In some of the reported injuries, the physicians performing the procedures appear to have been unaware that the radiation doses exceeded the expected threshold for injury, or were unaware of the intensity of the fluoroscopic beam. The protocols should be preplanned and address all aspects of the procedure, from patient selection through termination criteria. Know the radiation dose rates for the specific fluoroscopic system and for each mode of operation used during the clinical protocol. Know the impact of the protocol for the procedure relative to the potential for radiation injury due to the cumulative radiation dose to irradiated areas of the skin. Modify the protocol, if necessary, to limit the cumulative dose to any irradiated area of the skin to avoid doses that would induce unacceptable adverse effects.
Implement equipment features that aid in minimizing dose.
Enlist a qualified medical physicist to assist in implementing these principles in such a manner so as not to adversely affect the clinical objectives of the procedure. Physicians should know that radiation-induced injuries are not immediately apparent. Other than the mildest symptoms, such as transient erythema, the effect of the radiation may not appear until weeks following the exposure. Physicians performing these procedures may not be in direct contact with the patients following the procedures and may not observe the milder symptoms when they occur. Only when symptoms of serious injury occur do the physicians become aware of the magnitude of the radiation doses associated with the procedures.