Ir J Med Sci DOI 10.1007/s11845-014-1121-4
ORIGINAL ARTICLE
Radiation safety knowledge and practices among Irish orthopaedic trainees M. Nugent • O. Carmody • S. Dudeney
Received: 21 December 2013 / Accepted: 7 April 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Introduction Fluoroscopy is frequently used in orthopaedic surgery, particularly in a trauma setting. Exposure of patients and staff to ionising radiation has been studied extensively; however, little work has been done to evaluate current knowledge and practices among orthopaedic trainees. Aims This study aimed to investigate the knowledge and practices of Irish orthopaedic trainees regarding use of ionising radiation. Methods A confidential internet-based survey on workplace radiation safety practices was distributed via email to 40 higher specialist trainees. Questions included related to radiation safety training and regular work practices. Results A total of 26 trainees completed the questionnaire (65 % response rate). All reported regular exposure to ionising radiation. Compliance with body shields was high (25, 96 %), however, other protective measures such as thyroid shields were less frequently employed. The ‘as low as reasonably achievable principle’ was practised regularly by 14 (54 %). Radiation safety training was variable— while just over half (14) respondents felt adequately trained in radiation safety, 17 (65 %) had attended a radiation protection course. Use of dosimeters was particularly poor, with only 4 (15 %) using them regularly and most citing lack of availability as the main barrier. Conclusion Although most Irish orthopaedic trainees have some knowledge regarding radiation safety, many do M. Nugent (&) O. Carmody S. Dudeney Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland e-mail: [email protected] O. Carmody e-mail: [email protected]
not regularly use all available measures to reduce exposure to ionising radiation. Barriers to use of protective mechanisms include lack of availability and perceived impracticality. Keywords Radiation Orthopaedic Surgery Fluoroscopy Protection
Introduction Many orthopaedic procedures are performed under fluoroscopic guidance, especially in trauma surgery. This inevitably results in release of ionising radiation and exposure of staff and patients to both direct and scattered radiation [1]. Ionising radiation contributes to DNA and tissue damage, leading to increased risk of malignancy and other disorders such as cataract formation [2, 3]. Recognition of these effects has lead to the development of recommendations for safe practice including limitation of the radiation dose (for example, by appropriate positioning and minimising fluoroscopic time), use of appropriate radiation shields such as lead aprons and monitoring of cumulative radiation exposure by use of dosimeters [4]. Occupational radiation exposure is also dependent on several other factors including position in relation to the fluoroscope, fluoroscopic obliquity and use of features such as magnification or continuous fluoroscopy. The main principle for radiation protection in healthcare settings is use of doses ‘as low as reasonably achievable’ (ALARA) through a combination of these measures. Many published studies to date have investigated radiation exposure or knowledge of radiation doses among healthcare professionals, however, there is very limited information regarding knowledge and practice of radiation
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Ir J Med Sci
safety measures. Indeed, at the time of writing, a literature search revealed only three published studies in this area, two of which pertain to urology residents and one to basic surgical trainees [5–7]. To our knowledge, there are no previously published studies investigating the practices of orthopaedic specialist trainees. This study aimed to establish the current level of knowledge and training, and also the usual practices of Irish orthopaedic trainees in relation to radiation safety.
Table 1 Year of training (on higher surgical training programme) of respondents
Methods
Table 2 Sources of information on occupational radiation safety— note respondents could choose more than one option for this question
A 10-item non-validated questionnaire was created on http://surveymonkey.com and a link emailed to 40 specialist registrars enrolled on the Trauma and Orthopaedics Higher Surgical Training programme and practicing in Ireland. A reminder email was sent 3 weeks after the initial contact. The content of the questionnaire is detailed in ‘‘Appendix 1’’ and included questions pertaining to level of training, education in radiation safety and use of means to reduce radiation exposure.
Source of information
Number of respondents
Radiation protection course
17
Results The questionnaire was completed by 26 of the 40 trainees polled, giving a 65 % response rate. Trainees from all 6 years of the higher surgical training scheme were represented, as shown in Table 1. Overall, 14 (54 %) of respondents felt they had received adequate training in radiation safety, while 10 did not and 2 did not know if their training was adequate. Sources of education regarding radiation safety are detailed in Table 2. The single greatest source of information was formal radiation protection courses, which 17 (65 %) trainees had completed. 18 (69 %) were aware of the ALARA principle and 14 claimed to apply this ‘always’ or ‘frequently’ (Table 3). Mechanisms for monitoring or reducing occupational radiation exposure and barriers to their use are detailed in Figs. 1 and 2. Overall, there was good use of lead aprons with 25 trainees (96 %) using them always, however, other measures were not as frequently utilised, largely due to unavailability or perceived impracticality. In particular, use of dosimeters was very low with only a total of four trainees using them ‘always’ or ‘most of the time’. Of those who had dosimeters, many had not been recently checked (Table 4). Only one person knew that the recommended maximum annual exposure is 20 mSv (as per the International Commission on Radiological Protection (ICRP) recommendations [4]). 16 (62 %) respondents thought no extra precautions are required in pregnancy, while 10 did think extra precautions were needed, with some
123
Year of training
Number of respondents
1
3
2
3
3
6
4
6
5
6
6
2
Discussion with/lecture from person trained in radiation safety
5
Discussion with colleagues
11
Medical school
3
Books or journal articles
5
Internet None
2 1
Other
0
Those who selected ‘other’ were asked to clarify in a free text box, however, none chose this option
Table 3 Application of the ALARA principle Frequency of application of ALARA Always
Number of respondents 4
Frequently
10
Sometimes
6
Occasionally
2
Never
4
suggestions of measures such as reducing participation in cases requiring fluoroscopy and wearing extra lead aprons.
Discussion Although technological advances in image intensification have led to some reduction in ionising radiation doses, and overall doses are low, there is uncertainty in predicting the effects of cumulative low doses of ionising radiation over prolonged periods [1]. In addition, most studies evaluating occupational exposure to ionising radiation have considered whole body exposure, however orthopaedic surgeons are more at risk of radiation exposure to specific areas such as hand, eyes and thyroid, due to proximity to the
Ir J Med Sci Fig. 1 Use of mechanisms for reducing or monitoring occupational radiation exposure
Fig. 2 Barriers to use of mechanisms for reducing or monitoring occupational radiation exposure
Table 4 Most recent dosimeter check Time since last dosimeter check
Number of respondents
Not applicable (don’t have dosimeter)
12
Within 1 month
2
Within 3 months
2
Within 6 months
1
Within 1 year
2
More than 1 year Never
0 5
Don’t know
4
fluoroscopic beam [8–11]. In practice, application of the ALARA principle and care with use of protective equipment can help to reduce exposure, both for the patient and for the surgeon and other operating room staff. In this study, while reported compliance with body shields in the form of lead aprons was excellent, all other protective measures showed significant room for improvement. Lack of availability of items such as thyroid shields and dosimeters was given as a reason for not using them, however, this was not always the case. In particular, there was a very poor uptake of dosimeters with 9 trainees saying they were unavailable while a further 11 stated that
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Ir J Med Sci
they either forgot to wear a dosimeter or simply did not care. Other means of reducing exposure such as maximising distance from the source and minimising fluoroscopy time are implemented to a variable degree. These findings may be directly linked to the level of training and education of trainees in radiation safety as only just over half of the respondents felt that they had received adequate training in this area. This finding is similar to that of an American study investigating radiation safety practices among urology residents and fellows where just 53 % of respondents thought they had received adequate training in radiation safety [6]. The same study also found overwhelming underuse of dosimeters, frequently due to lack of availability, thus it would appear that these issues are not specific to Irish orthopaedic trainees. It may be the case that more effort is needed to develop and implement more comprehensive training in this area, as more robust training may improve understanding of the importance of radiation protection measures and hence compliance. Pregnant workers form a particular subset for whom greater concerns exist. In general, the most precarious period for foetal exposure to radiation is during weeks 8–15 of gestation while organogenesis is occurring [12]. The International Atomic Energy Agency (IAEA) advises that pregnant medical radiation workers may work in a radiation environment as long as there is reasonable assurance that the foetal dose can be kept below 1 mGy during the pregnancy. This corresponds approximately to the dose that all persons receive annually from natural background radiation [13]. To determine the radiation dose received, a pregnant surgeon (or other healthcare worker) needs to wear a dosimeter under her lead apron at the waistline, however, the foetal dose may be up to tenfold less than that recorded on the dosimeter [14]. A pregnant woman may further reduce the radiation dose by performing fewer procedures requiring high exposure, careful attention to the principles of exposure time, distance and shielding and wearing a second layer of protective lead aprons [14]. Although this study is limited by the small sample size, there was a good response rate. Overall, the findings suggest that significantly more education in the area of radiation protection would be of benefit for orthopaedic trainees; however, the issues of lack of availability of essential protective equipment also need to be addressed. Conflict of interest
Dr. Nugent has nothing to disclose.
Appendix 1: Questionnaire distributed to trauma and orthopaedic higher surgical trainees Level of training a.
SpR year 1
123
b. c. d. e. f.
SpR SpR SpR SpR SpR
year year year year year
2 3 4 5 6
What source(s) of education on occupational radiation safety have you accessed? (tick all that apply) a. b. c. d. e. f. g. h.
Radiation protection course Discussion with/lecture by someone with training in radiation safety Discussion with colleagues Medical school (undergraduate) Books or journal articles Internet None Other (please describe) Do you think that you have received adequate training on radiation safety?
a. b. c.
Yes No Don’t know Are you aware of the ALARA (‘as low as reasonably achievable’) principle?
a. b.
Yes No Do you apply the ALARA principle in daily practice?
a. b. c.
Yes No Sometimes When operating during a case that will involve radiation exposure, how often do you utilize each of the following protective mechanisms?
a. b. c. d. e.
Body lead (aprons) Thyroid shields Dosimeter Increasing source distance Minimal fluoroscopic time Of the above items, if you did not utilize them most of the time, what was the main reason?
a. b. c. d. e. f. g.
Unavailable Uncomfortable Forgot Did not know it was an option Did not care Other (please clarify) Not applicable (I use/do this [95 % of the time)
Ir J Med Sci
When was the last time your dosimeter was checked? a. Within 1 month b. Within 3 months c. Within 6 months d. Within 1 year e. [1 year ago f. Never g. Don’t know h. I do not have a dosimeter What is the maximum acceptable annual dose of whole body radiation exposure for a healthcare professional? Do you think pregnant trainees require any further steps to minimize exposure? (please specify)
References 1. Kesavachandran CN, Haamann F, Nienhaus A (2012) Radiation exposure of eyes, thyroid gland and hands in orthopaedic staff: a systematic review. Eur J Med Res 17:28 2. Linet MS, Slovis TL, Miller DL, Kleinerman R, Lee C, Rajaraman P, Berrington de Gonzalez A (2012) Cancer risks associated with external radiation from diagnostic imaging procedures. CA Cancer J Clin. doi:10.3322/caac.21132 3. Worgul BV, Kundiyev YI, Sergiyenko NM, Chumak VV, Vitte PM, Medvedovsky C et al (2007) Cataracts among Chernobyl clean-up workers: implications regarding permissible eye exposures. Radiat Res 167(2):233–243
4. Rehani MM, Ciraj-Bjelac O, Vano E, Miller DL, Walsh S, Giordano BD et al (2010) ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department. Ann ICRP 40(6):1–102 5. Soylemez H, Sancaktutar AA, Silay MS, Penbegul N, Bozkurt Y, Atar M et al (2013) Knowledge and attitude of European urology residents about ionizing radiation. Urology 81(1):30–35 6. Friedman AA, Ghani KR, Peabody JO, Jackson A, Trinh QD, Elder JS (2013) Radiation safety knowledge and practices among urology residents and fellows: results of a nationwide survey. J Surg Educ 70(2):224–231 7. Khan F, Ul-Abadin Z, Rauf S, Javed A (2010) Awareness and attitudes amongst basic surgical trainees regarding radiation in orthopaedic trauma surgery. Biomed Imaging Interv J 6(3):e25 8. Hafez MA, Smith RM, Matthews SJ, Kalap G, Sherman KP (2005) Radiation exposure to the hands of orthopaedic surgeons: are we underestimating the risk? Arch Orthop Trauma Surg 125(5):330–335 9. Sanders R, Koval KJ, DiPasquale T, Schmelling G, Stenzler S, Ross E (1993) Exposure of the orthopaedic surgeon to radiation. J Bone Joint Surg Am 75(3):326–330 10. Goldstone KE, Wright IH, Cohen B (1993) Radiation exposure to the hands of orthopaedic surgeons during procedures under fluoroscopic X-ray control. Br J Radiol 66(790):899–901 11. Mehlman CT, DiPasquale TG (1997) Radiation exposure to the orthopaedic surgical team during fluoroscopy: ‘‘how far away is far enough?’’. J Orthop Trauma 11(6):392–398 12. Dewar C (2013) Occupational radiation safety. Radiol Technol 84(5):467–486 (quiz 87–9) 13. (1999) Occupational radiation protection. IAEA Safety Standards Series: International Atomic Energy Agency, Vienna 14. Best PJ, Skelding KA, Mehran R, Chieffo A, Kunadian V, Madan M et al (2011) SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. EuroIntervention 6(7):866–874
123
ORIGINAL ARTICLE
Radiation safety knowledge and practices among Irish orthopaedic trainees M. Nugent • O. Carmody • S. Dudeney
Received: 21 December 2013 / Accepted: 7 April 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Introduction Fluoroscopy is frequently used in orthopaedic surgery, particularly in a trauma setting. Exposure of patients and staff to ionising radiation has been studied extensively; however, little work has been done to evaluate current knowledge and practices among orthopaedic trainees. Aims This study aimed to investigate the knowledge and practices of Irish orthopaedic trainees regarding use of ionising radiation. Methods A confidential internet-based survey on workplace radiation safety practices was distributed via email to 40 higher specialist trainees. Questions included related to radiation safety training and regular work practices. Results A total of 26 trainees completed the questionnaire (65 % response rate). All reported regular exposure to ionising radiation. Compliance with body shields was high (25, 96 %), however, other protective measures such as thyroid shields were less frequently employed. The ‘as low as reasonably achievable principle’ was practised regularly by 14 (54 %). Radiation safety training was variable— while just over half (14) respondents felt adequately trained in radiation safety, 17 (65 %) had attended a radiation protection course. Use of dosimeters was particularly poor, with only 4 (15 %) using them regularly and most citing lack of availability as the main barrier. Conclusion Although most Irish orthopaedic trainees have some knowledge regarding radiation safety, many do M. Nugent (&) O. Carmody S. Dudeney Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland e-mail: [email protected] O. Carmody e-mail: [email protected]
not regularly use all available measures to reduce exposure to ionising radiation. Barriers to use of protective mechanisms include lack of availability and perceived impracticality. Keywords Radiation Orthopaedic Surgery Fluoroscopy Protection
Introduction Many orthopaedic procedures are performed under fluoroscopic guidance, especially in trauma surgery. This inevitably results in release of ionising radiation and exposure of staff and patients to both direct and scattered radiation [1]. Ionising radiation contributes to DNA and tissue damage, leading to increased risk of malignancy and other disorders such as cataract formation [2, 3]. Recognition of these effects has lead to the development of recommendations for safe practice including limitation of the radiation dose (for example, by appropriate positioning and minimising fluoroscopic time), use of appropriate radiation shields such as lead aprons and monitoring of cumulative radiation exposure by use of dosimeters [4]. Occupational radiation exposure is also dependent on several other factors including position in relation to the fluoroscope, fluoroscopic obliquity and use of features such as magnification or continuous fluoroscopy. The main principle for radiation protection in healthcare settings is use of doses ‘as low as reasonably achievable’ (ALARA) through a combination of these measures. Many published studies to date have investigated radiation exposure or knowledge of radiation doses among healthcare professionals, however, there is very limited information regarding knowledge and practice of radiation
123
Ir J Med Sci
safety measures. Indeed, at the time of writing, a literature search revealed only three published studies in this area, two of which pertain to urology residents and one to basic surgical trainees [5–7]. To our knowledge, there are no previously published studies investigating the practices of orthopaedic specialist trainees. This study aimed to establish the current level of knowledge and training, and also the usual practices of Irish orthopaedic trainees in relation to radiation safety.
Table 1 Year of training (on higher surgical training programme) of respondents
Methods
Table 2 Sources of information on occupational radiation safety— note respondents could choose more than one option for this question
A 10-item non-validated questionnaire was created on http://surveymonkey.com and a link emailed to 40 specialist registrars enrolled on the Trauma and Orthopaedics Higher Surgical Training programme and practicing in Ireland. A reminder email was sent 3 weeks after the initial contact. The content of the questionnaire is detailed in ‘‘Appendix 1’’ and included questions pertaining to level of training, education in radiation safety and use of means to reduce radiation exposure.
Source of information
Number of respondents
Radiation protection course
17
Results The questionnaire was completed by 26 of the 40 trainees polled, giving a 65 % response rate. Trainees from all 6 years of the higher surgical training scheme were represented, as shown in Table 1. Overall, 14 (54 %) of respondents felt they had received adequate training in radiation safety, while 10 did not and 2 did not know if their training was adequate. Sources of education regarding radiation safety are detailed in Table 2. The single greatest source of information was formal radiation protection courses, which 17 (65 %) trainees had completed. 18 (69 %) were aware of the ALARA principle and 14 claimed to apply this ‘always’ or ‘frequently’ (Table 3). Mechanisms for monitoring or reducing occupational radiation exposure and barriers to their use are detailed in Figs. 1 and 2. Overall, there was good use of lead aprons with 25 trainees (96 %) using them always, however, other measures were not as frequently utilised, largely due to unavailability or perceived impracticality. In particular, use of dosimeters was very low with only a total of four trainees using them ‘always’ or ‘most of the time’. Of those who had dosimeters, many had not been recently checked (Table 4). Only one person knew that the recommended maximum annual exposure is 20 mSv (as per the International Commission on Radiological Protection (ICRP) recommendations [4]). 16 (62 %) respondents thought no extra precautions are required in pregnancy, while 10 did think extra precautions were needed, with some
123
Year of training
Number of respondents
1
3
2
3
3
6
4
6
5
6
6
2
Discussion with/lecture from person trained in radiation safety
5
Discussion with colleagues
11
Medical school
3
Books or journal articles
5
Internet None
2 1
Other
0
Those who selected ‘other’ were asked to clarify in a free text box, however, none chose this option
Table 3 Application of the ALARA principle Frequency of application of ALARA Always
Number of respondents 4
Frequently
10
Sometimes
6
Occasionally
2
Never
4
suggestions of measures such as reducing participation in cases requiring fluoroscopy and wearing extra lead aprons.
Discussion Although technological advances in image intensification have led to some reduction in ionising radiation doses, and overall doses are low, there is uncertainty in predicting the effects of cumulative low doses of ionising radiation over prolonged periods [1]. In addition, most studies evaluating occupational exposure to ionising radiation have considered whole body exposure, however orthopaedic surgeons are more at risk of radiation exposure to specific areas such as hand, eyes and thyroid, due to proximity to the
Ir J Med Sci Fig. 1 Use of mechanisms for reducing or monitoring occupational radiation exposure
Fig. 2 Barriers to use of mechanisms for reducing or monitoring occupational radiation exposure
Table 4 Most recent dosimeter check Time since last dosimeter check
Number of respondents
Not applicable (don’t have dosimeter)
12
Within 1 month
2
Within 3 months
2
Within 6 months
1
Within 1 year
2
More than 1 year Never
0 5
Don’t know
4
fluoroscopic beam [8–11]. In practice, application of the ALARA principle and care with use of protective equipment can help to reduce exposure, both for the patient and for the surgeon and other operating room staff. In this study, while reported compliance with body shields in the form of lead aprons was excellent, all other protective measures showed significant room for improvement. Lack of availability of items such as thyroid shields and dosimeters was given as a reason for not using them, however, this was not always the case. In particular, there was a very poor uptake of dosimeters with 9 trainees saying they were unavailable while a further 11 stated that
123
Ir J Med Sci
they either forgot to wear a dosimeter or simply did not care. Other means of reducing exposure such as maximising distance from the source and minimising fluoroscopy time are implemented to a variable degree. These findings may be directly linked to the level of training and education of trainees in radiation safety as only just over half of the respondents felt that they had received adequate training in this area. This finding is similar to that of an American study investigating radiation safety practices among urology residents and fellows where just 53 % of respondents thought they had received adequate training in radiation safety [6]. The same study also found overwhelming underuse of dosimeters, frequently due to lack of availability, thus it would appear that these issues are not specific to Irish orthopaedic trainees. It may be the case that more effort is needed to develop and implement more comprehensive training in this area, as more robust training may improve understanding of the importance of radiation protection measures and hence compliance. Pregnant workers form a particular subset for whom greater concerns exist. In general, the most precarious period for foetal exposure to radiation is during weeks 8–15 of gestation while organogenesis is occurring [12]. The International Atomic Energy Agency (IAEA) advises that pregnant medical radiation workers may work in a radiation environment as long as there is reasonable assurance that the foetal dose can be kept below 1 mGy during the pregnancy. This corresponds approximately to the dose that all persons receive annually from natural background radiation [13]. To determine the radiation dose received, a pregnant surgeon (or other healthcare worker) needs to wear a dosimeter under her lead apron at the waistline, however, the foetal dose may be up to tenfold less than that recorded on the dosimeter [14]. A pregnant woman may further reduce the radiation dose by performing fewer procedures requiring high exposure, careful attention to the principles of exposure time, distance and shielding and wearing a second layer of protective lead aprons [14]. Although this study is limited by the small sample size, there was a good response rate. Overall, the findings suggest that significantly more education in the area of radiation protection would be of benefit for orthopaedic trainees; however, the issues of lack of availability of essential protective equipment also need to be addressed. Conflict of interest
Dr. Nugent has nothing to disclose.
Appendix 1: Questionnaire distributed to trauma and orthopaedic higher surgical trainees Level of training a.
SpR year 1
123
b. c. d. e. f.
SpR SpR SpR SpR SpR
year year year year year
2 3 4 5 6
What source(s) of education on occupational radiation safety have you accessed? (tick all that apply) a. b. c. d. e. f. g. h.
Radiation protection course Discussion with/lecture by someone with training in radiation safety Discussion with colleagues Medical school (undergraduate) Books or journal articles Internet None Other (please describe) Do you think that you have received adequate training on radiation safety?
a. b. c.
Yes No Don’t know Are you aware of the ALARA (‘as low as reasonably achievable’) principle?
a. b.
Yes No Do you apply the ALARA principle in daily practice?
a. b. c.
Yes No Sometimes When operating during a case that will involve radiation exposure, how often do you utilize each of the following protective mechanisms?
a. b. c. d. e.
Body lead (aprons) Thyroid shields Dosimeter Increasing source distance Minimal fluoroscopic time Of the above items, if you did not utilize them most of the time, what was the main reason?
a. b. c. d. e. f. g.
Unavailable Uncomfortable Forgot Did not know it was an option Did not care Other (please clarify) Not applicable (I use/do this [95 % of the time)
Ir J Med Sci
When was the last time your dosimeter was checked? a. Within 1 month b. Within 3 months c. Within 6 months d. Within 1 year e. [1 year ago f. Never g. Don’t know h. I do not have a dosimeter What is the maximum acceptable annual dose of whole body radiation exposure for a healthcare professional? Do you think pregnant trainees require any further steps to minimize exposure? (please specify)
References 1. Kesavachandran CN, Haamann F, Nienhaus A (2012) Radiation exposure of eyes, thyroid gland and hands in orthopaedic staff: a systematic review. Eur J Med Res 17:28 2. Linet MS, Slovis TL, Miller DL, Kleinerman R, Lee C, Rajaraman P, Berrington de Gonzalez A (2012) Cancer risks associated with external radiation from diagnostic imaging procedures. CA Cancer J Clin. doi:10.3322/caac.21132 3. Worgul BV, Kundiyev YI, Sergiyenko NM, Chumak VV, Vitte PM, Medvedovsky C et al (2007) Cataracts among Chernobyl clean-up workers: implications regarding permissible eye exposures. Radiat Res 167(2):233–243
4. Rehani MM, Ciraj-Bjelac O, Vano E, Miller DL, Walsh S, Giordano BD et al (2010) ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department. Ann ICRP 40(6):1–102 5. Soylemez H, Sancaktutar AA, Silay MS, Penbegul N, Bozkurt Y, Atar M et al (2013) Knowledge and attitude of European urology residents about ionizing radiation. Urology 81(1):30–35 6. Friedman AA, Ghani KR, Peabody JO, Jackson A, Trinh QD, Elder JS (2013) Radiation safety knowledge and practices among urology residents and fellows: results of a nationwide survey. J Surg Educ 70(2):224–231 7. Khan F, Ul-Abadin Z, Rauf S, Javed A (2010) Awareness and attitudes amongst basic surgical trainees regarding radiation in orthopaedic trauma surgery. Biomed Imaging Interv J 6(3):e25 8. Hafez MA, Smith RM, Matthews SJ, Kalap G, Sherman KP (2005) Radiation exposure to the hands of orthopaedic surgeons: are we underestimating the risk? Arch Orthop Trauma Surg 125(5):330–335 9. Sanders R, Koval KJ, DiPasquale T, Schmelling G, Stenzler S, Ross E (1993) Exposure of the orthopaedic surgeon to radiation. J Bone Joint Surg Am 75(3):326–330 10. Goldstone KE, Wright IH, Cohen B (1993) Radiation exposure to the hands of orthopaedic surgeons during procedures under fluoroscopic X-ray control. Br J Radiol 66(790):899–901 11. Mehlman CT, DiPasquale TG (1997) Radiation exposure to the orthopaedic surgical team during fluoroscopy: ‘‘how far away is far enough?’’. J Orthop Trauma 11(6):392–398 12. Dewar C (2013) Occupational radiation safety. Radiol Technol 84(5):467–486 (quiz 87–9) 13. (1999) Occupational radiation protection. IAEA Safety Standards Series: International Atomic Energy Agency, Vienna 14. Best PJ, Skelding KA, Mehran R, Chieffo A, Kunadian V, Madan M et al (2011) SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. EuroIntervention 6(7):866–874
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