Lead shielding during X-rays: Radiologist available for interviews
Using a lead apron to cover areas not targeted for a diagnostic image is called lead shielding. The lead creates a barrier from ionizing radiation in X-rays.
As Jay Pahade, MD, medical director, Radiology, Yale New Haven Hospital explains, “pelvic shielding during X-rays was done because we thought we were protecting people’s reproductive organs from unnecessary radiation exposure.”
A body of research has led to the American Association of Physicists in Medicine no longer supporting shielding patients’ reproductive organs, called gonadal shielding, during X-ray imaging exams. The research shows that the impact of scatter radiation (radiation exposure outside the beam’s scope) on the pelvic organs is minimal during an X-ray. Any scatter radiation that reaches reproductive organs is usually from scatter that occur within the body, rendering a lead shield placed over a patient ineffective.
This is why at Yale New Haven Health, in most cases, patients coming in for an X-ray will not be offered a gonadal shield unless requested.
“This is a change in how we think and better serve patients,” said Dr. Pahade. “It did not make scientific sense to continue gonadal shielding.”
Yale New Haven Hospital discontinued gonadal lead shielding in March of 2020 followed by Bridgeport Hospital in September 2020. Soon all of its delivery networks will adopt the change, making Yale New Haven Health one of the first health systems in Connecticut to change what has been a standard practice for more than 50 years.
The optimal image
“When it comes to radiation our gospel is ALARA — As Low As Reasonably Achievable. We want to use the least amount of radiation necessary to create an image that answers the diagnostic question at hand,” said David Facchini, MBA, quality and safety manager, Radiology, Yale New Haven Health.
The lead shields can interfere with this approach.
“To help us achieve ALARA, our machines have auto exposure controls which are sensitive to the thickness and density of the person we are imaging,” said Adel Mustafa, PhD, chief, Diagnostic Radiology Physics, Yale New Haven Hospital “If the lead shield is in the area we want to image, the auto controls sense the shield and will increase the radiation as it perceives the patient as denser than they actually are.”
Another way the shields impact ALARA is when the shields are either misplaced or move, obscuring the image or blocking off surrounding areas that might need to be reviewed. This can result in additional X-rays and more radiation exposure to the patient.
The COVID-19 effect
COVID-19 exacerbated the need to stop gonadal shielding.
“Shielding requires closer contact between the technician and the patient. It also requires time and resources to properly disinfect the shields. COVID-19 pushed us to move quickly to minimize as many risks as possible to our patients as it related to infection control,” said Dr. Pahade.
Radiation in review
"I have discovered something interesting, but I do not know whether or not my observations are correct."
In 1895, with this thought, Wilhelm Roentgen, the scientist who discovered X-rays, introduced the world to photographing the invisible. Six months after this discovery, X-rays were used by battlefield physicians to locate bullets in wounded soldiers and the technology became pervasive to the point of shoe stores in 1930s and 1940s offering free foot X-rays to customers.
We now know medical imaging should only be performed when necessary and have a far better understanding of how to harness X-rays as a medical tool and mitigate risks associated with X-ray radiation. As with all medical imaging, “when we perform an X-ray we do a risk benefit analysis and the benefits must outweigh any risks,” said Dr. Mustafa.
After years of research, there is no evidence to suggest that routine X-rays taken in a radiology department damage the reproductive organs.
The role of radiation in diagnostic imaging is not often well-understood or discussed outside of the medical community, however this shift in practice will be visible to many patients coming in for X-rays. Ian Karol, MD, chairperson, Radiology, Bridgeport Hospital said, “We would like to keep the public informed of this current change of practice as we continue to adjust in order to maintain the best diagnostic care for our community.”
“Importantly, the Radiology team at Yale New Haven Health System wants to make sure patients know the change was made based on best available evidence, and is supported by multiple national organizations. So when you arrive for your X-ray, please don’t think we are being neglectful or forgetting to shield you,” said Dr. Pahade.