Radiation Detector at Landfill Makes Hospital Alter Practices

It all began on a sunny afternoon last September, as a garbage truck drove into the city’s Miramar landfill.

Before dumping that load Sept. 20, the Laidlaw Waste Systems driver had to take the truck past a radiation monitor, the radiological equivalent of an airport metal detector. Drivers do it dozens of times every day without incident.

But this time the detector began beeping and a warning light flashed. Something in this load was radioactive.

The same thing happened with another garbage truck at the landfill on Dec. 6.

The discoveries set in motion a chain of events that culminated March 2 in a state order that Sharp Memorial Hospital stop performing radioactive implants because of two incidents in which radioactive iridium-192 was thrown out with normal trash.

The hospital has since revamped its radiation-safety procedures with the help of a consultant, hired new staff and applied for a revised license. The inspector who cited the hospital says he is confident Sharp is cleaning up its act.

But what happened at Sharp could happen at any institution where personnel turnover and a heavy workload combine to make “doing it by the book” impossible, said the inspector, Frank O. Bold.

“The license is issued for a period of seven years. Over the years, if the new personnel don’t sit down and immediately read the entire license, then they really don’t know what needs to be done,” said Bold, a health physicist who spent 26 years in charge of radiation safety at General Atomics.

“It’s the responsibility of the radiation-safety committee to make sure that everything is going as it should. But like everything else, when you have busy people, those things fall through the cracks,” he said.

Over the last few years, Sharp has been a model in the San Diego medical community of a nationwide trend toward a bottom-line approach to hospital staffing.

Since patient-care positions cannot be trimmed much, this has meant eliminating many middle managers and consolidating multiple responsibilities under the few managers left.

“Hospitals are looking to reduce the layers of management, to cut through the bureaucracy. It’s a real trend in the industry,” said Jan Frates, a hospital consultant in San Diego. “So they’re often eliminating multiple checks and balances. Fewer people have to do the same amount of work.”

But the rules for assuring radiation safety are complicated and require close attention. With the Sharp staff new or very busy, it was easy for basic radiation-safety precautions to be ignored, Bold said.

Sharp itself said in a written response to Bold that “a turnover of personnel and associated lack of continuity” were among the more important contributors to the problems he uncovered.

State law calls for inspections every three years, with a grace period of up to 1 1/2 years beyond that.

The grace period on Sharp’s license, issued in April, 1985, was about to expire when the first iridium incident occurred, Bold said. An inspection backlog was created, he said, when the county took over enforcement of radiation-safety laws from the state in 1986.

He said he hopes to reach a three-year cycle on hospital inspections within the next year.

Dr. Ronald S. Scott, the doctor whose work with radioactive iridium-192 at Sharp was halted by the state action against the hospital, thinks it is the regulators who are at fault for lax radiation-safety procedures.

“If I were to apply for a license to set up a little operating room in my office (to do radioactive implants), the state would spend from now to the year 2000 getting around to approving every little tiny detail,” Scott said.

“But with an outfit like Sharp, it’s a big hospital, it’s got credentials--so the state says OK, you can do implants without checking very carefully that (it has) a really ironclad safety system in place,” he said.

But in state documents, Scott receives some of the blame for the Sharp radioactivity incidents.

In the first incident, five tiny “seeds” of iridium-192, shrink-wrapped together in a plastic strip, were in the trash truck. After checking the manifest, Bold concluded that the iridium came from Scott’s office. Scott says it was accidentally discarded during office remodeling.

And, although Scott contends the seeds had very little radioactivity in them, a report from the supplier indicates they contained eight times as much radioactivity as Scott said in a report he gave to Sharp.

The first investigation was fairly straightforward and took about a week. But tracing the second strip of seeds, 10 of them this time, took two months. The strip apparently had been included in linen sent from the hospital to California Linen Supply, and discarded when it was found there.

In both cases, the amount of radioactivity was so small that there was no danger to public health, authorities say.

The citations against the hospital noted problems with handling of radioactive materials both by Scott and the hospital:

* Deliveries were made to the main hospital receiving dock, rather than to the nuclear medicine department.

* Scott was allowed to order radioactive materials on the hospital’s license.

* Scott and the hospital failed to maintain accurate and complete written records on the materials. (For instance, on Sept. 21 Sharp returned 665 millicuries of iridium to the supplier--but was licensed to have only 500.)

* The individual designated in the license as custodian of the iridium-192 no longer worked at Sharp.

* Records of deliveries and returns of iridium-192 and other “sealed sources” of radiation were not kept.

* Iridium-192 seeds removed from a cancer patient last Nov. 20 were not counted. (Scott contends he did count them, but says he missed the fact that he was 10 short.)

* Linens from the room used in that procedure were not monitored for radioactivity before being sent for laundering.

An inspection also found a series of other problems, from lack of training of employees in radiation safety to the use of inappropriate instruments for radiation monitoring. Radioactive materials were being sent to another hospital without license authority, it was found.

Explanations from Scott and the hospital, sent to Bold, detail a series of wrong assumptions by both parties.

Scott said he assumed he bought a radioactive-materials license along with the medical practice he acquired in February, 1989.

When Scott ordered iridium seeds sent to Sharp under the hospital’s license, “there was confusion at the hospital receiving point,” he said. Scott said that at the urging of Robert Cook, radiology administrator at the time, he arranged to have the iridium sent to his office instead.

When the shipments to the hospital stopped, “the Radiology Department assumed Dr. Scott had received his own license and was ordering from it,” the hospital’s Oct. 17 response to Bold says.

Bold said inspections at other hospitals have not revealed problems as serious as those found at Sharp.

In four years in charge of radiological inspections for the county, Bold said, he has been called to a landfill half a dozen times because of radioactive trash. Before the Sharp incidents, none involved institutional problems.

Once, the trash contained a diaper from a child who had undergone a radioactive diagnostic test, he said. Another time someone who had undergone such a test discarded tissue used to wipe up after being sick.

If there was anyone pleased by the iridium incidents it was Robert Epler, deputy waste management director for the city of San Diego.

Epler takes pride in the fact that radiation monitors at the only city-run landfill--and the only landfill equipped with monitors--could detect a minuscule bit of iridium-192 inside a 37-cubic-yard capacity truck.

The five small seeds of iridium found there in September, and the 10 found in December, are described by Scott as 6 millimeters long and a half-millimeter in diameter, smaller than a grain of rice.

Radiation monitors were placed at entry points to the Miramar landfill several years ago to prevent dumping of radioactive waste, he said. At the same time, landfill employees learned to call the county’s hazardous waste response team when a monitor beeps.

Those iridium seeds “weren’t found by happenstance. I felt so proud,” Epler said.

If the seeds had been in trash sent to any of San Diego County’s five other landfills, however, they would have stayed there. None have radiation monitors, said Jeff Bosvay, a sanitarian with the county Department of Public Works.