Radiation Protection Issues Associated With The Administration of I131 Therapy to a Critically Ill Patient on an Inten

1. Radiation Protection Issues Associated With The Administration of I131 Therapy to a Critically Ill Patient on an Intensive Therapy Ward Dr Stephen McCallum Radiation Protection Service NHS Grampian Aberdeen Scotland s.mccallum@nhs.net

2. Introduction A female patient experienced respiratory problems following child birth and was diagnosed with advance papillary thyroid cancer. The patient now critically ill, was transferred to intensive therapy unit (ITU) where she was treated with I-131. Whilst in ITU the patient was constantly monitored and required round the clock nursing care. Tragically the patient died a few weeks later. The body was then embalmed and repatriated by air to a country in Southeast Asia. This presentation describes the radiation protection issues encountered and how they were dealt with.

3. Training and CommunicatingRisk to staff Staff in ITU had no previous experience working with active patients and so prior to administration a training program was put in place. One of the first issues encountered was staff attitudes and existing preconceptions about radiation risks. The staff group was quite large (50+) and there was a wide spectrum of views ranging from those who stated they were not happy about any additional risk even after training, to those who were happy to proceed. A dose constraint of 300uSv was established; however, despite explanation this was viewed by staff as a limit – beyond which they would not go!

4. Controlled area As the ITU ward was not designed for accommodating I131 patients and a large area had be cordoned off and designated a controlled area. Outside wall 1st floor Outside wall 1st floor

5. PPE and decontamination Arrangements were put in place to monitor staff doses using EPD and perform contamination checks using ram gene monitor. Staff diligently donned PPE on entry to the area.

6. Administration and patient care 1.5GBq of I131 Sodium Iodide was administered by nasal-gastric tube, the volume was 10ml. The patient was cared for by a team of 2-3 nurses at a time, working two shifts to cover 24hr period. Patient was ventilated and vital signs monitored remotely.

7. Dose to Staff Collective staff dose 17 days of the treatment was approximately 3.3mSv. Number staff involved 50+ Max dose to single member of staff 200uSv

9. Dose to undertakers At time of death it was estimated that 120MBq of I131 remained in the body. A risk assessment was carried out on behalf of the undertakers who were to embalm the body. A Radiation Protection Adviser attended the embalming to issue EPDs, carry out contamination checks and remove contaminated waste. The total dose to the undertakers carrying out the embalming was 27uSv.

10. Repatriation to Southeast Asia The final issue that had to be resolved was the repatriation of the still active body to Southeast Asiafor burial. Protracted discussions took place with the embassy and advice was sought from the UK Civil Aviation Authority. The technical instructions for the safe transport of dangerous goods by air published by the International Civil Aviation Organization state that precautions for carrying radioactive material do not apply to radioactive material implanted or incorporated in a person or live animal. Therefore following embalming the body was transported by air for Burial.

11. Conclusions This was an extraordinary situation that has not occurred in our hospital before. While we are confident that we complied with regulatory requirements and kept doses to staff ALARP - there is much to learn from this experience. The most difficult issue was dealing with a large group of nursing staff and trying to reassure them of that the risk to themselves were low and manageable. In hindsight the 300uSv dose constraint was perhaps too low and a more practicable figure would have been 600 – 1000uSv.

12. Acknowledgments • Staff of the radiation protection service, Nuclear medicine department and Radiopharmacy at Aberdeen Royal Infirmary • Skilled and dedicated staff in ITU • Aberdeen Radiation Protection Services for help and advice