Re: Release of I-131 Patients

[carol marcus <csmarcus@ucla.edu>]

At 08:37 AM 10/29/99 -0500, you wrote:
>Dear Radsafers:
>
>In response to a few non-medical HPs that have expressed interest in the
>release of I-131 patients - Don't you know that radiation from these
>patients is "good" radiation, but radiation from power plants is "bad"
>radiation??!!! - JUST KIDDING!!!
>
>I do agree that 500 mrem is 500 mrem, regardless of the source.  Fortunately
>(from the medical community's standpoint), nuclear medicine physicians did a
>good job of selling the idea that the release of these patients probably
>constitutes very little radiation hazard.  Basically, it boils down to
>perspective - it's OK to expose the general public to a little radiation if
>we are treating cancer, but it's not OK to expose them to the same amount to
>generate electrical power.  I'm not saying what's right - I'm just saying
>what is (at least in my opinion).
>
>Another issue regarding I-131 patients is the cost of hospitalization.  Both
>now and in the past, most patients treated with I-131 do/did not require
>hospitalization for medical care reasons.  It's purely a matter of isolating
>them to protect the general public at a cost of greater than $1000 per day
>for a hospital room.  I've never understood why the medical insurance groups
>never questioned this.  I would bet that as more and more hospitals elect to
>release these patients, the medical insurance groups will really pressure
>all hospitals to follow suit.  I'm not an expert on medical insurance
>carriers, but I believe that the trend is for medical insurance to pay a
>specific amount for a certain disease.  If the patient is hospitalized, the
>cost may exceed what the insurance carrier pays.  Thus, the hospital either
>has to eat the additional cost or the patient must pay the difference out of
>his/her pocket.  Again, this is my perspective which may or may not be
>correct.
>
>I would like to point out that we medical folks don't just administer 100 to
>200 mCis of I-131 and tell the patient, "Don't let the door hit you in the
>behind on the way out."  Realistically, the individuals most likely to
>receive the highest effective doses from these patients are other members of
>their family.  At our facility, we go through a fairly extensive
>questionnaire which gives us a reasonable idea of the patient's home
>situation.  We also ask a question about their occupation (e.g., do they sit
>next to a co-worker 8 hours/day).  Based upon the answers to these questions
>we make a determination of how much I-131 can be administered to the patient
>without requiring hospitalization and/or if the patient should be
>hospitalized.  We also provide the patient with written instructions (as
>required by NRC), some of which may be specific to the patient's situation.
>The doctor goes over these instructions with the patient and both the
>patient and the doctor sign them.  
>
>You can certainly argue that the patient may not understand the instructions
>or simply elect not to follow them; however, our doctors are pretty good at
>identifying such patients and will hospitalize them if necessary.
>Realistically, most patients are willing to follow these instructions to
>protect their family members.  We have even had a couple of patients who
>requested to be hospitalized to protect their family (they had small
>children at home).  In addition to the written instructions, we are
>currently developing an automated "Powerpoint" presentation to help the
>patient understand the importance of following the instructions.
>
>It seems that I have heard of a couple of facilities that have attempted to
>measure external dose equivalents to the family members of I-131 patients by
>issuing film or TLD badges to those family members.  Anyone know about this
>and if so, where we can view the results?  That would be interesting.
>
>Mack L. Richard, M.S., C.H.P.
>Radiation Safety Officer - IUPUI/Indiana Univ. Med. Cntr.
>Phone #: (317) 274-0330   Fax #: (317) 274-2332
>E-Mail Address:  mrichar@iupui.edu
>
>************************************************************************
>The RADSAFE Frequently Asked Questions list, archives and subscription
>information can be accessed at http://www.ehs.uiuc.edu/~rad/radsafe.html
>

Dear Richard and other Radsafers:

The "double standard" problem is interesting.  When you realize that the
average American will receive 3 nuclear medicine procedures in his/her
lifetime, numerous radioimmunoassays in lab tests, and possibly teletherapy
and/or brachytherapy, it's pretty scary to jeopardize these fields.  To do
so would cause real deaths, not the "make believe" deaths of low dose
ionizing radiation.

It is obvious by NRC's 10 CFR 20.1301(c) that the 500 mrem limit may be
applied to any group that makes a good case.  I may have been the first to
use this mechanism, and NRC suggested that I do so when they asked me to
write my petition, but hasn't it been used by others?  In the default
accident analysis for LLRW sites performed for 10 CFR Part 61, the 500 mrem
standard was used; I assume it remains justifiable under 1301(c).

I think that part of the problem with the 500 mrem patient discharge
standard is that it makes the rest of NRC's behavior, and much of Agreement
State regulatory behavior, look ridiculous.  All these atom-hunting meter
maids running around a licensee's facility and finding a few loose atoms
here or there, or the remnants of a spill, or a bone scan patient's saliva
on a styrofoam cup in a public trash container, suddenly realize that none
of this effort has any intellectually respectable basis.  Permissible
removable contamination levels have no scientifically valid basis, and just
cause the creation of paper to give inspectors something to inspect.
Finding, oh my God, an unlocked refrigerator with microcurie quantities of
C-14 and H-3 labeled compounds causes venomous NRC retribution, but the
whole thing is pathologically dumb, because NRC refuses to subject its
requirements to realistic physics calculations of radiation absorbed dose.
I remember NRC screeching about a tad of Sr-89 on the floor in a hallway of
a hospital.  You'd think personnel were dropping like flies as a result.  I
did a dose calculation that assumed that an INFANT LICKED UP ALL THE SR-89
ON THE FLOOR, and the radiation absorbed dose to the infant was
insignificant.  Now, you compare dysfunctional regulatory behavior like this
with the realization that loose atoms of I-131 are going to be around the
patient's home, and workplace, and that it doesn't matter because the dose
is low and safe, and even a regulator has to realize that this inconsistency
is very silly.  

However, instead of producing an intelligent reaction in the regulator, like
changing all of its requirements and creating a performance standard based
on dose, the regulator is afraid that his ignorance will show, and that he
will be downsized because most of what he does is "make work", and he wants
to kill the thing that shows how foolish he is instead of fixing his
foolishness.

As far as this I-131 patient discharge situation is concerned, the NRC
screwed it up by turning it into another paper jungle.  In California, the
PHYSICIAN has to know how to do the dose calculations, and the PHYSICIAN has
to educate the patient about specific radiation protection behavior, and if
the PHYSICIAN does not know how to do the calculations and/or does not have
time to spend with the patient, then THE PHYSICIAN CANNOT USE THE 500 MREM
RULE.  No paperwork.  Just getting down to the guts of the problem.
COMPETENCE AND QUALITY.  As far as the fear about insurance companies not
paying for inpatient stays because of this rule, I have heard about one case
at Stanford where the hospital ate the cost, but the Radiologic Health
Branch, or one of their Nuclear Medicine Counsel members, is prepared to
read the riot act to any insurance company who pulls this stunt and so I
haven't heard any more bad stories.  I would think that physicians who can
do the calculations and who will take the time to educate their patients
could take business away from docs who can't and won't, but we will have to
see how this plays out.  I had the 500 mrem rule myself for years before I
wrote my petition, and I nevertheless hospitalized many patients because of
socioeconomic considerations, compliance risk factors, or occasional
political situations which, while stupid, nevertheless made life easier for
my RSO, who has more than enough work to do.

It is also important to remember that it has NEVER been legal to keep an
I-131 patient in the hospital against his will, no matter how much I-131 is
in him/her.  It is battery to try.  So, no matter what anyone thinks of this
rule, a patient can always walk out no matter what a doctor says, and always
could.  If, in fact, there was any REAL risk to members of the public from
this radioactivity, it would have been made legal to forcibly retain these
patients.  But there never was a real risk; just NRC make-believe.

Ciao, Carol

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