Nuclear Medicine Hot Lab Emergency Procedures

Bellevue College T206 Nuclear Medicine Hot Lab Emergency Procedures

Personnel pertinent to this Emergency Procedures Handbook:

• Radiation Safety Officer
• HSEWI Safety Officer
• Program Manager, Nuclear Medicine Technology Program
• Emergency Operations Officer
• Public Safety 24-hour line: (425) 466-9365

T206 EMERGENCY PROCEDURES HANDBOOK

Section 1: Procedures

• Emergency procedures 3
• Public Safety/Custodian emergency response 4
• General rules for the hot lab 5
• Decontamination procedures 6
• RAM package ordering and delivery procedures 7
• Instructions to radiation workers 8
• Instructions to ancillary personnel 9-10

Section 2: WA State Radiation Emergency handbook 11-29

Section 3: Radioactive Materials Information

• Sealed sources written description with photos 30
• Mo-99/Tc-99m generator with photos 31-32
• MSDS sodium pertechnetate 33-41
• Tc-99m oxidronate (HDP) with photo 42
• MSDS Tc-99m oxidronate 43-47
• I-131 sodium iodide capsule with photo 48
• MSDS I-131 sodium iodide solution 49-53
• Sharps containers with photos 54
• MSDS acetone 55-60

T206 HOT LAB EMERGENCY PROCEDURES

This room contains radioactive materials, mostly in small quantities and in sealed containers. It is unlikely that any emission of radioactive materials out of the room or into the environment would occur in any foreseeable emergency. Here are appropriate responses for each of the following situations:

1. Liquid coming under door of T206: notify Public Safety (425) 466-9365, and then the RSO. If the RSO is not available in T208, ask for the HSEWI Safety Officer. Public Safety will secure the area and have a hazmat-trained individual clean the spill.
2. Fire/smoke emanating from T206: call Public Safety (425) 466-9365 immediately; notify the RSO and the HSEWI Safety Officer next.
3. Broken window/unsecured door of T206: call Public Safety (425) 466-9365 and the RSO immediately. Public Safety will secure the area.
4. Earthquake/damaged building: follow building evacuation procedures. Release of the radioactive materials in this lab is highly unlikely and any released amount would be immediately diluted to the extent that it would be not harmful to anyone.
5. Radiation exposure or skin contamination from radioactive materials: notify the RSO.

Emergency contact phone numbers: Bellevue College Public Safety: (425) 466-9365

PUBLIC SAFETY AND CUSTODIAL SERVICES RESPONSES TO LIQUID EMANATING FROM ROOM T206 (NUCLEAR MEDICINE HOT LAB) 

Response:

1. Contact Jennifer Prekeges, the college Radiation Safety Officer at x2475 or room T308L on campus.  This includes nights and weekends.
2. If unable to reach Jennifer quickly, call Nuclear Medicine Faculty.  This includes nights and weekends.
3. If neither can be reached, contact Adrienne Chambers, Emergency Operations Officer, or other college faculty who have expertise with radioactive materials handling.
4. Proceed to the second floor of the T building and cordon off the area to prevent bystanders from walking through the liquid.  Wait for one of the above-listed people to come deal with the problem.
5. After the absence of any radioactive material has been confirmed, Custodial Services may be called to clean the area (e.g., mop up excess water).

BACKGROUND:

Public Safety is listed as a first-line contact for any emergency involving the nuclear medicine hot lab, room T206.  As a reminder from your radiation safety inservice, most of our radioactive materials are sealed, such that there is virtually no possibility that they would ever get into the environment.  The only time this is not true is when we have one or two radionuclide generators on campus.  You would have been informed of this fact via an email distribution indicating that we have a generator in the hot lab for a week.

If liquid is emanating from T206, it is from one of two sources: the plumbing system (by far more likely) or radioactive Tc-99m in a liquid solution.  You won’t have any easy way to tell which it is, so you should make the prudent assumption that it is the latter.  Contacting the people listed above will bring someone who is able to determine if the material is radioactive and who is capable of cleaning the area in the case that it is radioactive.  Custodial services will become involved only after this determination is made and cleaning has been completed.

Tc-99m is a gamma-emitting radionuclide that is administered to thousands of people every day.  The amounts we are working with in the lab are roughly on the same order of magnitude as the highest amounts given to patients.  There is no potential for harm to you from ingestion, skin contamination, or radiation exposure from this material.

General Rules for Safe Use of Radioactive Material

1. Wear laboratory coats or other protective clothing at all times in areas where dispersible radioactive materials are used.
2. Wear personnel monitoring devices (body dosimeter) at all times while in areas where radioactive materials are used or stored. These devices should be worn at chest or waist level.
3. Wear disposable gloves at all times while handling dispersible radioactive materials.
4. Wear TLD finger badges when manipulating millicurie or greater quantities of radioactive materials.
5. Monitor hands and clothing for contamination after each procedure or before leaving the area.
6. Do not eat, drink, smoke, or apply cosmetics in any area where radioactive material is stored or used.
7. Do not store food, drink, or personal effects with radioactive material (e.g., in refrigerator).
8. Confine radioactive solutions in covered containers plainly identified and labeled with name of compound, radionuclide, date, activity, and radiation level, if applicable.
9. Store radioactive materials in locked cabinets. Sealed sources are stored in drawers. Radioactive liquids (such as prepared kits) are stored in the drawer marked “Prepared kits”. I-131 diagnostic capsules are stored in the drawer marked “I-131 capsule”. The Mo-99/Tc-99m generator is stored in the fume hood; the locking mechanism must be engaged when the lab session is completed.
10. Manipulate liquid radioactive materials behind an L-block shield. Prepare radiopharmaceutical kits and draw doses behind the L-block shield in the fume hood. Use syringe and vial shields for these activities.
11. Store radioactive materials in clearly labeled containers. The label should indicate the name of the radionuclide (sealed sources) or the radiopharmaceutical (unsealed materials).
12. Dispose of radioactive waste only in properly shielded receptacles. Tc-99m and I-131 waste will be stored for decay. All waste in syringes will be stored for decay in locked cupboards or sharps containers, with shielding as needed.
13. Never pipette by mouth.
14. Survey laboratory work area for contamination after each procedure, or at the end of the day. Decontaminate if necessary.
15. Only sealed radioactive materials may be taken out of the hot lab.

I understand the importance of and agree to abide by all of the rules listed above.

___________________________________________

Student Signature DATE

__________________________________

Print Name

Approved By: ___________________________________ Date: _________________________

DECONTAMINATION PROCEDURES

Any contamination incident beyond contamination of gloves and absorbent paper coverings needs to be reported on a Contamination Incident Form.

Note: nothing in this lab is so radioactive as to pose an immediate hazard to human health.

Surface (counter/floor/object) decontamination:

• Alert other persons by posting a note on the outside of the T206 door that there is a spill.
• Don gloves and shoe covers (available at the T208 front desk as well as in T206).
• Prevent the spread of contamination by containment with paper towels or other absorbent material.
• Clean area with commercial decontaminating agent.
• Check hands and clothing regularly for self-contamination.
• Monitor progress with a Geiger counter and wipe tests using alcohol swabs.
• Dispose of all waste materials into a marked garbage container, which will need to be stored for decay.

Decontamination of clothing:

• Use a Geiger counter to identify the limits of the contamination.
• If possible (e.g., lab coat contamination), remove the contaminated clothing item and store (e.g., in T208) for a period of time to allow for decay.
• If a clothing item is contaminated and cannot be immediately removed, rinse the contaminated area with water and check with a Geiger counter to determine residual activity.  Remove the clothing item within 2-3 hours.  Store the item for a period of time to allow for decay.
• After moving or removing the contaminated clothing item, use the Geiger counter to check for skin contamination.
• After the appropriate time period has passed, use a Geiger counter to verify that radioactive contamination has decayed.

Decontamination of skin:

• Use a Geiger counter to identify limits of the contaminated area.
• Clean the area with hand soap or commercial decontaminating agent and plenty of warm water.
• Cleaning should take at minimum 5 minutes and may require up to 90 minutes.
• Use the Geiger counter and alcohol swabs intermittently to check for removable contamination.
• Stop when one of these two conditions is met:
• Geiger counter reading <0.1 mR/hr (5 times background)
• No removable contamination on wipe test

Decontamination of eyes:

• Use the portable eyewash station to rinse affected eye(s).  Continue washing until the eyewash tank is empty and the wash solution stops flowing.
• Check eyes for contamination using a Geiger counter.
• If the Geiger counter reading is more than 0.5 mR/hr (25 times background), go to the NDT lab (T319) and continue to wash with its eyewash station.

ORDER AND DELIVERY OF RADIOACTIVE MATERIALS  PROCEDURES

1. Possession of any radioactive material (RAM) in an amount greater than the exempt quantity is allowed only as stated in the college’s radioactive materials license.  Ordering of RAMs must be done through the college’s Radiation Safety Officer (RSO).
2. When a RAM is ordered and is to be shipped to the college, The RSO will notify Public Safety and Custodial, Grounds, and Facilities departments.
3. If the RAM is an unsealed source, such as a Mo-99/Tc-99m generator, which will be stored in the fume hood, the notification to the Grounds and Facilities departments will alert staff to avoid the area of the fume hood exhaust for the duration of the source’s presence in the fume hood.
4. The delivery driver must check in with Public Safety in Room K100.  Public Safety will escort the delivery person to the Health Sciences, Education and Wellness T208 front desk (HSEWI administrative offices).
5. The RSO, HSEWI Office Manager, HSEWI Safety Officer, nuclear medicine faculty, and nuclear medicine program manager are authorized to receive RAMs.  The RAM package will be placed in Room T206 (the hot lab) and the RSO notified of its arrival.  RAM packages must not be left in an unsecured area.
6. The person ordering the RAM package (usually a nuclear medicine faculty person) will open or supervise students in opening each package containing a RAM, including the performance of surface wipe testing, measurement of external radiation level, and entering the RAM into the college’s inventory.  The RSO may also open RAM packages.
7. There are no standing orders for RAMs in this facility.

INSTRUCTIONS TO RADIATION WORKERS

“Radiation workers” for the purposes of this document refers to students enrolled in the RATEC,

RADON, and NMTEC programs. The following describes how these radiation workers are trained and

informed about radiation safety and protection.

Nuclear Medicine Technology:

1. Students are informed during orientation to the program about general rules for handling RAMs and basic radiation safety principles. They will sign off on these rules.
2. At orientation they are also given body and ring dosimeters and are instructed on their use.  Dosimeters are exchanged monthly, and students are instructed to check their readings on a quarterly basis.
3. Students receive didactic instruction on RAMs, radiation protection principles and applications, and safe handling of unsealed sources in the following courses (all part of the NMTEC curriculum):
4. NMTEC 201, Basic Nuclear Medicine Science (first quarter of the program) – radioactive decay, radiation detection instruments, inverse square law, attenuation/shielding calculations and applications
5. NMTEC 210, Radiopharmacy (second quarter of the program) – syringe and vial shielding, syringe and vial labeling, personal protective equipment
6. NMTEC 240, Radiation Safety (third quarter of the program) – general rules for handling RAMs, posting and survey requirements, transportation requirements, receipt and opening procedures, waste disposal, storage of RAMs, occupational exposure limits, ALARA concepts, effective doses, risk estimates and comparisons, state licenses, and federal regulations
7. NMTEC 241, Radiation Biology (third quarter of the program) – radiation biology, including chemical, molecular, cellular, tissue, and whole-body effects of radiation; also long-term deterministic and stochastic effects of radiation
8. At multiple points in the course of the program, students will be performing laboratory exercises, always with observation by a faculty member.
9. Students spend considerable time in the clinical setting after the first quarter of the program. During this time they are given on-the-job training in the safe handling of RAMs, including package receipt/opening, storage requirements, dose administration recordkeeping, radioactive waste disposal, and surveys and wipe tests for monitoring radiation levels. In the clinical setting, students are able to practice using various techniques to reduce radiation exposure, and their clinical instructors remind them to pay attention to this aspect of nuclear medicine practice.
10. In the last (sixth) quarter of the program, each student will have a weeklong radiopharmacy lab. Again, this lab will be performed under the supervision of a faculty member. One goal of the lab exercise is to ensure that students have a good grasp of these techniques and procedures.
11. In case of an emergency, students (like other personnel) will be directed to the “Emergency Procedures” document posted inside and outside T206 and asked to follow instructions.

INSTRUCTIONS TO ANCILLARY PERSONNEL

1. Area of radioactive materials (RAM) use/storage – T206

2. Potential hazards

   1. Mo-99, Cs-137, Ba-133, Co-57 and Eu-152 are sealed and/or inaccessible.
   2. Tc-99m is in liquid form (less than 50 mL total volume).  It could be spilled if one were to drop the vial to the floor or step on it.  The amount of radioactivity contained in a vial is about the same as what would be used for an imaging study in the nuclear medicine department of a hospital.
   3. I-131 is in the form of a capsule.  Liquid I-131 as sodium iodide is added to a binder, which absorbs the liquid and chemically binds the sodium iodide.  The amount of radioactivity is small (similar to what would be given for a diagnostic medical procedure), but it has a long half-life and hence requires greater attention.  Additionally, if ingested or inhaled, the radioactive I-131 would be taken up in the thyroid gland.  The capsule should not be handled or ingested, and it could be broken open by dropping or stepping on it.

3. Radiation safety procedures

   1. T208 front desk personnel

      1. Deliveries and pickups – the great majority of RAM deliveries will be from Cardinal Health’s Seattle radiopharmacy.  Cardinal’s delivery personnel have been instructed to check in with Public Safety before coming to the T building, so they should be escorted by a Public Safety Officer while on campus.  The following individuals have keycard access to T206 for the delivery or pickup:
         1. The Radiation Safety Officer
         2. Nuclear Medicine Technology faculty
         3. The Nuclear Medicine Technology program manager
         4. The HSEWI Safety Officer
         5. The HSEWI Officer Manager
            1. Packages should be placed/picked up from the area just to the left of the doorway inside T206.
               1. Spills/liquid coming from under doorway of T206 – follow directions on “Emergency Procedures” sheet (posted outside of T206).  There is an “emergency kit” in the top right-hand drawer behind the T208 front desk, consisting of gloves, shoe covers, a sign, and the T206 Emergency Procedures Handbook.  Should this situation occur, Public Safety will cordon off the area and will notify personnel who can check for the presence of radioactivity and clean the spill.  Custodial staff will only be asked to assist when there is no RAM present.

   2. Warehouse/mailroom personnel

      1. Deliveries – we expect delivery of RAM packages via the US Postal Service or commercial carriers to be rare.  In such a circumstance, the package should be delivered to the indicated recipient.  If the name is not a known Bellevue College person, notify the RSO as soon as possible.

   3. Custodial, building and grounds personnel

      1. Notification – custodial, facilities and grounds supervisors will be notified when a radioactive shipment is to be received, and how long it will be on campus.
      2. Room cleaning – provide cleaning service only when requested.  Custodial staff should have an escort (usually the RSO) during room cleaning.  The normal procedure for trash removal will be that the trash can will be placed outside the door for emptying after the contents have been checked to be sure that nothing is radioactive.
      3. Emanations from fume hood stack release – persons attending to the garden or the HVAC system on the roof of the T building will be notified of the potential for an inhalation hazard from the stack during those weeks.  Under most circumstances, no one will be allowed on the T building roof while this potential hazard exists.

   4. Public Safety

      1. Receipt/return of radioactive materials – Public Safety will be notified that a package delivery is planned.  The approximate time of delivery will be included.  The delivery person will call Public Safety on arrival, and will need to be escorted to the T building and up (in the elevator) to T208.  The delivery items are to be placed inside T206.  A similar protocol will be followed when the package is ready for pickup by the delivery person.
      2. Door – the T206 door should be locked at all times.  If the door is found unsecured or the window is broken, follow the directions on “Emergency Procedures” sheet (posted outside of T206).
      3. Fire/smoke/liquid emanating from T206 – follow directions on “Emergency Procedures” sheet (posted inside and outside T206).  The Emergency Operations manager also has a T206 Emergency Procedures Handbook.

4. Pertinent state and federal regulations

   1. The use of radioactive materials under a specific license is governed by Washington Administrative Code Title 246, specifically Chapters 221 (Radiation Protection Standards), 235 (Radioactive Materials – Specific Licenses) and 240 (Radiation Protection – Medical Uses of Radioactive Materials).
   2. State regulations are based on federal regulations promulgated by the Nuclear Regulatory Commission and found in the Code of Federal Regulations Title 10, Parts 20 (Standards for Protection against Radiation) and 35 (Medical Use of Byproduct Material).

5. Response to concerns

   1. If at any time you feel that a condition is or might be unsafe or might result in a violation of state regulations or license conditions, you should report that to the Radiation Safety Officer.

Radiation Safety Officer: Jennifer Prekeges

On campus: x2475 (425-564-2475)

1. If you believe that any state regulations, the conditions of the license, or personnel exposure limits are being violated in any way, you have the right to request an inspection of the facility.  Contact information for the Office of Radiation Protection can be found on the yellow “Notice to Employees” placard posted in the hot lab and is copied here.

Washington State Office of Radiation Protection

Radioactive Materials: (360) 236-3220

X-ray Machines: (800) 229-9729

www.doh.wa.gov/ehp/rp

Last Updated November 21, 2022