ENS 44073
ENS Event | |
|---|---|
07:00 Mar 13, 2008 | |
| Title | Agreement State Report of Leaking Iodine-125 Seed |
| Event Description | The State of Washington Department of Health, Office of Radiation Protection, provided the following information via e-mail:
On 10 March 2008 a patient was implanted with approximately 80 I-125 seeds. On 12 March 2008 (or 13 March 2008, it remains unclear as of this writing), the patient complained of pain and difficulty urinating. A cauterization was performed via the urethra. Upon removal of the cauterization equipment, some seeds also exited via the urethra. One seed, in particular, was visibly different from the rest. This seed was, upon closer observation, noted to be shorter than the others and, in fact, had been damaged. Cause of the damage (shear force during insertion or perhaps a result of the cauterization) has yet to be determined. A survey of the area including the patient using a Technical Associates TBM-3 showed contamination of the equipment and bodily fluids, while an external reading directly over the thyroid showed levels above background. The activity of the damaged I-125 seed was less than 300 microcuries. Licensee is assessing possible overexposure to the patient, organ dose calculations underway by licensee consultant.
The State provided the following information via email: On 10 March 2008 a patient was implanted with 102 I-125 seeds. On 13 March 2008 the patient complained of pain and difficulty urinating. A cauterization was performed via the urethra. Upon removal of the cauterization equipment, 'some' seeds also exited via the urethra. One seed, in particular, was visibly different from the rest. This seed was, upon closer observation, noted to perhaps be shorter than the others and, in fact, had been damaged. Cause of the damage (shear force during insertion or perhaps a result of the cauterization) has yet to be determined, although as of this writing the most logical conclusion would be over-heating from the cauterization procedure. A survey by the licensee of the area including the patient using a Technical Associates TBM-3 showed contamination of the equipment and bodily fluids, while an external reading directly over the thyroid showed levels above background. A CT scan was performed on 19 March 2008 to determine the number of seeds remaining in the patient. Results of that scan show the proper number, 92 seeds, remain in the patient of the total 102 implanted. Seed was damaged, probably from heat, but if not, then from some other mechanism. These were seeds from Best Medical International, Model 2301. Wipes of the remaining seeds showed contamination levels up to 500 nCi. While all seeds exhibited some detectable counts from the wipes, it is thought that one was actually leaking and had cross-contaminated the others while in storage together. Bioassay of the patient on 19 March 2008 showed a thyroid burden of 0.8 microcuries, a dose less than 1 Rem to the organ itself. Notified the R4DO (Whitten) and FSME (Delligatti). |
| Where | |
|---|---|
| Whidbey General Hospital Coupeville, Washington (NRC Region 4) | |
| License number: | WM-M0217-1 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+107 h4.458 days <br />0.637 weeks <br />0.147 months <br />) | |
| Opened: | Arden Scroggs 18:00 Mar 17, 2008 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Mar 21, 2008 |
| 44073 - NRC Website | |
Whidbey General Hospital with Agreement State | |
WEEKMONTHYEARENS 440732008-03-13T07:00:00013 March 2008 07:00:00
[Table view]Agreement State Agreement State Report of Leaking Iodine-125 Seed 2008-03-13T07:00:00 | |