Answer to Question #1753 Submitted to "Ask the Experts"

A "code situation" commonly refers to a medical event in a hospital requiring immediate medical intervention in an attempt to save a patient's life, such as CPR (cardiopulmonary resuscitation). When a code is called, the institution's code team is activated, resulting in the rapid response of up to as many as a dozen medical professionals. At our institution, the policy includes the following guidance for the first responder: "Necessary measures shall be taken to maintain life or prevent injury until help arrives (consistent with medical training and the safety needs of care providers)."

The safety needs of care providers takes on additional significance when the patient happens to be undergoing an inpatient ¹³¹I therapy, which is what I assume you are referring to in your question. Fortunately, it is very rare for a code to be called for an ¹³¹I patient, as stated in National Council on Radiation Protection and Measurements Report No. 37 (NCRP 1970), " . . . since, in principle, radionuclide therapy is not given to moribund patients." Unfortunately, the discussion of emergency events in the report is limited to patients requiring emergency surgery or who, having died, now require autopsy, cremation, or burial.

Another NCRP publication, Report No. 105 (NCRP 1989), gives a little more guidance regarding the code situation itself when it says: "Nurses may need to respond to emergencies relating to patients who have received therapeutic amounts of radioactive material. Lifesaving procedures should always begin as soon as possible without concern for exposure to radiation." Report No.105 goes on to say, "It is highly unlikely that a patient would contain a source of sufficient strength to be a significant health hazard to staff offering close emergency care."

Similar guidance is provided in Model Appendix H: Model Training Program, "Training for Individuals Involved in the Usage of Byproduct Material" of the draft Nuclear Regulatory Commission guidance document (USNRC 1998), NUREG-1556 Volume 9. It states that training programs should provide "instruction in procedures for notification of the RSO (radiation safety officer) and AU (authorized user), when responding to patient emergencies or death, to ensure that radiation protection issues are identified and addressed in a timely manner. The intent of these procedures should in no way interfere with or be in lieu of appropriate patient care. (10 CFR 19.12)." Several additional sections from this draft NUREG that deal with patient emergencies include 8.26 Item 10: "Operating and Emergency Procedures," 8.14 Item 8: "Training for Individuals Working in or Frequenting Restricted Areas," and Appendix N: "Emergency Procedures Emergency Surgery of Patients Who Have Received Therapeutic Amounts of Radionuclides" and "Autopsy of Patients Who Have Received Therapeutic Amounts of Radionuclides." However, none of them address the specific details of responding to a code.

There are a few recent articles (Thompson 2001), that may also be consulted and that provide contrasting viewpoints. I think that because of the rarity of these events, there is very little published that directly addresses your question. In 11 years as an RSO at a major metropolitan hospital I have never had to respond to a code of one of our therapy patients. I know of only one event at a nearby university hospital in this same time span.

I can offer the following advice, however. As pointed out in all of the above references, the RSO and authorized user (prescribing physician) must be informed immediately of any medical emergency involving a radioiodine patient. It is unlikely, however, that either of these individuals will arrive at the patient's bedside while the code is in progress, let alone ahead of the code team. Therefore, it is essential that nursing personnel have been trained in advance to provide an appropriate response to a code. I emphasize to our nursing staff that a code of a radioiodine patient needs to be dealt with the same way as for any other patient. The first priority is to provide any necessary lifesaving procedures. Our policy states that "the primary nurse shall remain at the scene summarizing the patient's history and events leading to the arrest . . ." It is the nursing staff that will need to provide guidance to the responding code team members concerning radiation risks and potential contamination issues. Prominent CAUTION: RADIATION AREA postings on the patient's door should serve to alert the code team that this is not a typical patient.

I also tell our nurses, in the event of a code, they should limit the number of staff and residents who get exposed by having any "observers" excused from the area. From a personnel exposure tracking and contamination control standpoint, it would be preferable to identify all code team members responding to the event prior to them leaving the room, as well as checking them for contamination. In the event that the patient must be removed to another location for stabilization or surgery, this may prove to be impractical. In reality, if code team members observe standard infection-control procedures there is little likelihood of significant contamination or radiation exposure to personnel over the relatively short time needed to stabilize the patient. Follow-up by the RSO would be necessary to determine the extent of any contamination beyond the confines of the patient's room.

One final suggestion would be to check with your institution's Emergency Department to review the sections of its emergency plan that deal with radioactively contaminated patients.

Bruce E. Hasselquist, PhD
Department of Radiology University of Minnesota

References
 

• National Council on Radiation Protection and Measurements. Precautions in the management of patients who have received therapeutic amounts of radionuclides. NCRP Report No. 37; 1970.
   
• National Council on Radiation Protection and Measurements. Radiation protection for medical and allied health personnel. NCRP Report No. 105; 1989.
   
• U.S. Nuclear Regulator Commission, NUREG-1556, Volume 9. Consolidated guidance about materials licenses: Program-specific guidance about medical use licenses (Draft Report for Comment); August 1998.
   
• Thompson MA. Radiation safety precautions in the management of the hospitalized ¹³¹I therapy patient, Journal of Nuclear Medicine Technology; 29(2):61-6; June 2001.
   
• Achey B, Miller KL, Erdman M, King S. Some experiences with treating thyroid cancer patients. Operational Radiation Safety, Supplement to Health Physics 80(5); 2001.