1. AP Training Logo Introduction Radiation is useful in medicine because of its ability to penetrate tissue, allowing imaging and non-surgical treatment of internal structures. Radioactive materials (isotopes or Radio-nuclides ) and radiation equipments are commonly used in the diagnosis and therapy (treatment) of patients. However, radiation may produce harmful biological effects. Use of radiation has to be justified and minimized for patients, co-workers and members of public. The responsible use of radiation must benefit the patient and the investigation of disease and treatment must outweigh risk of possible harmful effects. Principle of ionizing radiation safety In hospital environment (Ver.1.0)

3. Contents 1. Radiation and its effects on human 1.a What is ionizing Radiation 1.b Types of radiation 1.c How the X Ray Tube works 1.d Commonly used radioactive materials in the hospital environment 1.e How does radiation interact with human tissue 1.f Radiation accidents 1.g Young and rapid growing cells are more sensitive than mature cells 1.h Comparison of Administrative, Regulatory and Biological Effect Doses (Example) 2. Basic radiation safety principles, practices and monitoring devices 2.a ALARA Principle 2.b Basic radiation safety principles and practices 2.c Personnel monitoring devices 2.d Area monitoring devices 3. Mode of ionizing radiation exposures in hospital environment 4. Use of r adiation in hospital departments by equipment modalities 4.a X-Ray Radiograph 4.b Fluoroscopy 4.c Angiography 4.d Mammography 4.e Computed Tomography 4.f Dose comparison 4.g Common Shielding 4.h Nuclear Medicine 4.i Brachytherapy 4.j Radiotherapy 5. Emergency situation 6. Laws, Regulations and Standards and Radiation Safety Organization 7. Questions Principle of ionizing radiation safety In hospital environment (Ver.1.0)

5. 1.b Types of ionizing Radiation? Flash file 01_Types of radiations

6. 1.c How X Ray Tube works? Flash file 02_How X Ray Tube works.

10. 1.f-I Flash files 03_Radiation Injury_1 1-f-ii Flash files 04_Radiation Injury_2 1-f-iii Flash files 05_Radiation Injury_3 1.f Radiation accidents

12. 1.f-v Radiation accidents due to radioactive material

13. High Typically young and rapid growing cells are more sensitive to the radiation than mature cells . 1.g Young and rapid growing cells are more sensitive than mature cells Hair follicles are fast growing cell therefore during radiation treatment you will notice hair loss. Sensitivity Low Muscle, Joints, Central nerves, Fat Skin, Inner-layer of intestines, Eyes Bone marrow, Lymph system, Reproductive organs

14. 1.h Comparison of Administrative, Regulatory and Biological Effect Doses (Example) 100% of People Die, CNS Syndrome Permanent Infertility Radiation Worker Whole Body Regulatory Limit (20 mSv/yr) Eye Regulatory Limit (150 mSv/yr) 50% of People Die (450 – 500 rad) Nausea & Vomiting (10% of People) Whole Body Exposure Partial Body Exposure Extremities Regulatory Limit (500 mSv/yr) Rad or Rem General Public Whole Body Regulatory Limit (1 mSv/yr) No Clinical Symptoms Seen Below 100mSv Cataract Formation Loss of Hair Skin Reddening Decreased White Blood Cell Count Ulcers on the Skin Molecular Death (> 100,000 rad) Gastrointestinal Syndrome (1 rem = 10 mSv)

16. 2.a ALARA Principle Flash file 06_ALARA LINK TO Alara SLIDE.

19. (Survey Meters) These Survey Meters are used to detect leakage radiation of x-ray rooms. This type of survey meters are equipped with ionization chamber type detector. It is not suitable for Alpha, Beta and Neutron particles. But could be usable for high range of Gamma radiation. These Survey Meters are used to detect contamination radiation at Nuclear Medicine Department. For different particles such as Alpha, Beta, Gamma, Neutron, different detector has to be used. 2.d Area monitoring devices All survey meters are required to sent to authorized laboratory such as “Nuclear Malaysia Agency for annual calibration and certification.

20. Irradiation e.g. X-ray equipments External Contamination e.g. Tc-99M Nuclear Medicine Internal Contamination e.g. Neutron radiation In Hi-energy ranges 3. Mode of ionizing radiation exposures in hospital environment

22. 4.a X-Ray Radiograph (Radiation Safety in Radiology Department ) Only patient remain inside the room and operator and all other personnel stay out side the room. X-ray room is equipped with a lead-glass window to monitor the patient. Radiation warning light is installed above all entry doors to indicate risk.

23. 07_General X Ray System Imaging 4.a.i X-Ray Radiograph (Radiation Safety in Radiology Department )

24. 4.b Fluoroscopy Systems (Radiation Safety in Radiology Department) Patient and operator, normally radiographer and may be radiologist remain inside the room during examination procedure. The other personnel stay out side the room. Fluoroscopy / Angiography room is equipped with a lead-glass window to monitor the patient. Radiation warning light is installed above all entry doors to indicate risk. A typical dose profile for a fluoroscopy system Comparison between Over-Table Tube and Under-table Tube positions on dose profiles A typical Fluoroscopy system, provide radiation protection lead leaves

25. 4.c.i Angiography Systems (Radiation Safety in Radiology Department) CARDIOVIEW.swf TOPSPEED.swf

26. File_08 Radiation risk to operator (Angio)_1 File_08 Radiation risk to operator (Angio)_2 4.c.ii Angiography Systems (Radiation Safety in Radiology Department)

28. To link to previous page

29. 4.d Radiation Safety in Radiology Department Mammography Systems Mammography systems come with built-in lead-glass panel that allows the operator stands safely inside the examination room. Comparison between digital & analog images A modern Mammography System and patient. Typical position of x-ray tube and patient with compression.

30. 4.e Radiation Safety in Radiology Department Computed Tomography Systems Radiation dose profile for Computed Tomography system A typical Computed Tomography System A typical Computed Tomography Suite Only patient is to remain inside the room while the operator and all other personnel stays outside the examination room. CT room is equipped with a lead-glass window to monitor the patient during the exposure. Radiation warning light is installed above all entry doors to indicate risk.

31. File_15 CT Imaging System

33. Approximate Dose for operator in Medical Diagnostics Procedures Flash File 07_Comaprison 4. f.ii Radiation Safety in hospital environment Modalities and Departments involved

34. Personnel Protective Equipment (Shielding) used in Radiology Department. 4.g.i Common shielding devices (Radiology Department) Variety of lead aprons found in a typical radiology department. Some are supposed to be worn and some are designed to placed in front of operator.

35. Controlled and clean areas (Shielded Rooms) CT Room Entrance Example illuminated warning sign sliding shielded doors radiation warning sign 4.g.ii Radiation Safety in Radiology Department required shielded rooms A typical radiation shielded room for diagnostics equipments. Requirements are: Minimum thickness of wall > 2 mm lead eq. Radiation warning light and symbol sticker out side the room Size of the room is defined by MOH.

36. 4.h.i Radiation Safety in Nuclear Medicine Department The gamma rays have properties like x-rays. They emit out of the patient's body, and therefore present a potential external hazard to bystanders. To reduce this hazard, some patients may be placed in special lead-lined rooms for a few days. You can work safely with these patients by using a few simple techniques: (1) Put on shoe covers and protective gloves before entering the patient's room. (2) Work quickly, but effectively and courteously. (3) Maintain the greatest distance possible from the patient consistent with effective care. Radiation exposure drops off drastically with increasing distance. (4) Observe Universal Precautions while handling blood and other body fluids, especially urine. (5) Leave all trash, linens and food trays in the room. Upon leaving the room, remove gloves and shoe covers and place them in the trash box inside the room. (6) After leaving the room, wash your hands. (7) In the event of a medical emergency involving the patient, the patient's well-being is the primary consideration. All initial measures necessary to sustain the patient should be undertaken, regardless of radiation considerations. It may be possible to further reduce the external hazard by using portable shields. In general, lead aprons are minimally effective and their routine use during ordinary caregiving is not recommended. However, during prolonged procedures at close proximity to the patient (for example, a difficult blood draw), they can reduce exposure by about 15%.

37. Shielding being used in Nuclear Medicine Department. 4.h.ii Radiation Safety in Nuclear Medicine Department

38. Radioactive materials are being used in Nuclear Medicine Imaging Department (Molecular Imaging) (i) Gamma Camera which involve radionuclide such as Technetium 99m, I-131. (ii) Positron emission tomography (PET) 18-FDG Nuclear Medicine Diagnostics Nuclear Medicine Diagnostic Patients Patients may undergo imaging procedures in Nuclear Medicine while hospitalized. These procedures include bone scans, gallium scans, PET scans and so forth. They are performed with very small ("tracer") amounts of radioactive materials. The radiation levels from these patients are negligible, and present almost no hazard. Other than "Universal Blood and Body Fluid Precautions", there are no special radiation safety considerations for interacting with these patients. 4.h.iii Radiation Safety in Nuclear Medicine Department Diagnostics

39. 4.h.iv Radiation Safety in Nuclear Medicine Department Treatment Nuclear Medicine Therapy Patients Most of these patients are treated with radioactive iodine-131 (I-131). Iodine-131 has a half-life of 8 days and emits both beta particles and gamma rays . The beta particles are responsible for killing the tumor cells. They have such a short "range" in tissue that they do not leave the patient's body, and so present no external hazard. However, gamma rays emitted from I-131 could strong enough to give exposures to environment. These patients are being confined in a radiation shielded rooms for 2 to 3 days. Moreover , I-131 is excreted in the patient's urine, stools, saliva and perspiration, small amounts of radioactivity may be present on surfaces in the patient's room. This "contamination" can be ingested by "surface-to-hand-to-mouth" contact. A dedicated toilet is located inside these patient’s rooms and a special system collects and stores all waste in “Decay Tanks” for months before discharge to the main sewer.

40. Iodine-131 Therapy for Cancer of the Thyroid I-131 is used to treat patients with thyroid carcinoma or hyperthyroidism. I-131 is generally administered orally in a liquid, capsule, or caplet form. Any patient receiving major therapies may be admitted to the hospital as determined by patient-specific dose calculations. Radiation exposure and contamination are both concerns when working with I-131 patients. Since patient will become radioactive after having been given the treatment and will emit radiation patient will be required to remain within “The radionuclide treatment suite” until they are advised that it is safe to leave. This consists of a room, shower / bath and toilet. Patient will excrete a considerable amount of radioactive iodine in urine, faeces, sweat, saliva and nasal mucous and it is therefore very important that these substances are not allowed to 'contaminate‘ other people, or areas outside the suite. Patient may ONLY use the toilet, shower and washing facilities WITHIN the radionuclide suite. 4.h.v Radiation Safety in Nuclear Medicine Department Treatment

42. 4.i.i Radiation Safety in Brachytherapy Department A typical Brachytherapy treatment shielded room (as thick as 60 cm concrete wall A typical Brachytherapy system Image of source positioning

43. 4.i.ii Radiation Safety in Radiotherapy Department (Brachytherapy) In brachytherapy , small, sealed sources of radiation (typically Cs-137 or Ir-192), are positioned near the patient’s cancer site using special, surgically-implanted catheters. While these catheters are implanted in the operating room, the radiation sources themselves are inserted into these catheters in the patient’s room. Implant therapy is effective in some cases of uterine, prostate and lung cancer than external radiation therapy. In this case, a sealed source radioactive material, usually a gamma emitter such as cesium (CS-137) or iridium (Ir-192, is placed in a body cavity close to the tumor and left in place for a prescribed period of time say about 20 minutes. During the time the implant is in place, staff entering the room are exposed to gamma rays and must take precautions. Once the treatment is completed and the implant is removed, the patient is no longer radioactive and presents no hazard. Radiation exposure is the primary concern when working with brachytherapy patients. Contamination is not of concern as the radiation sources are “sealed.”

45. 4.j.i Radiation Safety in Radiotherapy (Treatment) Department (Linac) Radiation Therapy (or radiotherapy) is the medical use of ionizing radiation as part of cancer treatment. DNA in cancer cells which enables the cancerous cells to reproduce is damaged by radiation therapy. When the damaged cells die, the body eliminates them. Normal cells which may have been effected by radiation can repair themselves. Treatment can be delivered external to the body, (i.e. external beam radiation therapy) . A typical Linear Accelerator (Linac) Suite

46. 4.j.ii Radiation Safety in Radiotherapy (Treatment) Department (Linac) A typical shielded room for Linear Accelerator (Linac). The shielded wall could be as thick as 1 to 2 meters of concrete, depends on energy employed

47. 5. Emergency situation When there is an emergency accident involved with radioactive material, the effected area should be sealed to avoid unauthorized personnel to enter the site and appropriate source container should get ready to contain the radioactive material.

48. Regulatory requirements (Radiation Warning Sign Stickers) which are mandatory to placed outside the radiation room and during transport This sticker is used for X-Ray radiation This sticker is used for radioactive materials This sticker is used for transport of radioactive materials (Container) 6.a Laws, Regulations and Standards and Radiation Safety Organization

51. Licensee (SMSB) Person In-Charge Towards License (OBTL) Name………….. Radiation Protection Officer (RPO) Name …………. Individual Radiation Workers 6.d Laws, Regulations and Standards and Radiation Safety Organization

52. 7.i Questions Q.1 It is called ionizing radiation, because, these radiation carry enough energy to knock out _______ from an atom and atom become ionized due to electrically unstable state. Q.2 What is the type of ionizing radiation commonly found in hospital Imaging Department? Q.3 What type of radiation produced by Fluoroscopy system? Q. 4 What type of radiation produced by Brachytherapy system? Q.5 Basic concept of radiation protection is based on ______, Optimization and Limit of Dose. Q.6 ALARA stands for: Q.7 The ALARA concept is based on the assumption: a. nucleus d. proton e. water b. electron c. DNA a. Alpha b. Beta c. Gamma d. X-ray e. Neutron a. Gamma b. Neutron c. X-Ray d. Alpha e. Positron a. Gamma b. Neutron c. X-ray d. Electron e. Positron b. Justification a Just In Time c. Shielding d. Time a. as long as regulation allows b. as low as reasonably achievable c. as low as rationally attainable a. that only a large radiation dose can be harmful b. that any radiation dose can have some adverse effect c. That a little radiation dose can be beneficial e. Distance

53. 7.iii Questions Q.8 What is the Annual Dose Limit for radiation workers? a.100 mSv b. 50mSv c. 20mSv d. 1mSv e. 0.1 mSv Q.9 What is the Annual Dose Limit for public? (Please choose one.) a.100 mSv b. 50mSv c. 20mSv d. 1mSv e. 0.1 mSv Q.10 The three basic principles used in protecting oneself from radiation exposure are: a. time, distance, shielding b. ventilation, rules and regulations, procedures c. containment, protective clothing, surveys d. Justification, Optimization, Limit of Dose e. avoid radiation, avoid long working hours, avoid touching the radioactive materials Q. 11 A radiation worker is required to be monitored if: a. he/she is likely to receive in excess of 10% of the dose limits b. he/she wants to be c. if the annual radiation dose is likely to be greater than 10 milli sievert d. if any radiation is present in the workplace e. xxxx

54. 7.iv Questions Q. 12 A 0.25 mm lead equivalent apron will reduce scattered X-rays by: (Please choose one.) a. 10% b. 20% c. 50% d. 70% e. 90% Q. 13 Which statement about brachytherapy is FALSE: a. you should try to work behind mobile shields whenever possible b. other hospital staff members are allowed in patient rooms if stay times and posted instructions are observed c. pregnant visitors and minors ARE allowed in radiation isolation rooms d. the room and patient ARE NOT to be released until cleared by Radiation Safety e. Q. 14 If a brachytherapy source becomes dislodged from the patient, you should: a. not touch the source b. remove all unnecessary personnel and call Radiation Safety and Radiation Oncology c. try to get the source to the corner of the room with a broomstick, etc. d. do all of the above e. Q. 15 Radiation is useful in medical diagnosis because: a. of its ability to cause biological damage b. lead walls can absorb it c. of its ability to penetrate tissue d. it is easy to get a radiation-use license e.