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2019v1.0
RADIATION
PROTECTION
IN MEDICAL RADIOGRAPHY
In memory of my parents, Felix J. and Elizabeth M. Krohn,
To my sons, Joseph F. Statkiewicz, Christopher R. Statkiewicz, and Terry R. Sherer, Jr., with love,
And
To all with whom I may share my knowledge.
RADIATION
PROTECTION
IN MEDICAL RADIOGRAPHY
MARY ALICE STATKIEWICZ SHERER, AS, RT(R), FASRT
PAULA J. VISCONTI, PhD, DABR
E. RUSSELL RITENOUR, PhD, DABR, FAAPM, FACR
KELLI WELCH HAYNES, EdD, RT(R), FASRT
9TH EDITION
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
RADIATION PROTECTION IN MEDICAL RADIOGRAPHY, NINTH EDITION ISBN: 978-0-323-82503-0
Copyright © 2022 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verication of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2018, 2014, 2011, 2006, 2002, 1998, 1993, and 1983.
Library of Congress Control Number: 2021935647
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Printed in India
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Amy Buxton
Sonya Seigafuse
Lisa Newton
Laura Selkirk
Deepthi Unni
Manchu Mohan
F O R E WO R D
As an author of two imaging and exposure textbooks,
I welcome the opportunity to praise the textbook
Radiation Protection in Medical Radiography. Efforts to
minimize radiation exposure during imaging procedures are illustrated throughout my textbooks but need
more coverage of radiation protection. A thorough understanding of ionizing radiation and radiobiology is
critical for radiologic technologists (RTs) and other
medical radiation workers to perform their unique role
in optimization for radiation protection (ORP), which
is expertly accomplished in this textbook.
Our knowledge of ionizing radiation and its risk
continues to advance. Advancements in medical imaging and radiation therapy challenge our understanding
of radiobiology, radiation risk, and radiation protection
practices. The Radiation Protection in Medical Radiog-
raphy textbook has met these challenges throughout
the decades and continues with this edition. New
features incorporated into the ninth edition include
individual chapter references, now located in one section, as well as expanded coverage of topics that illustrate the dynamic nature of the profession such as dual
energy absorptiometry, digital breast tomosynthesis,
radioimmunotherapy, and radiation emergencies. I applaud the authors for their ability to effectively weave
new information into our long-standing traditions that
could impact current and future radiation safety practices, such as the profession’s current revision of patient
shielding policies. As a result, the reader gains much
insight into the dynamic nature of the medical imaging
and therapeutic profession.
Chapter 1 provides an excellent overview of ionizing
radiation and its interaction with matter. It emphasizes
the unique role of RTs in radiation protection for the
patient, themselves, and the public. The authors make
a compelling case for the need and importance of radiation protection as a shared responsibility among radiation workers and their employers.
The biological effects of ionizing radiation and
efforts to minimize risk are complex scientific concepts.
Chapter 1 effectively illustrates to the reader the importance of and responsibility for radiation protection and
provides practical examples for the RT when patients
ask about radiation risk of their imaging procedures.
The remaining chapters provide the depth of coverage necessary for a thorough understanding of radiation
protection and radiobiology as recommended by the
ASRT and will more than adequately prepare radiography students for the ARRT Radiography exam. Chapter
2 provides a compelling recount of historical events
such as the Three Mile Island and Chernobyl nuclear
plant accidents that illustrate the power of ionizing
radiation to do harm if not handled properly and safely.
Chapter 3 provides a concise but thorough discussion of the fundamental physics needed for the reader
to grasp the complex topic of x-radiation interaction
with matter. Chapter 4 provides a thorough explanation
of the radiation units dose equivalent and effective dose
with mathematical examples. This topic frames the
need for radiation monitoring discussed in Chapter 5.
Chapters 6–9 provide an overview of cell biology, molecular and cellular radiation biology, as well as somatic
and genetic effects on tissues and organ systems both
early and late. The authors’ concise discussion of the
historical evidence of radiation-induced biological effects offers insight into the continued debate regarding
radiation risk.
These foundational concepts are revisited in subsequent chapters to further the readers’ understanding
of radiobiology and radiation protection. For example,
Chapter 10 presents important information regarding
current radiation protection standards recommended
by major organizations both domestically and internationally. Chapters 11 and 12 focus on routine diagnostic
radiography including equipment design for radiation
protection, minimizing patient radiation exposure
during imaging procedures especially for vulnerable
populations such as pediatrics and pregnant patients.
Chapter 15 provides important tips during fluoroscopic imaging for protection of both patients and
radiation workers. Several chapters are devoted to special considerations for other modalities; Chapter 13
is computed tomography, Chapter 14 is x-ray breast
imaging, and nuclear medicine and radiation therapy
v
vi
FOREWORD
are discussed in Chapter 16. There are numerous
outstanding illustrations throughout the textbook
that help the reader grasp the important concepts.
Additionally, the appendices provide a wealth of information for further study.
The superior quality of the subject matter in each
chapter is a result of the noteworthy authors. Authors,
who are well-established educators and medical physicists, ensure that the content includes both depth and
breadth to meet the needs of RTs and other medical
radiation workers, in addition to the accuracy of the
content. Because our knowledge and understanding
of radiation risk have evolved throughout the decades,
it is essential to have qualified authors that not only
teach in the RT profession but include the perspective
and knowledge of medical physicists. These individuals
have served as authors for almost all the textbook editions, thereby ensuring its continuity and longevity as a
premier radiation protection textbook.
In summary, this textbook is a comprehensive handbook on radiation safety, protection, and radiobiology
that will meet your needs for successfully completing
exams and as a reference throughout your clinical practice. The accompanying free-standing workbook is full
of a variety of activities that will actively engage you
to maintain your knowledge and understanding of radiation protection. I commend the authors for continuing,
in the ninth edition, the superior coverage of such
essential topics in our profession. This textbook, in its
entirety, will ensure you have the tools to be successful as
you practice radiation protection in medical radiography.
Terri L. Fauber, EdD, RT(R) (M)
Professor Emeritus of Radiation Sciences
Virginia Commonwealth University
Author of Radiographic Imaging and Exposure, 6th edition
Coauthor of The Essentials of Radiographic Physics and
Imaging, 3rd edition
P R E F A C E
GOAL OF THE TEXTBOOK AND ACCOMPANYING ANCILLARIES
The overall intent of this textbook and the accompanying ancillaries is to offer new and current radiation
science professionals, on multiple educational levels,
essential and timely information on the elements of
radiation safety. This requires extended discussions on
radiobiology and relevant radiation physics that are
designed to fully educate students and professionals in
the safe use of x-rays and commonly used radionuclides
in both diagnostic imaging and therapy. This edition
includes substantial introductions to selective advanced,
recently developed, and new procedures involving the
use of ionizing radiation.
CONTENT
The ninth edition of Radiation Protection in Medical
Radiography has been updated and greatly expanded to
include radiation safety methods for both traditional
and newer imaging procedures. To accommodate information on new topics, the number of chapters has
increased from 15 in the previous edition to 16 in this
edition. All existing chapters have been revised and,
for some, considerably expanded to contain the latest
volume of updated information on both traditional and
newer subject matter. As is seen in the table of Contents
for this edition, the titles of Chapters 13 and 14 have
been changed to accommodate their enlarged dedication to specific advanced subject matter.
A slight change has also been made to the format of the
book whereby the individual chapter references are now
located in one section in the back matter of the book
instead of at the end of each chapter. As with previous
editions, the format of each chapter begins with a list
of objectives to be accomplished by the learner at the conclusion of that chapter. The objectives are followed by a
table of contents or outline that describes the main subject
matter included in each chapter. Subsequently, a catalog of
key terms is presented after the chapter outlines to alert
the reader to topics of significant importance.
An introductory paragraph typically begins each
chapter to create immediate awareness of chapter content. At the end of the contents of each chapter, there
is a detailed summary that emphasizes important
information to be remembered. Finally, to assess the
degree of learning, there is a set of general discussion
questions and multiple-choice review questions. A series
of appendices that enhance specific topics mentioned
throughout the book follows the last chapter. Following
these appendices, there is an updated and significantly
enlarged glossary to provide the learner with a quick
reference and study guide to important definitions.
Lastly, a detailed page index of subject matter topics
completes the textbook.
This edition begins with an introduction to radiation protection followed by reviews of various types
and sources of radiation and a beginning presentation
of the concepts of radiation dose. Other subject matter includes essential physics concepts relevant to radiation safety such as x-ray absorption in biologic
tissue, x-ray production and energy, and various
methods of x-ray interaction with matter. Discussion
of traditional and metric radiation quantities and
units, the discovery of x-rays, and early radiationinduced injuries is also included. State-of-the-art
radiation monitoring for personnel and area monitoring are fully described. A chapter offering an extensive overview of cell biology prepares the reader for
the discussions of molecular and cellular radiation
biology that follow.
The ninth edition also features detailed up-to-date
discussion about early tissue reactions and their effects
on organ systems as well as discourse about stochastic
effects and late tissue reactions caused by radiation
in organ systems. Priority is given to the topic of dose
limits for exposure to ionizing radiation. Because the
designs of diagnostic x-ray and ancillary equipment
constantly advance, equipment design for radiation
protection is also examined. Major emphasis is placed
on management of patient safety during diagnostic
x-ray procedures with discussion of effective communication between the radiographer and the patient, use
vii
viii
PREFACE
of immobilization, current shielding protocol and
revision of patient gonadal shielding policies, technical
exposure factors, postprocessing of radiographic images, considerations concerning repeat images, risk of
exposure during extended diagnostic imaging procedures, radiation protection for the pregnant or potentially pregnant patient, and various pediatric safety
protocols during radiographic imaging. Dual-energy
x-ray absorptiometry concepts are introduced and
addressed in this new edition.
Two chapters in the ninth edition are dedicated,
respectively, to discussing special considerations on
radiation safety in computed tomography and radiation
safety aspects in x-ray breast imaging. Both traditional
mammography and digital breast tomosynthesis (3D
mammography) are included in the latter discussion.
Because management of imaging personnel radiation
dose during diagnostic x-ray procedures is a topic of
vital importance, a detailed presentation of relevant
subject matter is also included. This features information on annual limits for exposed personnel, the “as
low as reasonably achievable (ALARA)” concept, dose
reduction methods and techniques, protection for pregnant personnel, basic principles of radiation protection
for personnel exposure reduction, protection during
fluoroscopic procedures, protection during mobile x-ray
examinations, protection during C-Arm fluoroscopy,
protection during high-level control interventional procedures, diagnostic x-ray suite protection design, and
the usage of radiation caution signs.
To create opportunity for advancement in other imaging modalities and the special considerations needed
in procedures in such disciplines, the final chapter of
the text covers radioisotopes and their associated radiation protection requirements. New to this chapter is
a section discussing radioimmunotherapy (RIT). This
final chapter also contains relevant information on
radiation emergencies, such as those initiated by the use
of radiation as a terrorist weapon, and the appropriate
handling and procedures to follow in such situations.
The nine appendices in this textbook provide the
reader with a wealth of supplemental material that significantly compliments and expands specific information given within various chapters in this textbook.
Bullets continue to be used to enhance readability by
calling attention to particular information, and key
terms, as in previous editions, are identified in bold
print. The authors have endeavored to present material
in this textbook in a succinct but sensibly complete
fashion to meet the ongoing needs of the various members of the health care sector. With each new edition, the
authors have sought to expand the scope of the subject
matter covered in the text to provide all readers with a
broader base of knowledge.
New to This Edition
Many additional figures and improved illustrations are
presented throughout the textbook. These and other
previously existing artwork serve to enhance the visual
impact of the text, thereby promoting visual learning
and aiding the reader’s understanding of various materials throughout the text.
The number of chapters has increased from 15 to
16 to accommodate the inclusion of specific new information throughout the text, including the creation of
two new chapters that are now dedicated to specific topics. The order of selective information throughout the
text has been altered to facilitate more effective and efficient delivery of all subject matter covered. As previously mentioned, this edition contains an updated and
considerably expanded glossary of relevant terms associated with radiation protection/safety, radiobiology,
and relevant radiation physics. The authors believe that
this glossary can serve as a very useful overall quick
reference and/or review tool. Several new topics have
been added to this edition to provide readers with a
state-of-the-art text on radiation protection/safety. The
new subject matter introduces readers to advanced
procedures that they may expect to encounter in the
modern clinical setting and therefore require an awareness and understanding of the methods of radiation
protection needed to ensure safety of patients, themselves, and other personnel while these procedures
are being performed.
Chapter Contents
Information covered in Chapter 1 includes a discussion of the use of ionizing radiation in the healing
arts, beginning with the discovery of x-rays in 1895,
the fundamental properties of x-rays, team concept in
the medical field, and the control of radiant energy.
Goals and concepts of radiation protection are
identified and a simplified introduction to the three
main radiation quantities and units of measure (both
traditional and metric) is provided to acquaint learners with these concepts earlier in their education.