Basic Physics Radiation

Chapter 1: Radiation Physics
Introduction
Why do we have this course?

The use of X-ray fluoroscopy has increased dramatically in recent years and is
spreading beyond the radiology department where users traditionally have
extensive fluoroscopy training. The power of fluoroscopy units, especially
portable units, has steadily increased. Thus, there is a higher potential for
excessive radiation exposure to personnel and patients. The FDA has articulated
particular concern about the following procedures (TableI-1):
Table I-1: Procedures of Particular Concern to FDA
Procedures Involving Extended Fluoroscopy Exposures ¤ ¥

Radiofrequency cardiac catheter ablation
Percutaneous transluminal angioplasty (PTCA, PTA)
Vascular embolization
Stent and filter placement
Thrombolytic and fibrinolytic procedures
Percutaneous transhepatic cholangiography
Endoscopic retrograde cholangiopancreatography (ERCP)
Transjugular intrahepatic portosystemic shunt (TIPS)
Percutaneous nephrostomy, biliary drainage, or stone removal
¤ FDA 1994
¥ Note: The risk of adverse radiation effects originating from a medically

necessary procedure is almost always offset by the benefit received by the
patient. However, in order to improve the benefit-risk tradeoff for these
procedures, it is incumbent on the operator to understand radiation effects and
utilize methods to avoid them or reduce their severity.
This course is written as a primer for medical personnel who use fluoroscopy
equipment in the practice of medicine. It covers some basic principles of radiation
physics, biology, and radiation safety in order to provide an understanding of the
optimal utilization of fluoroscopy, while minimizing exposures to the patient,
operators, and their colleagues. This course is a supplement to, and is not a
substitute for, traditional medical education.
Radiation Exposure and Public Health Measures
The greatest single source of man-made radiation exposure to the average

person in the United States comes from medical irradiation. Medical doses range
from a few mrad for a chest X-ray to thousands of rad in the treatment of cancer.
The average U.S. citizen gets an effective dose from diagnostic medical radiation
of about 100 mrad per year (Figure I-1)
Figure I-1: Sources of Radiation Exposure
Studies indicate that this medical radiation exposure can be reduced by

optimizing the use of fluoroscopy (NRCP 1989). These optimizing procedures
are given in Table I-2:
Table I-2: Optimizing Action Ranking for Fluoroscopy
Optimizing Action Potential Dose Reduction Factor

Audio output related to
1.3
X-ray machine output
Optimization of Video
3
Camera system
Required switching
between High (Boost) and Normal 1.5
modes
Optimizing Operator
2 to 10
Technique
Clearly good operator training is a very important means of reducing medical

radiation doses. This program is designed to give a minimal understanding of
radiation use and effects in medicine to assist in optimizing the techniques used.
Basic Radiation Physics
Knowledge of basic radiation physics is necessary for properly understanding

fluoroscopy safety.
Courtesy of Albert Einstein Archives

Radiation
What is radiation?
Radiation: is the transfer of energy in the form of particles or waves.
Energy: the ability to do work (Force·Distance)
X-rays are electromagnetic radiation. Electromagnetic radiation is a form of

pure energy which is carried by waves of photons. Electromagnetic radiation is
also known as light. Visible light, Radio and X-rays are all forms of
electromagnetic radiation which vary in energy and thereby wavelength and
frequency as well (Figure 1-1).
Figure 1-1: Forms of Electromagnetic Radiation
Courtesy of Phil Rauch and Laura Smith, 2000

Ionizing Radiation
X-ray radiation contains more energy than ultraviolet, infrared, radio waves,
microwaves or visible light. X-ray radiation has sufficient energy (>30 eV) to
cause ionizations. An ionization is a process whereby the radiation removes an
outer shell electron from an atom (Figure 1-2).
Figure 1-2: The Ionization Process
Alan Jackson, 2001

Non-ionizing radiation does not contain sufficient energy (30 eV) to cause
ionizations (Figure 1-3). While some non-ionizing radiation can be harmful, the
ionization process is clearly able to cause chemical changes in important
changes to biologically important molecules (e.g. DNA).
Figure 1-3: Non-Ionizing Radiations
Courtesy of Alan Jackson, 2001
X-ray Production
X-rays are produced when high velocity electrons are decelerated (slowed or
stopped) or by a nucleus of an atom especially by high atomic number material,
such as the tungsten target (anode) in a X-ray tube. An electrically heated
filament (cathode) within the X-ray tube generates electrons that are accelerated
from the filament to the tungsten target by the application of a high voltage to the
tube. The energy gained by the electron is equal to the potential difference
(voltage) between the anode and cathode. This electron energy is typically
expressed in kilovolts (kV). The accelerated electron interacts with the target
(anode) nucleus. As the electric field of the electron interacts with nucleus, the
electron releases energy in the form of X-rays. This method of of x-ray
production is called bremsstrahlung or braking radiation (Figure 1-4).
FIgure 1-4: X-ray Production (Bremstrahlung)
Courtesy of the University of Michigan Student Chapter of the Health Physics Society
Since the degree of interaction of the accelerated electron with the target nucleus
can vary, the energy spectrum, or distribution of energy, of the X-rays produced
by the bremsstrahlung process is continuous.
As smaller number of characteristic x-rays are also produced as excited

electrons interact with the electrons of the target atoms. The X-rays produced
from this interaction, with a given orbital electron, have a single specific energy
(discrete) instead of a continuous spectrum. Mammographic x-ray tubes are
designed to maximize characteristic production to optimize breast tissue
imaging. The amount of characteristic X-rays in a fluoroscopy beam is relatively
low.
The lower energy X-rays are absorbed within the X-ray tube. This reduces the
number of lower energy X-rays in the resultant spectrum since the lower energy
X-ray are less penetrating. The beam is considered "harder" when there is more
filtration. Most X-ray manufacturers add filtration, commonly consisting of
aluminum, since lower energy X-rays do not contribute to images and add to
patient dose.
The resulting x-ray spectrum energy (Figure 1-5) is a mixture of the characteristic
and bremsstrahlung radiation, less the primarily low energy X-rays absorbed by
the X-ray tube (and added filtration). The maximum energy of the X-ray
produced is equal to the maximum potential applied across the x-ray tube. This
peak X-ray energy is usually described with the unit kVp (kilovolt peak or kilovolt
potential). The type of target anode, potential (kVp) and added filtration produce
a beam of a given "quality" which implies specific shape of an X-ray spectrum.
Figure 1-5: Simplified X-ray Spectrum
Alan Jackson, 2001
X-ray Machine Parameters
The quantity of electron flow (current) in the X-ray tube is described in units of
milliamperes (mA). The rate of X-ray production is directly proportional to the X-
ray tube current. Higher mA values indicate more electrons are striking the
tungsten target, thereby producing more X-rays. The voltage (kVp) primarily
determines the maximum X-ray energy produced but also influences the number
of X-rays produced. Increasing the kVp attracts more electrons from the filament
increasing the rate of X-ray production. However, this relationship is not directly
proportional but higher kVp setting will result in a substantial increase in the
number of X-rays produced. The total number of X-rays produced at a set kVp
depends directly on the product of the mA and exposure time and is typically
described in terms of mA-s or mAs. Fluoroscopy is usually performed using 2 to
5 mA current at a peak electrical potential of 75 to 125 kVp.
X-ray Production Efficiency and Heat Loading
The production of x-rays is a relatively inefficient process so that only a small

fraction of the energy imparted by the decelerating electrons is converted into X-
rays. The remaining energy is converted to heat. Thus, the production and
dissipation of heat in the X-ray tube is a serious consideration. Thus, most x-ray
machines have rotating anodes to spread out the heat to prevent anode melting.
This is the reason why you can hear an X-ray machine make noise. Most
fluoroscopic x-ray machine anodes are primarily based on tungsten due to
tungsten's high melting point, excellent heat transmission, and high atomic
number. In spite of tungsten's favorable qualities, with sufficiently high usage, X-
ray production is prevented by the system to protect the tube. Substantial
improvements have been recently made in the ability of fluoroscopic X-ray
equipment to remove waste heat and thereby maintain high beam outputs.
Figure 1-6: Heat Production
Courtesy of: Phil Rauch and Laura Smith, 2000

Divergent Nature of X-ray Radiation
Once generated, the X-rays are emitted in all directions in a uniform manner
(isotropically). The lead housing surrounding the X-ray tube limits X-ray
emission through a small opening or port in the X-ray tube. The resulting primary
beam of useful radiation is shaped by additional lead shutters, or collimators, that
can be adjusted to provide different beam shapes or sizes.
Inverse-Square-Law (Radiation intensity with distance)
Since the initial beam travels in straight but divergent directions, geometry in a
three dimensional world dictates that the radiation intensity will decrease with the
inverse square of the distance. Consequently, the number of X-rays traveling
through a unit area decreases with increasing distance. Likewise, radiation level
decreases with increasing distance since exposure is directly proportional to the
number of X-rays interacting in a unit area. The intensity of the radiation is
described by the inverse square law equation:
Where XA is the radiation exposure rate at distance DA compared with the

exposure rate (XB) at some other distance (DB).
This effect is shown graphically in Figure 1-7:
Figure 1-7: Inverse Square Law
Courtesy of Scott Sorenson, 2000
1-Meter Distance: 1,000 X-rays pass through a

unit area. The amount of X-rays per unit area is
1,000.
2-Meter Distance: With increasing distance, the

beam diverges to an area 4 times the original area.
The same 1,000 X-rays are evenly distributed
over the new area (4 times the original). Thus the
amount of X-rays per unit area is 250 or 1/4 the
original. The resulting radiation exposure is 1/4
less.
This relationship indicates that doubling the distance from a radiation source
decreases the radiation level by a factor of four. Conversely, halving the
distance, increases the radiation level by a factor of four. Intelligent application
of inverse square law principles can yield significant reductions in both patient
and operator radiation exposures.
Example 1:
An operator normally stands 1 meter away from the patient during

cineangiography. The exposure rate at this point is 15 mrem/min (this unit will be
explained later) and total cineangiography time is 2 min. What is the reduction
should the operator stand 1.2 meters away?
Solution 1:
The original exposure was 30 mrem (15 mrem/min for 2 min). The new exposure
would be:
A 31% percent reduction in radiation exposure is achieved in this example.
X-rays Interactions with matter

X-rays have several fates as they traverse tissue. These fates fall into 3 main
categories (Figure 1-8):
Figure 1-8: X-ray Interaction-Imaging Considerations
No interaction: X-ray passes completely throughtissue and into the image

recording device. Producing an image
Complete absorption: X-ray energy is completely absorbed by the tissue. This

produces radiation dose to the patient.
Partial absorption with scatter: Scattering involves a partial transfer of energy to

tissue, with the resulting scattered X-ray having less energy and a different
trajectory. This interaction does not provide any useful information (degrades
image quality) and is the primary source of radiation exposure to staff.
X-ray Interaction with Matter
The probability of X-ray interaction is a function of tissue electron density, tissue

thickness, and X-ray energy (kVp). Electron dense material like bone and
contrast dye attenuates more X-rays from the X-ray beam than less dense
material (muscle, fat, air). The differential rate of interaction provides the contrast
that forms the image.
Tissue Electron Density Interaction Effects:
As electron density increases, the interaction with X-rays substantially increases.

Higher atomic number materials have increased electron density. Thus, bone,
which is substantially comprised of calcium, produces more attenuation, than
tissue, which is comprised of carbon, hydrogen and oxygen (all of which have a
lower electron density or atomic number than calcium). Thus, the image of bone
and soft tissue has contrast, or difference, between bone and soft tissue.
The concept of contrast and electron density X-ray interaction can be shown in
Figure 1-9.
Assume 1,000 X-rays strike the following body portions. The number of X-rays
reaching the recording media (film, TV monitor) directly effect the image's
brightness.
Figure 1-9: Electron Density and Image Contrast

In this example, 900 X-rays are capable of penetrating the soft tissue, while only
400 penetrate the bone (Higher electron density compared with soft tissue). The
contrast between the bone and soft tissue is (900-400)/900 = 0.56.
Tissue Thickness
As tissue thickness increases, the probability of X-ray interaction increases.
Thicker body portions remove more X-rays from the useful beam compared to
thinner portions (Figure 1-10). In fluoroscopy, this effect must be compensated
for while panning across variable tissue thickness to provide consistent
information to the image-recording device.
Figure 1-10: X-ray Penetration as a Function of Thickness
Note that on average, only 1 percent of the X-rays reach the image-recording
device (e.g., image intensifier, film), yielding useful information. Thus, 99 percent
of the X-rays generated are either absorbed within the patient (patient radiation
exposure) or are scattered throughout the examination room (staff radiation
exposure).
Energy
Higher kVp X-rays are less likely to interact with tissue and are described as
more "penetrating." Increasing kVp, thereby generating more penetrating
radiation, reduces the relative image contrast (or visible difference) between
dense and less dense tissue. Conversely, less radiation dose results to the
patient since less X-rays are absorbed. Figure 1-11 illustrates this effect. The X-
rays that do not reach the image recording device are either absorbed in the
patient (patient radiation dose) or are scattered throughout the exam room (staff
radiation dose)
Figure 1-11: X-ray Penetration as a Function of Energy
Application of Radiation Physics

How does these principles of physics relate to radiation safety? (Figure 1-12)
Figure 1-12: Square Hole-Round Peg
The fundamental tie between Physics and fluoroscopy Radiation Safety occurs
during the sequence of steps which lead to radiation biological effects. These
steps are deposition of energy (Figure 1-13) and biochemical changes caused by
X-rays (Figure 1-14).
Figure1-13: Deposition of Energy
Alan Jackson, 2001

Figure1-14: Biochemical changes
Alan Jackson, 2001
The biochemical changes produced by ionizing radiation radiations are the

fundamental event leading to radiation damage. The amount of energy absorbed
in a system is the best way to quantify the radiation damage. The amount of
energy absorbed per mass is known as radiation dose.
Description of Radiation Exposure/Units
There is a myriad of terms describing amount of absorbed by a system. This is

often confusing even to those quite familiar with radiation physics. Terms which
the operator should be aware of include those are:
The X-ray machine output is described in terms of Entrance Skin Exposure

(ESE) and is the amount of radiation delivered to the patient's skin at the point of
entry of the X-ray beam into the patient. The unit for ESE are Roentgens (R) (or
C/kg air in SI units). The unit Roentgen is defined in terms of charge (Coulombs)
created by ionizing radiation per unit mass (kg) of air (1 R =2.58 * 10-4 C/kg air).
The radiation exposure can also be measured at other locations and is the
quantity indicated by many radiation detectors such as Geiger-Muller meters.
This unit recognizes Wilhelm Conrad Roentgen (Röntgen), who invented
(discovered) X-rays, and gave this technology to the world without personal profit
(Figure 1-15). For this achievement, he received the Nobel prize in Physics.
Figure 1-15: Wilhelm Conrad Roentgen
The unit Roentgen is only defined for air and can not be used to describe dose to
tissue. Radiation dose is the energy (joules) imparted per unit mass of tissue and
has the US units of rad (radiation absorbed dose). Patient exposures, particularly
in Radiation Oncology are described in units of radiation dose. There is an
international (SI) unit for dose termed the Gray (Gy). The conversion between
the units is: 100 rad = 1 Gy.
The biological effectiveness of radiations vary. The unit rem (radiation

equivalent man, now person) is used to compare dose received by different types
of radiations (e.g. alpha particles) which have a different capacity for causing
harm than X-ray radiation. This unit is properly termed dose equivalent. The
dose equivalent is the product of the dose times a quality factor. Occupational
radiation exposure is described in terms of dose equivalent. There is an
international (SI) unit for dose equivalent termed the Sievert (Sv). The
conversion between the units is: 100 rem = 1 Sv.
Go To Chapter 2: Radiation Biology Chapter 2: Radiation Biology
Picture Courtesy of Michael Cohen, 1987

Biological effects of radiation
Most people know that radiation is potentially harmful to living systems,

unfortunately there are a number of misconceptions about radiation biology
which are perpetuated in popular culture.
Radiation Biology History
1895-Roentgen announces discovery of X-rays
1896-(4 months later) Reports of skin effects in x-ray researchers

1902-First cases of radiation induced skin cancer reported
1906-Pattern for differential radiosensitivity of tissues was discovered.
Relative Radiosensitivity of Tissue
The relative radiosensitivity (sensitivity to radiation exposure) of a variety

of tissue is shown in Figure 2-1 below:
Figure 2-1: Increasing Sensitivity to Radiation
Alan Jackson, 2001 from Seibert, 1996.
By 1906 Bergonie and Tribondeau realized that cells were most sensitive to
radiation when they are:
Rapidly dividing
Undifferentiated
Have a long mitotic future
Author Note: When DNA, which had not been discovered at this time, has no backup (single strand).
Radiation sensitivity
Radiosensitivity is a function of the cell cycle with late S phase being the most
radioresistant and G1, G2, and especially mitosis being more radiosensitive.
Mechanisms of Radiation Injury
Radiation can directly interact with a molecule and damage it directly. Because of
the abundance of water in the body, radiation is more likely to interact with
water. When radiation interacts with water, it produces labile chemical species
(free radicals) such as hydronium (H.) and hydroyxls (.OH). Free radicals can
produce compounds such as hydrogen peroxide (H2O2) which subsequently exert
chemical toxicity. The body has sophisticated protections against this type of
chemical damage. For example, this is why hydrogen peroxide foams when it is
poured on a cut. The hydrogen peroxide is being destroyed by an extremely
rapid enzyme, hydrogen peroxidase.
Nonetheless, while DNA and other repair methods are extremely capable of
protecting the body, some fraction of the damage is not repaired or may be
repaired incorrectly. In either case, if the DNA is damaged, several things can
happen. The most likely is that the damage will be repaired before the end of the
cell’s growth cycle. If not, the cell will probably die. There is some chance that the
cell will survive and behave differently because of the damaged DNA.
Radiation Damage to DNA
Radiation-induced structural changes to DNA can be readily observed (Figure 2-

2).
Figure 2.2: Radiation-Induced DNA Damage
Photomicrograph showing examples of radiation-induced chromosome damage in cancer cells following radiotherapy treatment
(Bushong 1980). Courtesy of Scott Sorenson.
When DNA is damaged, the harm can be magnified by the cellular machinery.
One example of a possible consequence is a cell which loses control over
replication-this mutation is better known as cancer. Ionizing radiation is thought
to initiate (start), but not promote (help grow) mutations.
Types of Radiation Effects
Acute Effects: Short term effects
Very large radiation exposures can kill humans. The lethal dose(LD) for half the
population (50%) within 60 days is termed the LD50/60d. The LD50/60d in humans
from acute, whole body radiation exposure is approximately 400 to 500 rads (4-5
Gy). The temperature elevation in tissue caused by the energy imparted is much
less than 1° C. The severe biological response is due to ionizing nature of X-ray
radiation, causing the removal of electrons, and therby chemical changes in
molecular structures.
Deterministic Radiation Effects
A number of ionizing radiation effects occur at high doses. These all seem to
appear only above a threshold dose. While the threshold may vary from one
person to another, these effects can be eliminated by keeping doses below 100
rad. The severity of these effects increases with increasing dose above the
threshold. These so-called deterministic (non-stochastic) effects are usually
divided into tissue-specific local changes and whole body effects, which lead to
acute radiation syndrome (Table 2-1).
Acute Whole Body Radiation Effects
Table 2-1: Acute Radiation Syndrome
Sorenson, 2000.
Syndrome Symptoms Dose (rad)

Radiation sickness Nausea, vomiting > 100 rad
Significant disruption of
Hemopoietic ability to produce blood > 250 rad
products)
Death in half the
LD50/60d > 250 - 450 rad
population
Failure of GI tract lining,
GI > 500 rad
loss of fluids, infections
CNS Brain death > 2,000 rad
These whole body (to entire body) doses are very unlikely for patients and staff from fluoroscopy
or any diagnostic radiology study.
Several factors, such as total dose, dose rate, fractionation scheme, volume of
irradiated tissue and radiation sensitivity all affect a given organ’s response to
radiation. Radiation is more effective at causing damage when the dose is higher
and delivered over a short period of time. Fractionating the dose (i.e. spreading
the dose out over time) reduces the total damage since it allows the body time
for repair. Patient exposures are higher than attending staff but they occur over
short periods of time whereas staff exposures are normally low and occur over
several years.
Acute Localized Radiation Effects
The Table 2-2 provides examples of possible radiation effects to skin caused by
typical fluoroscopy exposures. Note that patient and technique factors can
substantially increase exposure rates, significantly reducing the time necessary
for the subsequent effect.
Table 2-2: Dose and Time to Initiate Localized Radiation Effects
[Specific case studies of radiation-induced skin injury are presented in the next section]
Please note these localized effects will not be seen immediately (in the clinic).
These effects take time to develop and the minor effects may not be noticed and
are often attributed to other causes. This effectively results in a lack of warning
for serious effects such as dermal necrosis. This lack of warning has led the
FDA, HFH Radiation Safety Committee, and HFH Hospital Medical Executive
Committee (HMEC) to have concerns about fluoroscopy utilization.
Consequently, fluoroscopy safety training and monitoring of fluoroscopy times
were mandated.
Chronic Radiation Effects
Cataractogenesis
Cataract induction is of special interest to fluoroscopy operators since the lens of

eye often receives the most significant levels of radiation (provided lead aprons
are used). Radiation is known to induce cataracts in humans from single dose of
200 rad. Higher total exposures can be tolerated when accumulated over time.
Personnel exposed to the maximum levels each year in the State of Michigan
should accumulate no more than 150 rem to the lens of the eye over 30 years.
As such, the risk for cataracts is likely to be small. Nonetheless, it is imperative
that individuals who approach the State of Michigan dose limit (1,250 mrem per
quarter) wear leaded eyewear which can reduce the radiation dose to the eye by
85%. Leaded eyewear will be provided, by Henry Ford Health System, to
individuals with high eye doses. Once leaded eyewear is issued, this must be
worn for all tableside X-ray procedures.
Stochastic (Probabilistic) Effects
Since the discovery of radiation by Roentgen, there have been many groups in
which radiation effects have been studied (Bushong 1980) (Table 2-3):
Table 2-3: Groups Studied for Radiation Effects
Scott Sorenson, 2000.
Groups Studied for Health Effects

American Radiologists
Nuclear weapon survivors
Radiation-accident victims
Radiation-accident victims
Marshall Islanders (Atomic bomb fallout)
Residents with high levels of environmental radiation
Uranium miners
Radium watch-dial painters
Radioiodine patients
Ankylosing spondylitis patients (radiation therapy)
Thorotrast patients (radioactive contrast material)
Diagnostic irradiation in-utero
Cyclotron workers
Radiation Induced Cancer
These experiments have repeatedly shown that exposure to large radiation

doses results in an elevated risk of cancer. Thus, radiation is considered a
known human carcinogen. The experimental data suggest a non threshold dose
response relationship (Figure 2-3).
Figure 2-3: Stochastic Radiation Effects

Extrapolation of effects at higher doses using a straight line, predict that very
small radiation doses have corresponding small risk of causing a cancer. This
straight line assumption, called the linear, no threshold, dose response
relationship (LNT), involves the least amount of mathematical assumptions and
is thereby consistent with the ancient principle of scientific philosophy known as
Okam's razor (the simplest explanation which describes a phenomenon is the
best). There are also some reasonable models which predict this
relationship. The slope of this straight line can be used as a risk coefficient to
compare radiation risks with other hazards.
The LNT hypothesis implies that any amount of radiation exposure will increase
an individual's risk of cancer. Thus, all radiation doses should be mimimized or
kept As Low As Reasonably Achievable (ALARA).
Due to statistical considerations, such as the normal incidence of cancer (~30%),

the ineffectiveness of the production of cancer by radiation, stochastic effects
can only be shown at doses much higher than that received by occupational
workers. The effects from lower radiation exposures (such as those encountered
occupationally) are extrapolated from observations made at high doses (Upton
1999). In any case, this linear assumption is expected to provide the most
conservative, or highest, risk estimates. The slope of the line is the risk
coefficient.
Radiation Risk
The cancer risk coefficient derived from the LNT model for radiation exposure is
approximately 4.8 * 10-4 per rem. To put this number into perspective, imagine
that you have two similar groups of 10,000 people; exposed and not exposed.
Each member of the exposed group receive 1 rem 1,000 mrem) of radiation
exposure. The control group does not recieve any additional radiation exposure
beyond that received by natural sources. Since the natural incidence of cancer is
about 30%, the control group would expect about 3000 people to die from
cancer. In comparison, the exposed group would expect that about 3005 people
would die from cancer. Thus, the exposed group should expect about 5
additional cancers from the 1 rem exposure.
One way better understand radiation risks is to compare radiation risks with other
commonly accepted risks (Figures 2-4 and 2-5).
Figure 2-4: One in Million Risks
Alan Jackson, 2001
Figure 2-5: One in Million Risks
Alan Jackson, 2001

Radiation Induced Genetic Damage
Since radiation causes damage to DNA, genetic effects in human populations

have long been suspected. Unrepaired or incorrectly repaired chromosonal
damage can be passed on to subsequent generations. To date, there have been
no studies which show an increase in genetic disorders in human populations.
Nonetheless, animal studies have shown a relationship between radiation
exposure and genetic defects which suggest a linear, no threshold, dose
response relationship (LNT) much like that seen with cancer.
The 7 million mice, "Megamouse" project revealed the following conclusions

(Lam 1992):
Different mutations differ significantly in the rate at which they are produced by
a given dose.
There is a substantial dose rate effect with no threshold for mutation
production.
The male was more radiosensitive than the female. The males carried most of
the radiation induced genetic burden.
The genetic consequences of a radiation dose can be greatly reduced by
extending the time interval between irradiation and conception. Six months to a
year is
recommended.
The amount of radiation required to double the natural and spontaneous
mutation rate is between 20 to 200 rads.
Radiation apparently does not cause unique types of mutations, but simply
increases the mutations rate above their natural rate of occurrence. Controlled
studies of genetic effects are only available from animal models. The risk
coefficient for serious genetic disorders from radiation exposure is approximately
8 * 10-5 per rem (NCRP 116). This is less than the cancer risk coefficient (4.8 *
10-4 per rem). Thus, if you protect against cancer, you are simultaneously
protecting against genetic effects.
Radiation Induced Premature Aging
In animal populations, radiation was correlated with premature aging .
In-utero Radiation Health Effects
Once conception has occurred (mother is pregnant), the unborn child (fetus) can
be harmed by radiation. Certainly, the unborn child can have the same health
problems that an adult might have such as cancer and genetic defects. The Law
of Bergonie and Tribondeau predicts that a fetus would be exquisitely sensitive to
radiation since they are:
1. Rapidly dividing;
2. Undifferentiated; and
3. Have a long mitotic future.
Studies of children exposed to x-rays in-utero support that prediction. Thus,

based on a concern for cancer induction, X-ray examination of pregnant patients
has transformed from a standard health screening study to an extremely rare
study. Nonetheless, some X-rays of pregnant patients, particularly those to
protect the life of the mother, are performed when necessary to protect the life of
the mother typically under the guidance of a Radiologist.
In addition to the health effects which are a concern for an adult, there is also a
serious concern about the possibility of developmental errors (teratogenesis)
which can occur. There are three general prenatal effects which have been
observed:
1. Lethality;
2. Congenital abnormalities at birth; and
3. Delayed effects, not visible at birth, but manifested later in life.
The expression of effects are dependent upon the dose and stage of fetal
development (Figure 2-6):
Figure 2-6: Fetal Developmental Radiation Risks
A human embryo exposed to greater than 250 rads before 2 to 3 weeks of

gestation will likely result in prenatal death (miscarriage). Fortunately, those
infants, who survive to term at these extreme doses generally do not exhibit
congenital abnormalities.
Irradiation of the human fetus between 4 to 11 weeks of gestation may cause

multiple severe abnormalities of many organs. Irradiation during the 11th to 15th
week of gestation may result in mental retardation and microcephaly. After the
20th week, the human fetus is more radioresistant, however, functional defects
may be observed. In addition, a low incidence (one in 2000) of leukemia has
been observed in individuals who received prenatal radiation.
Medically indicated procedures involving radiation are appropriate for pregnant

women (Brent 1999). However, such procedures should be avoided if alternate
techniques are available or measures should be taken to minimize patient/fetal
exposure. Considering legal complications and ethical dilemmas resulting from
non-optimal prenatal radiation exposure, it is strongly suggested that physicians
consult with a Board-Certified Radiologist before performing fluoroscopy on
potentially pregnant patients.
Occupational Dose Limits
One way to control risks is to establish occupational exposure limits. These

limits are designed to eliminate threshold effects and minimize stochastic risks to
make radiation occupations as safe as other safe industries. The current dose
limits for the State of Michigan are shown in Figure 2-7.
Figure 2-7: State of Michigan Dose Limits

Note: The State of Michigan dose limits, originally promulgated in 1972 and based on older
recommendations, do not reflect the most updated information on dose limit recommendations.
The U.S. Nuclear Regulatory Commission allows a lens of eye dose limit of 15 rem per year and
a skin dose limit of 50 rem per year.
Patient Dose Limits
Medical X-ray procedures are performed to directly benefit the patient. Note that
limits have not been established for how much dose a patient may receive. The
regulations properly leave this matter up to the discretion of physicians. The
purpose of this course is to educate physicians about how to properly make that
decision for their patients. When in doubt, contact a Board Certified Radiologist.
Go To Chapter 3: General Fluoroscopy Concepts Chapter 3: Fluoroscopy

System Description and Operation
Modern fluoroscopy imaging systems (Figure 3-1) consist of: the X-ray tube
which produces X-rays; an Image Intensifier (I-I) that captures or stops the X-
rays and converts the X-ray energy into light; a closed-circuit video system which
ultimately producing a "live" image on a monitor. On some systems the light
output can also be distributed to a spot film or cinematography recording
systems, though the X-ray output must be greater for these imaging modalities.
Figure 1-2: Fluoroscopy System Components
Generator Control
The X-ray generator controls the quantity (number) and quality (spectrum of
energy) of the X-rays produced. There are three basic controls to the generator:
kVp - voltage applied accross the X-ray tube.
mA -Current across the X-ray tube.
Time - starting and stopping the exposure.
From a safety perspective, the beam- on- time is the most important control.
Beam-on-Time (Foot Pedal/Switch)
Radiation exposure during fluoroscopy is directly proportional to the length of

time the unit is activated by the foot pedal or switch. Unlike regular X-ray units,
fluoroscopic units do not have an automatic timer to terminate the exposure after
it is activated. Instead, depression of the switch determines the length of the
exposure which ceases only after the switch is released. Thus, cognizance of
beam-on-time is extremely important to fluoroscopy safety.
X-ray tube Current (mA)
The X-ray tube current (mA setting) essentially controls the quantity of X-rays
produced per unit time. If you double the mA, you double the patient and
operator exposure. The higher current mode (High Level Control or "boost"
mode) dramatically increases the number of X-rays produced and thereby
improves image quality. The boost mode is activated in some systems when the
foot switch is firmly depressed (a light push activates the normal, low dose,
mode). An audible alarm will indicate when the high level mode is being used.
HFH policy limits the rate for the boost mode to 20 R/minute (compared with
maximum of 10 R/minute for the normal, Automatic Brigtness Control (ABC)
mode and 5 R/minute for the manual mode). Both the patient and fluoroscopy
operator dose are proportional to the total amount of current used by the
machine. Thus, a light touch on the pedal (educated use of the boost mode) will
minimize both patient and worker doses.
During normal mode fluoroscopy, the average patient Entrance Skin Exposure
(ESE) is approximately 2 R/min. The level of radiation exposure falls off
exponentially with increasing tissue depth due to attenuation and inverse-square
effects. Only approximately 1% of the original radiation beam reaches the I-I for
image generation.
The ESE exposure rate can be as high as 20 R/min under certain conditions
using a high dose rate or "boost" mode if the patient’s skin is close to the X-ray
tube. During cineangiography, ESE may exceed 90 R/min.
Fluoroscopy Timer
Fluoroscopy machines are equipped with a timer and an alarm which sounds at
the end of 5 minutes of fluoroscopy use. This system is designed alert the user
when the usage is becoming significant and provide additional warnings 5
minutes after each reset. Fluoroscopy systems also display the total fluoroscopy
time for a procedure. There are internal requirements for recording fluoroscopy
times discussed
Fluoroscopy Monitoring
The Radiation Safety Committee requires that the total elapsed fluoroscopy time
be recorded for every procedure that exceeds 10 minutes of fluoroscopy. Certain
areas, primarily in the Henry Ford Hospital, are also required to record all
fluoroscopy times. Sheets used to record fluoroscopy times are available from
the Radiation Safety Office.
Imaging Modes
Automatic Brightness Control (ABC)
Modern fluoroscopy machines produce images from an I-I that captures the
radiation exiting the patient. The machine can be operated in either a manual
mode or in an Automatic Brightness Control (ABC) mode (Figure 3-2). When the
ABC mode is selected, the ABC circuitry controls the X-ray intensity measured at
the I-I so that a proper image can be displayed on the monitor.
Figure 3-2: Automatic Brightness Control System
Courtesy of Phil Rauch, 2000

ABC mode was developed to provide a consistent image quality during dynamic
imaging, When using ABC, the I-I output is constantly monitored and machine
factors are then adjusted automatically to bring the brightness to a constant,
proper level for adequate I-I function. Both patient and operator factors influence
the number of X-rays reaching the I-I. The ABC compensates brightness loss
caused by decreased I-I radiation reception by generating more X-rays
(increasing mA) and/or producing more penetrating X-rays (increasing
kVp). Conversely, when the image is too bright, the ABC compensates by
reducing mA and decreasing kVp.
The radiation exposure rate is independent of the patient size, body part imaged
and tissue type when the manual mode is used. However, the image quality and
brightness are greatly affected (often adversely) by these factors when the
operator "pans" across tissues with different thickness and composition. For this
reason, most fluoroscopic examinations are performed using ABC.
Obese patients drive the X-ray machine output up considerably. Thus, obese
patients have the greatest risk of skin injury.
Magnification Modes
Many fluoroscopy systems have one or several magnification modes.

Magnification is achieved by electronically manipulating a smaller radiation I-I
input area over the same I-I output area (Figure 3-3). A reduction in radiation
input subsequently results, lowering image brightness. The ABC system, in turn,
compensates for the lower output brightness by increasing radiation production
and subsequent exposure to patient and staff. Patient entrance skin exposures
can become quite high when small field of views are used.
Figure 3-3: Field of View
Normal Magnification Mode
Under Normal mode, there is little magnification with the whole beam used to
generate a bright image. The "Normal" mode is used in the majority of
fluoroscopy procedures. The radiation output is sufficient to provide images for
guiding most procedures or observing dynamic functions. The typical exposure
rate at the X-ray beam entrance into the patient Entrance Skin Exposure (ESE) is
2 R/min.
Under Mag 1 mode, a smaller beam area is projected to the same I-I output. The
resulting object size is larger, but the image is dimmer due to the less beam
input.
The Food and Drug Administration (FDA) regulates the construction of all
fluoroscopy systems. For routine fluoroscopy applications, the FDA limits the
maximum ESE to 10 R/min. The use of higher radiation rates ("High Level
Control" or "boost" modes) are useful in situations requiring high video image
resolution. ESE of up to 20 R/min is permitted for short duration. Special operator
reminders, such as audible alarms, are activated during "boost" modes.
Figure 3-4 illustrates the effect of changing Field-Of-View, or magnification

modes, on skin entrance exposure (ESE) for a typical fluoroscopy system:
Figure 3-4: Image Intensifier Input Exposure
Cineangiography
Cineangiography (cine) originally involved exposing cinematic film to the I-I

output, providing a permanent record of the imaged sequence. Technological
advances in film-less imaging have eliminated the film for most systems. The
cine mode extracts several separate diagnostic quality images per minute. The
amount of information collected for each of these images is essentially equivalent
to a normal flat plane X-ray image. The X-ray machine output required to
produce a cine movie is much higher than the level needed for normal
fluoroscopy. Consequently, dose rates during cine image collection are usually
10 to 20 times higher than normal fluoroscopy. For this reason, careful use of
cineangiography is required.
Field Size and Collimators
The maximum useful area of the X-ray beam, or field size, is machine specific.
Most fluoroscopy systems allow the operator to reduce the field size through the
use of lead shutters or collimators. Figure 3-5 shows a diagram of an X-ray tube
and collimator system.
Figure 3-5: X-ray tube and Collimator System
Irradiating larger field sizes increases the probability of scatter radiation

production (Figure 3-6). A portion of the increased scatter will enter the I-I,
degrading the resulting image.
Figure 3-6: Benefits of Collimation

Prudent use of collimators can also improve image quality by blocking-out "bright
areas," such as lung or other low density regions, allowing better resolution of
other tissues.
Benefits from using collimation
Limiting beam size by using the collimators provides many benefits:
1. The patient receives less total radiation exposure since less tissue is in
the radiation beam (Figure 3-7).
2. The workers in the area receive less radiation exposure since there is less
radiation available to scatter toward staff.
3. The image is improved since scatter contributes noise to the image.
Figure 3-7: Collimation Technique

Last Image Hold
Newer fluoroscopy units are often equipped with a last-view freeze-frame or

video recording. Use of these modes allows the operator to view an image at
leisure, avoiding unnecessary patient and staff radiation exposure caused by
constant fluoroscopy use.
Beam Quality (kVp)
The tube voltage (kV) controls the maximum energy of electrons produced by the
X-ray tube and the maximum energy of the resultant X-ray spectrum (kilovolt-
peak energy or kVp). Use of high kVp techniques can reduce patient dose but
contrast between differing tissues is also reduced. Experienced operators can
optimize the choice between image quality and patient dose through careful
adjustment. The ABC on most X-ray systems can change the kVp and mA used
to optimize imaging.
Image Display Monitor
The image quality available to the operator is dependent on proper adjustment of

the image monitor. These image monitor settings are adjusted during service
and annual testing. Operator adjustment of the brightness and contrast controls
can degrade image sharpness, contrast and distortion and should be done if
problems occur during use. If this happens, service should be contacted to
correct the problems. In addition, the eye's ability to discern detail on the image
monitor is improved under low light conditions. The need for good lighting for
surgical needs must be balanced with imaging considerations. Therefore, the
monitor settings should be calibrated for the area in which it is being used.
System Quality Control Checks
Quality Control (QC) checks are extremely important to ensure proper

performance of the equipment. Daily testing is required by JCAHO standards and
should be utilized to track system performance and optimize display monitor
settings. A simple test tool (Fig 3-8) can be used to monitor system
performance. This tool should be used to evaluate the X-ray system each day
prior to use and any discrepancies corrected immediately.
Figure 3-8: Quality Control Checks
Operator Exposure Profile
No portion of the operator's body should be in the primary beam during imaging.
Thus, the majority of the radiation dose received by the operator is due to
scattered radiation from the patient. After interacting with the patient, radiation is
scattered more or less uniformly in all directions (Figure 3-9).
Figure 3-9: Collimation Technique

It is important to note that the patient does not uniformly emit this scattered
radiation since some of the scattered radiation is absorbed or reduced in intensity
by passing through the patient. The intensity of scatter decreases with increasing
distance, due to inverse square law effects (see Chapter 1). Consequently,
scatter radiation is highest near its source (i.e. the X-ray beam entry point on the
patient). Because radiation scattered in the forward direction (into the patient) is
subject the most tissue attenuation, radiation levels are significantly lower on the
I-I side than the X-ray tube side.
Highest scatter radiation levels are often where the operator stands. Radiation
levels increase with decreasing distance from the point of X-ray entry (Figure 3-
10). In general, an operator positioned 3 feet from the X-ray beam entrance area
will receive 0.1% of the patient’s ESE. Staff members positioned further away
receive much less exposure due to inverse square law effects. In almost all
cases, the tableside operator will receive the highest occupational radiation
exposure during the fluoroscopic procedure. Tableside fluoroscopy receive
among the highest occupational radiation exposures within the health system.
Figure 3-10: Radiation Level vs. Entry Point
Radiation levels are highest beneath the table (when the X-ray tube is below the
patient) because the patient provides an effective beam stop (Figure 3-11).
Highest levels are directed at the operator's waist (See bar chart on figure).
Figure 3-11: Patient Shielding

The scatter radiation profile tilts with the X-ray tube. Higher exposure to the
operator’s head and eyes (which have low dose limits) results during oblique
angle projections where the X-ray tube is tilted towards the operator (I-I is tilted
away from the operator). Conversely, radiation exposure is decreased when the
X-ray tube is tilted away from the operator (I-I tilted towards the operator) (Figure
3-12). When possible, the operator should work on the I-I side of the table when
oblique angles are being imaged. While it is contrary to your instincts, generally
you should work closer to the image intensifier than the X-ray tube.
Figure 3-12: Tilt Exposure Profile

Effect of rotating X-ray system. Images taken with the I-I away (Figure 3-12)
result in higher radiation exposure to the operator's eyes compared to images
with the I-I towards the operator (Figure 3-13).
Figure 3-13: Tilt Exposure Profile
Image Quality Versus Patient Dose
A basic principle in Radiology is that you collect dose along with image
information. The clearest, least jittery, images produce the highest doses. Thus,
it is very important for clinicians to judiciously use appropriate judgment when
increasing the X-ray beam output and to learn to work with most amount of
(necessary) imaging imperfections as possible which still allow the needed
clinical outcome.
Go To Chapter 4: Case Studies of Radiation Injury

Chapter 4: Case Studies of Radiation Injury
Non-Symptomatic Skin Reactions
Minor skin reactions caused by X-rays can be easily misattributed to other

causes (e.g. sun exposure or rashes). Also, since these skin reactions are
delayed effects, they typically would not be be seen in the clinic. Thus, patients
and caregivers may not be aware of skin changes that can be caused by lengthy
fluoroscopic procedures (Wagner 1999). The following case study is a useful
example:
1. Physical examination one year following coronary angioplasty identified a

1 x 2.5 cm-depigmented area with telangiectasia on the patient’s left
shoulder. Total fluoroscopy time: 34 minutes.
2. One year after PTCA involving 66 minutes of fluoroscopy, a 10-cm
diameter hyperpigmented area with telangiectasia was evident on the
patient’s right shoulder.
The above skin changes were in areas not visible to the patients and were only
identified upon physical examination.
Symptomatic Skin Reactions
The circumstances leading to symptomatic radiation induced changes are varied.

Case reports are grouped according to common factors in order to identify the
reasons for radiation-induced effects.
PA Fluoroscopy
The posteroanterior (PA) orientation of the fluoroscope, when properly configured

with the image intensifier down close to the patient, is probably the least
problematic with regard to Entrance Skin Exposure (ESE) rate. However,
extended fluoroscopy usage has resulted in reports of skin damage. The
following case study, which did not occur at Henry Ford Health System,
illustrates this effect (Shope 1995).
On March 29, 1990, a 40-year-old male underwent coronary angiography,

coronary angioplasty and a second angiography procedure (due to
complications) followed by a coronary artery by-pass graft. Total fluoroscopy time
estimated to be > 120 minutes. Figure 4-1 shows the area of injury six to eight
weeks following the procedures. The injury was described as "turning red about
one month after the procedure and peeling a week later." In mid-May 1990, it had
the appearance of a second-degree burn.
Figure 4-1: 6-8 Weeks Post Procedure
Courtesy of Wagner, 1999

Note the square pattern of the injury.
Figure 4-2 shows the appearance of skin injury approximately 16 to 21 weeks

following the procedures with small ulcerated area present.
Figure 4-2: 16-21 Weeks Post Procedure

Appearance of skin injury approximately 18 to 21 months following procedures,
evidencing tissue necrosis:
Figure 4-3: 18-21 months Weeks Post Procedure
Figure 4-4 shows a close-up of injury area at 18-21 months:
Figure 4-4: 18-21 Months Post Procedure
Two additional reported cases of radiation-induced injury (Wagner 1999):

1. Following a transjugular intrahepatic portosystemic shunt (TIPS)
procedure involving 90 minutes of fluoroscopy, a discharged patient
developed erythema and discoloration on his back. One year after the
TIPS procedure an ulcer developed, which did not heal, and two years
later it was 4-cm in size. A split thickness skin graft from the right buttock
was performed.
2. Following a TIPS procedure lasting 6 hours and 30 minutes (no indication

of total fluoroscopy time), a 16- x 18-cm hyperpigmented area developed
on the patient’s back and progressed over a period of several months into
a central area with ulceration. After 14 months a split thickness skin graft
was performed leaving a depressed scar at the surgical sight.
These case studies indicate that extensive use of fluoroscopy can induce severe
skin damage, even under the most favorable geometries.
Steep Fluoroscopic Angles
When the fluoroscope is oriented at a lateral or an oblique angle, two factors

combine to increase the patient’s ESE rate. The first is that a thicker mass of
body tissue must be penetrated. The second is that the skin of the patient is
closer to the source because of the wider span of anatomy (Wagner
1999). Example cases are given below:
1. A PA oblique angle using a C-arm involved 57 minutes of fluoroscopy.

Twenty-four hours later the patient reported a stabbing pain in his right
thorax. Three days later an erythema developed which evolved into a
superficial ulcer. At two and half months after the procedure the area was
approximately 12-cm x 6.5-cm and described as a brownish pigmented
area with telangiectasia, central infiltration and hyperkeratosis.
2. A PA oblique angle was employed during a catheter ablation procedure
involving 190 minutes of fluoroscopy. A symptomatic discoloration was
noted several days after the procedure on the patient’s left upper back. In
the next few weeks the area had become painful and was draining. At
seven weeks the area was approximately 7- x14-cm in size and described
as a rectangular erythema with ulcers. After treatment, there was a
gradual lessening of tenderness with reepitherlialization, leaving a mottled
slightly depressed plaque.
3. A steep PA oblique angle through the right shoulder was employed
involving 51 minutes of fluoroscopy. Fourteen days after the procedure, an
erythema appeared on the right shoulder that progressed into moist
superficial ulcer with poor healing. This degenerated into a deep muscular
ulcer requiring a myocutaneous skin graft approximately 14 months after
the procedure.
The temporal progressions of these effects are consistent with high levels of
acute exposure to x-ray radiation. The temporal differences in the responses are
due in part to the levels of radiation received, but are also likely due to variations
in radiation sensitivity amongst the patients.
Multiple Procedures
Although intervals between procedures should permit the skin to recover, healing
might not be complete. This may lower the tolerance of the skin for further
procedures (Wagner 1999). Example cases are given below:
1. A patient underwent two PTCA procedures about one year apart. Skin
changes appeared approximately three weeks after the second procedure.
At seven weeks a cutaneous ulcer had developed over the right scapula
and healed without grafting.
2. A patient underwent two unsuccessful cardiac ablations involving
approximately 100 minutes of fluoroscopy in a lateral oblique orientation.
Approximately 12 hours after the second attempt, an
erythema developed in the right axilla. At one month the area was red and
blistering. At two years the area was described as a 10 x 5cm atrophic
indurated plaque with lineal edges, hyper- and hypopigmentation, and
telangiectasia. The patient was described as having difficulty raising her
right
arm.
3. Three PTCAs were performed on the patient, the last two completed on
the same day approximately 6 months after the first procedure. The total
fluoroscopy time was approximately 51 minutes. Erythema was noted
immediately after the last procedure. This progressed from a prolonged
erythema with poor healing into a deep dermal necrosis. The patient
underwent a successful split thickness skin graft two years after the last
procedure.
4. Past treatment of pulmonary tuberculosis often resulted in many patients
undergoing extensive exposure to fluoroscopy. These patients had a
demonstrated high incidence of breast cancer.
Previous procedures can lower the skin’s tolerance for future irradiation. Prior to
commencing any lengthy fluoroscopic procedure, the patient’s medical history
should be reviewed. The skin of the patient should be examined to ascertain if
any skin damage is apparent should the patient have a history of lengthy
fluoroscopic examinations. Direct irradiation of damaged areas should be
avoided when possible.
Positions of arms
Keeping arms out of the x-ray beam during some procedures can be a difficult.
Careful attention must be given to providing the arms with a resting position that
will not restrict circulation but will at the same time maintain the arms in an area
that is outside the radiation field (Archer 2000).
A middle-aged woman had a history of progressively worsening episodes of
arrhythmia. A radiofrequency electrophysiological cardiac catheter ablation was
scheduled to treat the condition. The procedure employed 20 min of beam-on
time for each plane of a bi-plane fluoroscope. Prior to the procedure the
separator or spacer cone was removed so that the fluoroscopic c-arms could be
easily rotated around the patient. The spacer cone is a spacer attached to the
tube housing designed to keep the patient at a reasonable distance from the x-
ray source. This is done specifically to avoid the high skin-dose rates that can be
encountered near the tube port.
The patient’s arms were originally placed at the patient’s side but the right arm
later fell into a lower position directly in front of this x-ray tube. However,
personnel were not aware of this change because sterile covers were draped
over the patient and did not correctly interpret the image (Figure 4-4). The right
humerus was directly in the beam at the port. Because the separator cones were
removed, the arm was only about 20–30 cm from the focal spot. With the soft
tissue and bone of the arm directly in the beam, the automatic brightness control
drove the output to high levels at the surface of the arm. The cumulative dose
probably exceeded 25 Gy (2500 rad). This procedure was not performed at
Henry Ford Health System.
Figure 4-4: Image of Arm resting on X-ray Tube Port
Courtesy of Archer, 2000
The patient was released from the hospital the day after the procedure. At the
time there were no complaints regarding her arm and no indication of erythema.
About three weeks after the procedure, a bright erythema was demonstrated
(Figure 4-5).
Figure 4-5: Three weeks Post Procedure
The condition worsened and at five months a large ulcer the size of the
collimated x-ray port developed.
Figure 4-6: Five Months Post Procedure
The separator or spacer cone ensures that a minimal distance between the X-
ray source and the patient is maintained (inverse square law effects). For some
X-ray machines, the spacer cone is designed to be removable in order to provide
more flexibility in positioning for some special surgical procedures (e.g., portable
C-arms). There is a risk of very high dose rates to the skin surface when it is
removed.
Skin Sensitivity
Some patients may be hypersensitive to radiation due to pre-existing health

conditions (Wagner 1999).
Erythema developed after diagnostic angiography and liver biopsy. Skin necrosis
requiring rib resection evolved in the same patient after a TIPS procedure. The
wound remained open for five years before a successful cover was put in place.
Investigation into the events revealed that the patient suffered from multiple
problems, including Sjøgren’s syndrome and mixed connective tissue disease.
Injuries to personnel
The following are modern-day examples of how improper use of the fluoroscope
can lead to injuries in personnel (Wagner 1999).
1. Hands of physicians have incurred physiologic changes indicative of high

cumulative doses of chronic low-dose-rate irradiation. Brown finger nails
and epidermal degeneration are typical signs. These changes were the
result of years of inserting hands into the x-ray field with the x-ray tube
above the patient.
2. Four cases of radiation-induced cataract have been reported in personnel
from procedures utilizing the x-ray tube above the patient orientation.
Doses accumulated to hands and eyes from frequently using the fluoroscope
with the tube above the patient can be extremely high. Only routine application of
proper radiation management techniques will be effective at avoiding such high
doses.
Go to Chapter 5: Protection Methods
Chapter 5: Reducing Radiation Exposure
External Exposure Protection
X-ray machines do not produce internal radiation exposure like radioactive

materials. There are three basic protection methods for external sources of
radiation: Minimizing exposure time, maximizing distance from the X-ray tube,
and the utilization of shielding.
Minimizing Exposure Time: Reduce "Beam-on-time"
Radiation exposure during fluoroscopy is directly proportional to the length of

time the unit is activated. Reductions can be realized by:
1. Not exposing patient while not viewing the TV image;

2. Pre-planning images. An example would be to ensure correct patient
positioning before imaging to eliminate unnecessary "panning;"
3. Avoiding redundant views;
4. Operator awareness of the 5-minute time notifications.
Fluoroscopy’s real-time imaging capabilities are invaluable for guiding

procedures or observing dynamic functions. However, there is no advantage over
conventional X-ray techniques when viewing static images. Use of Last-Image-
Hold features, when available, allows static images to be viewed without
continuously exposing patient and operator to radiation.
Human eye integration time or recognition time of a fluoroscopy image is

approximately 0.2 seconds. Therefore, short "looks" usually accomplish the same
as a continuous exposure. Prolonged observation will not improve the image
brightness or resolution (Seifert 1996).
Maximize Distance
A small increase in the operator's distance from the patient can significantly
reduce the operator's exposure. Standing one step further away from the patient
can cut the physician's exposure rate by a factor of 4 (AAPM 1998) (Figure 5-1).
You should periodically self-evaluate you personal technique to identify whether
opportunities to increase distance exist.
Figure 5-1: Benefit of Increasing Distance

Courtesy of Sorenson, 2000.
In percutaneous transluminal techniques, using the femoral approach rather than

the brachial approach yields distance benefits to the operator (Figure 5-2).
Figure 5-2: Influence of Technique

Substantial increases in operator distance may be realized through remote
fluoroscopy activation whenever automated contrast injectors are used.
Many procedures require staff to intermittently interact with the patient near the
fluoroscopy system. The operator can reduce staff exposure by delaying
fluoroscopy until these activities are completed and/or by alerting these
personnel when imaging; especially during high dose rate modes like
cineangiography (Figure 5-3).
Figure 5-3: Benefit of Alerting Staff

Room Lighting
Provisions should be made to eliminate extraneous light that can interfere with
the fluoroscopic examination. Room lighting should be dim to enhance
visualization of the image. Excessive light can decrease the ability of the eye to
resolve detail. Measures taken to improve detail often involve increasing
patient/staff exposure.
X-ray Tube Position
Fluoroscopy examinations have the smallest operator exposure when the X-ray
tube is underneath the examination table (Figure 5-3). Whenever possible, the
operator should avoid the X-ray tube side of the table when imaging oblique or
lateral images.
Figure 5-3: Benefit of Under-Table Position

Note: The benefit is exaggerated-some operator dose occurs on the I-I side.
I-I to Patient Air Gap
The operator must be aware of the X-ray tube-to-patient distance. Positions

closer can lead to extremely high patient exposures due to Inverse-Square-Law
effects (case study). Minimizing the air gap between the I-I and the patient
typically ensures that this distance is maintained. Use of the separator or spacer
cone can prevent serious effects. The spacer cone is a spacer attached to the
tube housing designed to keep the patient at a reasonable distance from the x-
ray source. This is done specifically to avoid the high skin-dose rates that can be
encountered near the tube port. Spacer cones protect patients from extremely
high local exposures by making it physically impossible to get too close to the X-
ray source (inverse-square law effects). For some X-ray machines, the spacer
cone is designed to be removable (Figure 5-3) in order to provide more flexibility
in positioning for some special surgical procedures (e.g., portable C-arms). There
is a risk of very high dose rates to the skin surface when it is removed.
Figure 5-3: Removable Spacer Cone

Courtesy of Rauch, 2000
Reduce Air Gaps
Keeping the I-I as close to patient’s surface as possible significantly reduces

patient and operator exposures (Figure 5-4). The I-I will intercept the primary
beam earlier and allow less scatter to operator and staff. In addition, The
Automatic Brightness Control (ABC) system would not need to compensate for
the increased X-ray tube to I-I distance caused by the air gap. The presence of
an air gap will always increase patient/operator radiation exposure and decrease
image quality.
Figure 5-4: Benefit of Reducing the Air Gap (I-I Close to Patient)
Care should be taken whenever the image view angle is changed during the
procedure (e.g, changing from an ANT to a steep LAO). The I-I is often moved
away from the patient while changing X-ray tube position. Large air gaps can
result if the table or I-I height remains unadjusted.
I-I to Patient Distance Example:
After changing views, a 10-cm air gap between I-I and patient is inadvertently
maintained. What is the increase in radiation exposure to a 20-cm thick patient
positioned with the table 30 cm away from the X-ray source, assuming the ABC
compensates by increasing mA only?
Note: mA only adjustments on ABC systems are reasonably common.
Solution:
Assuming the air gap could have been eliminated by moving the I-I closer, and
that the brightness loss follows the inverse square law:
The brightness level with the air gap is only 69% of the zero air gap brightness.
The ABC system compensates for brightness loss by producing 31% more X-
rays. The exposure rate to the patient and staff is subsequently increased by
31%.
Reducing air gaps between patient and I-I also reduces image blur. Blurring of
the image is caused by geometric magnification caused by air gaps. Gaps
between patient and I-I enhance geometric magnification. The objects will appear
larger with increasing gap size. However, note that image edges are more fuzzy
(Figure 5-4). The degree of "fuzziness" will increase with increasing air gap.
Figure 5-4: I-I distance and Image Blur

Minimize Use of Magnification
Use of magnification modes significantly increases radiation exposure to patient,

operator, and staff (See Chapter 3). Magnification modes should be employed
only when the increased resolution of fine detail is necessary.
Collimate the Primary Beam
Collimating the primary beam to view only tissue regions of interest reduces
unnecessary tissue exposure and improves the patient’s overall benefit-to-risk
ratio. Optimal collimation also reduces image noise caused by scatter radiation
originating from outside the region of interest (See Chapter 3). A good rule of
thumb is that fluoroscopy images should not be totally "round" when collimators
are available for use, the collimator edges should always be visible in the image.
Use Alternate Projections

Continuous exposure of the patient with the same projection (point of X-ray
beam entry) can cause very high skin dose to small areas. Thus, if the point of
X-ray beam (projection) entry can be changed, the skin may be spared from the
harmful effects of radiation. While this is an effective protection method, care
must be exercised to utilize this method intelligently since longer beam paths
through the patient can cause higher patient and worker dose.
Steeply angled oblique images (e.g., LAO 50 with 30 cranial tilt) are typically
associated with increased radiation exposure since: X-rays must pass through
more tissue before reaching I-I. ABC compensates for X-ray loss caused by
increased attenuation by generating more X-rays; Steep oblique angles are
typically associated with increased X-ray tube to I-I distances. The ABC
compensates for brightness loss caused by inverse square law effects by
generating more X-rays. Oblique views may bring the X-ray tube closer to the
operator side of the table, increasing radiation
exposure from scatter.
Operator exposure from different projections.
When possible, use alternate views (e.g., ANT, LAO with no tilt) when similar
information can be obtained (Figure 5-5). The physician can reduce personal
exposure by re-locating himself when oblique views are taken. For example,
dose rates can be reduced by a factor of 5 when the physician stands on the I-I
side of the table (versus X-ray tube side) during a lateral projection (AAPM
1998).
Figure 5-5: Physician Exposure for a variety of Projections

Projections with the X-ray tube neutral or tilted-away from the operator are
highlighted blue, while those tilted towards the operator are in red. Note the
decrease seen between the LAO 40 views. The caudal tilt causes the tube to be
more tilted away from the operator.
Optimizing X-ray Tube Voltage
Selection of an adequate kVp value will allow sufficient X-ray penetration while
reducing the patient’s dose rate. In general, the highest kVp should be used
which is consistent with the degree of contrast required (high kVp decreases
image contrast).
Henry Ford Hospital has many resources available (e.g., Staff Radiologists,
Medical Physicists) to assist the operator in optimizing the fluoroscopy image
while minimizing patient exposure.
Use of Radiation Shields
Use of radiation shielding is highly effective in intercepting and reducing

exposure from scattered radiation (Figure 5-6). The operator can realize radiation
exposure reductions of more than 90 percent through the correct use of any of
the following shielding options. Shields are most effective when placed as near to
the radiation scatter source as possible (i.e., close to patient).
Many fluoroscopy systems contain side-table drapes or similar types of lead

shielding. Use of these items can significantly reduce operator exposures. Many
operators have had little difficulty incorporating their use, even during procedures
requiring multiple re-positioning of the system.
Figure 5-6: Benefit of Hanging Shield
Ceiling-mounted lead acrylic face shields should be used whenever these units
are available, especially during cardiac procedures. Correct positioning is
obtained when the operator can view the patient, especially the beam entrance
location, through the shield.
Portable radiation shields can also be employed to reduce exposure. Situations

where these can be used include shielding nearby personnel who remain
stationary during the procedure.
Use of Personal Protective Equipment

Use of leaded garments substantially reduces radiation exposure by protecting
specific body regions. Many fluoroscopy users would exceed regulatory limits
should lead aprons not be worn. Operator and nearby staff (within 2 meters) are
required to wear lead aprons whenever fluoroscopes are operated at Henry Ford
Hospital. Due to the poor material qualities of Leaded garments, proper storage
is essential to protect against damage (Figure 5-6). Whenever leaded apron are
required, they must be supplied and paid for by your employer (Henry Ford
Health System)
Figure 5-6: Properly Stored Leaded Garments

Lead aprons do not stop all the x-rays. Typically at least a 80% reduction in
radiation exposure is obtained by wearing a lead apron (Figure 5-7). It should be
noted that the apron's effectiveness is reduced when more penetrating radiation
is employed (e.g., the ABC boost's kVp for thick patients). Two piece lead apron
systems are recommended for most users since they provide "wrap-around
protection" and distribute weight more evenly on the user. Some aprons contain
an internal frame that distributes some of the weight from the shoulders onto the
hips much like a backpack frame. So called "light" aprons should be scrutinized
to ensure that adequate levels of shielding are provided. State of Michigan law
requires the use of 0.5 mm lead equivalent aprons.
Figure 5-7: Lead Apron Protection Efficiency
Note that higher tube voltages sharply reduces the shielding benefits of lead aprons. Higher tube
voltages will occur when imaging large patients or thick body portions. Also note that light aprons
(0.25 to 0.35 mm Pb) provide less protection compared to the recommended 0.5 mm thickness.
Thyroid shields provide similar levels of protection to the individual’s neck region.
Thyroid shield use is required for operators who use fluoroscopy extensively
during their practice.
Optically clear lead glasses are available that can reduce the operator's eye
exposure by 85-90% (Siefert 1996). However, due to the relatively high threshold
for cataract development, leaded glasses are only recommended for personnel
with very high fluoroscopy work loads (e.g., busy Radiology and Cardiology
Interventionists). Glasses selected should be "wrap-around" in design to protect
the eye lens from side angle exposures. Leaded glasses also provide the
additional benefit of providing splash protection. Progressive style lenses for
bifocal prescriptions are available from a limited number of manufacturers.
The latex leaded gloves provide extremely limited protection. Standard (0.5 mm
lead equivalent) leaded gloves provide useful protection to the user’s hands.
However, trade-offs associated with use of 0.5 mm leaded gloves include loss in
tactile feel, increased encumbrance and sterility. For these reasons, use of
leaded gloves is left to the operator’s discretion. To minimize radiation exposure
to the hands, the operator should:
1. Avoid placing his hands in the primary beam at all times;

2. Place hands only on top of the patient. Hands should never be placed
underneath the patient or table top during imaging;
3. Consider using leaded gloves if hand placement within the X-ray beam is
necessary or positioned nearby for extended periods of time.
Radiation Monitoring-Dosimeter Badges
Unlike many workplace hazards, radiation is imperceptible to human senses.

Therefore, monitoring of personnel exposed to radiation is performed using a
radiation dosimeter or "badge." Monitoring is useful to identify both equipment
problems and opportunities for improving individual technique (ensuring radiation
doses are ALARA). Monitoring also documents the level of occupational
exposure.
The requirements for dosimetry has been determined by the Radiation Safety
Committee for each work area. These specify the types of dosimeters issued as
well as the collection frequency.
Some workers are issued a single whole body badge (black figure icon). This
whole body dosimeter should be worn on the collar outside of any protective
equipment worn (lead aprons). Readings from this position provide an estimate
of the radiation exposure to the eyes. Dose estimates to the individual’s whole
body are made using the appropriate algorithm. Other workers are issued
multiple dosimeters. These are designed to be worn as shown (Figure 5-8):
Figure 5-8: Protective Devices
Lieto and Jackson, 2000.
Ring badge and Sterility
Infection Control has evaluated the use of ring badges in surgical arenas. For
open surgical theaters, ring badges are contraindicated. Catheter procedures
may be performed with ring badges.
Dosimetry Practices
In order to provide an accurate estimate of personal risk, radiation badges are to

be used at all times when working with radiation. It is also important to turn in the
radiation badges on time. The accuracy of the readings depends on the timely
processing of the dosimeter with the corresponding control dosimeters.
Absent dosimeters are taken very seriously by the institution. Reports of which
individuals have failed to properly return dosimeters (who did not report the loss
of the dosimeter to the RSO) are sent to: the Radiation Safety Committee; the
Department chairs; the Hospital Medical Executive Committee; and the Board of
the institution. To avoid this negative attention, turn your dosimeter in on time
and promptly report the loss of a dosimeter to the Radiation Safety Office. A new
dosimeter will be issued at no cost and your good name will be preserved.
The Radiation Safety Officer (RSO) reviews dosimetry records on a monthly

basis. Investigations of any exposure exceeding the established standards are
performed to determine whether corrective action can eliminate or reduce
exposures for all concerned. The circumstances surrounding most cases of
excessive radiation exposures are often readily mitigated.
Radiation reports are provided annually to all monitored personnel employed or

practicing at Henry Ford Hospital. In addition, monthly reporting of radiation
exposure is available for highly exposed fluoroscopy users. Individuals can
access their personal records at any time, and written dose estimates are
provided upon request.
ALARA Philosophy
Regulatory dose limits should be viewed as the maximum tolerable levels. Since
stochastic radiation effects, such as carcinogenesis, can not be ruled-out at low
levels of exposure, it is prudent to minimize radiation exposure whenever
possible. This concept leads to the As-Low-As-Reasonably-Achievable (ALARA)
philosophy.
Simply stated, the ALARA philosophy requires that all reasonable measures to
reduce radiation exposure be taken. Typically, the operator defines what is
reasonable. The principles discussed in this manual are intended to assist the
operator in evaluating what constitutes ALARA for his/her fluoroscopy usage.
The Henry Ford Hospital administration is committed to ensuring that radiation

exposure to its medical staff and employees is kept ALARA. Full attainment of
this goal is not possible without the co-operation of all medical users of radiation
devices.
Henry Ford Hospital Radiation Safety Program
Hospital administration has authorized the Radiation Safety Committee (RSC) to

oversee all uses of radiation. The RSC is composed of physicians, physicists,
and other professionals who have extensive experience dealing with radiation
protection matters. The committee appoints a qualified expert (Medical Health
Physicist) to administer the day-to-day activities of the Radiation Safety Office.
Summary of Fluoroscopy Safety
1. Keep beam ON-time to an absolute minimum!

2. Always use tight collimation!
3. Do not overuse the magnification mode.
4. Keep the image intensifier as close to the patient as possible, and the tube
as far away from the patient as possible.
5. Keep the kVp as high as possible considering the patient dose versus
image quality.
6. Keep tube current (mA) as low as possible.
7. Minimize room lighting to optimize image viewing.
8. Do not overuse the high dose rate.
9. Personnel must wear protective aprons, use shielding, monitor doses and
know how to position themselves and the machines for minimum dose.
10. Change projections angle for long procedures to minimize local skin
doses.
11. Remember that the X-ray output, patient dose, and area scatter levels
increase for larger patients.
End of Manual!
Acknowledgements:
We wish to recognize the significant efforts of Scott Sorenson who gave a

substantial portion of this course material to the Medical Physics world to support
his public health efforts in fluoroscopy. Please also recognize the work of Ralph
Lieto, Phil Rauch and Laura Smith. Any errors in this training module are the sole
responsibility of Alan Jackson and Donald Peck of the HFH Radiation Safety
Office.
Fluoroscopy Operator Course Examination
Select from one of the following exams, but do not repeat any exam you have
tested with previously:

Basic Physics Radiation

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Basic Physics Radiation

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Chapter 1: Radiation Physics

Why do we have this course?

Table I-1: Procedures of Particular Concern to FDA

Procedures Involving Extended Fluoroscopy Exposures ¤ ¥

¥ Note: The risk of adverse radiation effects originating from a medically

Radiation Exposure and Public Health Measures

The greatest single source of man-made radiation exposure to the average

Figure I-1: Sources of Radiation Exposure

Studies indicate that this medical radiation exposure can be reduced by

Table I-2: Optimizing Action Ranking for Fluoroscopy

Optimizing Action Potential Dose Reduction Factor

Clearly good operator training is a very important means of reducing medical

Basic Radiation Physics

Knowledge of basic radiation physics is necessary for properly understanding

Courtesy of Albert Einstein Archives

Radiation: is the transfer of energy in the form of particles or waves.

Energy: the ability to do work (Force·Distance)

X-rays are electromagnetic radiation. Electromagnetic radiation is a form of

Figure 1-1: Forms of Electromagnetic Radiation

Courtesy of Phil Rauch and Laura Smith, 2000

Figure 1-2: The Ionization Process

Alan Jackson, 2001

Figure 1-3: Non-Ionizing Radiations

Courtesy of Alan Jackson, 2001

As smaller number of characteristic x-rays are also produced as excited

Figure 1-5: Simplified X-ray Spectrum

Alan Jackson, 2001

X-ray Machine Parameters

X-ray Production Efficiency and Heat Loading

The production of x-rays is a relatively inefficient process so that only a small

Figure 1-6: Heat Production

Courtesy of: Phil Rauch and Laura Smith, 2000

Inverse-Square-Law (Radiation intensity with distance)

Where XA is the radiation exposure rate at distance DA compared with the

This effect is shown graphically in Figure 1-7:

Figure 1-7: Inverse Square Law

Courtesy of Scott Sorenson, 2000

1-Meter Distance: 1,000 X-rays pass through a

2-Meter Distance: With increasing distance, the

An operator normally stands 1 meter away from the patient during

A 31% percent reduction in radiation exposure is achieved in this example.

X-rays Interactions with matter

Figure 1-8: X-ray Interaction-Imaging Considerations

Courtesy of Scott Sorenson, 2000

No interaction: X-ray passes completely throughtissue and into the image

Complete absorption: X-ray energy is completely absorbed by the tissue. This

Partial absorption with scatter: Scattering involves a partial transfer of energy to

X-ray Interaction with Matter

The probability of X-ray interaction is a function of tissue electron density, tissue

Tissue Electron Density Interaction Effects:

As electron density increases, the interaction with X-rays substantially increases.

Figure 1-9: Electron Density and Image Contrast

Courtesy of Scott Sorenson, 2000

Figure 1-10: X-ray Penetration as a Function of Thickness

Courtesy of Scott Sorenson, 2000

Figure 1-11: X-ray Penetration as a Function of Energy

Courtesy of Scott Sorenson, 2000

Application of Radiation Physics

Figure 1-12: Square Hole-Round Peg

Courtesy of Alan Jackson, 2001

Figure1-13: Deposition of Energy

Alan Jackson, 2001

Alan Jackson, 2001