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Radiation Protection Training for Vascular Surgeons in Twenty-One European Countries

Open ArchivePublished:February 05, 2020DOI:https://doi.org/10.1016/j.ejvs.2020.01.014
      Fluoroscopically guided therapies have become fundamental in the treatment of vascular disease. Today's vascular surgeons will expose themselves to radiation on a nearly daily basis throughout their careers and will likewise expose their patients and staff. Therefore, education and training in radiation protection is imperative.
      Radiation protection training for medical professionals is regulated at a national level. Although the European Council Directive on basic safety standards for protection against the dangers arising from exposure to ionising radiation
      European Union Council Directve 2013/59/EURATOM
      is mandatory for all member states of the European Union, there seem to be significant variations in national regulations in both member and non-member states. In the context of the forthcoming ESVS guidelines on radiation protection, a survey among the 21 representatives of the European Vascular Surgeons in Training (EVST) council was conducted to better understand current radiation protection training regulations for vascular surgeons in Europe.
      The survey was sent out in June 2019 and consisted of two parts. Part one included six questions focusing on national regulations about radiation protection training. If the EVST representatives did not know the regulations, they were asked to contact their national organisations. In the second part, the EVST representatives had to rate the availability of dosimeters and radiation protection equipment for vascular surgery trainees in their country.
      All 21 representatives completed the survey (Austria, Belgium, Bulgaria, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Netherlands, Norway, Portugal, Romania, Russia, Serbia, Slovakia, Spain, Sweden, Switzerland, and United Kingdom). Two thirds (14/21; 62%) responded that a mandatory course had to be undertaken or certification in radiation protection had to be obtained to become a vascular surgeon in their country. In 57% (8/14) of those countries, the course has to be passed before board certification in vascular surgery; in one country, trainees are obliged to take the course during medical school; in three, trainees must pass the course before being exposed to radiation; and in two before using radiation themselves. In all countries, this mandatory course consists of theoretical training. Additional hands on training and e-learning only exists in 4/14 countries. In less than half of the countries (6/14), a post-course examination is organised. The cost of this mandatory course are fully or partially paid for by the trainees themselves in 8/14 countries. In 50% of the countries, mandatory re-certification in radiation protection for vascular surgeons does not exist, while in the remaining seven countries re-certification is required yearly (n = 1), every two years (n = 3) or every five years (n = 3). In the countries where a mandatory radiation protection course is not required to become a vascular surgeon, voluntary training is available in 4/7 countries.
      In the second part of the survey, 13/21 (62%) of EVST representatives said that personal dosimeters were available for general or vascular surgery trainees in their country. In 7/21 countries, personal dosimeters are only available to staff members (not to trainees). The availability of lead aprons and thyroid collars for trainees in each country was rated with a median of 8 on a visual scale from 1 (not available) to 10 (always available and superior quality for every trainee). In contrast, the availability of lead glasses for trainees was rated with a median of 3 on the same scale.
      This short survey not only confirms significant differences in radiation protection training regulations for vascular surgeons across Europe but also reveals deficiencies. In one third of the countries included in this survey, there is no mandatory course or certification in radiation protection to become a vascular surgeon. In most countries where there is a mandatory course, it has to be taken only before board certification in vascular surgery and does not necessarily require re-certification. Part 2 of the survey shows relevant shortcomings in the availability of personal dosimeters and radiation protection equipment, especially lead glasses for trainees. However, the replies are based on the rating of one EVST representative per country and may not be representative of the entire country.
      While the European Directive is rather vague, leaving the responsibility to its member states to establish appropriate radiation protection curricula and providing continuing education and training to all individuals involved in medical radiological procedures,
      European Union Council Directve 2013/59/EURATOM
      the International Commission on Radiological Protection (ICRP) makes more specific recommendations. In their document on education and training,
      • Vano E.
      • Rosenstein M.
      • Liniecki J.
      • Rehani M.M.
      • Martin C.J.
      • Vetter R.J.
      ICRP Publication 113. Education and training in radiological protection for diagnostic and interventional procedures.
      the ICRP states that radiation protection education and training should be initiated at the start of the career, i.e. during medical school, and continue during residency, appropriate to the specialty and role of the physician. Once training is completed, it should be updated at least every 36 months. A second level of radiation protection training in addition to what is recommended for doctors using radiation has previously been proposed for interventional radiologists and cardiologists.
      • Valentin J.
      Avoidance of radiation injuries from medical interventional procedures.
      In the current document, the ICRP also applies this to other physicians conducting fluoroscopically guided procedures, such as vascular surgeons, and says that more radiation protection training in these groups should be a priority since it is inadequate in most countries. The ICRP calls on scientific and professional societies to contribute to the promotion and support of such radiation protection training.
      • Vano E.
      • Rosenstein M.
      • Liniecki J.
      • Rehani M.M.
      • Martin C.J.
      • Vetter R.J.
      ICRP Publication 113. Education and training in radiological protection for diagnostic and interventional procedures.
      The results of this survey are of concern. The limited availability of dosimeters, lead aprons/collars and especially protective goggles for vascular surgery trainees in several countries warrants action at an institutional level. Trainees involved in endovascular procedures must have access to adequate protective equipment. Younger persons are more susceptible to radiation and have a longer life expectancy, wherefore radiation induced effects may become relevant. Radiation not only puts our young colleagues at risk of deterministic effects, such as cataract, but also stochastic effects as well as potential harm to their children.
      The lack of regulated radiation protection education and training for vascular surgeons in several European countries supports the ICRP call for societies to contribute to radiation protection training. The ESVS should make every effort to implement these recommendations of the ICRP and to facilitate practical and clinically relevant radiation protection training within the ESVS Academy program.

      References

        • European Union Council Directve 2013/59/EURATOM
        Offical J Eur Union. 2013; 57 (available at:): L 013
        https://eur-lex.europa.eu/eli/dir/2013/59/oj
        Date accessed: December 23, 2019
        • Vano E.
        • Rosenstein M.
        • Liniecki J.
        • Rehani M.M.
        • Martin C.J.
        • Vetter R.J.
        ICRP Publication 113. Education and training in radiological protection for diagnostic and interventional procedures.
        Ann ICRP. 2009; 39: 7-68
        • Valentin J.
        Avoidance of radiation injuries from medical interventional procedures.
        Ann ICRP. 2000; 30: 7-67

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