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Re: what is news and what is not
Sandy,
May I re-post your response on the MedPhys list ?
I have been quite concerned about this issue on the "medical"
side for years. I have seen many occurrences of inadequate
control of High Radiation Area's (typically a roof or outer wall)
... then when incidents occur, blame assessment is the highest
priority (rather than addressing the actual problem). Reducing
the cost of construction (by thinning primary barriers and the
creative use of occupancy factors) drives many room designs
in the medical environment (long term - or serious - control of
the High Radiation Area may be left for the after-first-incident
review).
Before this sounds too malicious, I would offer the following
example (and true story) --- Some years ago, I encountered a
well intentioned physicist that had helped with the design a
new room for a linac (it produced 6MV & 15MV x-rays with a
dose rate in the collimated field of 600 rads/minute at 1 meter).
The strong encouragement was to economize, so the designer
was careful to include geometric calculations related to the
two story office building next door and the sidewalk on one
side of the new room. After thinning the roof (but carefully
missing the office building) and one of the primary barriers (for
the sidewalk), the design was approved --- with the addition
of a nice over-hanging roof). Both regions were assigned the
most minimal of occupancy factors ... Sometime later (about 6
months), the hospital decided to put a nice bench for the bus
stop under the over-hanging roof (a nice thought considering
the rainy climate). The busses stopped once an hour --- many
waited at the bus stop for most of the hour, so the bench was
quite popular ... about 18 months later, the hospital decided to
increase the height of the office building (from 2 to 4 stories) ...
(Much cheaper than buying new property in that part of town.)
In short, there is nothing so constant (in the hospital environment)
as change --- what is today a low occupancy area ... in 3 years can
be a fully occupied office space. An administrator will not remember
the restrictions that you set down (or your design criteria) when a
change in the floor plan is implemented.
Knowing this, can one so easily defend the minimal occupancy
factors (and the minimal control of these spaces) that appear in
many barrier designs for environments that are known to change
on an unknown time frame?
I have heard many say --- "I put that in my report!" --- after the
first incident occurs.
(Enough rambling ...)
My sympathies are with the worker on the roof,
not with the designer of the room.
Were the people running the linac told about the
issues associated with the roof?
News worthy?
In this forum, yes!
It was someone like us that designed that room,
it's roof, and roof control system (or lack thereof).
Doug J.
Douglas D. Jackson
St. Louis, MO
--------------------------------------------------------------
Sandy Perle wrote:
> Tim,
>
> I do understand your point. Our disagreement centers around what is news. Your
> opinion is that unless there is something to be gained, or some action to be taken,
> then the information is not newsworthy. I obviously disagree.
>
> In this case, there is much to be learned. This incident is no different than similar
> incidents in medical facilities, nuclear power plants, etc. Loss of Control where a High
> or VERY High Radiation Area can occur. In this instance, what can be assessed
> using root cause analysis:
>
> 1. Inadequate communication. Workers unaware that there was an installation or
> maintenance taking place.
>
> 2. Victim unaware that medical irradiation activities were taking place.
>
> 3. Areas accessible where extremely high doses could be received without
> knowledge of the facility management.
>
> 4. Inadequate procedures. Nothing in place to secure an area prior to irradiation.
>
> 5. Lack of visual or audible alarms in areas where access was possible.
>
> I could go on. Anyway, I've seen your comments, as have others, and, we'll just have
> to disagree what is news and what is not. In conclusion, the more we are aware of
> what is being told to the public, via written media, TV or radio, the better prepared we
> are to deal with it. The worse thing that can happen is for the public to raise a
> question or issue, and we professionals can only shrug our shoulders, demonstrating
> lack of knowledge, and more often than not, a perception that anything that happens
> in our field can't be bad, where there are no consequences. This is foolhardy at best.
> We need to be prepared to deal with issue, real, or perceived to be real.
> ------------------------------------------------------------------------
> Sandy Perle Tel:(714) 545-0100 / (800) 548-5100
> Director, Technical Extension 2306
> ICN Worldwide Dosimetry Service Fax:(714) 668-3149
> ICN Pharmaceuticals, Inc. E-Mail: sandyfl@earthlink.net
> ICN Plaza, 3300 Hyland Avenue E-Mail: sperle@icnpharm.com
> Costa Mesa, CA 92626
>
> Personal Website: http://sandy-travels.com
> ICN Worldwide Dosimetry Website: http://www.dosimetry.com
>
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