Radiation Safety Review for Radiation Oncology Staff MARCUS

Radiation Safety Review for Radiation Oncology Staff MARCUS JEANNETTE RADIATION SAFETY OFFICER 744 -2070

Office of Radiation Safety Responsibilities • Comply with regulations, laws, and guidelines regarding the safe use of radioactive material and radiation producing devices. • Protect employees, students, and the general public from overexposure to radiation at East Carolina University.

Regulatory Environment

Regulatory Environment This training is mandated by regulation, but why? There a number of factors involved and during the process of this training session you should gain a larger understanding of the reason. We will first look at where the regulations originate from and what agencies govern our operational use of radiation producing machines and radioactive materials.

Scientific Community International Commission on Radiation Protection ICRP National Council on Radiation Protection and Measurements NCRP The ICRP and NCRP are advisory bodies that collect and analyze data regarding ionizing radiation and put forth recommendations on radiation protection. The regulatory groups utilize these recommendations when developing regulations.

Federal Regulatory Groups Many Federal agencies have regulations that deal with radiation protection. Each agency regulates a different aspect as it pertains to their particular program area. NRC – Nuclear Regulatory Commission FDA – Food & Drug Administration FEMA – Federal Emergency Management Agency OSHA – Occupational Safety and Health Administration DOT – Department of Transportation EPA – Environmental Protection Agency USPS – United States Postal Service

State Regulatory Groups • In North Carolina, the Radiation Protection Section regulates the safe use of ionizing radiation (electronic product or radioactive materials) used at our facility. • We are authorized to use these sources of ionizing radiation via licensure (radioactive materials and accelerators) and registration (diagnostic x-ray equipment). Our facility has a radiation protection program that must meet the requirements set forth by the State in order to maintain these authorizations.

Licenses and Radiation Safety Committees

Current Licenses Managed By ECU • 074 -296 -1, Broad Academic License • 074 -296 -A 1, Physics Linear Accelerator • 074 -296 -A 2, LJCC Accelerators • 074 -296 -7, ECHI Nuclear Cardiology

ECU Radiation Safety Committees • • Basic Sciences-Radiation Safety Committee -Academic Research -Physics Linear Accelerator Clinical Radiation Safety Committee -Therapy Accelerators -High Dose Rate Applicator

Committee Responsibilities • Develop policies and procedures for the safe use of radioactive materials and radiation producing equipment. • Approve authorized users. • Provide technical advice to the RSO. • Review all instances of alleged infractions of the use of ionizing radiation’s or safety rules with the RSO and responsible personnel and take corrective actions. • Review periodic reports from the RSO.

Basic Radiation Physics

Ionizing vs. Non-Ionizing Radiations Ionizing Radiation • A radiation that has sufficient energy to remove electrons from atoms or molecules as it passes through matter. • Examples: x-rays, gamma rays, beta particles, and alpha particles Non-Ionizing Radiation • A radiation that is not as energetic as ionizing radiation and cannot remove electrons from atoms or molecules. • Examples: light, lasers, heat, microwaves, and radar

Atom Whether we talk about ionizing or non-ionizing radiation, its genesis is either within or very close to the exterior of the atom. The following is a brief review the atomic structure. The atom is comprised of a nucleus, which is made up of positively charged protons and electrically neutral (no charge) neutrons, surrounded by negatively charged electrons. In an electrically neutral atom, the number of positively charged protons and negatively charged electrons are equal.

Radiation Origins • Ionizing radiation (hereafter, referred only as “radiation”) can be generated by electronic means (xray units) or radioactive materials. • When electronic-product radiation is produced, the source is turned on and off like a light switch. Once the unit is off, the radiation exposure is over. The xray unit does not continue to radiate or become radioactive. • With radioactive materials, there is a little more involved. The source is always on until it decays away. Next: A review of both types of ionizing radiation generators – X-rays and Radioactive Materials.

Radioactive Material Types of Radiations GAMMA AND X-RADIATION Generally, stopped by lead. Sources include naturally occurring radioactive materials and cosmic radiation. Medical imaging FYI: As discussed earlier, x-rays can be produced by radioactive decay or electronic production. Both originate outside the nucleus of the atom. • Gamma rays and X-rays are essentially the same, except for where they originate. Gamma rays originate from the nucleus, and Xrays originate outside the nucleus of an atom. • These rays have no mass or no charge, and are very penetrating. • These rays are the same as light (electromagnetic radiation), only much more energetic. • Considered more of an external hazard than internal. • Both rays are great for imaging patients.

X-ray Generation Review FYI: If you’ve ever had an x-ray, when the x-ray technologists takes your “picture, ” it is over. The x-ray unit does not continue to produce radiation after the exposure is complete. • X-rays as produced by an x-ray unit are also know as “Bremsstrahlung. ” It is a German word for “braking radiation. ” • As depicted in the diagram, when the electron slows very fast (brakes) as it gets close to the atom of the target nucleus, x-rays (radiation) are formed. • X-rays are emitted in all directions; therefore, the structure housing the x-ray tube is shielded except for a port where the x-rays escape and can be used for diagnostic purposes.

Radiation Units Now that you have a little understanding of the physics behind ionizing radiation, how do we measure or quantify radiation? Here a few units of measure that are used (often interchangeably) in radiation protection: Absorbed Dose Exposure • A measure of ionization produced in air by X or gamma radiation. • Highly specific in that the unit specifies the matter being exposed and radiation producing the ionizations. • Unit: roentgen (R) • 1 R = 1000 m. R • • • A measure of energy deposition per unit mass irradiated. Considers all radiations imparting energy to all types of matter. Unit: rad 1 rad = 1000 mrad SI Units: gray (Gy) 1 Gy = 100 rad Dose Equivalent • • • It is numerically equal to the absorbed dose by a quality factor Dose equivalent is needed because the biological effect from a given absorbed dose is dependent upon the type of radiation producing the absorbed dose. Unit: rem 1 rem = 1000 mrem SI Units: sievert (Sv) 1 Sv = 100 rem

Radiation Units Dose Equivalent • The unit of measure, dose equivalent, was instituted to take into account the relative biological effectiveness of the differing types of radiations. • Some radiations like alpha particles are densely ionizing; therefore, as they pass through tissue, they are able to strip more electrons than beta particles or x-rays or gamma rays… 20 times greater. In short, alpha particles are better at producing damage. • Absorbed dose merely documents how much energy is being deposited per unit mass, it does not consider how effective each radiation is at producing damage in a biological system. • The more densely ionizing, the more damage is done. FYI: If you wear a badge, your dose in reported in “mrem. ”

Biological Effects and Radiological Risk

Biological. Acute Effects: Effects Who cares about electrons being stripped from atoms? • Electrons are essential in creating molecular bonds. When radiation breaks those bonds, the molecule ceases to function properly. • Research has shown that the body has great repair mechanisms, but when overwhelmed the repair may be incomplete or incorrect. • If enough damage to a region occurs, the result may be cell death. • Damage may manifest as “delayed” or “acute” effects. • • • Generally occurring in the individual receiving the radiation dose. A threshold dose must be exceeded before symptomatic. Example: Radiation Sickness Delayed Effects: • Can occur in the individual receiving the radiation dose or the offspring. • Probabilistic effect, whereby the increase in dose increases the probability that the effect occurs. • Example: Cancer or genetic mutation

Biological Effects • What we know about the effects of radiation come from a number of different exposed populations: – Atomic bomb survivors – Accident victims – Radium watch dial painters – Radiation therapy patients – Early experimenters with radiation • • Epidemiological studies of these groups have shown that following significant radiation doses, effects were observed. The effects were both acute and delayed.

Dose versus Effect • Nobody knows for sure what radiation dose does to us below the shaded region. There may be a threshold where there is no effect from radiation below a certain dose. • In Radiation Protection, as a protective measure, it is assumed that all dose carries some risk, this is represented by the straight red line on the diagram. FYI: There are other theories regarding the effects of radiation dose (as represented by the other lines – blue and gray), to include radiation hormesis. Radiation hormesis is a theory that chronic low doses of radiation is good for the body.

Radiation Risk • Understanding the different types of effects, regulatory agencies impose radiation dose limits that eliminate the likelihood of acute effects and reduce the likelihood of delayed, or risk-based, effects. • Regulatory groups are concerned with fatal risk estimates. • The current regulatory limit for an occupationally exposed worker is 5, 000 mrem per year. • When initially instituted, the radiation dose limit represented a risk that was “equal to” that of other safe industries. • Given that the regulatory limits are risk-based, and that increasing one’s dose increases one’s chance that an effect may occur, the law also requires radiation workers to employ the philosophy of ALARA, or keeping your radiation dose As Low As Reasonably Achievable.

Putting Radiation in Perspective! • Everyone on Earth is being exposed to radiation! • The average North Carolinian receives approximately 360 mrem of radiation dose per year. • Background radiation dose is affected by altitude, soil type and other factors. There is a wide variation of natural backgrounds in the world. • Some places have annual background radiation levels greater than the US dose limits for radiation workers…with no excess cancer mortality! Did you know some of the foods you eat contain naturally occurring radioactive material? Bananas contain low quantities of Potassium-40.

Practical Radiation Safety

Protecting Ourselves from External Exposure • Adhere to the three cardinal rules of external radiation protection: – TIME – DISTANCE – SHIELDING TIME Less Time = Less Exposure DISTANCE Greater Distance = Less Exposure SHIELDING More Shielding = Less Exposure

External Radiation Protection Consider This… similar to Exposure to a source of ionizing radiation is very the exposure from a light bulb (i. e. light and heat). The closer you are to the source, the more intense the light and heat are. Likewise, if you move away, the intensity decreases. If you put something opaque between you and the light bulb, you effectively eliminate the light. The longer you are close to the light bulb, you begin to feel the warming effects of the light. If however, you move quickly to and from the light, you’ll not likely feel the warming effect.

Exposure and Contamination A difficult concept to understand is the difference between exposure and contamination when we talk about radioactive materials. To illustrate the difference, consider a burning candle. • If you stand away from the candle, you are being exposed to the candle’s light. If you leave the room, your are no longer exposed to the candle’s light. • If you walk up to the candle, you are being exposed to the candle’s light. If you then reached out and grabbed the candle, you would get hot wax on your hand. If you left the room, you are no longer exposed to the light, but the wax on your hand (i. e. contamination) remains. If the wax were radioactive, the “contamination” would continue to expose your hand until you washed it off. Remember: Being exposed by a radioactive source does not contaminate you. You must have interacted with the source to get some of the source on you. Once on you, the contamination will expose you until it is removed.

General Safety Guides for Use of Radiation Producing Equipment • X-ray equipment should not be left unattended while in operating mode. • When in fixed radiographic rooms, operators shall remain behind the protective barrier. • If required to be in a room during a diagnostic x-ray exposure (e. g. fluoroscopy), wear a lead apron or stand behind a protective barrier. • Where your dosimetry, if applicable. • Follow established procedures; when unsure, stop and notify your supervisor or the RSO. • Keys MUST not be left in portable x-ray equipment.

Radiation Symbols • Caution Radioactive Materials • Caution Radiation Area when X-ray Energized

North Carolina Regulations for the Protection Against Radiation (NCRPAR)

NC Regulations for the Protection Against Radiation • This is the LAW. • Web location: http: //www. ncradiation. net/documents/15 A NCAC 11_1107. pdf

Highlights of NCRPAR • 15 A NCAC 11. 1600, Standards for the Protection Against Radiation. • 15 A NCAC 11. 0300, Licensing of Radioactive Material. • 15 A NCAC 11. 0600, X-rays in the Healing Arts (Not included in this Presentation). • 15 A NCAC 11. 0900, Requirements for Particle Accelerators (Not Included in this Presentation)

. 1600, Standards for the Protection Against Radiation • • . 1603, Radiation Protection Program. 1604, Occupational Dose Limits for Adults. 1610, Dose Equivalent to an Embryo Fetus. 1611, Dose Limits for Individual Members of the Public.

Radiation Protection Program (. 1603) • The Licensee or registrant must develop, document a radiation protection program commensurate with the scope and extent of licensed activities. • Program must insure compliance with the provisions outlined in. 1600 • For example compliance with occupational dose limits, record keeping, dose limits for members of the public, radiological area surveys, annual program review, etc.

Occupational Dose Limits (. 1604) The occupational dose limits for workers in North Carolina and the US are as follows: Whole Body (WB) 5, 000 mrem/yr Extremities/Skin 50, 000 mrem/yr Lens of the Eye 15, 000 mrem/yr Minor WB (< 18 years old) 500 mrem/year Declared Pregnant Worker 500 mrem/gestation By regulation, the institutional radiation protection program shall monitor individual’s exposure/dose if they are likely to receive 10% of the limit, or in the case of declared pregnant workers and minors the threshold is 100 mrem.

Personnel Monitoring Methods (Dosimetry) Monitoring Required Whole Body Extremity Internal Contamination Monitoring Method TLD or OSL Badge Finger Ring TLD Urinalysis or Bioassay Ring Badge Whole Body Badge Thyroid Bioassay

General Rules for Use of Dosimetry • Wear your own badge. • Wear your whole body (WB) badge whenever working with radiation sources • Notify the RSO immediately when a badge is lost. • Wear ring badges under gloves. • Store badges in designated areas at the end of each day of work.

Personnel Dosimetry - FYI • Dosimetry does not protect you from radiation. • Dosimetry is not a warning device (i. e. it will not alarm, beep or change color) • Dosimetry documents the radiation dose an individual receives when working with radiation sources. • It is ILLEGAL to intentionally expose an individual’s dosimeter.

Personnel Dosimetry Review • Each monitoring period dose report is reviewed by the Radiation Safety Officer • The report is compared against the institution’s investigational levels: >200 mrem/monitoring period to whole body > 2000 mrem/monitoring period to extremities > 800 mrem/monitoring period to the skin Action Required: Written notification from RSO to worker and investigation

Dose Equivalent to an Embryo/fetus (. 1610) • Occupational exposure to the fetus of a declared pregnant woman shall not exceed 500 millirem during the 9 month pregnancy. • Declare pregnancy as soon as possible

Declared Pregnant Workers • Available for those radiation workers who are pregnant or planning a pregnancy. • Purely VOLUNTARY! • To be apart of the program, you must DECLARE your pregnancy in writing to your supervisor and provide the estimated date of conception. The RSO must be notified immediately upon declaration. • The declared pregnant worker may be provided with a dosimeter that will be worn at the waist level. If lead is worn, the “fetal badge” shall always be worn under the lead.

Dose Limits for Individual Members of the Public (. 1611) • The total effective dose equivalent shall not exceed 100 millirem within one year. • The dose in any unrestricted area from external sources of radiation , exclusive of the dose contribution from patients administered radioactive material and released in accordance with the regulations, does not exceed 2 millirem in any one hour. • This is basically 2 millirem per week for a 50 week work period. • Patients recieving medical care exempted from this rule!

How do we comply with the Dose Limits for Members of the Public? • Radiation Safety Policies and Procedures • Radiological Area Surveys – Contamination surveys – External Radiation surveys • Environmental Monitoring – Landauer OSL Environmental monitors – Standard OSL monitors

Geiger Mueller Detector • Geiger counters are portable devices that detect and measure radioactivity. • Can be used to detect beta, gamma and X-ray radiation. • Geiger-Muller tube is filled with an inert gas that will conduct electricity when ionized. “The tube amplifies this conduction by a cascade effect and outputs a current pulse, which is displayed by a needle or audible clicks. ”

Licensing of Radioactive Material (. 300) • . 0350, Records and Reports of Misadministration • . 0356, Procedures for Administration Requiring a Written Directive • . 0364, Medical Events • . 0365, Report and Notification of a Dose to an Embryo/Fetus or Nursing Child

Records and Reports of Misadministration (. 0350) • Repealed as of November 1, 2007 • Changed to Medical Event, . 0361

Written Directives • The prescription or order given by a physician that is documented in the patient chart or electronic charting system (Lantis). • A written prescription must be completed by the authorized Physician. • Treatment summary will be completed by the chief radiation therapist and medical physics staff upon completion of treatment • The patients identity will be verified before each and each administrations written directive.

The Written Directive will Include: • • Volume (site) to be treated Radiation modality Dose per fraction Total number of fractions Treatment Pattern Prescription point or isodose Technique used

Medical Events (. 0364) Medical Event is the administration of radioactive material or radiation that results in: 1. A dose that differs from the prescribed dose by 5 rem effective dose equivalent, 50 rem to an organ or tissue. 2. The total dose delivered differs from the prescribed dose by 20% or more. . 3. An administration of the wrong radioactive drug containing radioactive material. 4. An administration of a radiopharmaceutical by the wrong route of administration. 5. An administration to the wrong patient.

Reporting a Medical Event • Notify the RSO Immediately • Call DENR, RPS within 24 hours of event – 919 -571 -4141 – Give the following information: • • • Callers Name Licensee: East Carolina University School of Medicine Date of Medical Event Date of discovery License Number: 074 -296 -A 2 Brief Description of Event

Reporting a Medical Event • ECHI will submit a written report to DENR within 15 days. • The report should include the following: 1. The licensee’s name 2. The name of the prescribing physician 3. Brief description of the event 4. Why the event occurred 5. The effect on the individual(s) who received the administration 6. Corrective Actions 7. Certification that we notified the individual involved • The Medical Event reporting form is available on the web at: www. ncradiation. net

Accelerator Safety • Maintenance should only be performed by a qualified expert with the proper training. Before entering the treatment room for any reason, always verify that LINAC or Cyberknife is in a beam off condition. Notify the operator before entering. • Before rotating the gantry, always verify that the treatment couch is positioned and the patient restrained so a collision cannot occur. • Notify your supervisor of any abnormal occurences with the LINAC/Cyberknife. . • Do not continue operation of the LINAC/Cyberknife or attempt to deliver a treatment if there is any indication of a malfunction of any kind. • Always remove the console keys and deposit them in a secure area when the LINAC/Cyberknife is unattended. The keys should always be removed at night and on the weekend.

Accelerator Safety • If a power failure or emergency stop should shut down the LINAC/Cyberknife during treatment, always remove the patient and have a maintenance check of the unit before completing treatment. • Emergency procedures are posted at all three shielded vaults. Emergency contacts are also listed. • Quality Assurance checks should be performed daily, monthly and annually. Review the Radiation Oncology policies and procedures regarding the type of checks that are to be performed • No one except the patient under treatment shall be in the accelerator room when the beam (x-ray or electron) is energized. When a patient must be held in position for radiation therapy, mechanical supporting or restraining shall be used. – This is a North Carolina Regulation for the Protection Against Radiation, 15 A NCAC 11. 0609(e)(2). – Absolutely NO exceptions to this rule.

LINAC Emergency Procedure In the event of any malfunction of the treatment unit(s) (mechanical, electrical, or otherwise) which may prove hazardous to the patient, therapist or the any member of the public: 1. 2. 3. 4. 5. Press any emergency off button. Remove patient and other personnel from vault. Close accelerator door. Call the Radiation Safety Officer AND the Medical Physicist listed below. Remain at the console and prevent entry of personnel into vault until problem has been resolved, if possible.

Emergency Call List Medical Physicist: Melodee Wolfe Beeper: 754 -3422 Home: 524 -5720 Claudio Sibata Beeper: 561 -9445 Home: 412 -2875 Radiation Safety Officer: Marcus Jeannette Beeper: 757 -5056 Home: 258 -8005

One Last Thought to Remember! Radiation protection is not just the responsibility of management, the Radiation Safety Committee, the Radiation Safety Officer or coworkers, it is all of our responsibility.

References • The North Carolina Regulations for the Against Radiation May be found at the following Website: http: //ncradiation. net/documents/15 ANCA C 11_1107. pdf