External Factors Impacting the
P
Practice
ti off Medical
M di l Physics
Ph i
Lynne Fairobent
Manager of Legislative and Regulatory Affairs
AAMP
ACMP - May 24, 2010
Career Experience

Regulatory

C
Consulting
lti
 Nuclear Regulatory Commission
 Department of Energy
 Science Applications International
Corporation, Inc.
 Lamb Associates, Inc.
 Advanced Technology and


•
Laboratories,
L
b
t i
Inc.
I
 The Environmental Company, Inc.
Association/Non--Profit
Association/Non
 Nuclear Energy Institute
 National Council on Radiation
Protections and Measurements
 American College of Radiology
 AAPM
Member Advisory Board School
of Health Sciences – Purdue
University
Member of the Annual Review
Team for DOE/NNSA on US medical
i t
isotope
production
d ti
capability
bilit
Outline
 The national (and international) focus on
medical errors and quality in health care




Federal legislative initiatives
State regulatory changes / legislation
Private insurance companies
Where do we go from here?
The national/international focus
 Past 2 decades  focus on medical errors
and healthcare quality (adverse incidents,
studies by US and European government
government-supported groups).
 Result:
R
lt iincreased
d concern with
ith verifying
if i the
th
quality of healthcare delivery and healthcare
professionals’ competence.
p
p
The Institute of Medicine
 In 2000, the National
Academy of ScienceSciencesponsored Institute of
Medicine published its
first book in a series on
h lth
healthcare
quality,
lit titled
titl d
“To err is human”.
The Institute of Medicine
 Concluded that 98,000 patients die each
year as a result of medical errors.
 Two key recommendations:
1 Standardize procedures
1.
2. Regularly validate professional competence.
The Institute of Medicine Report
“Recommendation 7.2:
Performance standards and expectations for health
professionals should focus greater attention on
patient safety.
Health professional licensing bodies should:
(1) Implement periodic reexamination and relicensing
off doctors,
d
nurses and
d other
h key
k providers,
id
based
b
d
on both competence and knowledge of safety
procedures, and
(2) Work with certifying and credentialing
organizations to develop more effective methods to
y unsafe providers and take action.”
identify
Technology
= Safety ??
The IAEA
Canada
 Focus on learning
from incidents and
potential incidents –
taxonomy to
categorize incidents
for analysis.
Errors & the AAPM
Media Influence
Increased media focus
While new technology saves
the lives of countless cancer
patients, errors can lead to
unspeakable pain and death.
January 24, 2010
Recent NY Times Articles
 THEY CHECK THE MEDICAL
EQUIPMENT, BUT WHO IS CHECKING UP
ON THEM?
Loose regulation
L
l ti off medical
di l physicists
h i i t has
h
allowed problems to enter a part of the
process meant to make health care safer
safer.
January 27, 2010.
Recent NY Times Articles


RADIATION THERAPY’S HARMFUL SIDE
 While radiation therapy has saved countless
lives, the dark side of the treatments is
hugely underreported.
underreported January 27,
27 2010.
2010
CASE STUDIES: WHEN MEDICAL RADIATION
GOES AWRY
 Patients often know little about the harm that
can result when safety rules are violated and
ever more powerful and technologically
complex machines go awry. January 27, 2010.
Recent NY Times Articles


AS TECHNOLOGY SURGES, RADIATION
SAFEGUARDS LAG
 While new treatments are more accurate, errors
in software and operation are more difficult to
detect. January 27, 2010.
MEDICAL GROUP URGES NEW RULES ON
RADIATION
 The American Society for Radiation Oncology
issued a six-point plan that it said would improve
safety and quality and reduce the chances of
errors in medical radiation. February 5, 2010.
Recent NY Times Articles


FDA TO INCREASE OVERSIGHT OF MEDICAL
RADIATION
 The agency said it would move to more
stringently regulate the most potent sources,
including CT scans. February 10, 2010.
RADIATION ERRORS REPORTED IN MISSOURI
 CoxHealth in Springfield, Mo., said 76 patients
over five y
years were overdosed because
powerful new equipment had been set up
incorrectly. February 25, 2010.
Increased media focus
St L
Louis
i T
Today:
d
Rural Missouri
Recent NY Times Articles


RADIATION BILLS RAISE QUESTION OF
SUPERVISION
 Officials are investigating billing practices at a
Florida cancer center, a case that p
points up
p
oversight concerns. February 26, 2010.
AT HEARING ON RADIATION
RADIATION, CALLS FOR
BETTER OVERSIGHT
 A dozen witnesses told a House
subcommittee that more needed to be done to
assure that radiation continues to help, not
harm, patients. February 27, 2010.
Congressional Focus
Last summer
Last fall
Congressional focus
AAPM Testifies Before Congress

As many of you know, there have been a
number of recent articles in the press
related to tragic errors in radiation
therapy. This combined with the recent
publicity on CT perfusion dose problems
has prompted Congress to call a hearing
entitled "Medical Radiation: an Overview
of the Issues". AAPM, along with ASTRO,
ACR, ASRT and MITA have been asked to
testify to help guide direction for
improving patient safety in the medical
use of radiation.
radiation We sincerely believe
that working together with all
stakeholders that we can improve safety
and quality in the medical use of
radiation.
Mike Herman, AAPM President
Congressional Hearing Transcript

http://energycommerce.house.gov/index.php?option=com
_content&view=article&id=1910:medical--radiation
_content&view=article&id=1910:medical
radiation--an
an-overview--of
overview
of--the
the--issues&catid=132:subcommittee
issues&catid=132:subcommittee--on
on-health&Itemid=72
AAPM Statement

In summary, the AAPM believes that patient safety in the
use of medical radiation will be increased through:
consistent education and certification of medical team
members, whose qualifications are recognized nationally,
and who follow consensus practice guidelines that meet
established
t bli h d national
ti
l accrediting
diti standards.
t d d We
W mustt also
l
learn from our mistakes by collecting and evaluating them
at the national level. AAPM has been working directly and
in cooperation with other stakeholders for years on some
of these issues and we are saddened that some people
are injured during what should be beneficial procedures.
We believe that more effort on all seven areas of focus
focus, by
all of us, working cooperatively, will continue to make the
use of medical radiation safer and more effective for the
people
p
p that need it.
Legislation
Why Should You Care?
 Regulations and/or Legislation can
greatly impact your dayday-to
to--day practice



Dictate what you must do.
Dictate what you can bill and how much.
much
Frustrate you when professional judgment
and regulation conflict!!
Legislative Interactions
 Federal/State


Interacting with Congress or State Legislature
N d to
Need
t monitor
it legislation
l i l ti
 First introduced
 When in committee
 On the Floor
 Write letters urging support of draft
legislation
 Know your representatives – both home and
business addresses
Who Can Draft a Bill?
 Anyone can draft a piece of legislation





Members of Congress
I di id l
Individuals
Special Interest Groups
Organizations
Associations
Who Can Introduce a Bill?
 Only members of Congress can
introduce legislation
 The member that introduces the bill is
known as the sponsor and all members
that signsign-on to the bill are called cocosponsors
The CARE Legislation
Who is the Alliance for Quality
Medical Imaging and Radiation
Therapy referred to as
Therapy,
“The Alliance”?
ASRT & the Alliance
 In July 1998, the ASRT and the SNM
Technologists
g
Section (SNMTs)
(
) recognized
g
the importance of collaborating with other
organizations and they founded the Alliance
f Q
for
Quality
lit medical
di l Imaging
I
i and
d Radiation
R di ti
Therapy
Members of the Alliance











American Association of Medical
Assistants
American Association of Medical
Dosimetrists
American Association of Physicists in
Medicine
American College of Medical Physics
American Registry of Radiologic
Technologists
American Society of Radiologic
Technologists
Association of Educators in Imaging and
Radiologic Sciences
Association of Vascular and Interventional
Radiographers
Cardiovascular Credentialing International
Joint Review Committee on Education in
Cardiovascular Technology
Joint Review Committee on Education in
Diagnostic Medical Sonography









Joint Review Committee on Education
in Radiologic Technology
Joint Review Committee on Education
Programs in Nuclear Medicine
Technology
Nuclear Medicine Technology
Certification Board
Section for Magnetic Resonance
T h l i t off International
Technologists
I t
ti
l Society
S i t
of Magnetic Resonance in Medicine
Society of Nuclear Medicine
Medicine-Technologist Section
Society for Radiation Oncology
Administrators
Society for Vascular Ultrasound
Society of Diagnostic Medical
Sonography
Society of Invasive Cardiovascular
Professionals
Members of the Alliance





Consulting Organizations:
American College of Radiology
American Healthcare Radiology
Administrators
American Society for
Therapeutic Radiation and
Oncology
Conference of Radiation
Control Program Directors
 Other Supporters
 American Cancer Society
 American Heart Association Council








on Cardiovascular Radiology
American Organization of Nurse
Executives
American Osteopathic College of
Radiology
Cancer Research Foundation of
America
Help Disabled War Veterans/Help
Hospitalized Veterans
International Society of
Radiographers and Radiological
Technologists
National Coalition of Cancer
Survivorship
Medical Imaging Consultants, Inc.
Philips Medical Systems, Inc.
CARE Bill

CARE stands for:
 Consistency, Accuracy, Responsibility,
and Excellence in Medical Imaging and
Radiation Therapy Act of 2010
Brief Legislative History


In 2000,
2000 a CARE bill was first introduced late in the
(R-NY).
106th Congressional year by Rep. Rick Lazio (RThe bill died when Congress adjourned.
A “new” CARE bill was introduced in the House on
March 13
13, 2001 by Rep
Rep. Heather Wilson (R
(R--NM) 107th
Congressional year.
year. The bill died when Congress
adjourned.
Brief Legislative History –
Th 108th Congress
The
C
 Jump
J
ahead
h d to
t 2004 – 108th Congress
C

House bill had 112 cosponsors
 73 Democrats
 39 Republicans

New Senate bill had 18 co-sponsors
 15 Democrats
 2 Republicans
 1 Independent
 Bill di
died
d when
h Congress
C
adjourned!
dj
d!
Brief Legislative History –
The
h 109th Congress
C
 Bills in both Houses of Congress –
however language is not identical
 Passed unanimously in Senate however,
however
no time left in Session to pass the House.
 Bill died!!!!!!
Brief Legislative History –
The
h 110th Congress
C


Hit a jjurisdiction issue between Senate Health,,
Education, Labor and Pension (HELP) and
Finance committees
Interference from imaging provisions of State
Children
Children's
s Health Insurance Program (SCHIP)
(
and Medicare Improvements for Patients and
Providers Act ((MIPPA)
Brief Legislative History –
The
h 110th Congress
C



House introduced H.R. 583 – Rep. Doyle [PA[PA-14]

150 co-sponsors (including sponsor)*
 97 Democrats
 53 Republicans
Senate introduced S. 1042 – Sen. Enzi [WY]

26 co-sponsors (including sponsor)*
 8 Democrats
 17 Republicans
 2 Independents
Both Bills were identical!
(*A off O
(*As
October
t b 24
24, 2008)
Challenges to CARE in 110th Congress


For the first time challenges were raised by the
 Equipment
E i
t manufacturers
f t
 OB/GYN and ophthalmology organizations
since ultrasound was included in the draft
legislation for the first time
 Crisis pregnancy centers – again due to the
inclusion of ultrasound; nurses use
ultrasound in the crisis pregnancy centers to
verify or check pregnancy status
 Infusion
I f i nurses
Sonography concerns, coupled with presidential
election year politics brought the CARE bill’s
bill s
process to a standstill. It DIED!!!!
Current Status –
Th 111th Congress
The
C
 Introduced by Rep. John Barrow, [GA[GA-12]





on September 25, 2009
R f
Referred
d to
t the
th House
H
Ways
W
& Means
M
and
d
Energy & Commerce committees.
Minor adjustments to tie enforcement
more closely to Medicare.
Currently
y has 89 Cosponsors
p
No Senate bill
http://www.thomas.gov/cgi--bin/query/z?c111:H.R.3652:
http://www.thomas.gov/cgi
A Bill
To amend the Public Health Service Act to
make the p
provision of technical services for
medical imaging examinations and radiation
therapy treatments safer, more accurate,
and less costly.
costly
CARE Act
 Excludes physicians, physician assistants



and nurse practioners
Does not mandate licensure but does not
preclude licensure
p
Currently excludes Advanced Imaging
Modalities covered by MIPPA – PET, CT,
MR N
MR,
Nuclear
l
M
Medicine
di i
Requires Secretary of HHS to work with
expert advisers to develop standards (e
(e.g.,
g
regulations)
The CARE Bill will:
 Set uniform standards for personnel
performing
f
i medical
di l imaging
i
i and
d radiation
di ti
therapy services paid for by all health
programs under the jurisdiction of HHS.
 Direct the Secretaryy to update
p
federal
certification standards for persons
performing medical imaging, planning and
delivering radiation therapy treatments.
treatments
The CARE Bill will:
 Recognize state licensure standards that
meet or exceed the federal standard.
standard
 Require
q
HHS to examine each state’s
existing licensure program to ensure it
meets the federal standard.
 Direct HHS to ensure that no later than 3
years after the date of enactment of the
l i l ti
legislation,
all
ll programs under
d HHS
jurisdiction adhere to the standards
including payment for medical imaging or
radiation
di ti therapy
th
procedures.
d
CARE bill
Senate Status
 Senators Enzi,, [WY]
[
] and Harkin [IA]
[ ]

poised to introduce bill once more cocosponsors are identified
Language is slightly different that H.R.
3652



Removes exclusion
R
l i for
f MIPPA
Tightens dates for enactment
Discussions with Rep. Barrows, sponsor of
H.R. 3652 indicate he is willing to accept the
changes when it comes to the floor of the
House for a vote.
MIPPA
MIPPA
 Medicare Improvements for Patients and
Providers Act of 2008 (Section 1834 of the
Social Security Act, (e) (2) (A) Factors for
Designation of Accreditation Organizations)


signed into law in July 2008
Requires practice accreditation for the
advanced imaging
imaging” modalities which includes
“advanced
CT, MR, and Nuclear Medicine.
 Does not include x-ray, fluoroscopy, sonography,
or anything in radiation oncology.
oncology
MIPPA [[2]]
 MIPPA facts:


Only
y addressed the big
g ticket imaging
g g items
They only impact 17% of Medicare diagnostic
imaging expenditures
 Only accredits the facility
facility, not the personnel
performing the imaging
 The accrediting body can place requirements on
th operators
the
t
off imaging
i
i equipment
i
t but
b t these
th
requirements can be very minimal such as
p
g a manufactures operators
p
course
completing
 Requires Centers for Medicare and Medicaid
Services (CMS) to recognize accrediting bodies
Accrediting Bodies Recognized By
CMS U
Under
d MIPPA
 American College of Radiology
 Intersocietal Accreditation Commission


on Accreditation
The Joint Commission
The Problem/Concern

All have different requirements for personnel,
AAPM iis on record
d iindicating
di ti concern with
ith
not requiring board certification for medical
physicists
A
American
i
Medical
M di l Isotopes
I t
Production Act of 2010
American Medical Isotopes
P d
Production
i Act
A off 2010
•Rep. Edward Markey, [MA-7]
•Passed House
•Pending
Pending in the Senate
To promote the production of
molybdenum-99 in the United
States for medical isotope
production,, and to condition and
p
phase out the export of highly
enriched uranium
for the production of medical
isotopes.
Increased regulation likely:
Learning from errors:
 Most are process
failures resulting
from inadequate
SOPs, staffing,
resources:
Advocacy
How to g
get involved.
Grassroots
 Grassroots advocacy means promoting


the profession’s interests and issues by
communicating with elected officials or
regulators in an effective and efficient
manner.
Grassroots involvement rarely
y takes up
p
much of your time yet a few moments
spent could have a huge impact.
If you have a phone or if you’ve ever sent
an email, you can be an active part of the
process.
When You
You’re
re at Home




Become active in state and local
affiliate societies.
Vote in state and local elections.
Keep up to date on state and local
news and
d currentt political
liti l trends
t
d in
i
your community.
Serve as a resource for your state
and local lawmakers on health care
issues.
issues
When You
You’re
re Not on the Hill

Some of the most effective
lobbyists never step foot in the
Capitol.





Volunteer for campaigns.
Make yourself a resource.
resource
Be a “polite pest.”
Show
S
o and
a d tell.
te
Don’t be a “one issue advocate.”
Up On The Hill

Now that I’m here, how do I make
tthem
e listen?
ste
 Understand your issue – the pros and





the cons.
Play the numbers game.
Make it personal.
M k “Th
Make
“The Ask.”
A k”
FOLLOW UP!
Be honest
honest, gracious and courteous
courteous.
R
Regulatory
l t
Process
P
Regulatory Interactions
 Key Agencies


Nuclear Regulatory Commission (NRC)
Food and Drug Administration (FDA)

Health and Human Services



Centers for Medicare and Medicaid Services (CMS)
Department of Homeland Security (DHS)
Department of Transportation (DOT)
 Center for Radiological Devices and Health
 Center for Drugs
 National Institutes of Health
 National Cancer Institute
 National Institute for Biomedical Imaging and
Bioengineering
The Nuclear Regulatory Commission
(NRC)




Created by the Energy Reorganization Act of 1974,
recent amendment Energy Policy Act of 2005
Exercises authority through licensing
licensing, regulations,
regulations
and enforcement
Scope
p of authority
y includes commercial nuclear
power plants;
l
medical,
di l academic,
d i and
d industrial
i d
i l use;
transport, storage, and disposal of radioactive
material
May relinquish authority over radioactive materials
to Agreement states
NRC Commissioners



Chairman Gregory
g y Jazcko
 Sworn In: 1/21/05
Term
Ends: 6/30/13
Kristine L. Svinicki
 Sworn In: 3/28/08
Term
Ends: 6/30/12
George Apostolakis
 Sworn In: 4/23/10
Term
Ends: 6/30/14
NRC Commissioners Continued


William Magwood
g
 Sworn In: 4/01/10 Term
Ends: 6/30/15
William C. Ostendorff
 Sworn In: 4/01/10 Term
Ends: 6/30/11
NRC Web Addresses




NRC Medical Uses Toolkit:

http://www.nrc.gov/materials/miau/med-use-toolkit.html
NRC Part 35 Regulation:

http://www.nrc.gov/reading-rm/doc-collections/cfr/part035/
NUREG 1556, Volume 9, Revision 1;

http://www.nrc.gov/reading-rm/doccollections/nuregs/staff/sr1556/v9/#abstract
Specialty Board(s) Certification Recognized by NRC
Under 10 CFR Part 35

http://www.nrc.gov/materials/miau/miau-reg-initiatives/spec-boardhttp://www
nrc gov/materials/miau/miau reg initiatives/spec board
cert.html
Purpose
p
of the ACMUI



Advises NRC on policy and technical issues
that arise in the regulation
g
of the medical uses
off radioactive
di
ti material
t i l in
i diagnosis
di
i and
d therapy.
th
Evaluates certain nonnon-routine uses of
radioactive
di
i material;
i l provides
id technical
h i l
assistance in licensing, inspection, and
enforcement cases; and brings key issues to
the attention of the Commission for appropriate
action..
action
Membership includes health care professionals
from various disciplines who comment on
changes to NRC regulations and guidance.
CRCPD



Mission is to “promote consistency” in addressing
and resolving
g radiation protection
p
issues. Began
g
with the agreement state initiatives in 1959.
1968 - CRCPD established as a nonprofit
nonprofit, non
non-governmental organizations dedicated to radiation
protection. Established a forum for states to discuss
and
d talk
t lk about
b t state
t t initiatives
i iti ti
and
d to
t share
h
resources.
Is the only association that addresses all radiation
protection issues. Responsible for developing
suggested state regulations.
How Regulations Are Introduced
 Agency initiated



Advanced Notice of Proposed Rulemaking
P
Proposed
d Rule
R l
Final Rule


Initiated by member of public
Must include all elements of rulemaking
package
k
equall to
t th
those initiated
i iti t d by
b an agency
 Petition for Rulemaking
Developing Regulations
Rule Language
Implementation and
Interpretation
R
Recent
t USA
Today Article
March 17, 2010.
NRC’s
NRC
s Patient Release Rule
 Questions 10 CFR § 35.75
 In 2005 Peter Crane filed a Petition for


Rulemaking questioning the regulation
Most in the medical community
requested NRC deny the Petition
NRC denied the Petition but this did not
end Mr. Cane’s concerns
Rep. Markey – Patient Release
State regulations
 Professional Licensure or registry.
 More states are implementing strong
definitions of a QMP, with Board
certification the only
yp
pathway.
y
 CRCPD SSRs incorporate QMP definition
Licensure & the AAPM/ACMP
 Joint subcommittee formed to promote
minimum practice standards through
licensure or registration regulations.
 The AAPM Board has approved significant
funding to support this effort (new staff
member, IT support, lobbying).
State regulations
Licensure
 NY, FL, TX, HI.
 NY law:
NY Licensure
 18
18--month phase
phase--in period, then Board
certification required.
Registration
 20 states, with more drafting new regs.
 Manyy follow ACMP/AAPM QMP definition.
 Wide variation in professional standards
and enforcement
MA Registry
CT: Proposed Registry
Accreditation: State laws
Accreditation - Private insurers:
BCBS MA
The ABR
ABR, through MOC:
 TG
TG--127 is working
g with the ABR to
implement a peer review
review--based system to
satisfy the PQI requirement.
Task Group 11 – standards for solo
practice physicists in RadOnc

In 2003,
recommended
d d
peer review,
p
practice
accreditation,
and standardized
procedures.
procedures
Task Group
p 103 – p
peer review

In 2005,
recommended
d da
specific process
for p
peer review,
provided tools
for reviewers to
ensure efficient
use of time &
consistent
reviews.
i
TG 103 recommendations
 Regular review by an outside QMP
 Review includes onon-site visit and written
report
 Major components:





Independent output verification
Chart audit using a template
QA/QC program and documentation (standard
procedures for calibrations
calibrations, dose calcs)
Is physics coverage sufficient for services
provided?
Continued professional development & new
technologies
TG 103 documents
Path forward?
 Minimum standards for practicing clinical
medical physics will likely have the force of
regulation in most states within a decade.
 Major components:




Minimum education & training requirements
Board certification
Peer review at regular intervals
Continuing professional development (MOC)
 Error prevention programs will gain more
prominence.
How do we respond?
 If we (AAPM/ACMP) do not define our
profession, others will do it for us.
 Current efforts:

Licensure / registration with strong template

ASTRO/ACR/IAC/TJC – strong accreditation

Develop Minimum Practice Standards

Work with CRCPD (SSRs) & FDA (devices)

Congress:

CARE bill for Training & Education standards

Tie Medicare funding to accreditation
Part 37




Intent to move orders into regulation
Proposed rule to be issued midmid-June 2010
120--day Comment Period
120
Need input from members currently under
orders – HDR and Gamma Knife licenses
 Review against current order
Table 1 – Radionuclides of Concern
Cat 2 (TBq) 1
06
0.6
Cat 2 (Ci) 2
16
Am -241/BE
0.6
16
Cf-252
0.2
5.4
Co-60
0.3
8.1
C 244
Cm-244
05
0.5
14
Cs-137
1
27
Gd-153
10
270
Ir-192
0.8
22
P 238
Pu-238
06
0.6
16
Pu-239/BE
0.6
16
Pm-147
400
11,000
Ra-226
0.4
11
Se-75
2
54
Sr-90 (Y-90)
10
270
Tm-170
200
5,400
Yb-169
3
81
Radionuclide
Am 241
Am-241
Combinations of
radioactive
materials listed
above3
See footnote 4
1. The aggregate
gg g
activity
y of multiple,
p ,
collocated sources of the same
radionuclide should be included when
the total activity equals or exceeds the
quantity of concern.
2 The primary values used for compliance
2.
with this Order are TBq. The curie (Ci)
values are rounded to two significant
figures for informational purposes only.
3. Radioactive materials are to be
considered aggregated or collocated if
breaching a common physical security
barrier (e.g., a locked door at the
entrance to a storage room) would allow
access to the radioactive material or
devices containing the radioactive
material.
4. f several radionuclides are aggregated,
the sum of the ratios of the activity of
each
h source, i off radionuclide,
di
lid n, A(i,n),
A(i )
to the quantity of concern for
radionuclide n, Q(n), listed for that
radionuclide equals or exceeds one.
[(aggregated
[(
gg g
source activity
y for
radionuclide A) ÷ (quantity of concern for
radionuclide A)] + [(aggregated source
activity for radionuclide B) ÷ (quantity of
concern for radionuclide B)] + etc..... ≥1.
Good Practice? Or how to get to know your
local FBI or Homeland Security Agent!!!!!
We have a Cs
Cs--137 brachytherapy sealed
source '3M' type sources that we no
longer use and would like to find a new
h
home
for
f them.
th
Th
There
are 22 sources in
i
the current inventory ranging in activity
from 9.1 to 33.7 mgmg-RaRa-eq. There is a
storage safe, 'L'L-Block', wheeled transport
pig and sturdy wheeled steel work table in
the package.
If you are interested please contact me at .
. . . !!!!!
*From the medical physics list serve – 9/13/07
Good Practice? Or how to get to know your
l
local
l FBI or H
Homeland
l dS
Security
it A
Agent!!!!!
t!!!!!
 We have Cesium 137 for LDR
Brachytherapy procedures that we
no longer do. If anyone is
interested in the Cesium please
respond to this post.
you are interested p
please contact
If y
me at . . . . !!!!!
*From the medical physics list serve –
9/25/07
 Questions????????