ORAU Team

NIOSH Dose Reconstruction Project

Technical Information Bulletin: Dose Reconstruction from 

Occupationally Related Diagnostic X-ray Procedures

Document Number:

ORAUT-OTIB-0006

Effective Date: 12/08/2003

Revision No.: 01 

Controlled Copy No.: _________

Page 1 of 21

Subject Expert: Ronald L. Kathren

Approval: Signature on File______________ Date:12/08/2003

Judson L. Kenoyer, Task 3 Manager

Concurrence: Signature on File_________ Date:12/09/2003

Richard E. Toohey, Project Director

Approval: Signature on File__________ Date:12/09/2003

James W. Neton, OCAS Health Science Administrator

Supersedes:

Revision No.: 00

RECORD OF ISSUE/REVISIONS

ISSUE 

AUTHORIZATION 

DATE

EFFECTIVE 

DATE

REV. NO.

DESCRIPTION

Draft 10/27/2003 00-A New document to establish the technical basis 

for the development of a generic document to 

use to perform dose reconstruction from 

occupationally related diagnostic X-ray 

procedures. Initiated by Vern Shockley.

Draft 10/30/2003 00-B Draft revision to incorporate NIOSH and internal 

review comments. Initiated by Vern Shockley.

Draft 11/06/2003 00-C Draft revision to incorporate verbal NIOSH 

comments. Initiated by Judson Kenoyer.

11/14/2003 11/14/2003 00 First approved issue. Initiated by Judson 

Kenoyer.

Draft 11/24/2003 01-A Draft revision that limits the use of this document 

to post 1970. Initiated by Judson Kenoyer and 

Elyse Thomas.

12/08/2003 12/08/2003 01 Approved issue of Revision 01. Initiated by 

Judson Kenoyer.
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 2 of 21

ACRONYMS AND ABBREVIATIONS

cm centimeter

DF dose conversion factor

EEOICPA Energy Employees Occupational Illness Compensation Program Act of 2000

ESE entrance skin exposure

Gy gray

HVL half value layer

ICRP International Commission on Radiological Protection

ICRU International Commission on Radiological Units

IREP Interactive RadioEpidemiological Program

kVp Peak Kilovoltage, applied kilovoltage

lat lateral

mA milliampere 

mAs milliampere-second

mm millimeter

NCRP National Council on Radiation Protection

NIOSH National Institute for Occupational Safety and Health

PA posterior-anterior

PFG photofluorography

R roentgen

RMS root mean square

SID source to image distance

SSD source to skin distance
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 3 of 21

DOSE RECONSTRUCTION FROM OCCUPATIONALLY RELATED DIAGNOSTIC X-RAY 

PROCEDURES

Ronald L. Kathren, Vernon E. Shockley, Elyse M. Thomas, and Timothy D. Taulbee

1.0

An additional contribution to occupational radiation exposure of workers may be from medical 

diagnostic x-ray procedures that are imposed upon the worker as a condition of employment. 

Although clearly occupationally related, the dose from these exposures was typically not measured 

nor was it considered or included as a part of the overall occupational exposure of the employee. With 

the passage of the Energy Employees Occupational Illness Compensation Program Act of 2000 

(EEOICPA), diagnostic medical x-rays administered in conjunction with routine or special physical 

examinations required as a condition of employment are recognized as a valid source of occupational 

exposure and are to be included in the determination or reconstruction of the dose to the worker. 

Unlike occupational exposures incurred during normal work processes, diagnostic medical x-ray 

exposures were not monitored, necessitating reconstruction of the doses acquired in this manner. 

Introduction

The EEOICPA is codified in 42 United States Code 7384-7385 and provides compensation for 

workers and former workers in the nuclear weapons production programs of the U.S. Department of 

Energy and predecessor agencies (DOE) who have been diagnosed with cancer providing that the 

cancer was “at least as likely as not” to have been attributable to the occupational dose acquired while 

working in the DOE programs. To enable this determination to be made, the National Institute for 

Occupational Safety and Health has been charged under the provisions of Title 42, Code of Federal 

Regulations, Part 82, with developing dose reconstruction methods and with applying the doses to 

determined the probability of causation -- i.e. the likelihood that the cancer was attributable to the 

occupational radiation exposure incurred by the worker. Of necessity, this requires knowledge of 

specific organ doses. Accordingly, a comprehensive guidance document for external dose 

reconstruction has been developed to assist qualified health physicists in implementation of the 

EEOICPA (OCAS 2002). This report supplements and expands upon the guidance provided in the 

OCAS document by providing more specific and detailed methodology for dose reconstruction from 

diagnostic medical x-rays that were sustained by workers as a condition of employment, and provides 

the technical basis for dose reconstruction in the absence of specific dose measurements or records 

of technique factors. The additional guidance provided in this report is needed because of the paucity 

of available technical data and records specific to medical diagnostic exposures experienced by 

workers in the DOE weapons program 

2.0

A number of factors determine the dose to the patient from a diagnostic x-ray procedure. For a more 

or less standard medical radiographic (i.e. diagnostic) unit with a tungsten target (anode) and focal 

spot of 1-2 mm, these include the basic machine settings used for the exposure, viz. the applied 

kilovoltage of the beam (kVp, also known as peak kilovoltage or kilovolt peak), beam current (mA), 

and time of exposure, distance, waveform, amount and kind of filtration used, collimation or use of 

diaphragms, tube housing characteristics, the type and speed of the film, development procedure, 

screens, grids and the size of the patient. While the list of factors enumerated looks formidable, in the 

absence of direct measurements of the beam itself, which are rarely available, the dose to the patient 

can be estimated with a reasonable degree of accuracy with knowledge of only the three basic 

machine parameters: applied kilovoltage, current, and time, along with filtration, collimation and 

waveform characteristics. The implications of these factors insofar as patient dose is concerned are 

briefly discussed below.

Technical Factors Affecting Diagnostic X-Ray Dosage
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 4 of 21

2.1 APPLIED KILOVOLTAGE AND FILTRATION

The energy of the x-ray beam is determined by the applied kilovoltage and the filtration, and is 

sometimes referred to as beam quality. X-rays, as produced in a typical medical x-ray tube, are 

bremsstrahlung produced when electrons from the cathode are accelerated into the anode as a result 

of the potential difference or applied kilovoltage between the two electrodes. As such, x-rays from a 

medical x-ray tube are a distribution or spectrum of energies ranging from zero to the applied 

kilovoltage, which refers to the potential between the anode and cathode of the tube. For a typical 

unfiltered x-ray spectrum, the average energy is about one third of the peak or maximum x-ray 

energy, or applied kilovoltage. Hence most of the x-rays produced are very much lower in energy 

than the applied kilovoltage of the beam, and thus are attenuated by the torso or other portion of the 

body being radiographed and never reach the film. These x-rays are of little value in radiography but 

contribute significantly to patient dose.

To reduce the dose to the patient, filtration in the form of a specified thickness of absorbing material is 

added to the beam. This has the net effect of absorbing a large fraction of the lower energy x-rays 

that are of little or no value in making the radiograph while allowing a greater fraction of the more 

energetic and radiographically useful x-ray photons to pass. In this manner, the dose to the patient is 

significantly reduced while at the same time radiographic quality may be enhanced. A filtered x-ray 

spectrum has a correspondingly higher average energy than before it was filtered, although the 

photon fluence rate is much reduced. Such a beam is said to have been hardened. A corollary to this 

filtration technique is to use a higher applied kilovoltage, and filter the beam relatively heavily to 

eliminate most of the low energy radiographically useless photons from reaching the patient. 

Beam energy is specified in terms of quality, or hardness, which in turn may be specified in terms of 

the half value layer (HVL) in aluminum. Unfortunately, this parameter is seldom available, and even if 

known is of limited value, in part because it does not specify the maximum energy of the beam or its 

true quality, since as the HVL measurement is made, the absorbers act as filters and the beam is

further hardened. Thus the first HVL is always smaller than the second HVL beam, which in turn is 

smaller than the third, and so forth. A useful although rarely available measure is the homogeneity 

factor, which is simply the ratio of the first and second HVLs. Since the first HVL is always the 

smallest, the homogeneity factor will always be < 1, and the closer it approaches unity, the more 

closely the beam approximates a monoenergetic photon beam whose energy can be determined from 

the HVL. What is most commonly, although not always, available, is the kVp of the machine and the 

external or added filtration. All x-ray tubes have so-called inherent filtration, which is the window or 

port of the x-ray tube. In medical diagnostic units, the window or beam port through which the useful 

beam emerges is purposely made very thin, typically equivalent to 0.5 mm Al in attenuation, and 

hence provides little beam hardening.

Although the benefits of filtration with respect to improved radiographic images were known and 

understood as early as March 1896, within months of the discovery of x-rays (Magie 1896), initially 

diagnostic radiographs were made with no added filtration. Recommendations, albeit not specific as 

to thickness, were put forth in 1937 by the International Committee for Radiological Units which 

specified aluminum filters for x-rays of 20 to 120 kVp which incorporated the diagnostic x-ray energy 

range (ICRU 1937). This was consistent with, although not as specific as, the 1936 recommendation 

of the U.S. Advisory Committee on X-Ray and Radium Protection, the forerunner of the NCRP, which 

called for total filtration 0.5 mm of Al equivalent for radiographic installations, and 1 mm Al for 

fluoroscopy (NBS 1936). Generally, manufacturers of radiographic x-ray tubes complied with this 

standard, and medical radiographic tubes in use in the 1940’s typically had inherent filtration of 0.5 

mm Al (Morgan and Corrigan 1955, pp. 308-310). 
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 5 of 21

Typical external or added filtration in the 1940’s ranged from none to 1 mm Al. In 1949, the NCRP 

recommended 1 mm of added Al filtration for radiographing thick parts of the body such as the chest 

in 1949 and this thickness was in use during World War II in 100 mA units in larger military hospitals, 

and hence presumably at the various Manhattan District sites which were under the aegis of the U.S. 

Army (Olson, Trask and Dessent 1966). Subsequently, recommended thicknesses were increased 

not only for patient protection but for improved radiographic image quality; in 1955, the NCRP 

recommendation for diagnostic x-ray units called for 2 mm total Al filtration for new machines (NBS 

1955), the filtration increased again to 2.5 mm by the 1960’s for medical diagnostic units operating 

above 70 kVp (NCRP 1968). For machines already in operation, these recommended filter thickness 

might not have been utilized for some time after the date of the recommendation.

The relationship of beam intensity1 to applied kVp and to filtration is complex and to some extent is 

machine specific and hence is best determined empirically. However, in the absence of empirical 

data for a specific machine, adequate contemporary empirical and theoretical data exist upon which to 

determine within a reasonable degree of uncertainty, the machine output. Additional filtration reduces 

the entrance skin exposure2

I = Ioe-0.5t

(ESE), generally in an exponential manner. For a typical single phase 

half, full or self rectified machine operating in the diagnostic range of 80 –100 kVp, each additional 

mm of Al filtration will effect a reduction of about 40 per cent in the ESE (Trout et al. 1952; Taylor 

1957). The approximate intensity reduction afforded by any thickness of Al filtration can thus be 

determined by the following exponential equation:

or

ln (I/Io) = - 0.5 t

in which t is the thickness of Al, in mm, and I and Io are the beam intensities with and without the filter, 

respectively. In the absence of specific measurements or empirical data, this correction can be 

applied to determine the effect of filtration on beam intensity, and is consistent with the guidance put 

forth in OCAS-IG-001 Revision 1 (2002).

Similarly, increasing the kVp will increase the beam intensity or exposure rate. This can be calculated 

using Kramer’s rule, but such calculations are difficult, complex and time consuming, even with high 

speed computers, and are at best approximations. However numerous empirical studies of beam 

intensity as a function of kVp have been carried out over the years and provide ample credible 

evidence to show that for a given amount of filtration, increasing the applied kVp will increase the 

beam intensity according to the 1.7 power of the applied kilovoltage (Handloser 1951; Trout et al. 

1952; Kathren 1965; Cameron 1970). In the absence of specific measurements or empirical data, this 

function can be applied to determine the effect of applied kilovoltage on beam intensity, and is fully 

consistent with the OCAS guidance document (OCAS 2002). 

 

1

 As used herein, beam intensity refers to the output of the machine in terms of exposure in the special sense 

per mAs. Exposure in the special sense is referenced to ionization in air and as such is not a dose quantity. 2 Throughout this document, italics will be used to differentiate exposure in the special sense from exposure in 

the general sense. Thus exposure refers to exposure in the special sense. A brief discussion of exposure in 

both the general and special sense can be found in numerous publications, including NCRP Report 82 (1985) 

and ICRU Report 60 (1998). It is important to note that the definition and application of the quantity exposure 

and its concomitant unit the roentgen have undergone several important modifications over the years, which 

have been documented throughout the literature.
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 6 of 21

It should be noted that the effects of filtration and kVp tend to offset one another; addition of filtration 

reduces the exposure or dose per mAs, while increasing the kVp increases the exposure and dose 

per mAs. Higher kVp radiographic techniques typically require shorter exposures in terms of mAs, 

and the dose reduction from additional filtration at the recommended level more than offsets the 

additional dose from using increased kVp. However, there is not a direct correspondence or 

proportionality between the effects of filtration and kVp. 

2.2 CURRENT AND EXPOSURE TIME

Diagnostic x-ray exposures are typically specified in terms of milliampere-seconds (mAs), the product 

of x-ray tube current and the exposure time. Other factors being equal (e.g. kVp, filtration, film, 

development and screen combination) radiation exposure is thus proportional to the number of mAs. 

The current in an x-ray tube refers to the number of electrons accelerated across the evacuated 

volume of the x-ray tube, flowing from the cathode to the anode. For a given applied kilovoltage, the 

number of x-ray photons produced, and hence the exposure, will at least in theory be directly 

proportional to the x-ray tube current, and indeed this is and has been historically true for most 

medical radiography units over their designed tube current range. Thus, in the absence of 

measurements or other data or information to the contrary, it is reasonable and consistent with long 

standing radiographic practice (Sante 1946) to assume linearity of beam intensity and hence patient 

dose with tube current.

Exposure time refers to the time that the beam was on or the machine was producing x-rays and is, 

for all practical purposes, linear with exposure. To avoid or minimize image blurring from the beating 

heart, exposure time was minimized, and the current concomitantly and proportionately increased to 

obtain the desired exposure in terms of mAs. However, from a dose reconstruction standpoint, it 

should be noted that earlier medical radiographic units were equipped with mechanical timers whose 

accuracy was not as good as the electronic timers used on later model apparatus. Gross bias errors 

in timer accuracy are unlikely in that these would result in over- or underexposure of the radiograph 

and so would be quickly detected and corrected. More subtle are small random errors, which might 

produce uncertainties of perhaps + 20 per cent in the exposure. 

Chest photofluorography, which resulted in very much greater patient doses from a diagnostic 

procedure, was used sporadically until as late as the early 1960’s. Photofluorography used a 

smaller film (4 x 5 inches), a smaller SSD (42 inches), and both a higher kVp and typically a several 

fold greater exposure in terms of mAs. Exposure was regulated by photometers, which utilized the 

exposure to the film to determine the time of exposure. 

2.3 DISTANCE

X-ray beam intensity is a function of distance from the target, approximating inverse square at large 

distances from the tube. Radiographic chest films were taken at a standard source to image distance 

(SID) of 72 inches; the source refers to the focal spot of the tube and the image to the plane of the 

film. The distance to the patient, sometimes expressed in terms of the source to skin distance (SSD), 

is somewhat smaller since the patient is positioned between the source and the film cassette and 

hence, the entrance skin exposure (ESE) to the patient is somewhat greater than the exposure at the 

plane of the film. In addition, patient attenuation would further reduce or attenuate the number of 

photons reaching the film. To compensate for the increased attenuation provided by a larger patient, 

x-ray technicians would sometimes increase the beam settings for a large patient, or, if the machine 

was so equipped, might use a high speed Bucky diaphragm, likely with a somewhat higher kVp. It 

thus may be appropriate for an individual dose reconstruction to increase the ESE or skin entrance 

kerma for a large or stout patient. Based on standard contemporary techniques (Picker 1941; Fuchs 
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 7 of 21

1958; Cahoon 1961) for patients with a chest thickness of 25-27 cm, an increase of +50 % from the 

ESE to the average patient should be sufficiently conservative; for still larger patients, a factor of 2 

would be appropriate. The average worker chest size is taken to be 22-24 centimeters. 

2.4 COLLIMATION AND WAVEFORM CHARACTERISTICS

Among the other factors that potentially affect patient dose are collimation and waveform. X-ray 

waveforms are of three types: half wave rectified, which is almost never seen; full wave rectified, 

which is typical of virtually all medical radiographic units, and constant potential. A half wave rectified 

machine produces 60 half sinusoidal shape pulses of x-rays per second, each with a duration of 1/120 

of a second. A full wave rectified machine produces 120 half sinusoidal pulses of x-rays per second, 

each with a duration of 1/120 second. Thus, for a given setting of kVp and mA, the intensity of the 

beam from a half wave rectified machine will be half that of the beam from the full wave rectified type. 

A constant potential machine produces a more or less steady (i.e. unpulsed) output of x-rays and has 

a somewhat greater beam intensity – approximately 10 per cent – as compared with a full wave 

rectified machine operating at the same kVp and mA. 

Collimation refers to the size of beam. Early, the philosophy was to use a fairly large aperture (i.e. 

limited collimation) to ensure that the entire area of interest was included in the radiograph. 

Subsequently, because of patient protection concerns, beams were collimated such that the smallest 

beam consistent with the area of interest was used, thereby limiting the area of the patient exposed, 

and, in the case of chest radiography, minimizing dose to organs such as gonads, thyroid, and 

gastrointestinal tract. A practical check of collimation can be made by reference to the radiograph; a 

well collimated beam will leave a small unexposed area or penumbra effect at the edges of the 

radiograph, while a poorly collimated beam will produce a radiograph that is exposed all over its area. 

Beam diameter limiting cones were used in radiography during the 1940’s and beyond to improve 

radiographic image quality by reducing scatter (Glasser et al. 1944, p. 136) and were sometimes 

equipped with an Al filter, 1 mm in early years and thicker later on. 

Due to the reported variation in the literature and measurement data on the effects of collimation, the 

claimant favorable assumption of no external collimation of the primary beam should be used when 

measurement data, technique, or other information to describe the collimation are not available for xrays taken prior to 1970. This is based on the following claimant favorable assumptions and 

professional judgment:

1. In the late 1950s, there was significant research into the gonadal dose and the reasons for the 

observed variation in dose. This research described the effects of filtration, collimation, and 

centering. By the early 1960s, techniques were being modified incorporating additional 

collimation. While these techniques were likely fully incorporated at most DOE facilities by 

1965, to allow for the possibility that some smaller facilities might not have had the resources 

to update their equipment and to be claimant favorable, the year 1970 was selected. 

2. In 1968, the National Council on Radiation Protection and Measurements (NCRP) in Report 33 

updated their guidance on medical x-ray protection. While many DOE facilities had probably 

already incorporated the guidance in this report, some smaller facilities might not have 

incorporated the guidance by 1968. To ensure that these facilities were in fact in conformance 

with the 1968 recommendations, an additional two-year period was added. 

3. By the late 1950s, reports in the literature of most of the surveys of medical x-ray facilities 

revealed low gonadal doses, indicating adequate collimation. A few surveys clearly indicated 

the use of collimation was limited. Of the eight surveyed facilities at Oak Ridge, only one 
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 8 of 21

(13%) had a moderately high male gonadal dose (5 mrad). All of the other facilities, the male 

gonadal dose was less than 2 mrad. Variation between the other facilities appeared to be the 

result of differences in the use of filtration and cone size. Since most facilities were using 

some form of collimation by the late 1950s, by the mid 1960s most, if not all, facilities were 

probably using some form of collimation. Since references as to when all facilities were using 

adequate collimation were not found, professional judgment was used to estimate this time 

period to be the mid 1960s. To fully assure claimant favorability, this assumption has been 

further expanded by 5 years to 1970 to allow for the uncertainty in professional judgment.

The organ doses in this document apply to chest x-rays performed after 1970 which are assumed to 

be properly collimated. Organ doses for chest x-rays performed before 1970 which may have been 

minimally collimated, will be published in a separate document.

2.5 SCREENS, GRIDS, AND OTHER FACTORS POTENTIALLY AFFECTING PATIENT 

DOSE

A number of other factors also affect the x-ray exposure required to obtain a proper radiograph and 

hence the dose to the patient. However, knowledge of these factors is unnecessary for dose 

reconstruction purposes if beam measurements are available or if the primary machine characteristics

of applied kilovoltage (kVp), time and current (mA) are known along with the amount of primary beam 

filtration, although they can be used as additional confirmation of the applicability of the reconstructed 

dose. Hence, for completeness, only brief mention will be made of these factors, which are: tube 

housing, type and speed of the film, development procedure, screens, and grids.

X-ray tubes used for diagnostic radiography are typically enclosed in a protective lead tube housings 

with the primary beam brought out through a port or window in the side of the housing. Although 

some reduction of the dose to the patient is achieved, largely through elimination of scattered 

radiation and improved collimation, this so-called diagnostic tube housing is primarily for the purpose 

of protection of the operator and unexposed x-ray film and nearby individuals other than the patient. 

The issue is moot, however, since virtually all x-ray tubes used to x-ray the DOE weapons worker 

cohort have been equipped with protective tube housings, which limited leakage to < 0.1 R/hr at one 

meter from the tube. 

The exposure needed for a suitable diagnostic radiograph is in some measure a function of film speed 

and development. So called fine grain emulsions produce a superior radiographic image but require 

additional exposure as compared with so called fast films, which typically have a larger grain size. 

Underdevelopment of films will also require additional exposure to achieve satisfactory radiographic 

quality. Intensifying screens are used within the cassette to intensify the radiographic effect and 

thereby effectively increase film speed and reduce patient dose. Film speeds have typically increased 

since the 1940’s and reduced patient doses appreciably, perhaps by half. Grids, specifically the 

Potter Bucky diaphragm (also more or less colloquially known as a Bucky) are sometimes utilized for 

thick section radiography, but rarely used for chest radiography except with very large patients. In 

any case, the above are all factored into the technique (i.e. kVp, mA) that is used and except in rare 

instances and a virtually complete absence of other data, are not of importance in dose 

reconstruction.

2.6 SUMMARY AND APPLICATION OF TECHNICAL FACTORS

For convenience and possible application to cases in which other and more suitable data are not 

available, or for generic use, the effect of various technical factors has been tabulated below in Table 

2.6-1. Samples of technique factors are represented in Table 2.6-2.
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Table 2.6-1. Relationship of Beam Intensity and Various Technical Factors

Parameter Units Relationship with intensity

Applied voltage kVp Intensity proportional to 1.7 power of kVp

Tube current mA Linear

Exposure time s Linear

Filtration mm Al Intensity decreases by ~40% for each additional mm 

Al

Patient Size (chest 

thickness) 

25-27 mm 

> 27 mm

Dose increased by factor of 1.5 

Dose increased by factor of 2

Distance d Approximately inverse square relationship (1/d2) holds 

for distances > about 30 cm from target

Uncertainty ± 30% Assumes all errors are positive, + 30% should be used 
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Table 2.6-2. Samples of Technique factors used for different types of X-ray equipment.

Machine View Current (mA) Voltage (kVp) Exposure time (sec.)

Type II PAa 300 110-120 1/30

Type III PA 300 120 1/40 

Type IV PA 300 120 1/40 a PA indicates a posterior/anterior view, the average PA chest measures 26 cm. The average Lat. chest measures 34 cm.

3.0

Not all workers were required to undergo medical diagnostic x-ray examinations as a condition of 

employment, and among those who were, the procedure was usually limited to a single PA chest film, 

although a lateral chest film might also be taken. Some workers were examined with chest 

photofluorographic units which produced a much greater dose than the standard PA radiograph. A 

very small fraction might have undergone lumbar spine or other specific procedures if there was a 

medical indication.

Reconstruction of Diagnostic Medical X-Ray Doses

The incidence of defective films necessitating retakes is not known, but it is likely to have been very 

small, and certainly no more a few per cent and probably much less. Trout et al (1973) in their 

analysis of the rejection rate of chest radiographs obtained during the Coal Mine “Black Lung” 

program reported an average rejection rate of 3% among 67,000 radiographs. Retakes should serve 

as a signal to give special consideration to the evaluation of technique factors, and hence the 

resultant dose calculations. A retake in a very large individual might serve as a signal that the initial 

radiograph was taken with technique factor settings suitable for a smaller person, and that the second 

radiograph reflected an additional and larger dose. Retakes in African-Americans may signal that the 

initial exposure was too great, and indicative of an overriding of the standard or automatic technique 

factors because of a perception held by some x-ray technicians that African-Americans had greater 

bone density or other characteristics that required additional exposure. Similarly, retakes in females 

may be indicative of manually altered settings to increase beam intensity under the misimpression 

that additional exposure was required for women because of the larger amount of breast tissue. 

Unless machine settings have been recorded, it is impossible to determine whether the retake was 

necessitated by an arbitrary manual increase in machine settings to obtain a greater exposure. If 

machine settings are available, then an adjustment for the increased doses can be made using the 

data provided in Table 2.6-1. If machine settings are not available, then to ensure claimant 

favorability for African-Americans and women whose records indicate retakes, an upward adjustment 

of the organ doses from the first radiograph is indicated; increasing doses by a factor of two in these 

cases should more than compensate for the supposed additional exposure. 

Diagnostic medical x-ray dose reconstruction is best accomplished when actual measurements of 

beam intensity are available. Use of actual measurement data is the simplest and most direct means 

of assessing diagnostic medical x-ray doses, typically requires few, if any assumptions, and has the 

least amount of uncertainty. Hence, use of actual measurement data, where available, is preferred for 

diagnostic medical x-ray dose reconstruction and should be used if available. Actual beam 

measurements are most likely to provide the most accurate estimates of organ doses.

X-ray output measurements are likely to be unavailable, particularly prior to about 1980. In the 

absence of suitable measurement data, medical diagnostic x-ray dose reconstruction can be 

accomplished using technique factors along with published output data that provide beam intensity 

per mAs as a function of kVp, filtration, and distance. The use of technique factors will typically 

require a number of assumptions, and these, of course, should be claimant favorable. If both 

measurement data and technique factors are unavailable or unknown, then dose estimates can be 
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made using the default values shown in Table 3.3-1. Use of default values is a last resort. 

Reiterating, the first choice should be to use actual beam measurement data when available. 

3.1 RECONSTRUCTION WHEN MEASUREMENTS ARE AVAILABLE

Although beam output measurements may typically be unavailable, diagnostic medical x-ray dose 

reconstruction using actual measurement data is the preferred method for determining the dose to the 

worker from this source, so much so that special effort to determine if such measurements have been 

made is justifiable. Beam output measurements are typically made in terms of exposure and are 

quantified in units of R, and depending on the measurement device and technique may have a wide 

range of uncertainty. The best measurements are those made with integrating ionization chambers 

designed for medical x-ray applications; until about 1970 or so, there were two such instruments in 

common usage and availability in the United States, the Victoreen R-meter, or Landsverk L series ion

chambers. More recently, a wide variety of such instruments have become available. Measurements 

with R-meters and similar chambers, if properly done, have a high degree of reliability and a low 

degree of uncertainty. Generally, the uncertainty of properly done measurements in the energy region 

of interest should not exceed + 2 % of the measured value (Kathren and Larson 1969). 

Other integrating devices such as film, TLD and pocket ionization chambers have also been used for 

beam output measurements. Measurements made with these types of dosimeters should be used 

with great caution. All are, to varying degrees, energy dependent, and correction for beam energy is 

a necessity. This requires knowledge of the x-ray beam energy and the response of the dosimeter as 

a function of energy. Typically, pocket ionization chambers provide the least reliable measurements 

with the greatest uncertainty, and results obtained with these devices are highly suspect and should 

be used with great caution. Film and TLD, if appropriately calibrated to the beam energy, can provide 

satisfactory measurements, albeit with a considerable degree of uncertainty. The widely used LiF 

TLDs, compared with higher Z phosphors and film, show relatively good energy and other response 

characteristics, and, if properly used can provide uncertainties similar to those of R-meters. 

Considerably greater uncertainty – perhaps on the order of several tens of a percent – may apply to 

film dosimeters. No specific uncertainty values can be provided here, as each film dosimeter and TLD 

system is different, and reference to the literature is necessary to determine the appropriate values for 

specific dosimeter systems. 

Beam output measurements usually define or directly determine the ESE, or can be corrected to 

obtain a reasonable estimate of the ESE for a given procedure by using the generic intensity 

relationships shown in Table 2.6-1. The ESE will, of course be in units of R, which must be converted 

to kerma and then to organ dose. As discussed above, an exposure of 1R is typically taken to be 

equal to a kerma of 1 rad (10 mGy); actually, 1R is slightly less than 1 rad (10 mGy) of kerma, but the 

difference is small and making the numerical equivalence greatly simplifies the dose reconstruction as

well as providing a small additional measure of claimant favorability.

Once the ESE has been converted to entrance kerma, doses to a number of different organs from 

various radiographic procedures can be obtained from tables A2 through A9 of ICRP Publication 34 

(ICRP 1982). Use of these tables requires knowledge of the x-ray beam quality expressed in terms of 

the HVL in Al. If the kVp and filtration are known, HVLs can be estimated from the data given in Table 

A16 of ICRP Publication 34 (ICRP 1982, p. 77) or Table B.2 in NCRP Report No. 102 (p. 98). In 

general, the greater the kVp and filtration, the greater the HVL. If the actual beam quality is unknown, 

as is likely the case, to ensure claimant favorability a higher rather a lower HVL should be assumed. 

In the absence of actual data, recommended default values for beam quality are 2.5 mm Al HVL for 

radiographs taken prior to 1980, and 4.0 mm for radiographs subsequently. These values are likely 

overestimates of HVL and hence are claimant favorable.
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 12 of 21

However, Tables A2 to A9 in ICRP Publication 34 do not include all the organs that have been 

identified in the IREP code. For those organs included in the IREP but not specifically identified in 

ICRP Publication 34, use of the dose conversion coefficient for the organ specified in ICRP 

Publication 34 that is anatomically the closest would seem to be a reasonable and simple first order 

approach that generally would be claimant favorable or neutral. Thus, the factor for lung would be 

applied to all other organs within the thoracic cavity – i.e. thymus, esophagus, and stomach. Since an 

appreciable fraction of the skeleton, and in particular the trabecular bone which has a large surface to 

volume ratio and the sternum lies within the trunk, the factor for lung would also be applied to the 

bone surfaces. For organs in the abdomen – i.e. liver, urinary bladder, and colon – the dose 

conversion coefficient for ovary would be used. For the eye, the analogous organ is the thyroid. Skin 

dose can be obtained by reference to Table B.8 in NCRP Report No. 102 (NCRP 1989, p. 103), which 

provides backscatter factors for different beam qualities and field sizes. For chest radiography, a 

backscatter factor of 1.35 is recommended to ensure claimant favorability.

It is useful to prepare a summary table of beam parameters as shown in Table 3.1-1. This table is 

taken from actual data and measurements available for the Hanford Site and is shown here as an 

example of what a summary table should include where measurements are available. The table 

includes not only the measured values for given time periods, but a reference to those values as well 

as other salient data pertaining to beam and exposure. 

Table 3.1-1. Example of Summary Data Based on Actual Beam Measurements for the Hanford Site.

Date 

Measured

10/18/1999 2/04/98 4/22/1997 11/11/1993 3/30/1990 1/21/1988

Procedure Chest PA 

14"×17"

Chest PA 

14"×17"

Chest PA 

14"×17"

Chest PA 

14"×17"

Chest PA 

14"×17"

Chest PA 

14"×17"

Machine type XMA - 360 XMA - 360 CONXI Type 

12

CONX Type 12 CONX Type 

12

CONX Type 12

Machine 

settings kVp:

110 110 110 110 110 110

mA 300 300 300 200 200 200

Exposure 

time 

1/60 sec 1/60 sec 1/30 sec 1/30 sec 1/30 sec 1/20 sec

mAs 5 5 10 6.7 6.7 10

Added filter 2.7 mm 2.7 mm 2.5 mm 2.5 mm 2.5 mm 2.5 mm

Filtration 

used for 

calcs.

4.0 mm 4.0 mm 4.0 mm 4.0 mm 4.0 mm 4.0 mm

Source to 

skin distance

72" 72" 72 " 72 " 72 " 72 "

Entrance skin 

exposure

11 mR 11 mR 17 mR 21mR 21 mR 

(Assumed)

35 mR

mR/mAs 2.2 2.2 1.7 3.3 3.3 3.5
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 13 of 21

Date 

Measured

10/18/1999 2/04/98 4/22/1997 11/11/1993 3/30/1990 1/21/1988

Date range 2/98 to date 4/97 to 2/98 3/90 to 4/97

Reference Washington 

State Dept. of 

Health 

Measurement

Washington 

State Dept. of 

Health 

Measurement

Washington 

State Dept. of 

Health 

Measurement

Washington 

State Dept. of 

Health 

Measurement

Measured at 

11.7 mR by 

State. The 

1993 value 

was used, as it 

was higher for 

same 

settings& 

machine. 

Washington 

State Dept. Of 

Health 

Measurement

Date Measured 1/20/1988 1/28/1983 4/12/1959 2/1/1946 Before 2/46

Procedure Chest PA 14"×17" Chest PA 14"×17" Chest PA 14"×17" Chest PA 14"×17" Chest PA 14"×17"

Machine type CONX Type 12 G.E. DXR 750 Unknown Unknown Unknown

Machine settings 

kVp: 

110 100 80 80 Unknown

mA 100 200 300 500 Unknown

Exposure time 1/10 sec 1/20 sec 1/30 sec 1/20 sec Unknown

mAs 10 10 10 25 Unknown

Added filter 2.5 mm 2.5 mm 1.5 mm 1.5 mm 1.5 mm

Filtration used for 

calcs.

4.0 mm 2.5 mm 2.5 mm 2.5 mm 2.5 mm

Source to skin 

distance

72 " 72 " 72 " 72 " 72 "

Entrance skin 

exposure

35 mR 35 mR 40 mR 79 mR 120 mR

mR/mAs 3.5 3.5 4 3.2 Unknown

Date range 1/83 to 3/90 4/59 to 1/83 2/46 to 4/59

Reference Washington State 

Dept. of Health 

Measurement

Kathren to Heid 

memorandum 

Dated 1/28/83

Rising & Soldat 

letter to Norwood 

dated 4/30/59

Mancuso et al. 

Dated 1966

Based on 

experience & 

references of 

early 1940s x-ray 

dose. Assumed 

for Hanford.
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 14 of 21

3.2 RECONSTRUCTION USING TECHNIQUE FACTORS

When beam measurement data are unavailable, as is likely to be the case, technique factors can be 

used to obtain reasonable estimates of exposure. The basic data required are kVp, filtration, 

exposure in mAs, and distance. Beam output data are available from a number of publications, 

including NCRP Report No. 102 (NCRP 1989). Table B.3 in this report (p. 99) provides average air 

kerma rates for medical diagnostic x-ray equipment operating at various kVps with 2.5 mm Al filtration 

at distances from 30 to 182 cm from the source. Correction for different thickness of Al filtration can 

be made by reference to Table 2.6-1. Alternatively, Figure B.1 (p. 109) in NCRP Report No. 102 

provides a graphical representation of air kerma at 100 cm for various values of kVp and filter 

thickness > 2.5 mm Al. Using these tables, a reasonable estimate of beam output and hence 

entrance kerma can be obtained. Once the entrance kerma has been determined, organ doses are 

determined in the manner described above for reconstruction using measurement data. 

3.3 RECONSTRUCTION USING DEFAULT VALUES

Default values of entrance kerma have been developed for the three most commonly used 

occupational medical diagnostic x-ray procedures: PA chest radiography; lateral chest radiography; 

photofluorographic chest films when actual measurement data or knowledge of technique factors are 

absent. The default values are considered to be maxima developed from review of patient doses as 

reported in the literature, machine characteristics, and knowledge of x-ray procedures used during the 

time periods indicated. Sufficient conservatism was included in the determination of the default 

values to ensure with near certainty (99+ per cent confidence) that the actual exposures from the 

specified procedures would not exceed the default values, thus ensuring claimant favorability. In 

determining these factors, it was assumed that a minimum of filtration was used along with low 

kilovoltage techniques, slow film speeds with standard development, and no additional collimation or 

use of cones. The default entrance kerma values for the three procedures are given in Table 3.3-1. 

Table 3.3-1. Default Dose Values by Procedure 

Period

Entrance kerma, cGy Entrance kerma, cGy Entrance kerma, cGy

PA chest Lateral chest Photofluorographic chest

Pre-1970 0.20 0.50 3.0

1970-1985 0.10 0.25

Post 1985 0.05 0.13

The above default values can then be used as described above in lieu of actual measurement data or 

entrance kerma derived from technique factors.

4.0

Table 4.0-1 provides organ dose conversion factors and organ dose calculations for dose 

reconstruction for chest x-rays performed after 1970.

Application and Reporting of Occupational Medical X-Ray Dose Reconstruction
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 15 of 21

Table 4.0-1. Organ doses for Default Entrance Kerma Values

Organ View

Dose Conversion 

Factor (mGy per Gy air 

kerma) (a)

HVL 2.5 mm Al

Organ Dose 

1970-1985

(rem) (c,d)

Thyroid PA 32 3.20E-3

Lat 115 2.88E-2

Eye/Brain PA 32 3.20E-3

Lat 115 2.88E-2

Ovaries PA 1 1.00E-4

Lat 0. 6 1.50E-4

Liver/Gall 

Bladder

PA 1 1.00E-4

Lat 0. 6 1.50E-4

Urinary 

Bladder

PA 1 1.00E-4

Lat 0. 6 1.50E-4

Colon 

Rectum

PA 1 1.00E-4

Lat 0. 6 1.50E-4

Testes PA 0.01 1.00E-6

Lat 0.1 2.50E-5

Lungs 

(male)

PA 419 4.19E-2

Lat 193 4.83E-2

Lungs 

(female)

PA 451 4.51E-2

Lat 220 5.50E-2

Thymus PA 451 4.51E-2

Lat 220 5.50E-2

Esophagus PA 451 4.51E-2

Lat 220 5.50E-2

Stomach PA 451 4.51E-2

Lat 220 5.50E-2

Bone 

Surfaces

PA 451 4.51E-2

Lat 220 5.50E-2

Remainder PA 451 4.51E-2

Lat 220 5.50E-2

Breast PA 49 4.90E-3

Lat 255 6.38E-2

Uterus PA 1.3 1.30E-4

Lat 0.6 1.50E-4

Bone 

Marrow 

(male)

PA 92 9.20E-3

Lat 37 9.25E-3

Bone 

Marrow 

(female)

PA 86 8.60E-3

Lat 29 7.25E-3

Total Body 

(male) 

PA 131 1.31E-2

Lat (b) 64 1.60E-2

Total Body 

(female)

PA 118 1.18E-2

Lat (b) 60 1.50E-2

Skin (e) PA 1.35E-1

Lat 3.38E-1
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Table 4.0-1. Organ doses for Default Entrance Kerma Values (cont’d)

Organ View Dose Conversion Factor 

(mGy per Gy air kerma)

HVL 4.0 mm Al (a)

Organ Dose 

Post 1985

(rem) (c,d)

Thyroid PA 78 3.90E-3

Lat 164 2.13E-2

Eye/Brain PA 78 3.90E-3

Lat 164 2.13E-2

Ovaries PA 5.2 2.60E-4

Lat 2.5 3.25E-4

Liver/Gall 

Bladder

PA 5.2 2.60E-4

Lat 2.5 3.25E-4

Urinary Bladder PA 5.2 2.60E-4

Lat 2.5 3.25E-4

Colon/Rectum PA 5.2 2.60E-4

Lat 2.5 3.25E-4

Testes PA 0.01 5.00E-7

Lat 0.1 1.30E-5

Lungs (male) PA 628 3.14E-2

Lat 313 4.07E-2

Lungs (female) PA 674 3.37E-2

Lat 351 4.56E-2

Thymus PA 674 3.37E-2

Lat 351 4.56E-2

Esophagus PA 674 3.37E-2

Lat 351 4.56E-2

Stomach PA 674 3.37E-2

Lat 351 4.56E-2

Bone Surfaces PA 674 3.37E-2

Lat 351 4.56E-2

Remainder PA 674 3.37E-2

Lat 351 4.56E-2

Breast PA 116 5.80E-3

Lat 343 4.46E-2

Uterus PA 5.2 2.60E-4

Lat 2.1 2.73E-4

Bone Marrow 

(male)

PA 178 8.90E-3

Lat 76 9.88E-3

Bone Marrow 

(female)

PA 172 8.60E-3

Lat 59 7.67E-3

Total Body 

(male)

PA 192 9.60E-3

Lat 106 1.38E-2

Total Body 

(female)

PA 178 8.90E-3

Lat 99 1.29E-2

Skin (f) PA 7.00E-2

Lat 1.82E-1

a. Dose conversion Factors from Tables A.2 through A.9, ICRP Publication 34 (1982). 

b. The values for lateral x-rays from ICRP 34 (1982) appear to be switched in Table A9. All the other values for male to 

female dose have the male values higher than the female. The factors were changed to agree with the other factors listed for 

other HVLs. 

c. Source to Image-Distance 183 cm. 
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 17 of 21

d. Image Receptor Size (cm) 35.6 x 43.2. 

e. Calculated using backscatter factor of 1.35 from NCRP Report 102, Table B-3. 

f. Calculated using backscatter factor of 1.35 from NCRP Report 102, Table B-3. 

5.0

Error (deviation from the correct, true, or conventionally accepted value of a quantity) and uncertainty 

(defined in terms of the potential range of a stated, measured, assumed, or otherwise determined 

value of a quantity) provide an indication of the confidence or validity of the dose estimates. Error 

implies knowledge of what the correct or actual value is, which is, of course, not known. Therefore, 

the more appropriate factor is uncertainty, which is expressed in terms of a confidence level, which in 

turn is expressed as a percent. Thus, the 99% confidence level indicates that the correct or true 

value, although not actually known, has a 99% probability of falling within the range cited. The 

statement of confidence level typically includes all potential sources of error, both random and 

systematic; the precision or reproducibility of the measurement; and accuracy, or how close the 

measurement or estimate of dose comes to the actual or correct value.

Uncertainty Analysis for Diagnostic Medical x-Ray Doses

In theory, a large number of factors can introduce uncertainties or affect the X-ray machine output 

intensity and dose to the worker. However in practice only five factors can be reasonably considered 

to have a meaningful or significant impact on dose uncertainty. These are: 

1. Measurement error

2. Variation in applied kilovoltage

3. Variation in beam current

4. Variation in exposure time

5. Distance from the worker to the source of the X-rays (SSD)

The influence of such other factors as use of screens, grids, reciprocity failure, film speed, and 

development, while potentially variable, do not affect the beam output intensity per se except indirectly 

insofar as these may determine the exposure settings (i.e. kVp, mA, and time) used.

Medical x-ray doses, when measured, were largely derived from actual measurement of X-ray 

machine output with R-meters or similar ionization chamber devices suitably designed for 

measurement of photons in the medical x-ray energy range. If properly calibrated and used, R-meters 

and similar instruments typically and historically have had an uncertainty of + 2% for photon energies 

below 400 keV (Kathren and Larson 1969). Although more recent versions of these instruments 

might provide a somewhat smaller uncertainty, perhaps on the order of + 1% (NBS 1985, 1988), for 

conservatism, the uncertainty range of + 2% should be applied to measurements of X-ray intensity.

Theoretically, for a given set of machine settings and parameters, X-ray output should be constant 

and unvarying. However, this is not true in practice. Although output is essentially constant unless 

focal spot loading occurs, as might be the case when the power rating of the machine is exceeded, it

is unlikely that power ratings were ever exceeded because such an event would be difficult to achieve 

in practice and could result in damage to the X-ray tube. However, even with the use of constant 

voltage transformers to control line voltages, slight variations might occur in line voltage input or other 

internal voltages, which in turn could alter the kVp of the output beam. In general, for a given kVp 

setting, variation in kVp falls within + 5% of the machine setting (Seibert et al. 1991). Since as noted 

above, beam intensity is approximately proportional to the 1.7 power of the applied kilovoltage; this 
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 18 of 21

translates to an uncertainty of approximately ± 8.6% with respect to output beam intensity in the 80 to 

100 kVp range used for diagnostic chest radiographs. For conservatism, this is rounded up to + 9%.

Similarly, slight variations in tube current are normal; as a tube ages, or heats up from use, current 

can change and typically will drop. With all other factors constant, beam intensity will be reduced in 

direct proportion to the change in tube current. Typically, the reduction in beam output from current 

variation is not more than a few percent under normal operating conditions; large decreases are 

readily detectable and manifest themselves as underexposed radiographs and result in maintenance 

on the machine to restore the output or, as a temporary measure, an increase in the current or kVp to 

provide the necessary intensity for proper radiography. For a given kVp setting, the output of the 

beam is a function of the tube current, which in turn is measured by a milliammeter, which measures 

average tube current. The measurement is subject to uncertainties; there might be minor changes in 

output as the tube heats from normal use. These variations are typically small, and the estimated 

uncertainty in beam intensity or output attributable to current variation is + 5%. 

Another parameter that has potential to affect the dose from a diagnostic radiograph, perhaps 

significantly, is the time of exposure. The potential importance of this parameter is underscored by 

noting that virtually all medical diagnostic medical x-ray units used in the DOE complex were of the full 

wave rectified type. A full wave rectified machine produces 120 pulses of X-rays per second. Thus, 

in a typical radiographic exposure time of 1/20 of a second, only six pulses would result. A small error 

in the timer that resulted in a change of only + 1 pulse would correspondingly affect the output by + 

17%; for an exposure time of 1/30 of a second, the change in output corresponding to a deviation of + 

1 pulse is + 25%. Early mechanical timers were notoriously inaccurate; accuracy improved 

significantly with the introduction of electronic timers. Measurements of reproducibility made in the 

late 1980s and beyond by the State of Washington for the machines at Hanford suggest that the 

timers, and indeed the entire X-ray output, were fairly constant. However, for conservatism, the 

assumed uncertainty in beam output attributable to timers has been taken to be + 25%. 

The final factor likely to affect worker dose relates to distance from the source of the X-rays, which is 

an important determinant of the entrance skin exposure from which organ doses are calculationally 

derived. For a given individual, the SSD will be determined largely by the body thickness of the 

worker and the accuracy of the positioning. For a typical worker, the estimated variation in SSD is no 

more than a few centimeters, with an upper limit of perhaps 7.5 cm. Using inverse square, this 

indicates an uncertainty of + 10% from this source.

There are two approaches to determine the combined uncertainty from the five potential sources of 

dose uncertainty listed above. The first, and most conservative in that it gives the greatest range, 

would be to assume that the uncertainties are additive, which would give an uncertainty range of 2 + 9 

+5 + 25 + 10 = + 51%. However, a more reasonable approach would be to assume that the 

uncertainties are in fact random, and to compute the statistical root mean square (RMS) value. The 

RMS value is simply the square root of the sum of the squares, and computes as + 28.9%. Rounding 

this up to + 30% would seem to provide an adequate and suitably conservative indication of 

uncertainty. Thus, for an individual ESE or derived organ dose, an uncertainty of + 30% at the 99% 

confidence level can be assumed; for further conservatism it might be appropriate to assume that 

errors are all positive, and only + 30% should be used. 
Effective Date: 12/08/2003 Revision No. 01 Procedure No. ORAUT-OTIB-0006 Page 19 of 21

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