"If the shield affects the image, it can cause the child to be exposed to higher levels of radiation. ”
Written by | Ling Jun, Yan Xiaoliu, Wang Hang
Recently, the radiology department of a hospital in Zhoushan, Zhejiang Province, was placed on file by the Daishan County Health Bureau for failing to remind each other to wear and use personal protective equipment when conducting X-ray imaging examinations on two subjects, and was subject to administrative punishment.
This news has been on Weibo's hot search, and the cumulative number of reads has exceeded 100 million so far. X-ray and CT are essentially X-ray examinations, which are ionizing radiation, and more than a certain dose will cause damage to the human body. Many hospitals and local health departments have released news on official platforms to popularize the importance of science protection.
In this regard, a former chairman of the Radiological Society of the Chinese Medical Association told the "medical community" that the mainland's rules and systems for radiation examination and protection may be backward, and the current equipment has a low radiation dose. However, it should still be complied with until the system is changed, so there is no problem with fines.
Since 2019, many agencies in the United States and Europe have called for or updated guidelines to say that shielding protection in X-ray inspections is no longer supported. In the relevant guidelines issued in the United Kingdom in 2020, even pregnant women and children are not recommended for shielding protection in most cases.
At the 2021 Asia-Pacific Forum on Medical Imaging Quality and Safety (APQS) held in Taipei, Asian experts at the meeting had a heated discussion on "whether X-ray inspection still needs protection", trying to reach a consensus on whether to follow the "Western model" and cancel lead coat protection.
Not wearing protective clothing, is it common?
Common shielding protective equipment includes lead caps, lead scarves, lead aprons, lead triangle scarves, etc., which are used to cover non-inspection irradiation areas to block X-ray penetration to achieve the effect of protection.
According to the "Regulations on the Administration of Radiological Diagnosis and Treatment" revised in 2016 by the mainland, when radiology diagnosis and treatment staff carry out medical radiation on patients and subjects, they should shield and protect sensitive organs and tissues adjacent to the irradiation field. The reason for violating the regulations, the Zhoushan medical institution that was punished this time explained that due to the large number of patients, it was inconvenient to put on and take off protective clothing.
This is not the first time that a medical facility has been penalized for failing to strictly enforce protective practices. The "medical community" checked and found that on October 14, 2023, law enforcement officers of the Health Commission of Zhoukou City, Henan Province, supervised and inspected the DR (digital X-ray photography) room of a hospital, and found that the patients and accompanying persons in the room were not wearing protective equipment. The hospital involved was given an administrative penalty of "warning and a fine of 4,000 yuan".
Earlier, on March 20, 2018, a hospital in Zhijiang City, Hubei Province, was found to have failed to protect the patient's sensitive organs (head, thyroid and gonadal areas) adjacent to the irradiated field of view during chest X-ray. All protective equipment in the hospital was also found to be damaged, broken and stained to varying degrees, which did not meet the national occupational health standards. In the end, the hospital was given a warning and fined 3,000 yuan.
The "medical community" understands that there are indeed differences in the actual operation of various hospitals in China. Ms. Cheng, who lives in Shenzhen, recently took her child to the hospital and had to undergo a CT scan because she was suspected of pneumonia. She remembered that the child wore a lead cap, his eyes were covered with a long strip of lead cloth, and his abdomen was covered with a lead blanket from his ankles down. At the same time, her friend took her son to see a doctor in Beijing, wearing a lead hat and covering his crotch.
Ms. Wang, who is undergoing cancer treatment, said that she had taken X-rays before PICC (peripheral venous puncture central venous catheterization) and did not do any protection at that time. "I feel like it might be a bit of a hassle to wear a lead suit. And there are too many people in the hospital, and the operation is an assembly line. In order to speed up the process, some details are skipped. ”
"According to the relevant national regulations, the site should be equipped with the basic types of protective equipment, the quantity of which should meet the needs of the work. In practice, especially for adolescents, the non-irradiated thyroid gland is a key protection area. A radiologist in the southwest told the "medical community".
A patient who has done protection is doing an examination/Source: "Gulin County Traditional Chinese Medicine Hospital" official account
Europe and the United States have not done protection for many years
The director of the radiotherapy department of a tertiary hospital had studied in Europe and participated in radiotherapy-related work, and he told the "medical community" that in the hospital where he studied, X-rays and other radiological examinations were indeed done without wearing protective clothing.
In 2019, the American Society of Medical Physicists issued a statement stating that the shielding of patients' gonads and fetuses during X-ray diagnostic imaging should be stopped. According to the statement, the practice of protecting the gonads and fetuses by wearing lead clothing has been a tradition for decades, but with advances in technology and the accumulation of evidence of radiation exposure, this practice may become obsolete.
Studies have shown that a 4-year-old child, for example, now routinely receives a radiation dose of 0.06 mGy for an X-ray, compared to 2.5 mGy a few decades ago. By way of comparison, the radiation dose threshold for permanent male infertility is 3500-6000 mGy.
Except in extreme cases, the amount of radiation currently being empowered by imaging techniques is much lower than the exposure to fetal harm, and there is no clear evidence of a benefit to gonadal protection, the association said. At the same time, local shielding does not prevent the scattering of X-rays in the body, which is the main source of radiation dose to organs in non-inspection areas.
On the one hand, if the doctor's shielding operation is not accurate enough and affects the examination site, it may lead to repeated examination or misdiagnosis. On the other hand, the latest X-ray equipment is equipped with automatic exposure technology, which automatically increases the radiation dose to increase the exposure if the instrument detects a shield in the beam range, which in turn exposes the patient to more radiation.
The American Radiological Association and the American Dental Association followed suit, updating the guidelines in 2021 and early 2024, respectively, with the former noting that the use of gonadal lead shielding does not help reduce radiation risks and calling on U.S. states to revise regulations and guidelines.
Nationwide Children's Hospital also said in its "Parent Answers" on its website that it will no longer protect children from X-rays, "and if the shield affects the image, it may cause the child to be exposed to higher levels of radiation." ”
In 2020, the United Kingdom issued an 87-page "Guidelines for the Use of Shielding Protection in Diagnostic Radiological Patients", pointing out that the use of shielding can only be considered in a small number of cases, such as the distance between the gonads and the irradiation site is less than 5cm, or the need for repeated X-ray examinations in a short period of time for certain diseases.
For pregnant women, the examination outside the pelvic area does not need to be protected by lead clothing, and if the examination is close to or covers the pelvic area, it is recommended to directly change the protocol and use non-ionizing radiation imaging examination.
However, the guidelines also point out that due to the deep-seated fear of "radiation" among the public, doctors should also fully weigh the psychological needs of patients when abandoning the use of shielding protection. If the patient insists on wearing a lead suit, but the doctor judges that the protection at this time "does more harm than good", he should patiently explain to the patient and fully convey the correct medical information.
Should it be emulated?
Although Europe and the United States have given good reasons for abolishing shielding protection in X-ray examinations, a number of domestic experts told the "medical community" that whether the mainland should follow suit needs to be further confirmed.
"In response to this problem, the mainland's standards are still based on research in the 80s, and it is really necessary to update and revise them in a timely manner from a professional point of view. A radiologist, who asked not to be named, told the medical community, "but only if there is a lot of upfront evidence gathering to prove that the current equipment can reach a level where the radiation has no effect on the human body." ”
The expert pointed out that it is difficult to say whether the equipment used in Europe and the United States is exactly the same as ours, and it is impossible to make a direct horizontal comparison, "Although the radiation dose of DR and CT has been greatly reduced, how much has it been reduced? Under what circumstances is a large dose still needed? There needs to be evidence-based evidence, in other words, under what circumstances protection is not needed, and under what circumstances is it needed, and this should be further confirmed based on data from the mainland." ”
The above-mentioned radiologist in southwest China said that in the domestic radiology-related conferences and academic discussions she participated, little attention was paid to the wearing of protective clothing. "Medical decision-making requires weighing the pros and cons. In accordance with the internationally accepted principles of radiation protection, accurate diagnostic results are obtained to guide the next step of treatment, and the benefits to patients outweigh the radiation caused by the examination. In a variety of application scenarios such as screening, diagnosis, and follow-up, more research may also be needed to distinguish and refine. ”
The "medical community" learned from the clinical front line that the preparation and protection facilities of the X-ray examination room are standard and the hard indicators of quality control inspection. Some doctors believe that the medical requirements and standards between China and foreign countries are very different, and they are closely related to the diagnosis and treatment process and norms, and cannot be copied from the situation in Europe and the United States.
Today, the "Medical Doctor Station" app voted on this hot search topic, and more than 80% of users believe that it is necessary for patients to wear lead clothing protection when doing radiology projects.
In fact, it's not just the difference in medical care between the mainland and Europe and the United States. At the 2021 APQS conference, although attendees almost unanimously agreed that "obscuring the anatomy and increasing the amount of radiation is a potential risk of continuing to use shielding", experts from various Asian countries did not agree on whether to discontinue shielding.
In addition to differences in healthcare systems and technology, psychological factors, cultural factors, patient anxiety, and legal issues also complicate the problem. "In many cases, even if the radiation risk is negligible, doctors may choose to use protective shields to ease their patients' fears. "According to the minutes, while Western radiologists have also allowed such cases to occur, certain cultural factors in specific Asian countries may increase the frequency of this occurrence.
Although the meeting basically concluded that shielding is no longer a necessary part of routine radiological examinations, it also pointed out that this is only a reference, and that it is up to countries to formulate their own policies on future protection.
Source: Medical community