Medical Imaging Technology Puts Doctors at Risk for Cancer

EVANSVILLE, Ind. — Dr. Chris Haughn was in his bedroom changing clothes to go to his children’s Christmas play when his first seizure hit.

Milly Haughn, Chris’ wife, remembers she was fixing the hair for one of their daughters when their youngest son came to her screaming and crying that “daddy was hurt really bad.”

“I thought it seemed weird. I went into the room, and Chris was on the floor, flopping around having a seizure,” she said.

Instead of a school play, Chris was taken to an emergency room.

In less than a year the 46-year-old healer was dead.

Haughn’s family is now suing St. Vincent Evansville hospital where he worked. As a surgeon, Haughn made a career doing surgeries and procedures that often used imaging technology called fluoroscopes. The widely used X-ray device allows doctors to see into patients’ bodies in real-time, as if watching a continuous video, assisting doctors in saving countless lives.

But a Courier & Press examination of court records, academic studies and government research has found the healthcare providers who use these modern imaging devices may be putting their own health at risk.

The prolonged stream of radiation required to use the devices exposes physicians to the equivalent of 50,000 chest X-rays over the course of their career, one study found. Doctors and medical staff who use the devices are twice as likely to die of cancer compared to those who don’t use them.

Yet federal enforceable standards limiting workplace exposure to this radiation are decades out of date. Efforts to update them have been slow, leaving doctors and hospitals on their own to do more.

“I think we need to raise awareness of the exposures that medical staff face in these kinds of procedures, and that includes interventional fluoroscopy,” said Michael Seymour, a former OSHA official who now advocates for doctors.

“They did a CAT scan, an MRI, and they said, `We found a mass,”’ recalled Milly Haughn, Chris’ wife.

The doctors there didn’t have to tell the couple what that meant. Chris, a surgeon, and Milly, a nurse, knew the prognosis wasn’t good.

“We both knew, OK, that’s going to be gioblastoma, and you’re going to be dead (with)in a year,” Milly said.

Within six months of the confirming diagnosis, Chris succumbed to brain cancer.

The couple, both Ohio natives, met in 1999 when they worked at Akron City Hospital. She was a nurse. He was in his surgical residency. They married in 2002 and moved to Newburgh, Indiana, in 2005.

Initially attracted to the Evansville area when Chris was offered a surgical partnership, they soon fell in love with the region. The family enjoyed fishing together, hiking, trips to Florida and just being at home together.

Three lawsuits against St. Vincent Evansville allege the physicians involved developed cancers through workplace radiation exposure at the hospital, although Haughn’s was the only fatal case.

Doctors Roger Shinnerl and Brett Weinzapfel, allege radiation exposure caused their thyroid cancers.

The lawsuits allege the hospital’s radiation safety practices were inadequate. The first of the suits is scheduled to take place early next year.

St. Vincent has denied the lawsuits’ allegations and filed a motion for summary judgment in their favor. The hospital declined a request for interviews but issued a statement: “Our highest priority is the safety and well-being of our patients and staff. We have robust safety policies and procedures in place for many scenarios and we adhere to regulations and guidelines regarding radiation requirements for medical equipment. At this time we cannot comment concerning ongoing litigation.”

Terry Noffsinger, an Indianapolis attorney, is one of four lawyers representing the doctors’ lawsuits. He believes the lawsuits, filed in Vanderburgh County Circuit Court, may be the first of their kind.

“After the suit was filed we’ve heard concerns from others,” Noffsinger said. “Attention to radiation safety is becoming more of a priority.”

The lawsuits do not accuse manufacturers of any of the imaging equipment or protective gear of wrongdoing. Noffsinger said attorneys considered a product liability suit but there wasn’t evidence for that.

“It was not the equipment that was defective; it was how the equipment was being used,” he said.

The hospital provided the imaging equipment and personal protection gear used by doctors during procedures there, according to the lawsuits.

“We learned about inadequate training, the poor and missing personal protection equipment, no dosimeter badge readings (to measure radiation exposure) for years _ all-in-all a dangerous place to work if you’re involved with radiation,” Noffsinger said.

The lawsuits allege the hospital was negligent in maintaining personal protective equipment and ignored complaints about it, and not enough of these protections were available, including the leaded skirts, jackets, aprons and thyroid shields worn by doctors and staff.

Finally, the lawsuits also allege the hospital did not effectively monitor radiation exposure or communicate to personnel the risks of cumulative exposure to that radiation.

“The doctors all started working there around 2007, working in the same labs, then (were) diagnosed eight years later within 13 months of each other,” Noffsinger said. “It was also important that for an almost two-year period at the start, there were no records on the amount of radiation exposure these men had.”

The Haughns aren’t alone.

Across the country, brain tumors have been reported in dozens of physicians regularly exposed to radiation in the operating room. An increasing reliance on fluoroscopy to diagnose and treat patients is being blamed for dozens of brain tumors and other illnesses in healthcare providers.

About 8,500 doctors, 13,000 nurses and 11,500 technicians work with these fluoroscopically guided procedures, according to some estimates.

A growing body of studies and reports is calling attention to the health issues faced by these medical professionals who are repeatedly exposed over time to low doses of ionizing radiation from the equipment.

A cardiologist, the type of physician most associated with fluoroscope-guided procedures, will have radiation exposure to the head equivalent to about 50,000 chest X-rays during their careers, according to one economic study of the issue by the Organization for Occupational Radiation Safety in Interventional Fluoroscopy (ORSIF). The resulting health effects add up to almost $49 million annually.

Doctors, nurses and technicians exposed to this radiation risk developing health effects including brain tumors, premature cataracts and thyroid disease.

Larger efforts to quantify the extent of this risk have concluded that more details and study are needed, but evidence pointing to the problem continues to grow.

One such study in 2016 by the National Institute for Health found that medical imaging technologists who performed fluoroscopy-guided procedures had approximately twice the risk of death from brain cancer compared to those who never did the procedures as well as increased risks of melanoma and breast cancer.

The prolonged stream of radiation required to use Fluoroscopy devices exposes physicians to the equivalent of 50,000 chest X-rays over the course of their career, one study found.

Brain tumors in healthcare providers doing fluoroscopic procedures were first reported in 1997. A study in 2014 compiled reports of brain or neck tumors in 36 physicians exposed to such radiation for prolonged periods. Half of those were glioblastoma, the same type of tumor as Haughn’s. In 2016, the number was updated to 43 doctors and nurses.

Glioblastoma (GBM) is an aggressive form of brain cancer, according to the American Brain Tumor Association. Hard to treat and even harder to cure, there is a 50 percent chance patients will live past 11 to 15 months with treatment.

It’s also relatively rare. Only 15 percent of brain tumors are glioblastoma, according to the association, with the vast majority of them occurring randomly and not through inherited genetics.

Very little appears to be known about GBM’s risk factors, with one exception. According to the association’s web site: “The only confirmed risk factor is ionizing radiation to the head and neck region.”

A general surgeon, Haughn was trained in laparoscopic, bariatric and minimally invasive surgery — all techniques involving fluoroscopy use.

The X-ray technique most people are familiar with uses radiation to take still pictures of inside the body. By passing through various parts of the body, the X-rays produce images of tissues, organs and bones, according to the federal Centers for Disease Control and Prevention (CDC).

But fluoroscopy uses these same X-rays to see these images continuously, in real-time, on a monitor “much like an X-ray movie,” according to the U.S. Food and Drug Administration, which regulates fluoroscopes and other X-ray systems.

Fluoroscope use has expanded rapidly in recent years in a wide range of medical specialties where they are often used to guide various examinations and procedures for diagnosing and treating patients, according to the National Cancer Institute, which has been studying cancer risks of medical workers exposed to this radiation since the early 1980s.

Higher-than-expected reports of left-sided brain tumors in doctors who do these procedures raised concerns about exposure, according to the cancer institute. Although not every physician with documented brain tumors was reported to be on the left side, the high number was significant because doctors typically stand with the left side closer to the radiation, according to the National Cancer Institute.

A subsequent study would later fail to find that doctors who used fluoroscopes did not have a higher risk of death compared to other doctors, including for brain cancer. However, researchers noted no radiation dose information was available to determine if the risks increased with greater exposure, and they were unable to look at specific cancer diagnosis information.

At least one organization believes the evidence warrants a closer look.

Although it’s not as well known as some larger health and cancer nonprofits, the Organization for Occupational Radiation Safety in Interventional Fluoroscopy (ORSIF), is laser-focused on its mission.

“Our goal is to raise awareness among the medical staff and hospital administrators and any other relevant parties about the hazards associated with radiation exposure and these kinds of operations and procedures, and what can be done to reduce those exposures,” said Michael Seymour, ORSIF’s director of advocacy programs and a former OSHA official.

“I think we need to raise awareness of the exposures that medical staff face in these kinds of procedures, and that includes interventional fluoroscopy.”

Seymour was director of OSHA’s Office of Physical Hazards in 2005 when the agency worked on a rule to update the federal standards for ionizing radiation exposure.

Seymour said ORSIF has gathered significant research on the issue.

Among its findings are that 85 percent of the brain cancers in doctors who do these procedures were on the left side of the brain, where they are exposed to higher radiation.

“So that’s very suggestive that the brain cancers that we’ve seen seem to be associated with this exposure,” Seymour said. “There is a substantial body of literature on the effects on the thyroid, including cancer.”

Other studies have linked cataract development to radiation exposure, as well as muscular-skeletal disorders and back pain attributed to the heavy lead aprons and protective gear worn during procedures.

An alphabet soup of government agencies, regulations and research efforts oversee and offer guidance for fluoroscopic guided procedures and other radiation uses in the workplace.

The Occupational Safety and Health Administration (OSHA) enforces safe use of radioactive equipment in the workplace. This includes not just health care facilities, but also research institutions, nuclear reactors and their support facilities, nuclear weapon production facilities, and other various manufacturing settings.

These radiation sources can pose a considerable health risk to affected workers if not properly controlled, according to OSHA.

Although the U.S. Environmental Protection Agency has protective guidelines for X-ray procedures, including fluoroscopes, they are considered non-binding.

Manufacture of radioactive equipment such as fluoroscopes and other medical imaging devices falls under the U.S. Food and Drug Administration.

OSHA’s inspections, when they happen, are made without warning to the workplace being inspected. However, they mostly occur after complaints from employees or a local authority such as a health or fire department.

In the last five years, from federal inspections at healthcare-related facilities such as hospitals and dental facilities for violations of the radiation standard, 19 resulted in citations for violations, according to OSHA.

In addition to federal agencies, states may also regulate use of medical imaging and other radioactive devices. This is done through OSHA-approved state plans administered by the states. The plans are required to be at least as stringent as federal regulations. There are 28 states, including Indiana, with their own OSHA plans but six of these states’ plans only cover local and state government workers.

Updating federal and state exposure standards is important because it is the cumulative effects of radiation exposure over time that creates the risk to healthcare providers.

OSHA attempted to update federal standards for workplace exposure to ionizing radiation, beginning in 2005, but Seymour said that effort was sidelined as other regulatory activities competed for agency resources.

Given the lengthy amount of time creating federal regulation can take, other approaches may offer better solutions, such as an increased emphasis on using already available protections.

“What is not being used consistently, as far as I know, is that there are lead-lined surgical caps that can be used that are not frequently used,” Seymour said. “There are thyroid shields that are used sometimes, but not as often as they should be. There is personal protective equipment that can be effective if is maintained properly and its use is monitored and enforced.”

Other types of shielding, including movable shields, also are available, he said.

Distance from the radiation source is another possible means of reducing exposure.

“Unfortunately, the way these procedures are done, the physician is right next to the patient’s body. So the physician is right there next to the (radiation) source,” Seymour said.

There are robotic technologies, that would allow the physician to be in another room controlling it without needing protective equipment, he said. These robotic systems are add-ons that could be used with existing fluoroscope technology.

This also would allow nurses and technicians to be farther away from the source and reduce their exposure.

“The physicians that do this work, they are dedicated to saving lives, and that’s their focus. So it can be a little challenging to get through to them that they need to think about their own safety, in an environment where they are 100 percent focused on the patient and the effectiveness of the procedures they are doing,” Seymour said.

“These are dedicated people who work miracles for a living. They shouldn’t have to work those miracles at the cost of their own health.”

Chris loved his work, Milly said, and he felt a duty to help others.

“He was the kindest, most caring and empathetic person you would ever meet. It didn’t matter if you were the president of the hospital or a homeless person who was brought in, he was going to treat everybody with the same care and compassion,” she said.

He also worked hard to make every minute count with his family.

“He wasn’t home very much, but when he was, we made every effort to make sure that it was the six of us,” Milly said. “It wasn’t a typical Monday through Friday, nine-to-five type of family where everybody sits down at 6 o’clock for dinner every single night. We always had family dinner but it may not have been until 8:30 or 9 o’clock at night.

“So there were a lot of times that it didn’t matter if we were doing anything special. It was just the fact that we got to be with Daddy.”

Milly said she expected living with the long hours Chris spent in the operating room and hospital, accepting it even though it meant time away from family life with their four children.

Chris’ loss, however, is something the family is still struggling with.

“The worst part of the day for me is around nine or 10 o’clock at night when all the kids are in bed. Everything’s quiet, and I’m by myself, you know,” she said. “In the past, even if Chris was on call or was stuck at the hospital, I could call him. I could text him. We could go through the day. If there was something funny that I had to tell him if I just needed to rant about something, I could.

“I don’t have that now.”

Even in his absence, Chris remains ever-present in his family’s daily routine.

“He’s in our life every day,” Milly said. “Every day there is a conversation about happy memories with Chris.”

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