ML20054A461
| ML20054A461 | |
| Person / Time | |
|---|---|
| Issue date: | 08/27/1975 |
| From: | North H, Wenslawski F NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20049A151 | List:
|
| References | |
| FOIA-82-11 NUDOCS 8204150473 | |
| Download: ML20054A461 (12) | |
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1 DRAFT INSPECTION REPORT FORM 1.
Name and Address of Licensee 2.
Date of Inspection 12/3/74 Ann unced Veterans Administration Hospital 3.
Type of Inspection Reinspection Wilshire and Sawtelle Blvd.
Los Angeles, California 90073 4.
License Number (s), Docket Number (s), Number and Date of Last Amendment for Each License - Category and Priority of Each Licensee 04-00181-04, Amendment No. 62, February 6,1974, (G(1), II 5.
Date of Previous Inspection SeDtember 28, 1973 6.
Proprietary Information Instrumentation Quality Control Procedures i
T % r.c.tO u,u ?! h :n. m j - Jn f('id 7.
Scope of Inspection if Other than Routine Routine l
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Participants (Licensee Representatives & Titles, State Representatives, etc.)
L. W. Wetterean, RS0, Physicist W. H. Blahd, M.D., Chief, Nuclear fledicine Service
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Management Interview (Information Required for N/C Cases)
W-L. W. Wetterean, RSO, Physicist W. H..Blahd, M.D., Chief, Nuclear Medicine Service 10.
Action and Date: Letter to Licensee AEC-591 Clear December 3,1974 i
AEC-591 N/C
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Recommend Reinspection Date b~I~ni
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H. S. florth Rait[o pecialist b' 4 //
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Inspector (s)
Date of Report
..l&l-F. A. WeaslAwski,A..;, Radiation Specialist c> }19 l 7f
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-Revieweb
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" Date crf Review i
Herbert E. Book, Chief Radiological & Environmental Attachment to Section 1010 Protection Branch 8204150473 820216 PDR FOIA NELSON 82-11 PDR
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Veterans Administration Hospital Los Angeles, California 90073 License No. 04-00181-04
- 13. Inspection Summary The licensee's program continues substantially as described in previous inspection notes. Since the last inspection, the licensee has ceased the use of generators and is now purchasing technetium-99m at a rate of approximately 2 curies per week from Mediphysics. The licensee is continuing the on-going training prcj &m in the use of radioactive materials.
The licensee has established a quality control program covering all instrumentation. The program provides for daily, weekly and monthly tests and for maintenance o.' records of the tests.
Quality control procedures are contained in a manual, a copy of which was provided to the inspector. The licensee has requested that this manual be considered to be Confidential, not for release.
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The inspection disclosed no items of noncompliance or health and safety significance. A Form AEC-591 was issued at the conclusion of the inspection reflecting these findings.
- 14. Summary of Licensed Program The licensee is engaged in the practice of nuclear medicine and in addition in the training of professional and technical level personnel i
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and performing research in the areas of medical specialties. The clinical nuclear medicine staff consists of one staff physician, one clinical radiobiochemist, one biologist, four nuclear medicine technologists, and one nuclear medicine technology trainee. The
.9dy, Nuclear Medicine Training Section consists of the head of the training program, a biologist instructor, three physicians in train-ing in the field of nuclear medicine, four technologists and two or three pharmacists training in the field of radiopharmacy during the summer months for a period of approximately six weeks. The licensee's research use of radioactive materials involves principally small quantities of carbon tritium, iodine, mercury and indium, and work j
is performed in the following laboratories : Arteriosclerosis, Cardiology, C-14 Lab.', Metabolic Laboratory, Dermatology, Cerebral Circulation, Gastroenterology, Neurobiochemistry, Renal Laboratory, and Endocrinology.
The licensee badges a. total of 76 individuals
- 3nr;g as the result of possible contacts with licensed materials. An inventory of the licensed material possessed at the time of the inspection is attached to these notes as Appendix A.
On the basis of discussions with the licensee, an examination of records and a tour of facilities it appeared that materials were possessed and used as authorized by the license.
- 15. Oroanization and Administration The Acting Hospital Director is Mr. Joseph Bermingham.
Reporting to him as Chief of Staff is Ed Wright, M.D.
Reporting to Dr. Wright
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. is Dr. William Blahd, Chief, Nuclear Medicine Service, who is assisted by Dr. M. Winston, the Assistant Chief. Mr. Wettereau is the licensee's RSO and acts as Dr. Blahd's Administrative Officer.
Mr. Wettereau is also an active participant in the licensee's training program, both in the Nuclear Medicine Training Section and the
,,, y Radioisotopes Training Course. Mr. Bennett assists Mr. Wettereau one day per week. Reporting to Dr. Blahd is the Nuclear Medicine Training Section headed by Dr. Gambino, a biologist, who is in charge of the Nuclear Medicine Training Program which presently includes three physicians and four nuclear medicine technologists and during the summer two to three radiopharmacists in a six-week intern service.
Also reporting to Dr. Blahd is the Clinical Section which normally includes one staff physician, presently Dr. G. T. Krishnamurthy who is presently assisted by Dr. J. Pritchard. The staff also includes one clinical radiobiochemist, Dr. Tubis, one biologist in the field of radioimmunoassay, four nuclear medicine technologists and one
..~,na nuclear medicine technology trainee.
The Wadsworth Hospital Research 40
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Services,., headed by Dr. Guze.hesearch use of licensed materials shown j
in the following list which identifies the laboratory's responsible user of the isotopes used.
l Laobraotry Responsible User Licensed Material
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Arteriosclerosis Lab.
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Cardiology Dr. Rollet Tritium
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C-14 Lab.
Dr. M. Schotz Tritium (lipid research)
Metabolic Lab.
Dr. S. Lavin C;14, I-125 Dermatology Dr. Wright Hg-203 (Chief of Staff)
Cerebral Circulation-Dr. Olden'dorf Tritium, C-14 In-113M - - - ~
Gastroenterology Dr. Morton Grossman I-125, Tritium, C-14 t/ v u l + Y o
Neurobiochemistry Dr. Euyler Tritium, C-14, I-125 s, o-,oye
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Renal Lab.
Dr.~ Coleman-Ca-45,
Endocrinology Dr. Hirshman I-125 & 131 p,.,
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~- 'r Condition 12A of the license specifies that materials shall be used by individuals author,ized by the licensee's Radioisotope Committee, Dr. W. Blahd, Chairman. Appendix B, a memorandum dated May 1, 1973, identifies the licensee's Radioisotope Committee and the various-individuals serving on that Committee.
Individual positions and researchers are authorized to use materials only when they have satisfied the Committee of their qualifications.
For individuals who have no experience using licensed materials or have not had recent experience a radioisotope training course is provided on a continuing basis. A copy of the radioisotope training course schedule is attached as Appendix C.
The licensee institution is also a participant with UCLA in a physician training program and as such has high standards for technician and physician training.
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- 16. Facilities i
During the inspection the inspector toured the following facilities
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and noted the-items. reported.for each facility:
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Building 114 Hot Lab Record of receipt of RAM maintained identifies supplier, chemical P st-5
.,c::k form, total volume, assay date, special accettnt, total accoun't and consigne
' : lear Chicago, Mediac, dose calibrator and Baird 530A Sir 3 e Channel well scintillation counter avail!ble. Access controlled by lock and key.
RS0's Lab-Office j,,gg NMC, PC-3A proportional, TEW-GM and Nuclear-Chicago 3" auto gamma,
well counters available.
Portable instruments include Nuclear Chicago, Ion Chamber, TEW-GM and T/A BUG-1A.
l Building 115 Radio Immunio Assay (RIA) Lab Mr. R. Huebotter, ' Biologist in charge l
R. Taylor, M.D., Resident in Nuclear Medicine Monthly performed, approximately the following number of tests:
AustraliaHepatitisAntigenb-.d} -
60 c
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B-12 U+"
120 3
Serum Folate (H )
100 Digoxin (I125) 500 T-3, T-4 300
?.Bukman 310, 300 sample, 3 channel gamma spectrometer Packard Tri Carb. 332 Liquid Scintillation, 3 channel Room 28 Cerebral Circulation Studies by Dr. Oldendorf, L. Braun, Shigo Hyman, ll3m g,3 and C
. Carry out liquid l4 using rats ani rabbits and In scintillation counting of liquid samples.
Packard Tri Car'h., L.S.
and Baird Atomic gamma well, Model 708.
Building 213 fluclear Medicine Clinic R. Cullison, Acting Technologist Supervisor Instrumentation available:
fluclear Chicago, Pho Gamma, H.P.
fluclear Chicago, Clincom Nuclear Chicago, Model 8725, 2" single channel gamma analyzer for uptakes fluclear Chicago, 5" Crystal, Pho Dot V, Scanner Picker flucicar, Magna Scanner 500 (3" crystal)
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. Lab 20 133 Used for XE lung perfusion tests Mediphysics device Nuclear Chicago, Mediac dose calibrator 3.
Nuclear Chicago, single channel, 2 crystal TOBOR Records of receipt and use of RAM maintained.
Color coding of individual dose units (syringes) to identify isotope and quantity.
Old Wadsworth Hospital Site AF-10 Out Patient Clinic ilr. K. Forrest, Registered Technician Nuclear Chicago Pho Gamma III Volemetron, blood volume device
.y.c Picker Nuclear, Magna Scanner 500 fluclear Chicago, single channel 1" crystal used for uptakes l
Mediac dose calibrator (individual patient doses prepared and calibrated in Building 213 and sent to the Out Patient Clinic as required, where doses are recalibrated).
j Color tagged of doses is used.
Access to all facilities is controlled by personnel during normal l
l working hours and lock and key at night. The housekeeping staff has been advised of the presence of RAM's and instructed in their duties.
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Equipment See item flo.16 18.
Radiological Safety Procedures y2 24 The licensee has developed a Procedures Manual, May 1974 (Appendix D) and Q.C. procedures for counting instrument (Appendix E) both of which are considered Proprietary. The procedures were developed in response to an AMA requirement for hospital certification. Copies of the licensee's procedures, license application and the regulations are available.
Forms AEC-3 are posted as required.
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Personnel Monitoring - External Radiation Monthly film badges and TLD finger rings used by technicians are 4
-eg c; supplied by Radiation Detection Company. A total of 76 badges and,17 i
i rings are currently used.
To assu,he a review of exposure data the RSO personally transfers the Radiation Detection Company exposure data to individual AEC-4 forms.
Exposure data for the period 3rd quarter 1973 to end of October 1974
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The high exposures during this period were as follows:
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Monthly - Film 280 mrem Film Annual (1973) 800 mrem Monthly - Ring 1010 mrem Ring Annual (1973)
- 3070 mrem
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_9 p lio Annual average whole body exposure #50 mrem.
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Exposure to Airborne RAM Not applicable.
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Effluents to Unrestricted Area Not applicable.
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Disposals The licensee disposes of liquid and solid waste by transfer to W. H. Hutchinson and Sons (Cal Salvage). Since the last inspection a total of five disposals totaling 68, 55 gal, drums and 291.3 millicuries of activity have been made. Records of disposals are maintained.
- 23. Miscellaneous Surveys, Evaluations and Records Routine area surveys are performed monthly of approximately 35 laboratories by the RSO or his assistant. Surveys consist of dose rate evaluation with occasional smears. The RSO relies on individualfin labs to notify him of spills or occurrences of more than minor significance. When smearable activity
.m is identified, cleanup and resmear to no significant activity levels is required.
Records were examined. flost surveys disclosed background level dose rates up to a maximum of 1.5 mr/hr.
Itost in the region of 0.1 to 0.3 mr/hr or less.
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. Leak test records of the following sealed sources were examined and found to be timely and at background levels:
90 RA-1-Sr medical applicator 60 R-30-Co
- i I-125' Bone Mineral Analyzer 24.
Soecial License Condition 3
Condition 18 requires bicassay for.H when quantities greater than 100 mci are handled. No such use was identified.
- 25. Posting and Labeling Posting and labeling were observed during the tours of facilities.
No discrepancies with regulatory requirements were identified.
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Independent Measurements
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None l
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- 27. Operations Observed Patient counting in clinic.
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Incidents, Overexposures, Theft or loss, Equipment Malfunction The licensee maintains a log of unusual occurrences (Radiation Safety Non Routine Radsafety Surveys) which was examined.
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The following items were identified. All items were described in full and corrective actions reported.
11/30/73 Disconnected I.V. drip tube, 3 mci Tc99* fiAA, spill -
a decontaminated.
l31 11/18/74 Receipt of damaged RISA shipment.
10, 5 util
- syringes, resulting from the TWA crash of 1/16/74, reported to H. florth at IE:V, later 10 more syringes received. All disposed as radioactive waste.
3/13/74 Patient contaminated with 500 uCi of In113hTPA. Patient decontaminated.
133 10/11/74 Xe
-Saline solution spill,16.8 mci lost. Airborne concent/ation calculated as 2.24x10-4 uC1/cc assuming all released at once.
The ventilating fan was running which served to reduce
- .m.-4' the airborne concentration.
Initial concentration was greater than 500 times the Appendix B Table II limit for 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> but with fan running the 24-hour air concen-tration was less than Appendix B Table II value. The release was not detectable on film badges or with a Cutie Pie.
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47 11/5/74 Four'2 uCi, Ca syringes were lost in transit (fell out of the container). The syringes were recovered intact.
fio exposure resulted.
- 29. Other Information or Continuation from Previous Paraaraphs flot applicable
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