[Date Prev][Date Next][Thread Prev][Thread Next][Date Index][Thread Index]

Re[2]: Radiography Events



     For a real eye-opener, access the Center for Devices and Radiological 
     Health web site, and get info on the consequences of biplanal cardiac 
     catheterization, both of the head and the heart.  Often, multiple 
     sessions are required due to complications (angioplasty, clot 
     "busting", stint insertion, etc.).  The total dose to a small area of 
     the back (behind the heart) or head is large enough to eventually 
     (perhaps years later) to produce a radiation induced skin lesion 
     identical to that expected from an equivalent acute exposure of 
     radiation (50+ Gy is not uncommon).


______________________________ Reply Separator _________________________________
Subject: Re: Radiography Events
Author:  radsafe@romulus.ehs.uiuc.edu at guardian
Date:    1/19/99 8:40 AM


There definitely seems to be an epidemic of radiography events.  Here's the 
most recent one that I've seen - copied from the January 19, 1999 NRC daily 
events report.  A radiography trainee is showing radiation injury to an 
extremity - estimated dose "3000 to 5000 rem" [sic] (The "rem" unit should
not 
be used for high level, acute exposures, since the normal quality factors 
don't apply.) 
 
The opinions expressed are strictly mine.   
It's not about dose, it's about trust. 
 
Bill Lipton 
liptonw@dteenergy.com   
 
Other Nuclear Material                           |Event Number:   35251     
 | 
+------------------------------------------------------------------------------
+ 
+------------------------------------------------------------------------------
+ 
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 
01/13/1999| 
|LICENSEE:  GLOBAL X-RAY                         |NOTIFICATION TIME: 
10:58[EST]| 
|    CITY:                           REGION:  4  |EVENT DATE:        
12/31/1998| 
|  COUNTY:                            STATE:  TX |EVENT TIME:        
18:00[CST]| 
|LICENSE#:  L-3663                AGREEMENT:  Y  |LAST UPDATE DATE:  
01/15/1999| 
|  DOCKET:                                       
|+----------------------------+ 
|                                                |PERSON         
ORGANIZATION 
| 
|                                                |BLAIR SPITZBERG      R4   
  
| 
|                                                |DON COOL, NMSS       EO   
  
| 
+------------------------------------------------+FRANK CONGEL         IRD  
  
| 
| NRC NOTIFIED BY:  FACSIMILE                    |                          
  
| 
|  HQ OPS OFFICER:  LEIGH TROCINE                |                          
  
| 
+------------------------------------------------+                          
  
| 
|EMERGENCY CLASS:          N/A                   |                          
  
| 
|10 CFR SECTION:                                 |                          
  
| 
|NAGR                     AGREEMENT STATE        |                          
  
| 
|BAD1 20.2202(a)(1)       PERS OVEREXPOSURE      |                          
  
| 
|                                                |                          
  
| 
|                                                |                          
  
| 
|                                                |                          
  
| 
+------------------------------------------------------------------------------
+ 
 
                                   EVENT TEXT                               
  
  

+------------------------------------------------------------------------------
+ 
| AGREEMENT STATE REPORT REGARDING OVEREXPOSURE OF A GLOBAL X-RAY TRAINEE
(10  
| 
| REM WHOLE BODY AND EXTREMITY HIGH ENOUGH TO CAUSE INJURY)                 
  
| 
|                                                                           
  
| 
| The following text is a portion of a facsimile received from the Texas    
  
| 
| Department of Health:                                                     
  
| 
|                                                                           
  
| 
| "10 CFR Part 20.2202(a)(1) - Exposure (real or threatened) [greater than
or  
| 
| equal to] TEDE of 25 rem, eye/lens 15 rem, skin/extremities 50 rads."     
  
| 
|                                                                           
  
| 
| "A Texas licensee - Global X-Ray had a trainee overexposure - [Whole Body 
  
| 
| approximately equal to] 10 rem and extremity high enough to cause injury."
  
| 
|                                                                           
  
| 
| There was no additional information available on the facsimile.           
  
| 
|                                                                           
  
| 
| (Call the NRC Operations Center for a contact telephone number and        
  
| 
| address.)                                                                 
  
| 
|                                                                           
  
| 
| ***UPDATE AT 0908 EST ON 1/15/99 FROM BRADLEY CASKEY VIA FACSIMILE
RECEIVED  
| 
| BY TROCINE***                                                             
  
| 
|                                                                           
  
| 
| Reference:  Incident file #7404 - Radiography Trainee Overexposure -
Global  
| 
| X-Ray - L-3663                                                            
  
| 
|                                                                           
  
| 
| At approximately 1100 CST on January 1, 1999, Global X-Ray (L-3663) called
  
| 
| the Texas Department of Health to report an incident that occurred the    
  
| 
| previous evening (December 31, 1998) at approximately 1800 CST.  A        
  
| 
| radiography trainee was involved in an incident that had the potential of 
  
| 
| being a significant overexposure (approximately 10 rem whole body and a   
  
| 
| licensee-calculated finger exposure of approximately 800 millirem)
involving 
| 
| a 123-curie Iridium-192 source.  On Tuesday January 5, 1999,
representatives 
| 
| from the Texas Department of Health met with representatives from the
Global 
| 
| X-Ray facility.                                                           
  
| 
|                                                                           
  
| 
| The following text is a portion of a facsimile received from the Texas    
  
| 
| Department of Health:                                                     
  
| 
|                                                                           
  
| 
| "... On December 31, 1998, a radiographer and a radiographer trainee were 
  
| 
| working with a 123-curie Iridium-192 radiography source at a temporary job
  
| 
| site when the trainee failed to retract the source into the shielded      
  
| 
| position.  A collimator was not being used because an elliptical shot was 
  
| 
| being performed.  As a result, the trainee was exposed to the source at   
  
| 
| [the] end of the guide tube for approximately 4 minutes at a distance of  
  
| 
| approximately 2 feet and touched the end cap where the source was located
3  
| 
| or 4 times for 2 or 3 seconds each time.  [The] only shielding was from
the  
| 
| brass end cap.  Symptoms of a radiation injury [appeared] on the index    
  
| 
| finger of the right hand on January 10, 1999."                            
  
| 
|                                                                           
  
| 
| "[The] radiographer and trainee were sent on the job by the office
manager,  
| 
| who had been told by the company president that the radiographer could act
  
| 
| as a trainer because the paperwork requesting he be named a trainer had
been 
| 
| mailed to the Bureau of Radiation Control."                               
  
| 
|                                                                           
  
| 
| "[The] radiographer was new with the company, was not familiar with the   
  
| 
| trainee he was [sent] out with, and did not know that he was not a        
  
| 
| radiographer.  [The] radiographer had been a trainer for several other    
  
| 
| radiography companies and was familiar with the requirements of a trainer 
  
| 
| working with a trainee."                                                  
  
| 
|                                                                           
  
| 
| "[The] trainee thought they had finished work for the day and had taken
his  
| 
| tool belt off and put it in the truck.  His dosimeter and alarming rate   
  
| 
| meter was on his tool belt; therefore, he did not have [them] on when he
was 
| 
| reshooting two radiographs at the end of the day.  He had an operating    
  
| 
| survey meter but did not use it during the radiographs."                  
  
| 
|                                                                           
  
| 
| "Calculations were made to approximate the whole body and finger extremity
  
| 
| exposures.  [The] trainee was uncertain of the details of the incident and
  
| 
| was only able to give approximations...  Whole body exposure calculations 
  
| 
| were approximately 10 rem, and finger extremity exposure calculations were
  
| 
| 3,000 to 5,000 rem.  [The] appearance of radiation injury symptoms 10 days
  
| 
| from the date of the incident supports the extremity calculations."       
  
| 
|                                                                           
  
| 
| The NRC operations officer notified the R4DO (Spitzberg), NMSS EO         
  
| 
| (Surmeier), and IRD (Congel).    
 
You wrote: 
 
>Anyone notice the rash of radiography events of late? 
 
>I recall an overexposure in Seattle a month ago and now this event in 
>Texas.                                             |
************************************************************************
The RADSAFE Frequently Asked Questions list, archives and subscription
information can be accessed at http://www.ehs.uiuc.edu/~rad/radsafe.html

************************************************************************
The RADSAFE Frequently Asked Questions list, archives and subscription
information can be accessed at http://www.ehs.uiuc.edu/~rad/radsafe.html