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Re: overexposure - mother breast feeds child after I-131 therapy
At 09:06 AM 8/10/98 -0500, you wrote:
>HOSPITAL | |EVENT NUMBER: 34618 |
>
>+----------------------------------+ +-----------------------+
>
>
>
>+------------------------------------------------+-----------------------------
>+
>|LICENSEE: WESTERN PENNSYLVANIA HOSPITAL |NOTIFICATION DATE:
>08/07/98
>|
>| CITY: PITTSBURGH REGION: 1 |NOTIFICATION TIME: 17:03
>[ET]|
>| COUNTY: ALLEGHENY STATE: PA |EVENT DATE:
>07/28/98
>|
>|LICENSE#: AGREEMENT: N |EVENT TIME:
>12:00[EDT]|
>| DOCKET: |LAST UPDATE DATE:
>08/07/98
>|
>|
>+-----------------------------+
>| |PERSON
>ORGANIZATION|
>| |TOM MOSLAK RDO
>
>|
>| |FRED COMBS, NMSS EO
>
>|
>+------------------------------------------------+
>
>|
>|NRC NOTIFIED BY: MILE PACILIO, RAD SAF OFF |
>
>|
>|HQ OPS OFFICER: DICK JOLLIFFE |
>
>|
>+------------------------------------------------+
>
>|
>|EMERGENCY CLASS: NOT APPLICABLE |
>
>|
>|10 CFR SECTION: |
>
>|
>|BAE1 20.2202(b)(1) PERS OVEREXPOSURE |
>
>|
>| |
>
>|
>| |
>
>|
>| |
>
>|
>| |
>
>|
>+------------------------------------------------+-----------------------------
>+
>
> EVENT TEXT
>
>+------------------------------------------------------------------------------
>+
>| - OVEREXPOSURE OF A 4 YEAR OLD CHILD DUE TO BREAST FEEDING BY HIS MOTHER -
>
>|
>|
>
>|
>| ON 07/28/98, A 43 YEAR OLD FEMALE PATIENT REPORTED TO WESTERN PENNSYLVANIA
>
>|
>| HOSPITAL TO BE EVALUATED FOR THYROID ABLATION THERAPY. DURING
>CONSULTATION
>|
>| WITH HOSPITAL PERSONNEL, THE PATIENT DENIED BREAST FEEDING HER 4 YEAR OLD
>
>|
>| SON. THE PATIENT CLEARLY HAD THE ABILITY TO SPEAK AND UNDERSTAND THE
>
>|
>| ENGLISH LANGUAGE. A HOSPITAL RADIATION TECHNOLOGIST ADMINISTERED A 3.02
>
>|
>| MILLICURIE CAPSULE OF I-131 TO THE PATIENT IN PREPARATION FOR A WHOLE BODY
>
>|
>| SCAN SCHEDULED ON 07/31/98.
>
>|
>|
>
>|
>| ON 07/31/98, THE PATIENT RETURNED TO THE HOSPITAL FOR A WHOLE BODY SCAN.
>
>|
>| THE PATIENT WAS COUNSELLED BY THE ATTENDING HOSPITAL PHYSICIAN AND A
>
>|
>| MEMBER OF THE HOSPITAL RADIATION SAFETY OFFICE CONCERNING THE PRECAUTIONS
>
>|
>| SURROUNDING THE IMPENDING ABLATION THERAPY SCHEDULED FOR 08/04/98. AFTER
>
>|
>| THIS COUNSELLING, THE PATIENT ADMITTED TO BREAST FEEDING HER SON DURING
>
>|
>| THE PREVIOUS THREE DAYS, STATING THAT SHE HAD BEEN TOO EMBARRASSED TO
>
>|
>| DISCLOSE THIS DURING HER PREVIOUS HOSPITAL VISIT. THREE HOSPITAL
>EMPLOYEES
>|
>| TOLD THE PATIENT TO IMMEDIATELY DISCONTINUE BREAST FEEDING HER SON.
>
>|
>|
>
>|
>| ON 08/03/98, THE PATIENT AND HER SON RETURNED TO THE HOSPITAL IN ORDER TO
>
>|
>| HAVE ANY UPTAKE BY HER SON ASSESSED. A BIOASSAY OF THE CHILD'S THYROID
>
>|
>| GLAND DETERMINED THAT IT HAD A BURDEN OF 2.7 MICROCURIES OF I-131, WHICH
>
>|
>| EQUATES TO AN ORGAN DOSE OF 184 RADS (TEDE = 5.5 RADS). DURING SUBSEQUENT
>
>|
>| CONVERSATIONS WITH THE PATIENT, SHE REVEALED THAT SHE HAD CONTINUED
>
>|
>| TO BREAST FEED HER SON OVER THE WEEKEND, INCLUDING IMMEDIATELY BEFORE
>
>|
>| REPORTING TO THE HOSPITAL FOR THE BIOASSAY.
>
>|
>|
>
>|
>| HOSPITAL PERSONNEL SUSPENDED ADMINISTERING ANY ADDITIONAL I-131 TO THE
>
>|
>| PATIENT AND ARE CONTINUING TO FOLLOW THE CONDITION OF THE PATIENT AND
>
>|
>| THE CHILD. THE HOSPITAL NUCLEAR PHYSICIAN NOTIFIED THE CHILD'S PHYSICIAN
>
>|
>| WHO IS COORDINATING FOLLOWUP CARE, INCLUDING ASSESSMENT BY A PEDIATRIC
>
>|
>| ENDOCRINOLOGIST AND PROTECTION BY THE LOCAL CHILD YOUTH SERVICES.
>
>|
>| THE HOSPITAL NUCLEAR PHYSICIAN ALSO NOTIFIED THE PATIENT'S ATTENDING
>
>|
>| PHYSICIAN AND SURGEON CONCERNING THIS INCIDENT IN ORDER TO COORDINATE
>
>|
>| THE PROTECTION OR TREATMENT ALTERNATIVES FOR THIS PATIENT.
>
>|
>|
>
>|
>| HOSPITAL PERSONNEL DO NOT PLAN TO ISSUE A PRESS RELEASE REGARDING THIS
>
>|
>| INCIDENT.
>
>|
>+------------------------------------------------------------------------------
>+
>
>
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>Dear Radsafers:
Does anyone have the actual dosimetry calculations for this case? Using
ICRP no. 53 for a 5-year old, and assuming the peak uptake is the measured
uptake, I calculate only 76 rad, about 2 1/2 times lower than stated.
In any case, this dose is not expected to have any significance for the child.
Watch NRC spin-doctor this into a radiation emergency, and report this as an
Abnormal Occurrence to Congress! NRC will probably figure out some way to
blame the licensee, as well. After all, the breast-feeding incident in 1990
at Tripler in Hawaii was also entirely the mother's fault, yet the NRC's
Anapolis graduates blamed the Army docs at Tripler even though NRC's medical
consultant and the ACMUI blamed the patient's mother.
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