Awareness and attitudes amongst basic surgical trainees regarding radiation in orthopaedic trauma surgery
1 Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd, United Kingdom
2 Blackpool Victoria Hospital, Blackpool, Lancashire, United Kingdom
This study investigated the awareness and attitudes of
basic surgical trainees. Trainees were asked to answer questions from a pre-set
questionnaire. Fifty basic surgical trainees from England and Wales were involved in the study. The areas covered were basic knowledge of radiation
hazards, use of protective wear, pregnancy test in female trauma victims of
reproductive age, and principles of safe radiation. All the questions were
asked in the context of orthopaedic trauma surgery. All questions were evidence
It was unfortunate to notice that basic surgical trainees
are lacking in the essential knowledge of ionising radiation. Most of the
trainees are not adhering to radiation safety principle, and are not practising
safely. The authors strongly recommend that surgical trainees should have more
robust training and information available in this context. And they suggest
that it should be provided on local, regional and national basis. � 2010
Biomedical Imaging and Intervention Journal. All rights reserved.
Keywords: radiation protection, surgical trainees, training
Modern orthopaedics is becoming increasingly characterised
by operative intervention, especially trauma surgery, where x-rays
(fluoroscopy) are used. With the ever-growing knowledge and awareness of
radiation amongst patients, it is crucial that surgical trainees get more
awareness of ionising radiation. A literature search revealed many studies
regarding exposure of orthopaedic surgeons (both junior and senior) to
radiation. But no study has been done in the context of the trainees� awareness
of ionising radiation. The authors therefore decided to assess the awareness
and attitudes of the basic surgical trainees towards ionising radiation in
orthopaedic trauma surgery.
Materials and Methods
Fifty basic surgical trainees were involved in the study,
and were asked to complete a questionnaire (Figure 1). All the questions were
evidence based [1-14], and covered the following topics:
- knowledge of the area of the body most exposed to radiation in
orthopaedic trauma surgery
- hand dominance and its effects on radiation exposure
- knowledge of any literature of about radiation safety
- knowledge of the thyroid shield and its usage
- grade of surgeon and risk of radiation exposure
- pregnancy test in female patients of childbearing age
- gonadal shield in children
- multiple radiological studies for critically ill patients and their
impact on deciding the number of radiological studies (cumulative radiation
- knowledge of ALARA principle
- monitoring of radiation exposure
Fifty basic surgical trainees were involved in the study.
Their responses to the 13 questions are tabulated in Table 1.
There are plenty of studies done on radiation exposure in
orthopaedic trauma surgery [1-14], but only eight out of 50 surgical trainees
from this study population had read any literature about it. Smith et al.
reported that hand exposure to radiation is a limiting factor in orthopaedic
trauma surgery. This differs from the previously studied groups, such as
cardiologists and radiologists, in whom the limiting factor is the dose to the
lens of the eye . Jones et al. advised the orthopaedic surgeons to use dose
reduction gloves for high risk procedures .
Sanders et al. found in their study that there is no
positive correlation between the hand dominance of the surgeon and radiation
exposure to hands . They used gas sterilised thermoluminescent dosimeter
ring worn on each hand. The rings were later submitted for dose evaluation. In
this study, 23 trainees thought that hand dominance does affect radiation
Bahari et al. and Muller et al. discussed the significance
of the thyroid shield in orthopaedic trauma surgery. Bahari showed that there
was significant difference in the unshielded thyroid groups as compared to the
shielded thyroid group (p<0.05) . Muller and colleagues discussed the
effectiveness of lead thyroid shield in reducing x- ray exposure in trauma
surgery interventions of the lower leg. They concluded that the average
registered ionising dose without thyroid shield was 70 times higher as compared
to the measurement with thyroid protection . Alonso concluded that the
thyroid shield should be made available to operating staff within a 2-metre
zone . Herscovici also advised surgeons to wear protective devices .
Tasbas et al. reported that the assistant surgeon is more
at risk than the senior surgeon . In the study, they found that the
orthopaedic surgeon was always standing at a safe distance (>90cm), but the
assistant surgeon always stood nearby (10 cm) to the x-ray source for
positioning of the patient. The reading on the badges of the assistant surgeon
was more than the orthopaedic surgeon. In this study, 15 trainees thought that
senior surgeons received higher level of radiation exposure. Thirty trainees
thought otherwise, while five trainees thought it to be equal exposure.
Alonso et al. studied the effects of scattered radiation
during hip fracture fixation and considered that beyond 2 metres from the
radiation source, the scattered dose received was consistently low while within
the operating distance, the scattered dose received by staff was high for both
lateral and anteroposterior projections . Herscovici advised surgeons to
increase their distance from the x-ray beam to reduce the risk from radiation
. In this study, 24 trainees did not know the difference between scattered
and direct radiation while 15 trainees considered scattered radiation to be as
harmful as direct radiation. Only 11 trainees did not consider scattered radiation
to be as harmful as direct radiation.
Flik et al. recommended that pregnancy test is mandatory
for all females of childbearing age who are involved in trauma. They reported
that trauma affects up to 8% of pregnancies, and is the leading cause of death
among pregnant women in the United States . Bochicchio et al. concluded that
rapid pregnancy test should be done in all female trauma victims of
childbearing age. They were of the view that trauma patients diagnosed with
incidental pregnancy (pregnancy status unknown to the trauma team) are
routinely exposed to doses of radiation exceeding the recommendations of the American College of Obstetrics and Gynecologists . In their study of 3,976 women of
reproductive age admitted in trauma centre, 13 (11.4%) were found to be
pregnant incidentally. Foetal mortality in these patients was significantly
higher than others (10 out of 13, 77%) . Mann and colleagues argued that
trauma surgeons must balance the risks and benefits of diagnostic radiographic
procedures on potentially pregnant patients, and should know the range and
likelihood of possible radiation effects on pregnancy . In this study, 34
trainees considered it mandatory while 16 did not. When asked whether a
pregnancy test will be requested in such cases, 38 responded positively.
Gul et al. found out that children receive many
radiographs with avoidable excess radiation from inadequate positioning or
complete omission of gonadal shields. In their opinion, this may increase the
potential for disease in the future offspring of these patients. They concluded
that strict adherence to guidelines is required to decrease the radiation
exposure in children . Their view was supported by Herscovivi .
In a study conducted in an urban level 1 trauma centre in
the United States, 46 trauma patients who stayed for more than 30 days in a
surgical intensive care unit were studied for cumulative effective dose (CED)
of radiation from radiologic studies. The mean CED in this study group was 30
times higher than the average yearly radiation dose from all U.S. sources . In this study, 30 surgical trainees said that they weighed the pros and
cons of radiation while requesting multiple radiological studies in critically
ill patients while the remaining 20 trainees were of the opinion that they take
it for granted, and request the x-rays without weighing pros and cons.
Bahari recommended that orthopaedic surgeons should adhere
to ALARA principles . ALARA stands for As Low As Reasonably Achievable. It means
that while requesting x-rays (diagnostic, as well as fluoroscopy in theatres),
surgeons should request as less as reasonably possible. Herscovici advised the
orthopaedic surgeons to limit the radiation exposure . Oddy concluded that
the principle of minimising radiation exposure must be maintained by all
trainees at all times . Unfortunately, most (47 out of 50) trainees in this
study were unaware of the ALARA principles.
Bahari also recommended that routine monitoring of
radiation exposure is essential in preventing radiation-related diseases .
Sanders argued that extremity dosimetry for surgeons regularly using x-ray
should be considered  while Herscovici advised that radiographic units
should undergo periodic calibration . In this study, 46 trainees liked the
idea of routine monitoring of radiation.
The results of this study show that the basic surgical
trainees are lacking in the essential knowledge of ionising radiation in
orthopaedic trauma surgery. Most of them had never read the literature about
it. Most of the surgical trainees did not wear the thyroid shield, and some of
them were even unaware of it. Most of the trainees did not know the difference
between scattered and direct radiation. One-third of trainees did not consider
pregnancy test to be mandatory. Even worse, one-fourth of trainees did not even
ask for a pregnancy test. Two-fifths of the trainees requested radiological
studies without weighing the pros and cons. The majority (47 out of 50) did not
know about the safety principle for radiation.
Based on the above facts, the authors recommend that basic
surgical trainees should have more information and knowledge about the ionising
radiation. The courses should be arranged at local as well regional and
national level. They trust this course can be included in their induction for
junior doctors. This will not only help the professional competence of surgical
trainees, but it will make them safe doctors as well.
Figure 1 Questionnaire on ionising radiation for surgical trainees.
Table 1 Presentation of results
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Tasbas BA, Yagmurlu MF, Bayrakci K, et al. Which one is at risk in intraoperative fluoroscopy? Assistant surgeon or orthopaedic surgeon? Arch Orthop Trauma Surg. 2003;123(5):242-4.
Flik K, Kloen P, Toro JB, et al. Orthopaedic trauma in the pregnant patient. J Am Acad Orthop Surg. 2006;14(3):175-82.
Bochicchio GV, Napolitano LM, Haan J, et al. Incidental pregnancy in trauma patients. J Am Coll Surg. 2001;192(5):566-9.
Mann FA, Nathens A, Langer SG, et al. Communicating with the family: the risks of medical radiation to conceptuses in victims of major blunt-force torso trauma. J Trauma. 2000;48(2):354-7.
Gul A, Zafar M, Maffulli N. Gonadal shields in pelvic radiographs in paediatric patients. [Bulletin]. New York, N.Y.: Hospital for Joint Diseases; 2005. p. 13-4.
Kim PK, Gracias VH, Maidment AD, et al. Cumulative radiation dose caused by radiologic studies in critically ill trauma patients. J Trauma. 2004;57(3):510-4.
Oddy MJ, Aldam CH. Ionising radiation exposure to orthopaedic trainees: the effect of sub-specialty training. Ann R Coll Surg Engl. 2006;88(3):297-301.
|Received 10 October 2009; received in revised form 9 January
2010, accepted 10 January 2010
Correspondence: Home 19 LLwyn Yr Ian Morriston, Swansea SA6 6SZ, United Kingdom. Tel.: +447846 520775; E-mail: firstname.lastname@example.org (Faisal Rauf Khan).
Please cite as: Khan FR, Ul-Abadin Z, Rauf S, Javed A,
Awareness and attitudes amongst basic surgical trainees regarding radiation in orthopaedic trauma surgery, Biomed Imaging Interv J 2010; 6(3):e25