Re: 131-I, Blood, Sweat & Te

["Mike Bohan" <mike.bohan@yale.edu>]

        Reply to:   RE>131-I, Blood, Sweat & Tears

Dear Janet,

This is a tall order, but I'll take a crack at it!  Here comes 15 years of
thankless tears, toil and hard won wisdom!  Maybe those Nuc. Power types, will
realize that, we on the medical side of things, have some ethics after all! 

1. Patient Education

We spend time with the patient before administration to explain the treatment
and provide them with as much information as they can understand.  We discuss
the reasons for the isolation precautions, the metabolism of I-131 therapy,
routes of excretion, the advantages, disadvantages and alternatives to the
treatment.  We tell them what the release limits are and how we determine when
they can be released from isolation.  We tell them how we handle the wastes
produced (Decay in Storage > 10 T1/2's) and we ask their assistance in reducing
the volumes of wastes produced and in avoiding wastes which will present
significant sanitary hazards in 80 days of non-refrigerated storage.  The
authorized user (AU) repeats a synopsis of this and advantages/alternatives
before obtaining consent and administering the dose.  We (RSO Staff) calibrate
and administer the dose in the presence of the AU to ensure administrations are
in accordance with the Quality Management Program (QMP).  We use a check sheet
to make sure all aspects of the QMP requirements have been satisfied.

2. Room Preparation

We cover all floor surfaces with HERCULITE (tm?), which is a commercially
available plastic floor covering commonly used in the Nuc. Power industry.  We
securely tape it to the floor to prevent patient slips and falls, and we tape
all seams, especially in the private bathroom.  We cover all tables and shelves
with absorbent blue covers which are securely taped down.  (TIP - leave a tab on
all tapes so they can easily be removed after completion of treatment --- with
latex gloves on!).  We cover all door knobs, switches, telephones, bed rails,
call buttons and TV controls with saran wrap or plastic bags.  We place two
plastic bag lined cardboard boxes in the room to gather all trash and medical
personnel barrier controls in one and all linen in the other.  (TIP - ask the
patient to pour all liquids down the drain and all uneaten food down the toilet
except for items that may clog the drains [e.g., bones, banana peels, etc.], and
to allow all wet linen [e.g., bath towels & wash cloths] to dry before placing
in linen box).  (TIP - Cover toilet seats or exchange them with spare one's
after treatment and check that toilet flushing and sink drains are clear and
have fast flows before treatment is begun.)  We place a movie theater type
stanchion barrier in front of the door to prevent people from mistakenly
entering the room after therapy has begun. (TIP - Clergy & Doctors will not read
the warning instructions before entering the room.  The Clergy because they
think they are protected by god and the Doctors because they believe they are
GOD's!  8-} ---> Just kidding, for any Clergy and MD's out there!!)  Make sure
Nursing staff is well trained in wearing barrier clothing - minimum requirement
- gloves, gowns and shoe covers, add double gloving, eye protection, face masks
and hair covers, if splashing or respiratory complications exist - and in proper
degowning techniques.  Also teach them to wash hands and survey themselves upon
exiting the room.   If significant splashing (Foley bag/urine handling) or
respiratory problems exist, bioassay all involved nursing and/or ancillary
personnel after treatment -- keep a shift log to ensure all are done.   Dispose
all urine and excreta via sanitary sewerage system -- unless special
considerations prevent this method. (See - Ken Miller, RSO @ Hershey Medical
Center) 

3. Release Criteria & Instructions

We release the patient when they fall below 5 mR/hr @ 1 meter *AND* calculate
below 30 mCi by proportional measurements compared to the initial measurement at
1 meter @ administration (conservative CYA internal policy).  We use an ion
chamber survey meter (Keithley 36150) and a meter stick for this measurement,
preferable the same ones throughout.  If they have children or siblings less
than 18 yrs old at home, we hold them to 8 mCi per NCRP recommendations (Report
No. 37), unless alternative arrangements can be made.  We give them both oral
and written instructions to follow after release and a phone number to call if
questions arise after release, and we encourage them to use it if necessary.  We
basically tell them to avoid close personal contact (wet kisses, sleeping
together, etc.), food prep. for others, bathroom tips (flush toilet, rinse sink,
tub, shower 3x), keep toothbrushes and linen separate, separate bathroom if
possible, and to segregate and wash separately their laundry for 1 week.  We
also recommend, if appropriate, that they refrain from unprotected sexual
contact for 1 month post Rx and child bearing per physicians' recommendation. 
(TIP - these are ALARA recommendations --- not orders.   We also tell them that
if something inadvertently occurs, that the potential exposures, short of
drinking the toilet water, are minimal from a health effects standpoint.) 

4. Room Decon.

All protective covers are removed starting from the room entrance to the
bathroom last.  Fold all covers during removal carefully in on themselves to
avoid "Hot Particle" [contaminated food, hair, etc. particles] spread.  Put all
floor covers in separate plastic bag so they can easily be recovered, cleaned
and reused after total decay.  Survey all extra linen for general release if
uncontaminated.  Leave the bathroom to the end -- usually the area with most
contamination.  (TIP - ask all male pts. to sit down when they urinate or you'll
be surprised at how must splashing occurs and how hard is is to decontaminate
painted walls).  Perform GM survey to identify any "hot spots".  Perform wipe
testing to document all accessible areas of the room are less than 200 dpm/100
cm-sq.  (TIP - get a cheap portable scaler [we use an "old" Ludlum Model 22 (>
20 yrs old!, with bubble display! -- How quaint!)] with a LEG scintillation
probe.  Build a simple counting jig with a little lead foil shielding around the
LEG probe to cut down the low energy background.  Calibrate it with a Ba-133 
Std. source [spectrum abundance's and energies close to I-131].  You should be
able to get an MDA @ 4.66 sigma near 200 dpm  [This is why the shielding is
important].  This allows you to decontaminate the room without running samples
all over campus to get back to your lab.  If you can't get down to 200 dpm use
it anyway to prescreen wipes before you take then to the office for definitive
assay.  By the way, we also use this system to perform thyroid bioassays, with
different calibration factors of course, we get an in-phantom MDA of < 1 nCi.  
(TIP - All direct handling of >30 mCi I-131 doses are performed by RSO Staff,
because we couldn't always run down the AU's or Nuc. Med. Techs within the 48
hr. bioassay period.)

Well that was a mouthful....  I don't know if that was complete or comprehensive
enough for you, but it's free, so what can you expect!!!  Of course, all
equipment mentioned is for example only and no endorsements are implied!  And,
as usual, don't forget my e-signature endnote!  

<><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><
Michael J. Bohan, RSO   |  e-mail: mike.bohan@yale.edu
Yale-New Haven Hospital |    Tele: (203) 785-2950
Radiological Physics    |     FAX: (203) 737-4252
20 York St. - WWW 204   |    As usual, everything I say may be plausibly
New Haven, CT    06504  |    denied at my employer's convenience ...
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--------------------------------------
Date: 27/06/96 2:06 PM
To: Mike Bohan
From: radsafe@romulus.ehs.uiuc.edu
I am a new subscriber to the list, but I was told that you recently had a 
discussion of 131I therapy.  I am interested in knowing any information 
anyone has to share on the following:
Patient instruction prior to therapy
Patient room preparation
Patient room decontamination
Any other useful hints

My e-mail is jlf.hsafety@mhs.unc.edu

Thank you.

Janet Foreman
Associate Radiation Safety Officer
UNC-CH