ML20214M495

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Forwards Rept on Malfunction of Nuclear Powered Pacemaker, Per Condition 13 of License SNM-1605.Related Info Encl
ML20214M495
Person / Time
Site: 07002199
Issue date: 06/10/1983
From: Gavazzi A
VETERANS ADMIN. MEDICAL CENTER, WASHINGTON, DC
To: Vacca P
NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS)
Shared Package
ML20213D562 List:
References
NUDOCS 8609110141
Download: ML20214M495 (9)
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Text

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Midic:1 Cinttr 50 trying Street, NW.

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Washington D.C. 20422 M Veterans 7#~.2/97

%EJ Administration June 10,' 1983 p3.02

.Ms.. Patricia C. Vacca%

in Reply Refer To:

SNM-1605 Material Licensing Branch Division of Fuel Cycle and Material Safety US Nuclear Regulatory Commission

'7ashington, D.C.

20555

Dear Ms. Vacca:

i The enclosed report is provided in compliance with condition 13 of this medical center's by product material 4

license # SNM-1605.

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vazzi Medical Center Director enclosure i

i 8609110141 860829 REG 1 LIC70 SNM-1605 PDR I

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Report of f,:..

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Malfunction of Nuclear Powered Pacemaker b

This' report is a written follow-up to the telephone report made on June 9, 1983 by Mr. Bowman.

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1. -Manufacturer:

Cordis

'2.

.Model. Number:

184A 3:

Date-Implanted:

Jan. 19,.1977 4.

Date Halfunction'was discovered:

June 2, 1983_

- 5.

Nature of Failure:

Failure to Sense

6. ICurrent Status of Patiient:

The patient left the hospital against medical ad-vice. -The attending physician plans. to contact the patient:

and-attempt to persuade him;to. allow'further tests.

7..This report was' written'by John Bowman, RSO.

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k R PORT OF PACEMAKER REMOVAL /PATittiT DEATH

/6()f, Docket No. 070 CA87 )/ // 8bl. S/Y, ///ec/.k (This note should be filed in the license issued to:

License No. SNM-TIME AllD DATE OF CALL:

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CALLER'S NAME:

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CALLER'SINSTITUTI0t} DDRESS

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j NAME OF MANUFACTURER OF PACEMAKER:

dC[LO M Serial No.:

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MODEL NUMBER OF PACEMAKER:

/9,/977 DATE IMPLANTED:

e' REASON FOR CALL:

l Death of patient --- Date of Death Cause of death:

Pacemaker-related? Yes.

No Removed from patient Reason for removal:

X Other--Explain: $1Llhtsdw flewwl flgg fgua (g

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PACEMAKERBEINGRETURNEDTOTHEMAt(FACTURER?

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Yes, by No; explain:

CALLER REMINDED TO FILE WRITTEN REPORT WITHIN 30 DAYS? Yes [

No

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(L tzh duce Signature of NRC staff member who took call t

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Washington D C 20 R EC _ Vt.D K Veterans h Administrat.

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ion 8 RUCLEM MEDICINE SERVICE (115) in n.piy n i., To: 688/115 7 v 's July 29, 1982

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James.J. Smith, M.D.

f.Y T(f Director, fluclear Medicine Service (115)

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VA Central Office 1

Washington, D. C. 20420 q,: s -

SUBJ: New Radiation Safety Officer J/.

  • 1.

Please advise the Licensing Department of the U.S.

Aar.

Regulatory Commission that John 0. Bowman is the new Radi 7,T" Safety Officer for this VA medical center.

'O 2: Mr. Bowman's experience and qualifications are listed on llRC-313M Supplement A and attachments (enclosed), as required by USNRC Guide 10.8.

3.

For reference, our license numbers are:

a.

08-00942-05 b.

08-00942-04 d SNM-1605 Q

4.

Please advise me if you need any additional information with regard to this change in personnel.

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Medical Cen r Director i

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Enclosures i

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9 23, En.-,e.

IA C n :v e c.fts e Washington, D.C 2:<.rn f

Ocp$f' 7%a.9

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1 Fr ;u NRC 313M SUPPLEMENT A U.S. NUCL, REGULATORY COMMISSION

d

TRAINING AND EXPERl'ENCE AUTHORIZED USER OR RADIATION SAFETY OFFICER

1. N AME OF AUTHORIZED USER OR RA_DIATION SAFFTY. OFFICER 2 STATE OR TERRITORY IN WHICH LICENSED TO

'" # C" C" "' ' C' " '

JOHN 0. B0mMN

3. CERTIFICATION SPECIALTY BOARD CATEGORY MONTH AND YEAR CERTIFIED A

B C

4. TRAINING RECEIVED IN BASIC RADIOlSOTOPE HANDLING TECHNIQUES TYPE AND LENGTH OP TRAINING LECTURE /

SUPERVISED FIELD OF TRAINING LOCATION ANO DATE(S)OF TRAINING LABORATORY LABORATORY A

B COURSES EXPERIENCE tuaaa m.wa C

0

.ArkansasStUniv.(1971-72) 60 hrs.

10-hrs.

Memphis St. Univ.(1972-74) 60 lirs.

60 hrs.

RAOlATION PHYSICS AND INSTRUMENTATION i

Arkansas Dept of Health 0JT

b. RADIATION PROTECTION (1975-77) 200 hrs.

Arkansas.St. Univ.(1971-72) 180 hrs.

c. MATHEMATICS PERTAINING TO THE USE AND MEASUREMENT Mem his State Univ.

OF RAOIOACTIVITY (1972-74) 60 hrs.

  • " ^ ' ' " " ' '
e. RADIOPHARMACEUTICAL None CH E VIST RY s
5. EXPERIENCE wlTH RADDATCON. (Actualuse of Radioisotooes or E:u: alent Experience)

ISOTOPE l MAXIMUM AMOUNT l WHERE EXPERIENCE WAS CAINED I OUR ATION OF EXPERIENCE l TYPE OF USE Cf 252 10 mci Memphis State Univ.

3 months Heutron Activation Co 60 27 mci Arkansas Dept. of Healtt 2 years Radiation Detection Training FORM NRC.333M Sucolement A to-7st Page5

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1669

,#2m2s Jchn O. Bo.wman 9

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Agas 31 Education:

BS in Physics from Arkansas State University, Jonesboro, Arkansas, 1972.

MS in Physics'from Memphis State University, Memphis, Tennessee, 1977.

Previous Professional Experience:

Bealth Physici,st for the Arkansas Department of Health, Bureau of Environmental Health Services in Little Rock, Arkansas (1975-1977).

Industrial Hygienist (Compliance Officer) for the US Department of Labor - OSHA in the Little Rock Area Office (1977-1980).

I conducted inspections.of plants to check for compliance with OSHA regulations and general duty require-i ments.

Environmental Protection Specia61ist for the US-EPA Office of Noise Abatement and Control, Standards and Regulations Division, Surface i

Transportation Branch (Mar. 1980- Jan. 1981)

I was an assistant project officer for the ra11 yard property-line noise regulation.

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I am a Lieutenant in the Medical Service Corps of the US Army Reserve and I am currently commander of headquarters company of the 92D. Field Hospital in Baltimore Maryland. I l

have been a member of the army' reserve since February 1978.

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O soir> o street. " w.

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Washington D.C. 20422 R ECE Vt D g veterans y,g..

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Administrat, ion 8 NUCLEM MEDIClhE SIAVICE (115) desy n e., ro: 688/115 July 29, 1982

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James.J. Smith, M.D.

Director, Nuclear Medicine Service (115) 3

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q:3. #2'C VA Central Office

.,7 Washington, D. C. 20420 i

SUBJ: New Radiation Safety Officer

.2 ~ *

~

1.

Please advise the Licensing Department of the U.S.

'uhhar.

/

Regulatory Commission that John 0. Bowman is the new Radilt(on '.>"

Safety Officer for this VA medical center.

S's '

2 Mr. Bowman's experience and qualifications are listed on 11RC-313M Supplement A and attachments (enclosed), as required by USNRC Guide 10.8.

3.

For reference, our license numbers are:

a.

08-00942-05 b.

08-00942-04 c.

SNM-1605 4.

Please advise me if you need any additional information with regard to this change in personnel.

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N Medical C n r Director j

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Enclosures

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1A Can:rs'. c.its :e hsh14 ton. D.C p en i

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8 ps;;:2 NRC 313M-SUPPLEMENT A U.S NUC', REGULATORY COMMISSION

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TRAINING AND EXPERIENCE AUTHORIZED USER OR RADIATION SAFETY OFFICER

l. NAVE OF AUTHORIZED USER OR RAOIATION S AFETY. OFFICER 2 STATE OR TERRITORY IN WHICH LICENSEO TO

' " ^ * " ' ' " ' ' ' ' " '

JOHN 0. BOUMAN I

3. CE RTIFICATION SPECIALTY SCARD CATE G OR Y MONTH AND YEAR CERTIFIED A

B l

C A TRAINING RECEIVEDIN BASIC RADIOlSOTCPE HANDLING TECHNIQUES TYPE ANO LENGTH OF TRAINING LECTURE /

SUPERVISEO PIE LO OF TRAINING LOCATION AND D ATE (S) OF TR AINING LA80RATORY LAeORATORY A

B COURSES EMPERIENCE lHoural 90eurs)

C D

. Arkansas St Univ.(1971-72) 60 hrs.

10 hrs.

Memphis St. Univ.(1972-74) 60 hrs.

60 hrs.

R AOi ATiON ewYSICS ANO INSTRUMENTATION Arkansas Dept of Health OJT

t. RADIATION PROTECTION (1975-77) 200 hrs.

Arkansas.St. Univ.(1971-72) 180 hrs.

c. MATHEuATic$ rERTAiNino TO THE USE ANO MEASUREMENT Memphis State Univ.

OF R ADIOACTIVITY (1972-74) 60 hrs.

Arkansas Dept. oT Health 40 hrs.

C. R ADt ATION 8tOLOGY l

l l

.. R AOioew ARMACEuTiCA' None CHEVISTRY l

s. EXPERIENCE WlTH P ADI ATloN. (Ac:ualuse of *s:1:oisarcars or E:u.sient Emeriencel ISOTOPE l MAXIMUM AMOUNT l WHERE EXPERIENCI WAS G AINED l OVR ATION OF EX7ERIENCE l TYPE OP U5E Cf 252 10 mci Memphis State Univ.

3 months fleutron Activation i

Co 60 27 mci Arkansas Dept. of Healtt 2 years Radiation Detection Training l

1 FORV NRC-3139 Swootemeat A te-7st PA;e 5 l

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O Aga 31 Education:

BS in Physics from Arkansas State University, Jonesboro, Arkansas, 1972.

MS in Physics 'from Memphis State University, Memphis, Tennessee, 1977.

Previous. Professional Experience:

Realth Physici,st for the Arkansas Department of Realth, Bureau of Environmental Health Services in Little Rock, Arkansas (1975-1977).

2ndustrial Hygienist (Compliance Officer) for the US Department of Labor - OSHA in the Little Rock Area Office (1977-1980).

I conducted inspections. of plants to check for compliance with OSHA regulations and general duty require-ments.

Environmental Protection Speciaklist for the US-EPA Office of Noise Abatement and Control, i

Standards and Regulations Division, Surface Transportation Branch (Mar. 1980- Jan. 1981)

I was an assistant project officer for the rallyard property-line noise regulation.

I am a Lieutenant in the Medical Service Corps of the US Army Reserve and I am currently commander of headquarters company of the 92D. Field Hospital in Baltimore Maryland. I have been a member of the army reserve since February 1978.

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