[ RadSafe ] Fwd: Contamination

Bob Cherry bobcherry at satx.rr.com
Sat Dec 3 15:46:24 CST 2011

A little more background on the Tripler Army Medical Center (TAMC) case:

TAMC self-reported it although, at that time, NRC regulations did not
require this incident to be reported because the administration was to a
patient in accordance with physician's orders. The NRC could not cite TAMC
for the ablation of the infant's thyroid for the same reason. The NRC
subsequently changed 10 CFR 35 to address situations like this.

The patient was from the Marshall Islands and did not know English. TAMC
brought in a translator to talk to her. She was asked the question about
nursing an infant because that question was on the form being translated.
Apparently something got lost in the translation because TAMC gained the
impression that she was not a nursing mother. 

The NRC investigated the incident and ended up issuing a notice of violation
for not having the patient sign the interview form. The NRC was going to
fine TAMC for this, probably because of the bad outcome for the infant. The
Army strongly objected to the fine because of self-reporting and TAMC did
everything else in compliance (not counting the mistranslation). Forms were
properly signed for every thyroid ablation at TAMC except for this single
occurrence and signing the form for this incident would not have changed the
unfortunate outcome for the infant. The NRC backed away from a fine for

I was at TAMC's higher headquarters when this happened. When I mentioned the
incident to an Air Force colleague (Hi, Ed!), he told me that a similar
incident had occurred at an Air Force medical center a few years earlier
that the Air Force did not report to the NRC.

When an NRC staffer (and former Army officer) was speaking at an Army
conference about this incident (before the NRC made its final decision about
the fine) and said the NRC was inclined to make an example of the Army over
this incident, I stood up and said if the NRC did that, the real lesson
would be to not self-report something when NRC regulations do not require a
report. Further, the NRC should have been grateful to some small extent that
the Army brought a shortcoming in its regulations to NRC attention rather
than punishing the Army for it.

Bob C

-----Original Message-----
From: radsafe-bounces at health.phys.iit.edu
[mailto:radsafe-bounces at health.phys.iit.edu] On Behalf Of Jeff Terry
Sent: Saturday, December 03, 2011 1:22 PM
To: The International Radiation Protection (Health Physics) Mailing List
Subject: [ RadSafe ] Fwd: Contamination

Hi All, 

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Jeff Terry
Chair, Advanced Test Reactor Users Organization Assoc. Professor of Physics
Life Science Bldg Rm 166 Illinois Institute of Technology
3101 S. Dearborn St. 
Chicago IL 60616
terryj at iit.edu
Twitter: http://www.twitter.com/ATRNSUOchair
Twitter: http://www.twitter.com/nuclear94

Begin forwarded message:

> From: Laurence F Friedman <friedmanla at iit.edu>
> Subject: Contamination of others by I-131 therapy patients
> Date: December 3, 2011 1:15:28 PM CST
> To: radsafe at health.phys.iit.edu
> In the annals of the USNRC there are at least two cases of nursing mothers
who were administered I-131 and subsequently nursed their infants. One case
was a diagnostic study and relatively little damage was done to the infant
thyroid. The second, at Tripler Army Medical Center in Honolulu, the patient
was given a therapeutic dose. The infant's thyroid was ablated.
> During a routine NRC inspection of a Pittsburgh hospital the staff
informed the inspector that a male patient, who had been given 200 mCi of
I-131 orally, had had sexual intercourse with a female visitor the day after
the administration. The patient was a physician and, according to the staff,
the action was not out of character for him,. The hospital tried to get the
woman to come in for a bioassay (thyroid count) but she refused. The
incident had occurred a year or two before the inspection so no action was
taken by the NRC and I don't believe the incident was documented.
> I don't know if this is the sort of cross-contamination you are looking
for but since all body fluids and the breath contain I-131 after an
administration there must be other instances of transfers similar to these.
> Laurence F. Friedman, Ph.D., CHP
> Senior Lecturer, Physics Department
> Illinois Institute of Technology
> Room 182, Life Science
> 3101 South Dearborn
> Chicago, IL 60616-3793
> (312) 842-1789
> friedmanla at iit.edu

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