“I’d probably be a quadriplegic,” Dean J. Kereiakes, MD, an interventional cardiologist, said when asked what would have happened if two top neurosurgeons at his hospital hadn’t rushed him to the operating room (OR) for a cervical decompression in February this year.
Dr. Kereiakes had orthopedic problems for years due to the heavy lead aprons he wore in the cath lab. He regularly dosed himself with steroids for disc pain so he could stand up straight and continue to do procedures. “Several times a year I’d go on a tapering dose of prednisone of about 10 days to 2 weeks, and this would take care of it.”
But then his luck ran out. “I’m told in retrospect that my gait — the way I walked — was different, and I was also having some myoclonic jerking in my legs when I was going to sleep. I thought it was peculiar, but I didn’t really tie it together that this was an upper tract injury response.”
At a restaurant with his wife, he found himself unable to sign the check. “I couldn’t write my name.” By the next morning, “I had a floppy right foot, and as I turned around to put my scrubs on, everything fell apart. My arms began to not function and my legs — I couldn’t walk.”
Admitted to The Christ Hospital Heart & Vascular Center in Cincinnati — the very hospital he works in — Dr. Kereiakes had CT and MRI scans and consulted with neurosurgeons he counts as friends. He was given extremely high doses of intravenous steroids. “But instead of getting better, the pain came back, and I started posturing — when you posture, it looks like a praying mantis, your arms are flexed up, your wrists are flexed, and your fingers are spasmed together.” His wife and the nurses couldn’t pull his fingers open, “so they rolled me back, and the posturing started to go away.”
This prompted the neurosurgeons to bring him to the OR “by 6 a.m., and they are ‘unzipping me in the back’ to basically get my spinal cord off my spine. I had cord compression at C2-3 and C 6-7.”
Postop, Dr. Kereiakes couldn’t move his right leg and couldn’t close any of his fingers. “You lose control of things like bladder and bowel function — you have a catheter in — and you say to yourself, ‘How am I going to live like this?.’ ”
The quick-thinking of his neurosurgeons prevented permanent paralysis, and after a long 6-month recovery, Dr. Kereiakes is back in the cath lab, performing procedures. But crucially, he will no longer have to wear a lead apron.
Ending Careers Early. A Catalyst for Change
Typically, interventional cardiologists, interventional radiologists, electrophysiologists, and others working in labs where they are exposed to ionizing radiation wear lead aprons and garments, such as thyroid collars, leaded caps, and glasses, to protect them during procedures.
Long-term occupational exposure to radiation is linked to cataracts; brain tumors; cancers, including leukemia, multiple myelomas, lymphomas, and thyroid cancers; and left-sided breast cancers in women because the aprons don’t always cover the left side of the chest adequately.
Individual states set the standards in terms of the thickness of the lead required, varying from 0.25- to 0.5-mm–lead-equivalent aprons, which reduce exposure by 85%-95%. Radiation safety officers monitor the badges that staff wear to record their radiation exposure and will warn them when their levels are too high.
But — as Dr. Kereiakes freely admits — ambitious interventionalists don’t always take much notice. “They would come and say, ‘Hey your badge is really high,’ and so I would just put it in a drawer and carry on,” he said. “When you are younger, you feel immortal.”
James B. Hermiller Jr., MD, president of the Society for Cardiovascular Angiography & Interventions (SCAI), agrees: “The feeling is that, with lead, you are indestructible, and no one wants to show any weakness.”
Another occupational hazard related to those protective lead aprons was also being ignored, that of orthopedic injury. In surveys done by SCAI, around half of interventional cardiology respondents report cervical, lumbar, hip, knee, or ankle joint injuries.
While Dr. Kereiakes recognizes likely bias — with those afflicted more likely to complete these surveys — he believes that the problem is huge and “is ending careers early.”
“It’s interesting that radiation is at the forefront of protection and occupational safety, but you are much more likely to be taken out of work because of orthopedic injury,” explained Dr. Hermiller, director of Structural Heart Program at Ascension St. Vincent Heart Center in Indianapolis.
His own story “is not as compelling as Dean’s, but 17 years ago, I ruptured a disk in my lower spine and had emergent surgery and I now need a neck surgery.”
Dr. Hermiller’s hospital, too, has purchased multiple radiation protection systems. “If you want to do this job for 30 years, you have to protect yourself early and at all times,” he said.
His focus as SCAI president is to help get these protection systems in place at more hospitals.
But significant challenges remain, not least the cost, which can be $150,000-$200,000 per lab. He estimates that fewer than 10% US hospitals with cath and other labs using radiation have installed such systems.
Most systems are not US Food and Drug Administration (FDA) approved because they are not attached to equipment in the cath lab, something that Nadia Sutton, MD, MPH, chair of the SCAI Women in Innovations committee, said many physicians are not aware of. “The companies [marketing the systems] are telling us that we can ‘shed our lead,’ ” she said. “It could be safe, but we are using the data provided by the companies.”