[ RadSafe ] Radiography Incident

Tue Apr 3 22:48:54 CDT 2012

"I read about one case in which an HDR patient was sent back to her nursing home with the source still in her!"

That is true, it happened in a clinic in Pennsylvania in early 1990s. I worked for the same company, in a different clinic, after the event.

However, the lesson learned from that event are enormous, and led to re-engineer the device. I am eager to hear if the industrial radiography devices learned anything from that.

The event of Pennsylvania took place after the Ir-192 source broke off the loader wire. The medical physicist ignored the area monitors alarm and suspected they are false alarms. It was the dumping grounds radiation monitors at the gates which first led to the discovery of the accident. The source was left in a dead end plastic applicator used to guide the source to the treatment area, then the applicator was thrown in the trash bin when patient died at the nursing home.

The most important modification to the device was to have an on-board radiation monitor to confirm the return the source itself to the safe, rather than the old cable length counting system using optical sensors at the outlet of the device.

It would be quite an expensive endeavor to retrofit industrial radiography systems, but it is possible to require such safety interlocks from manufacturers, by regulations for newly licensed systems.

Ahmad

------------------------------
On Wed, Apr 4, 2012 4:57 AM AST (Arabian) William Lipton wrote:

>I read about one case in which an HDR patient was sent back to her nursing
>home with the source still in her!
>
>Bill Lipton
>It's not about dose, it's about trust.
>
>
>
>On Tue, Apr 3, 2012 at 9:03 PM, Chris Alston <achris1999 at gmail.com> wrote:
>
>> Philip
>>
>> Medical HDR machines were derived originally from the industrial field
>> radiographic machines.  It would be entirely congruent to bring the
>> technology full-circle, and apply lessons learned in clinical R&D to
>> safety in field radiography.  However, as has been pointed out, there
>> are already simple rules, validated many times over, which are not
>> being followed.  E.g., wearing an alarming high-range dosimeter.  So,
>> a higher level of engineering may not be useful, unless it can
>> robotically protect people from themselves.
>>
>> Cheers
>> cja
>>
>>
>> ---------- Forwarded message ----------
>> From: Philip Egidi <Egidi.Philip at epamail.epa.gov>
>> Date: Tue, Apr 3, 2012 at 9:03 AM
>> Subject: Re: [ RadSafe ] Agreement States v. NRC (was: radiography
>>  incident)
>> To: "The International Radiation Protection (Health Physics) Mailing
>> List" <radsafe at health.phys.iit.edu>
>> Cc: CJB01 at health.state.ny.us, radsafe-bounces at health.phys.iit.edu
>>
>>
>>
>> OK, as a former materials inspector who has survived two IMPEP reviews,
>> I offer the following:
>>
>> 1) the program can be found compatible by the auditors who review the
>> regulations and records: check.
>> 2) field audits of inspections by IMPEP staff can show the inspectors
>> are trained and doing their job (or not): check.
>> 3) review of records during inspections can show patterns of certain
>> individuals getting higher doses than other workers and can be flagged
>> for follow up (which RSOs do all the time): check.
>>
>> That DOES NOTHING to change the behavior of the companies and workers in
>> the field once the inspections are over.  It is the culture of the
>> industry.  The best way to get these companies to change their behavior
>> is through heavy fines.  If the fines are big enough, and not negotiated
>> away for promises of better future performance, only then will the
>> companies enforce a stricter safety culture.  It is more profitable now
>> to just pay the small fines and get the slap on the hand than it is to
>> change the culture.
>>
>> Unannounced inspections during off hours is a good way go catch these
>> folks behaving badly.  But if you don't know where they are working, you
>> can't inspect them - so you almost always tip your hand when you call
>> and ask where the crews are.  This also happens under reciprocity
>> inspections (when they come in from another state).  Unfortunately, that
>> means extra staff hours and time that the States just don't have.  The
>> recession hits all programs, including inspections.  State program staff
>> are generally underpaid and overworked, and some States have license
>> writers also doing inspections as well as incident response.  It takes
>> time to become a good inspector, you just can't hand someone a checklist
>> and cut them loose.  Add to that the radiography often happens far from
>> the State capital where the inspectors are based, and you get
>> significant travel costs on top of everything else.
>>
>> However, there is also room for improvement on the hardware side.  For
>> example, I also inspected high dose rate afterloaders for brachytherapy
>> at hospitals.  Those devices also use I-192, although much smaller
>> sources (~10 Ci).  Since they involve sending a high-activity source
>> into a human being, those gizmos have hardware and software mechanisms
>> to prevent unintended exposure.  The HDR units control when, how long,
>> and how far out the source is extended into the catheter; a similar
>> device could be designed for the guide tubes that would also allow the
>> operator to stand further back as opposed to the hand cranks that are
>> only about 35 feet long.  This too would reduce dose on a daily basis to
>> the radiographer.  If a smaller, field hardened system could be devised
>> for radiography cameras, this would result in lower dose to the workers.
>> Couple that with digital radiography, and doses in this sector can be
>> reduced tremendously.  It just takes a lot of time and money to get put
>> in place.
>>
>> For disconnects, such as what sparked this thread, it still appears to
>> me that something was not communicated in the post - the person who
>> retrieved the source may have not followed his training and got himself
>> a lot more dose than what he could have gotten.  Putting a guide tube
>> around your neck with a source in it to climb down a ladder is just
>> plain stupid.  If he was trained in retrieval, then he should have known
>> better.  We already discussed the fact that he didn't listen to his
>> alarming ratemeter.
>>
>> I agree with the previous poster about the lack of education and
>> language barriers in the field.  Very high turnover, and the companies
>> steal workers from each other on a routine basis.
>>
>> PVE
>>
>> Philip Egidi
>> Environmental Scientist
>> U.S. Environmental Protection Agency
>> Office of Radiation and Indoor Air
>> Radiation Protection Division
>> Center for Waste Management and Regulations
>> Washington, DC
>>
>> phone: 202-343-9186
>> email: egidi.philip at epa.gov
>> cell: 970-209-2885
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