Raising awareness and protecting staff from ionising radiation: an interview with Katie Hurst

Summary

Katie Hurst is a general surgery registrar based in the Thames Valley Deanery and chair of the Trainees’ Committee for the Royal College of Surgeons of Edinburgh. In this interview, we talk to Katie about the work she is doing with the Royal College of Surgeons of Edinburgh on raising awareness and protecting staff from ionising radiation.

Questions & Answers

Hi Katie, can you tell us about yourself and how you became involved with the Royal College of Surgeons of Edinburgh?

I am a general surgical registrar based in Oxford, part of the Thames Valley Deanery. When finishing medical school I became extremely interested in improving training morale and training opportunities which led me to work closely with the Royal College of Surgeons of Edinburgh. I am currently the chair of the College Trainees’ Committee and I sit on Council as the trainee representative. I'm also chair of the Sustainability Group for the College.

How did you first become aware of the risk of ionising radiation to staff safety?

The College had been made aware of a project that was looking at radiation protection and the significant risk of ionising radiation to staff safety.

Papers have shown that there is an up to four times increased risk of breast cancer in female surgical registrars working with ionising radiation compared with the general population.[1] Research has also demonstrated an increased risk in those female trainees working in trauma or orthopaedics compared to urology and general surgery who don't use the ionising radiation. In addition, these cancers tends to be within the upper outer quadrant of the breast.[2]

Multiple studies have confirmed that the upper outer quadrant of the breast and the axilla aren't safely protected from ionising radiation during procedures, particularly in trauma and orthopaedics where surgeons are taking multiple x-rays or using the C-arm in theatre. [3, 4] The team are often standing sideways, holding a leg up for example, and so the upper quadrant of the breast is exposed; due to the positioning, but also that the gowns do not effectively cover this part of the breast. The surgical gowns we currently wear are fitted for males, not females. Often they are tabard gowns that come across the front and leave the side of your chest wall and axilla exposed.

There is also risk for other cancers when you’re using ionising radiation, for example thyroid cancer.

The College takes matters like this extremely seriously, and has asked me to look into the current data and guidelines to ensure members, fellows and colleagues are adequately protected.

Is there any guidance currently in the NHS on radiation safety?

I have carried out some background research and found that radiation protection and what happens within hospitals is led at a trust level. There is an overarching Health and Safety Executive (HSE) document that looks at radiation protection throughout the NHS, making sure establishments are safe, but it is extremely vague. It primarily highlights patient safety over staff – informing how to keep your patients safe from ionising radiation, but there's very little regarding employees. What's absolutely astounding is there isn't a document that says we need to protect our staff from radiation by using adequate personal protective equipment (PPE). I thought, if we could find that paper and lobby for change, say that everyone should have adequate PPE to protect the axilla, this would be an easy win. All trusts would be compelled to do this. Unfortunately that paper doesn't exist, which is quite shocking.

Everything around radiation protection is at a local level – led by radiation protection officers within each trust. This causes widespread variation around the country. It is a complete postcode lottery of what protection is available and how seriously they want to take this issue. Unfortunately, this is also where we hit our stumbling blocks. How do we make sure everyone is doing the same thing throughout the country when all changes are made at a local level. Also, the funding for change must come from the trusts, which creates an issue for trainees who do not hold long term contracts with trusts.

Why are trainees at particular risk?

We have been working closely with the British Orthopaedic Association (BOA) who have led a lot of the work in this area. Several trainee surgeons throughout the country have completed studies or audits looking at what protection is available in their trust. They have found that only around 30% of the gowns available provide adequate protection. The other 70% of gowns do not. Trainees are often one of the last to enter into theatre, as they are frequently reviewing patients or arranging things to ensure the day runs smoothly. Consequently, they are more likely to be wearing an ill-fitting gown.

The second element is funding. Trusts may provide adequate protection for consultants or members of staff who have permanent contracts but, as trainees, we move hospitals every six to twelve months, commencing new contracts each time. Trusts are obviously not willing to pick up the cost for trainees spending such little time in a department, and NHS England isn’t technically responsible for radiation protection.

We shouldn't really be needing to self-fund our own PPE. So that’s the next hurdle – how do we get this funded?

Are there any companies already looking at improving the theatre gowns?

Yes. The initial data on ionising radiation and the increased risk of breast cancer came from the USA. There are a few companies that have looked at making vests that cover the axilla; either on top or underneath the tabard that you're wearing. One company makes bolero style PPE with sleeves. The only problem is these additions weren’t actually made for the purpose of protecting axilla. It’s an improvement and protects you if you stand still but as you lift your arms, the bolero comes up and again you’re exposed.

Another company has looked at making a vest that allows you to move and importantly keep the area protected. The vest is made from offcuts of their gowns meaning it is a very sustainable option and also reasonably priced.

What are your next steps?

One of the first things we need is accurate UK data on the scale of the problem, to allow us to lobby for change. Thankfully, the BOA have ethics approval to run dosimetry studies early this year; which will involve placing dosimeters in the axilla and around the breast of staff carrying out certain operations to see if there is a significant level of radiation effecting the area. If we can prove this is an unacceptable level, then we can lobby for change. Part of the dosimetry study will also look at what options for PPE are out there and which would give adequate protection.

In the meantime, as a College we're trying to raise awareness through conferences, social media and our membership magazine. I presented in November last year at the Future of Surgery conference in London and so many people attended the session and were engaged in the topic.

Although we’ve been quite female focused, this does affect men too. Men can get breast cancer and also they're still at risk of other radiation-related cancers. The tabards do generally cover the testicular area because they're long, but we still need to make sure men are adequately protected.

The Royal College of Surgeons of Edinburgh have collaborated with the BOA to release 12 steps in reducing radiation risk while we await the study results. For example, step back from the beam, don't stand sideways when you're taking a shot, reduce the number of shots. This campaign was released at Christmas and has been really well received.

Overall, we want to raise awareness, encourage more people to talk about these issues and scientifically look at the link between an increase risk in breast cancer and people working in hospitals with ionising radiation. It is not acceptable and we need to keep our staff safe.

If you would like to find out more or are doing similar work, please contact Katie at katie.hurst@doctors.org.uk.

References

1. Chou LB, et al. Increased breast cancer prevalence among female orthopedic surgeons. J Womens Health (Larchmt), 2012; 21(6):683-9.
2. Chou L, et al. Cancer prevalence among a cross-sectional survey of female orthopedic, urology, and plastic surgeons in the United States. Women’s Health Issues, 2015; 25(5): 476–481.
3. Lee AH. Why is carcinoma of the breast more frequent in the upper outer quadrant? A case series based on needle core biopsy diagnoses. Breast, 2005;14(2):151–2.
4. Valone LC, et al. Breast radiation exposure in female orthopaedic surgeons. J Bone Joint Surg Am, 2016;98(21):1808-1813.