their neck for their films.

My point is that it's not *irrational* because, while the data may not technically support it, the data is NOT ironclad (no randomized studies), and pretty much every single doctor you come across acts like radiation IS a big risk. It may ultimately be *wrong*, but not irrational to worry.

And if I had gone down to hold the patient's neck, I'm pretty sure (from future experiences) that the tech would have seen my belly and not even allowed me in. They don't want the liability.

I've been supportive of you on this thread, because I think it's prudent and reasonable for a pregnant woman to minimize exposure, when circumstances permit, but you're not helping yourself out with posts like the above.

First of all, the absence of randomized trials doesn't mean that there isn't significant data to speak authoritatively about your situation. Secondly, the fact that "pretty much every single doctor you came across acts like radiation is a big risk" isn't evidence of anything other than every single doctor you came across is underinformed about radiation safety protocol and radiobiologic effects.

Lastly, what are "future experiences"? Do you mean experiences you've had since the one in the OP?

 

[neusu]

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 on this topic but obviously no randomized controlled studies.

3) There's a box on all 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. That was something *necessary* for my health, not a piece of scut.

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 actually 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. 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. Especially for a piece of scutwork.

In what trimester are you? We have PA/NPs and fluoro techs who are in the operating room during pregnancy who wear the baby badge to determine their exposure under the lead. While I realize being pregnant may raise significant concerns about yourself and your unborn child, but radiation safety has been well documented and continues to be a large concern in the medical community. With that said, you are doing the right thing to avoid radiation. Even so, your aversion is likely unfounded.

PS Thanks for doing the flex/ex and not calling us.

 

[dpmd]

My point is that it's not *irrational* because, while the data may not technically support it, the data is NOT ironclad (no randomized studies), and pretty much every single doctor you come across acts like radiation IS a big risk. It may ultimately be *wrong*, but not irrational to worry.

Just because a bunch of people are irrational about it doesn't make it any less irrational. Doctors are not immune from being unscientific and even completely superstitious in their practice. I am not saying everything needs concrete data in order to do it, or even advocating giving up the superstitions, I just want people to own it. There are a few things I do and teach those underneath me that I know are irrationally based. I make sure that they know that. If you want to avoid anything that is a negligible risk to your pregnancy that is fine, just don't get bent out of shape if not everyone wants to jump in to do your work for you since there is absolutely no reason why they should have to. There are leaded pregnant people near radiation all the time in medicine because there are acceptable limits. If someone wants to make you do something not within limits you have every right to be pissed about it and fight it, but this is just not one of those scenarios. If you had told your attending that you knew you were being irrational but that you would really appreciate not having to do it it is possible she would have responded differently. I bet she was just irked that someone would use their pregnancy to get out of doing a job they were perfectly capable of doing.

 

[cartoondoc]

I agree that doctors can be irrational. But if your doctor is concerned about something like getting an X-ray while pregnant and you believe them, I don't think that's an irrational response. I think that is pretty normal.

I think you are giving my attending too much credit. I don't think she knew the data--I think she just didn't care. On another occasion, I told her weeks in advance I'd have to leave for an hour for a scheduled gestational diabetes test, and she agreed to cover me. A few hours before my test, she informed me she had an appointment to go to and I'd have to find someone else to help me or else cancel.

 

[neusu]

I agree that doctors can be irrational. But if your doctor is concerned about something like getting an X-ray while pregnant and you believe them, I don't think that's an irrational response. I think that is pretty normal.

I think you are giving my attending too much credit. I don't think she knew the data--I think she just didn't care. On another occasion, I told her weeks in advance I'd have to leave for an hour for a scheduled gestational diabetes test, and she agreed to cover me. A few hours before my test, she informed me she had an appointment to go to and I'd have to find someone else to help me or else cancel.

Your doctor was concerned about the X-Ray because of protocol. We routinely get CT scans on pregnant women where it is indicated. Certainly, I have to check the box for "pregnant," each time, nonetheless the study is completed. I have yet to hear about a baby affected.

Your attending was likely just being lazy. You were, also, likely using pregnancy as an excuse to get out of a flexion/extension image. As a neurosurgery resident, I do these all of the time. You do not have to expose yourself to radiation to complete these images, you stand behind the wall as do the x-ray techs. If that is too much radiation, perhaps the hospital is not the right work environment for you as portable x-rays are going randomly and spontaneously throughout the hospital.

 

[dpmd]

You do not have to expose yourself to radiation to complete these images, you stand behind the wall as do the x-ray techs. If that is too much radiation, perhaps the hospital is not the right work environment for you as portable x-rays are going randomly and spontaneously throughout the hospital.

I think her hospital has a policy where the doc actually has to hold the head during the xray.

 

[cartoondoc]

You were, also, likely using pregnancy as an excuse to get out of a flexion/extension image. As a neurosurgery resident, I do these all of the time. You do not have to expose yourself to radiation to complete these images, you stand behind the wall as do the x-ray techs. If that is too much radiation, perhaps the hospital is not the right work environment for you as portable x-rays are going randomly and spontaneously throughout the hospital.

You don't know me, but that's completely untrue. I was genuinely worried. I spent about five times as long trying to work out coverage than the five minutes it would have taken to do the films.

And I've been part of many flex-ex films since then. Our facilities require you to stand directly in the path of the X-ray beams to hold the patient's head. Certainly not behind a wall. On another occasion (years later), a tech refused to let me participate until I swore there was no chance I was pregnant.

 

[dpmd]

I agree that doctors can be irrational. But if your doctor is concerned about something like getting an X-ray while pregnant and you believe them, I don't think that's an irrational response. I think that is pretty normal.

I meant that the doctor who was worried about the ankle xray was being irrational.

Also, you seem to feel entitled to your attending making things easier for you. That is not their job. Sure it sucks that she was busy when she was going to help you out, but why does your appointment matter more than hers?

 

[LucidSplash]

And I've been part of many flex-ex films since then. Our facilities require you to stand directly in the path of the X-ray beams to hold the patient's head. Certainly not behind a wall. On another occasion (years later), a tech refused to let me participate until I swore there was no chance I was pregnant.

Wait how long ago was this? I was initially reading this as something that happened recently, not "years" ago. I'm not sure what your goal is here with this question if it is in the distant past.

 

[colbgw02]

And I've been part of many flex-ex films since then. Our facilities require you to stand directly in the path of the X-ray beams to hold the patient's head. Certainly not behind a wall. On another occasion (years later), a tech refused to let me participate until I swore there was no chance I was pregnant.

This is crazy talk. Standing directly in the beam's path would make for crappy radiographs, assuming you're not the patient. And if you think that's a minor point, then you know less about radiation physics than I thought.

 

[cartoondoc]

Also, you seem to feel entitled to your attending making things easier for you. That is not their job. Sure it sucks that she was busy when she was going to help you out, but why does your appointment matter more than hers?

I guess the fact that I told her about it weeks ago and she told me it was okay, then backed out at the last minute. You don't think it's rude if someone does that to you?

In my field (PM&R), the attending and resident work side by side, so it's less of the hierarchical structure that you see in surgery or IM. If the resident takes a vacation or is out sick, the attending always covers.

The reason I am mentioning this years later is because there are still residents and med students getting pregnant and I think it's a matter of general concern.

 

[cartoondoc]

This is crazy talk. Standing directly in the beam's path would make for crappy radiographs, assuming you're not the patient. And if you think that's a minor point, then you know less about radiation physics than I thought.

OK fine, like one foot away.

 

[colbgw02]

And I've been part of many flex-ex films since then. Our facilities require you to stand directly in the path of the X-ray beams to hold the patient's head. Certainly not behind a wall. On another occasion (years later), a tech refused to let me participate until I swore there was no chance I was pregnant.

Wait how long ago was this? I was initially reading this as something that happened recently, not "years" ago. I'm not sure what your goal is here with this question if it is in the distant past.

The reason I am mentioning this years later is because there are still residents and med students getting pregnant and I think it's a matter of general concern.

Whoa. Totally missed this.

OP, hope your kiddo is okay. Peace, I'm out.

 

[cartoondoc]

She's actually horribly mutated.

 

[Rendar5]

I guess the fact that I told her about it weeks ago and she told me it was okay, then backed out at the last minute. You don't think it's rude if someone does that to you?

In my field (PM&R), the attending and resident work side by side, so it's less of the hierarchical structure that you see in surgery or IM. If the resident takes a vacation or is out sick, the attending always covers.

The reason I am mentioning this years later is because there are still residents and med students getting pregnant and I think it's a matter of general concern.

Well, then since it's not really about you anymore, I can tell you that in general, it should not be a matter of general concern for other residents, and you should worry about it as much as you worry about residents getting vaccines for their kids.

 

[cartoondoc]

But my colleagues and I *have* residents and sometimes they are pregnant, and we still do this at my facility. So should I demand they hold the neck?

 

[Law2Doc]

OK fine, like one foot away.

In terms of the drop off in radiation a foot is huge. As is wearing lead. It's fine to try and minimize radiation and fine to ask to not work with radiation during pregnancy where that's an option. But that's more about your own sensibilities than real risk to your baby -- its not fine to continue to suggest there is a real measurable risk in the scenario you laid out. As a Doctor you are sometimes going to need to convince patients who need an imaging study that the risks to their baby are very low, and that's even in a situation where the fetus will actually be in the image. It will be very hard to do this if you don't even appreciate that being outside of the beam, wearing lead, during a very low radiation study is not the equivalent to being a patient IN THE BEAM or being in a higher radiation situation like cath lab. The fact that you can reference other physicians or techs who don't "get" what the real risks of radiation are in your scenario doesn't help your argument. It just tells us that you are an uninformed person who has chosen to surround themselves with like minded people. Your government has set radiation thresholds for pregnant radiation workers at much higher than you are getting because it not deemed unsafe. Again, I think if there are alternatives to you being proximate to xrays while pregnant, by all means do so, but don't try to pretend that you are in the same situation as a patient who is in the actual path of an xray because you are a foot away and wearing lead. You aren't. Not even close. and if a doctor or tech tells you different then stop taking advice from them -- it's just not true.

 

[dpmd]

But my colleagues and I *have* residents and sometimes they are pregnant, and we still do this at my facility. So should I demand they hold the neck?

It really is up to you. If you want to do the residents job for them even though it is perfectly acceptable for them to do it themselves, it is fine. Just don't act like it is some terrible thing being done to the pregnant person. As people said, the decision to work while pregnant exposes you to many other things that are a much greater risk (the altered patient probably being the biggest, but think about what a needlestick could mean, or just an infectious patient/family member that you may not even know has something). Heck, the decision to live at all while being pregnant exposes you to all sorts of things that are likely a bigger theoretical risk than the situation you are describing. From the things you eat or don't eat, the amount of exercise you get, the people you come into contact with, the only way to avoid all potential risk to a pregnancy is to put the pregnant person in a bubble. Otherwise, people just need to be rational and understand that some compromises will need to be made. Not everyone will be as willing to pick up the slack so a pregnant person can live in her bubble. Being mad about that is more irrational than being afraid of being in lead next to a patient getting an xray.

 

[Rendar5]

But my colleagues and I *have* residents and sometimes they are pregnant, and we still do this at my facility. So should I demand they hold the neck?

I just answered your question on whether there's a risk to them or not. Whether or not you want them o hol the neck is going to be a matter of how much you care to correct their myths about radiation, how busy it is, etc. Me, I'm gonna tell them not to worry and to put lead on, and if they still insist on not exposing themselves, I will do it for them and make them read a chapter on radiation esposure and tell me about it the next day =p. You give me extra work, Ill give you extra work.

Though, honestly, I've never really heard of holding someone's neck for C-spine plain films, C-spines are pretty rare for me, and I don't do flex-ex views (granted this is EM, not PM&R)

 

[dpmd]

Though, honestly, I've never really heard of holding someone's neck for C-spine plain films, C-spines are pretty rare for me, and I don't do flex-ex views (granted this is EM, not PM&R)

They always wanted a doc present for a flex ex, but I am pretty sure it was just to intervene if the patient became a quad or something. I can't say for sure because somehow I never had to be there for one, but the technique allows for using pillows to support the neck or a hand. Sort of like sometimes for a portable lateral someone has to hold the limb in place if tape and pillows isn't cutting it (or if you just want to get it done faster).

 

[Winged Scapula]

But my colleagues and I *have* residents and sometimes they are pregnant, and we still do this at my facility. So should I demand they hold the neck?

As others have said, its up to you.

Frankly, I'd use the situation to educate and ask the pregnant staff to reevaluate their risks.

At the end of the day however, you can't always fight ignorance. I still have pregnant OR staff who refuse to be in the room when I'm using radioactive isotopes, despite an in-service by me and Nuc Med, about the lack of risk to them.

 

[shopsteward]

As others have said, its up to you.

Frankly, I'd use the situation to educate and ask the pregnant staff to reevaluate their risks.

At the end of the day however, you can't always fight ignorance. I still have pregnant OR staff who refuse to be in the room when I'm using radioactive isotopes, despite an in-service by me and Nuc Med, about the lack of risk to them.

An unworried pregnant woman probably has better prospects for herself and her baby than a worried one. But pregnant women are bombarded by pseudo-medical advice in the popular media about what they need to avoid in order not to damage their fetus, from the obvious (cigarettes and alcohol) to the wholly or mostly harmless. Alternatively, they are bombarded with advice on what they should be doing in order to make the baby as fit and healthy and clever as possible. Sensible medical advice has little hope of getting through this general media chaff and misinformation from friends and relatives, and can even end up looking heartless. The end result is some women who ignore even the obvious good practice and others who are guilted into spending the first 20 years of their offspring's life worrying about the possible deleterious effects of something which was completely harmless. Add in an unhealthy degree of public sentimentality about pregnancy, and there is little hope of reason prevailing.

 

[inep]

This might be helpful. Note that x-rays are only listed for the person receiving it. Because the OP here is talking about holding the c-spine in neck films, then I think the 'arm x-ray' dose would be reasonable. This is 1 microsievert. For comparison, the dosimeter on my desk has measured 12 microseverts of radiation in the past week doing nothing but sitting there.

 

[Law2Doc]

Bear in mind that the radiograph dose you have provided is for someone actually in the beam, not a foot away from the beam and wearing lead. As a result this table is hugely misleading with respect to OPs concerns. OP is toward the low end of the blue.

 

[dpmd]

Bear in mind that the radiograph dose you have provided is for someone actually in the beam, not a foot away from the beam and wearing lead. As a result this table is hugely misleading with respect to OPs concerns. OP is toward the low end of the blue.

I don't think it is hugely misleading at all. That poster specified that the arm xray seemed most appropriate since the hand/arm holding the head might actually be in the beam (or at least really close) so the exposure is at most that, which is super low and not anything that needs to be worried about (since it is lower than typical background radiation for a day according to the chart). I am not sure what you found so misleading about that.

 

[Law2Doc]

I don't think it is hugely misleading at all. That poster specified that the arm xray seemed most appropriate since the hand/arm holding the head might actually be in the beam (or at least really close) so the exposure is at most that, which is super low and not anything that needs to be worried about (since it is lower than typical background radiation for a day according to the chart). I am not sure what you found so misleading about that.

Patients getting arm xrays aren't always wearing the same amount of lead as OP would be, but I get your point. (And "really close to the beam" and in the beam are night and day.) But my main concern was not that you would understand this. The OP has repeatedly not demonstrated an understanding that standing a foot away from an X-ray (in lead) and actually personally getting an xray are not the same thing, or that cardiac cath and a spine xray are not the same thing. So I was concerned that a table which shows unrelated doses ranging all the way up to things like power plant melt downs is going to be scary and uninformative.

 

[dpmd]

Patients getting arm xrays aren't always wearing the same amount of lead as OP would be, but I get your point. (And "really close to the beam" and in the beam are night and day.) But my main concern was not that you would understand this. The OP has repeatedly not demonstrated an understanding that standing a foot away from an X-ray (in lead) and actually personally getting an xray are not the same thing, or that cardiac cath and a spine xray are not the same thing. So I was concerned that a table which shows unrelated doses ranging all the way up to things like power plant melt downs is going to be scary and uninformative.

I was thinking about the dose to her actual arm and how even that maxes out at a really low value (meaning any dose to the part of her behind her lead is so low as to be considered practically zero), but I see your point about her irrationality and how she may not interpret things as I did.

Also, I remember the differences in dose with regard to distance since I had to take the fluoroscopy exam, but since even the in the beam dose is low enough to not be a problem and I don't know how they shoot the films at her place (maybe her hands actually make it onto the film? I have seen that before for other kinds of films) I figured it was easier to just combine the two into the "not an issue" group.

 

[BlondeDocteur]

Despite this discussion becoming a bit snippy, it was full of great information-- thanks to the rad onc folks for chiming in.

Here's how I handled it. I was pregnant for 9 months in my second year of surgery residency, the majority of which was in the ER and ICU at a very busy trauma center. I was quite comfortable with wearing lead and being present for X-rays (as the experts noted, the risk to the fetus is almost nil, and well below tolerated exposure limits). I was present for hundreds upon hundreds of plain films, many times holding the body part in question (we too required an MD to hold the neck when a c-collar was removed before imaging; and multiple orthopedic snap trauma series required someone nearby to help stabilize/hold the affected limb) or standing nearby to get the result to intervene quickly (i.e. did a chest tube evacuate the pneumo? is the line in place? etc). Not only did I not mind it intellectually, to step out of the role and find someone else would have been unduly burdensome to the running the ICU/ER.

I was not comfortable with being in the operating room for endovascular cases, not just because of the prolonged fluoro time but because the service was ridiculously over-stacked and the role of the junior resident was to simply stand there holding the wire while the attending/fellow/senior did anything interesting. My actual contribution to the procedure was nothing, so I simply asked to stand behind the shields and watch everything on the screen. If I had been given the opportunity to actually perform parts of the case, I'm not sure what I would have done.