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The State of California provided the follo … The State of California provided the following information via email:</br>During a teletherapy treatment of a cat on 6/22/09, an apparent malfunction of the MDS-Nordion Model C-146 teletherapy device resulted in the radiation beam not terminating at the end of the treatment. Two entries into the treatment room were apparently made with the radiation beam on, one by a technologist (who wore dosimetry), and one by a veterinarian (who did not wear dosimetry). The veterinarian was exposed to the beam when he removed the cat from the treatment table. The technologist reportedly did not enter the beam. The technologist's dosimetry was submitted to the dosimetry vendor for emergency evaluation.</br>The veterinarian indicated that he was aware of the location and size of the radiation treatment beam when he removed the cat, and only his lower arms entered the beam. The beam was approximately 70 R/minute at the treatment site. The veterinarian estimated his time in the beam at one and one-half to two minutes. A re-enactment will be conducted as soon as the veterinarian returns to the office from a trip he is on the rest of the week. </br>A state inspector arrived at the licensee facility at 0630 on 6/24/09 to investigate this event. The licensee has suspended use of the teletherapy device pending the results of the onsite investigation.</br>California 5010 Number: 052309</br>* * * UPDATE FROM ROBERT GREGER TO VINCE KLCO (VIA EMAIL) ON 6/29/09 @ 1919 * * *</br>The current best estimate for the dose to the veterinarian has changed to less than one rem (both whole body and extremity). This is based on an on-site re-enactment of the event today that confirmed a significantly lower exposure time and dose rate for the event than was originally believed to have existed. </br>Notified FSME (Foster) and R4DO (Powers).
Notified FSME (Foster) and R4DO (Powers). +
07:00:00, 22 June 2009 +
45,159 +
13:30:00, 24 June 2009 +
07:00:00, 22 June 2009 +
The State of California provided the follo … The State of California provided the following information via email:</br>During a teletherapy treatment of a cat on 6/22/09, an apparent malfunction of the MDS-Nordion Model C-146 teletherapy device resulted in the radiation beam not terminating at the end of the treatment. Two entries into the treatment room were apparently made with the radiation beam on, one by a technologist (who wore dosimetry), and one by a veterinarian (who did not wear dosimetry). The veterinarian was exposed to the beam when he removed the cat from the treatment table. The technologist reportedly did not enter the beam. The technologist's dosimetry was submitted to the dosimetry vendor for emergency evaluation.</br>The veterinarian indicated that he was aware of the location and size of the radiation treatment beam when he removed the cat, and only his lower arms entered the beam. The beam was approximately 70 R/minute at the treatment site. The veterinarian estimated his time in the beam at one and one-half to two minutes. A re-enactment will be conducted as soon as the veterinarian returns to the office from a trip he is on the rest of the week. </br>A state inspector arrived at the licensee facility at 0630 on 6/24/09 to investigate this event. The licensee has suspended use of the teletherapy device pending the results of the onsite investigation.</br>California 5010 Number: 052309</br>* * * UPDATE FROM ROBERT GREGER TO VINCE KLCO (VIA EMAIL) ON 6/29/09 @ 1919 * * *</br>The current best estimate for the dose to the veterinarian has changed to less than one rem (both whole body and extremity). This is based on an on-site re-enactment of the event today that confirmed a significantly lower exposure time and dose rate for the event than was originally believed to have existed. </br>Notified FSME (Foster) and R4DO (Powers).
Notified FSME (Foster) and R4DO (Powers). +
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00:00:00, 29 June 2009 +
4640 +
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02:11:47, 2 March 2018 +
13:30:00, 24 June 2009 +
2.271 d (54.5 hours, 0.324 weeks, 0.0747 months) +
07:00:00, 22 June 2009 +
Agreement State Report Involving a Potential Personnel Overexposure Due to Equipment Malfunction +
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