Department
of Radiation Oncology
KENNETH NORRIS JR. CANCER CENTER
1441 Eastlake Ave., Los Angeles, CA, 90033 (323) 865‑3050
INSTRUCTIONS FOR PATIENT AND FAMILY WHEN PATIENT IS
RELEASED FROM HOSPITAL
WITH AN OPHTHALMIC PLAQUE CONTAINING RADIOACTIVE I‑125
SEEDS
Patient
Copy
_________________________________________________
was treated on ______________
name of patient
date
with ______
millicuries of I‑125 in the form of
_____ seeds in a gold ophthalmic plaque. Maximum exposure rate at 1
meter was measured to be ____ mR/hr (must
be < 2 mR/hr) with the lead eye patch in place. The plaque is scheduled to
be removed at _________ on _________________
.
time
date
Please show this form to every physician consulted concerning the patient until the plaque is removed. Until the plaque is removed, persons under 45 years of age should not remain closer than 2 meters (≈6 feet) from the patient for ____ hours per day. No further radiation safety precautions will be necessary after you return to the hospital and have the plaque removed.
The State of California has issued strict guidelines governing the release from the hospital of patients that have radioactive sources in their body. For I‑125 eye plaque patients, such as yourself, the guidelines are easily met if you rigorously comply with the few rules given in the following:
SPECIAL PRECAUTIONS while the plaque is in place:
1.
To
keep hospital costs to a minimum, I‑1 25 eye plaque patients for whom
there is no medical reason for hospitalization, are allowed to convalesce
at home during the nominal one week treatment time. In accepting the hospital
discharge, you, the patient agree to abide by all the following safety
guidelines. If you are unable to comply with the following rules, please advise
the ophthalmology and radiation oncology physicians in charge of your care so
that arrangements can be made.
2.
The
radiation dose to other people from the isotopes contained in your eye depends
on three factors: time, shielding and distance. By sitting across the room from
people and wearing your lead lined eye patch, you can reduce the radiation
levels to other persons to levels that are well within regulations. Please wear
the eye patch at all times when others are around, and maintain a distance of
six feet or greater from them.
3.
To
minimize the concerns of non‑family members and the possible exposure of
children and pregnant women to radiation, we have the following rules:
a)
No
children under 18 or pregnant women may visit while you have the plaque in
place.
b)
You
must restrict your activities to your home and backyard. You may not go out in
public, go to work, go to church or to a friend's house.
4.
Use
of the lead lined eye shield and the six foot rule reduces the radiation levels
so that it is safe for your own childrenand family. Remembering that distances
of separation greater than six feet offer increased levels of protection, you
may wish to modify your life style to achieve this during the week.
5.
It
is preferred that you sleep in a bed by yourself while you have the plaque.
6.
Spouse
or other person caring for
patient:________________________________________________
7. Other:
___________________________________________________________________________
IF THE PATIENT MUST BE HOSPITALIZED,
OR IF DEATH SHOULD OCCUR,
NOTIFY THE FOLLOWING INDIVIDUAL(S)
IMMEDIATELY
________________________
________________________ Dr. Astrahan (323) 865-3091
Radiation Oncologist
Ophthalmologist
Medical Physicist
Should you
have any additional questions on matters of radiation safety, please call the
Medical Physicist.
_______________________________
___________________________
Radiation safety officer signature
date