How to Fight the Fear Under the X-Ray Beam
2020; Lippincott Williams & Wilkins; Volume: 51; Issue: 7 Linguagem: Inglês
10.1161/strokeaha.120.029655
ISSN1524-4628
Autores Tópico(s)Diversity and Career in Medicine
ResumoHomeStrokeVol. 51, No. 7How to Fight the Fear Under the X-Ray Beam Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBHow to Fight the Fear Under the X-Ray BeamInterventional Neuroradiology Fellow Mom to Be Carmen Parra-Farinas, MD Carmen Parra-FarinasCarmen Parra-Farinas Correspondence to: Carmen Parra-Farinas, MD, Department of Medical Imaging, St. Michael's Hospital, Toronto, Ontario, Canada, 30 Bond St, Toronto ON M5B 1W8, Canada. Email E-mail Address: [email protected] https://orcid.org/0000-0002-6444-2188 Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada; St. Michael's Neurovascular Program, St. Michael´s Hospital, University of Toronto, ON, Canada; and Department of Medicine, Universitat Autònoma de Barcelona, Spain. Originally published2 Jun 2020https://doi.org/10.1161/STROKEAHA.120.029655Stroke. 2020;51:e121–e123Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 2, 2020: Ahead of Print Diversity stimulates creativity, innovation, respect, and inclusiveness. It steers and drives today's society.Very few women opt to work in the field of endovascular surgical neuroradiology. This is surprising given that ever more women are entering health sciences. In 2019, women medical students outnumbered men for the first time, according to the Association of American Medical Colleges. This growth has not been reflected, however, in specialisms involving endovascular procedures. It is not clear why, and it is likely many of us would find it difficult to explain. Worries about occupational exposure to ionizing radiation, especially during our fertile years, is undoubtedly, along with other reasons, one of the key ones.1,2In 2015, the results of 5 independent clinical trials of second-generation stent-retriever devices made the neurointerventional field something even more necessary for our society. More and more professionals are needed. Therefore, being a woman should not be an impediment to choose this path.My aim is to help women who work or would like to work in this field and others who are exposed to ionizing radiation at work to manage the issues linked to pregnancy. This means understanding the risks involved to prevent potential discrimination and unnecessary restrictions for pregnant women or for women hoping to start a family.Pregnancy and Ionizing RadiationDeciding to be a neurointerventionist, for women as well as men, is a great challenge in many ways. It is a physical challenge, as it requires long hours standing with heavy equipment and disrupted sleep, and the fact that we need to own decisions, that will be impactful to the life of our patients and their families, is also a psychological challenge. In addition to these challenges, we are all concerned about excessive occupational exposure to ionizing radiation, being even more difficult for women during our fertile years. Pregnancy is not a risk-free endeavor. The risks associated with exposure to ionizing radiation during pregnancy, and the importance of taking additional safety measures has been highlighted in a number of earlier publications.1,3–6Ionizing radiation effects can be classified into 2 categories: deterministic and stochastic effects. Deterministic effects depend on time of exposure, dose, and type of radiation. They have a threshold of dose below which the effect does not occur, and severity increases with doses above that threshold. Stochastic effects have an increase probability of occurrence with increased dose. However, there is not a threshold level of dose and severity does not depend on the magnitude of absorbed doses.1A developing human embryo or fetus is particularly sensitive to ionizing radiation, especially in the eighth to fifteenth weeks of gestation.3 In the International System of Units, a millisievert (mSv) is defined as the average accumulated background radiation dose to an individual for 1 year, exclusive of radon, in the United States. One millisievert is the dose produced by exposure to 1 milligray (mGy) of radiation. Based on that, a fetal exposure at over 200 mGy, a much higher dose than that to which we are exposed in the profession, could cause miscarriage, neural development issues, and childhood cancers.7 Worries about excessive exposure during pregnancy are not, therefore, unfounded. A radiation dose of <100 mSv poses a minimal or possibly nonexistent risk to the embryo/fetus.1,5,8 If this dose is not exceeded, the lifetime risk of our children developing cancer or other complications is negligible. This assertion is based on numerous studies on mammals. But hardly any studies have been carried out on humans. Chandra et al7 found objective evidence that the ionizing radiation received by the embryo/fetus is minimal even at perceptible prenatal exposure levels. They showed that, provided we take appropriate precautions, the risk of complications during pregnancy is minimal or nonexistent. Practically speaking, to attain any preconception or perinatal risks, a woman needs to be directly exposed to the radiation beam for a continuous length of time without wearing personal protective equipment.1 Therefore, assuming that a lead protective apron is worn, it is estimated that the effective equivalent radiation dose is 1.5 mSv for 9 months on the basis of the guidelines set forth by the National Council on Radiation Protection and Measurements. If we compare this to being on airplane, flying across the United States would expose you to about 0.035 mGy of cosmic radiation. That means that you would need to fly 43× from coast to coast to get an equivalent dose.How to Fight the Fear Under the X-Ray BeamWhen I found out I was pregnant, I was terrified. This fear, which is understandable, together with a lack of knowledge and the misinformation out there on the risks associated with exposure, can cause severe anxiety and workplace stress, even leading, potentially, to miscarriage.2,6,9 The feelings of guilt and uncertainty that overwhelm us during pregnancy can sometimes lead to practices that go way beyond standard safety measures and which could cause as much harm as good. Many women who are exposed to ionizing radiation opt to use 2, or even 3, lead aprons. In 1992, Marx et al,10 using two 0.5 mm lead aprons, demonstrated that the ionizing radiation received by the embryo or fetus, measured using radiation badges placed below the apron at belt level, was less than the detectable minimum. But this practice is uncomfortable, and the extra weight could cause back injuries while providing hardly any extra protection. Various authorities have issued guidelines on occupational exposure during pregnancy,9 but there is no unified database on exposure and potential long-term complications. To ensure proper compliance with these regulations, experts recommend monthly monitoring using fetal dosimeter badges.9 I decided to wear two 0.5 mm lead aprons, although as mentioned above, it seems not entirely necessary, along with a weekly fetal dosimeter badge. I was exposed every day, and the level of ionizing radiation during my pregnancy was undetectable.Future GoalsIonizing radiation during our fertile years is one of the main reasons we are not attracted to this field. Greater awareness of this field will bring with it a better understanding of the risks and how to reduce them, helping us to tackle the concerns that could lead women to avoid working in this area. At the same time, the more common it becomes to see pregnant women working in neurointervention, the more we will be able to counter the discrimination and barriers that could stem from pregnancy.The pregnancy involves a very important change in every women´s body; this new physical condition makes it even more difficult to be able to work at the same rate in such a physically demanding role. As working mothers, we need to know that careful planning, an understanding of the risks, and minimizing ionizing radiation doses using appropriate safety measures can allow us, in most cases, to perform procedures safely and without significant risk. This should alleviate our concerns.Although the neurointerventional international group is diverse in terms of training background and nationalities, the truth is that women are under-represented. It is easy to make excuses for why this has happened, but we all need to find ways to increase the number of women that work as neurointerventionists. Women may face hostile attitudes from physician colleagues who feel that a colleague's pregnancy negatively affects their own work hours. Therefore, an inclusive working environment is one of the keys to a successful career. This requires dialogue and understanding. We are different, but necessary. In spite of the real physical issues, I did not find being pregnant held me back; it empowered me to go forward with my career despite those many challenges. Being a mother is a massive change in every sense of the word. If you then factor in a job with no fixed timetable, one that is mentally and physically demanding, and the fear of a complication that we can only imagine, clearly, this is not an easy time. I often felt guilty during this period. Guilty for not dedicating enough time to my baby daughter and for carrying on working as if nothing was happening, while my bump kept getting bigger and both the baby and I needed to rest.There are still many barriers to overcome, but the success of the field also depends on us. I do not want to set myself up as an example, but I do want to show the world that it is possible to be a mother, a working woman, and an interventional neuroradiologist. Information makes us free, believing in ourselves helps us to keep going, and persistence enables us to succeed.ConclusionsVery few women opt to work in the field of endovascular surgical neuroradiology. Nuerointervention is an exciting field that is also challenging and rewarding. There is no good reason why women should not enter and have a successful career without limits. Worries about occupational exposure to ionizing radiation represent one of the key reasons. Now is the time for the specialty to reach out and embrace women into the specialty, as more and more professionals are needed in this field. As the numbers grow, women may be the key to securing a successful future. Therefore, being a woman should not be an impediment to choose this path. Greater awareness of this field will bring with it a better understanding of the risks and how to reduce them, helping us to tackle the concerns that could lead women to avoid working in this area.AcknowledgmentsThe most magical day of my life was the day I became a mother. Carmen was born on February 11, 2020. She is a healthy and happy baby. I want to thank St. Michael's Hospital Neurovascular Team, including attending physicians, fellows, residents, nurses, and technologists. This would not have been possible without your support.Sources of FundingNone.DisclosuresNone.FootnotesFor Sources of Funding and Disclosures, see page e123.Correspondence to: Carmen Parra-Farinas, MD, Department of Medical Imaging, St. Michael's Hospital, Toronto, Ontario, Canada, 30 Bond St, Toronto ON M5B 1W8, Canada. Email [email protected]comReferences1. Vu CT, Elder DH. Pregnancy and the working interventional radiologist.Semin Intervent Radiol. 2013; 30:403–407. doi: 10.1055/s-0033-1359735Google Scholar2. Ghatan CE, Fassiotto M, Jacobsen JP, Sze DY, Kothary N. Occupational Radiation Exposure during Pregnancy: A Survey of Attitudes and Practices among Interventional Radiologists.J Vasc Interv Radiol. 2016; 27:1013–1020.e3. doi: 10.1016/j.jvir.2016.03.040Google Scholar3. Shaw P, Duncan A, Vouyouka A, Ozsvath K. Radiation exposure and pregnancy.J Vasc Surg. 2011; 53(1 Suppl):28S–34S.Google Scholar4. Skrzypek M, Wdowiak A, Panasiuk L, Stec M, Szczygieł K, Zybała M, Filip M. Effect of ionizing radiation on the female reproductive system.Ann Agric Environ Med. 2019; 26:606–616. doi: 10.26444/aaem/112837Google Scholar5. Measurements. NC on RP and, Measurements. NC on RP and, Scientific Committee 4-4 on the Risks of Ionizing Radiation to the Developing Embryo and Nursing Infant. F. Preconception and prenatal radiation exposure : health effects and protective guidance.2013. http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3382419.Google Scholar6. De Santis M, Di Gianantonio E, Straface G, Cavaliere AF, Caruso A, Schiavon F, Berletti R, Clementi M. Ionizing radiations in pregnancy and teratogenesis: a review of literature.Reprod Toxicol. 2005; 20:323–329. doi: 10.1016/j.reprotox.2005.04.004Google Scholar7. Chandra V, Dorsey C, Reed AB, Shaw P, Banghart D, Zhou W. Monitoring of fetal radiation exposure during pregnancy.J Vasc Surg. 2013; 58:710–714. doi: 10.1016/j.jvs.2013.01.052CrossrefMedlineGoogle Scholar8. Brent RL. Saving lives and changing family histories: appropriate counseling of pregnant women and men and women of reproductive age, concerning the risk of diagnostic radiation exposures during and before pregnancy.Am J Obstet Gynecol. 2009; 200:4–24. doi: 10.1016/j.ajog.2008.06.032CrossrefMedlineGoogle Scholar9. Dauer LT, Miller DL, Schueler B, Silberzweig J, Balter S, Bartal G, Chambers C, Collins JD, Damilakis J, Dixon RG, et al.; Society of Interventional Radiology Safety and Health Committee; Cardiovascular and Interventional Radiological Society of Europe Standards of Practice Committee. Occupational radiation protection of pregnant or potentially pregnant workers in IR: a joint guideline of the Society of Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe.J Vasc Interv Radiol. 2015; 26:171–181. doi: 10.1016/j.jvir.2014.11.026CrossrefMedlineGoogle Scholar10. Marx MV, Niklason L, Mauger EA. Occupational radiation exposure to interventional radiologists: a prospective study.J Vasc Interv Radiol. 1992; 3:597–606. doi: 10.1016/s1051-0443(92)72903-0Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Rossignol M, Rigouzzo A, Verspyck É and Le Guern V (2021) Mortalité maternelle par thromboembolie veineuse en France 2013–2015, Gynécologie Obstétrique Fertilité & Sénologie , 10.1016/j.gofs.2020.11.012, 49:1, (67-72), Online publication date: 1-Jan-2021. Rossignol M, Jonard M and Cohen H (2021) Mortalité maternelle par accident vasculaire cérébral en France 2013–2015, Gynécologie Obstétrique Fertilité & Sénologie , 10.1016/j.gofs.2020.11.013, 49:1, (73-78), Online publication date: 1-Jan-2021. Beaman C, Kaneko N, Meyers P and Tateshima S (2021) A Review of Robotic Interventional Neuroradiology, American Journal of Neuroradiology, 10.3174/ajnr.A6976, 42:5, (808-814), Online publication date: 1-May-2021. Altschul D (2021) From a female perspective, Journal of NeuroInterventional Surgery, 10.1136/neurintsurg-2021-017961, 13:8, (681-682), Online publication date: 1-Aug-2021. July 2020Vol 51, Issue 7 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.120.029655PMID: 32482140 Originally publishedJune 2, 2020 Keywordsradiation, ionizingwomenpregnancyradonbackground radiationPDF download Advertisement SubjectsAngiographyCerebrovascular ProceduresPregnancyRisk Factors
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