Portable Chest Radiograph in ICU: A Pregnant Nurse Offers to Hold
02:10. You are called to the ICU to perform a portable AP chest radiograph on a 74-year-old man (92 kg) who is intubated, sedated with propofol, and has just been repositioned. He is pulling at his endotracheal tube and the nurse is concerned about extubation. The nurse caring for him tells you she is 14 weeks pregnant and offers to hold his arms. The bed space is 3.5 m from the next patient, who is awake; there is no lead screen in the ICU. Your DR unit is set at 85 kVp and 2.0 mAs; the department has a strict no-repeat policy for portable films, and the intensivist wants the image within 20 minutes to guide a ventilator change. No other staff are immediately available.
1. What do you do in the next five minutes? Set out the order in which you would consider your options and the dose reasoning behind each step.
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First response: thank her, explain the position clearly, and decline her offer as the first-line plan - she is a volunteer, not a required member of the team, and justification and optimisation apply to her as well as to the patient.
Order of alternatives:
- Ask the intensivist for a small propofol top-up or a bolus of analgesia. A 2–3 minute delay is compatible with the 20-minute deadline and removes the need for anyone to hold.
- Mechanical restraint. Bed arm supports, a sheet, or simply tucking the arms under a warmed blanket will usually control a sedated patient's reach long enough for a 2.0 mAs exposure.
- Call a non-pregnant colleague if the first two fail and time is genuinely tight.
- Only then allow her to hold, with full protection and a single exposure.
Why this order: a single portable chest gives a foetal dose in the low microgray range even without shielding, and far below the 1 mSv dose constraint applied after a declared pregnancy - but 'very small' is not the same as 'justified'. The team dose is the sum of every avoidable scatter exposure across a shift, and the ethical weight sits with the fact that alternatives exist at essentially no clinical cost.
2. If holding is unavoidable, state the specific protective measures you would apply and explain the physical reason behind each one.
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- Distance and position: stand at the head end, at least 1 m from the collimated field edge and out of the primary beam. Scatter falls off with the inverse square of distance, so doubling the distance cuts the scatter dose to a quarter before any shielding is considered.
- Collimation: restrict the field to the lung fields. Scatter is generated by the volume of tissue irradiated, so tighter collimation reduces both patient and staff dose simultaneously.
- 0.5 mm Pb-equivalent apron correctly worn (overlap at the front, no gaps), with a thyroid collar. At 85 kVp this attenuates roughly 90–95% of scattered photons; a cracked or folded apron does not, so it must be checked before use.
- Hands and arms out of the beam, holding through a sheet or blanket rather than directly.
- One exposure only. The no-repeat rule is a dose rule, not a convenience rule: a repeat doubles her dose and the patient's.
- No shielding is required for the patient 3.5 m away - scatter at that distance is trivial - but close the curtain and tell him what is happening so he does not move.
- Fix technique at the lowest mAs that will give a diagnostic film; do not use grid-free portable technique with an inflated mAs 'just to be safe'.
3. After the exposure, what must be recorded, communicated, and escalated, and to whom?
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Document on the request/record: that a pregnant comfortor assisted; her name and role; the reason no alternative was workable; the apron and collar used; the exposure factors and the DAP displayed by the unit; and the number of exposures (one).
Communicate: confirm with the intensivist whether the image is diagnostic - if the ETT tip is not clearly seen, the clinical answer is usually repositioning, not an immediate second exposure, and that decision belongs to the intensivist and radiologist.
Escalate: inform the Radiation Protection Supervisor/RPA the same shift, so the event can be reviewed against ALARA and any local reporting threshold. Advise the nurse to declare her pregnancy to occupational health so that a dose constraint of 1 mSv for the remainder of the pregnancy and a dedicated dosimeter are formally applied. File an internal incident/justification review - not because a limit was exceeded, but because the system, not the individual, allowed an avoidable exposure to be considered.
Do not describe this to the nurse as an 'overexposure'; giving her accurate dose context protects both her and the department's credibility.