Logistical Problems in Project managing a Nuclear Medicine Department - A Physician's Perspective Dr P Shanmuga Sundaram, MBBS, DRM, DNB (N Med), MNAMS Head, Dept. of Nuclear Medicine & PET CT, Amrita Institute of Medical
Jan 15, 2016
Logistical Problems in Project managing a
Nuclear Medicine Department - A Physician's Perspective
Dr P Shanmuga Sundaram, MBBS, DRM, DNB (N Med), MNAMS
Head, Dept. of Nuclear Medicine & PET CT,
Amrita Institute of Medical Sciences, Cochin
What is Nuclear Medicine• A subspecialty of medicine, which uses minute
amounts of radioisotopes to image various organs of the human body & to treat specific diseases
• Superior to anatomical imaging by its physiological basis & ability to identify diseases at an early stage
• But very name ‘nuclear’ has negative connotations
• Diagnostic & Therapeutic Nuclear medicine
• Gamma & Beta Emitting Radioisotopes
• Thallium Heart scan – Diagnostic test
• Radio iodine Therapy
Diagnostic Nuclear Medicine• 99m Technetium the most extensively
used diagnostic medical isotope
• Provides high-quality image mapping – blood flow to the heart, – spread of cancer to bones etc
• Delivers low radiation doses to patients
• A decay product of another reactor produced radioactive element Molybdenum
• Molybdenum produced & supplied as 99Moly - 99mTc generator on a weekly basis
Myocardial Perfusion imaging
To detect Skeletal Metastases
Therapeutic Nuclear Medicine
• Radioactive Iodine (131I) in thyroid cancer & hyperthyroidism treatment
• In bone pain alleviation, liver cancer, Rheumatoid arthritis management etc.
• Targeted delivery of high radiation to diseased cells & sparing normal cells
• Most of therapeutic radio isotopes are nuclear reactor produced
• Have relatively longer half life
Present status of 99mTc generators in India• Indian Nuclear reactors NOT capable of producing “High specific activity Molybdenum”
• Dependent completely on Imported Molybdenum
• Worldwide short supply as there are only 5 nuclear reactors capable of Moly production
• 70% of world’s 99mTc need met by Canada & Netherlands nuclear reactors
• Right now worldwide 99mTc resource crunch & 300% price increase in 99mTc weekly consignment
• Financial strain on Indian nuclear-medicine centres
So What is the solution?
• 99mTc crisis may not be completely solved even if existing nuclear reactors restart production
• High time for India, a nuclear empowered country to have its own nuclear reactor
• India can supply isotopes to other SAARC & ASEAN countries
• Also, better to have regional dispensing centres
• It is possible to ensure affordable & uninterrupted supply of medical isotopes
Ultimate NM Diagnostic - PET CT Imaging• “Investigation of this Century” - PET CT
Positron Emission Tomography with CT
• PET CT modality has revolutionized cancer care – ability to detect early malignancy– for cancer staging – its response to therapy – in cardiology & neurology
• AIMS – only PET CT centre in state of Kerala
• 18FFlouro Deoxy Glucose (FDG), half-life 110 minutes
• The flip side of PET CT – high cost & short half-life of PET isotopes
PET CT SCANNER
FDG TRANSPORT CONTAINER
Whole body PETCT showing multiple metastases
Issues in PET Isotopes
• Establishing & maintaining a cyclotron a financially challenging and daunting task
• Limited number of cyclotrons located mainly in metros
• No cyclotron in Cochin but it is a prerequisite to ensure uninterrupted supply of FDG
• Possible to air transfer FDG from other metrosIn spite of its short half life
FDG transport a logistical nightmare• FDG transported only on large aircraft with
exclusive cargo carriage sections (i.e. smaller ATR flights cannot)
• FDG categorized as “Dangerous Goods Regulations” (DGR)
• Both pilots of transport carrier needs to be ‘DGR certified’
• Mandatory cooling period in airport cargo area
FDG transport a logistical nightmare• Smooth workflow mandatory at FDG
production site – at the cyclotron facility
– local transport team
– air cargo ground staff
• Smooth workflow at destination– Ground cargo handling staff
– Hospital transport team
– At the user department
Logistics of FDG air transport from
Mumbai cyclotron to our centre• Mumbai preferred because of its better air connectivity
• An early morning flight preferred
– Patients fast overnight
– Early morning FDG production at a cyclotron facility
– Cyclotron to airport road transfer faster in early morning
Time chart of FDG production & transport
• 1-3 AM – Production, QC & FDG Packaging
• 3-4 AM – cyclotron facility to airport cargo terminal
• 4-5 AM – Cooling time
• 5-5.30 AM – Aircraft loading
• 5.30 – 7.20 AM – In flight
• 7.20 – 7.40 AM – Clearance & handing over of FDG consignment to hospital staff waiting at Cochin airport
• 7.40 – 8.15 AM – Road transport of FDG from Cochin airport to PET CT Centre
• 8.15 am – 11.15 AM – FDG Injection to patients in batches
Problems faced by our PET CT centre in FDG supply and
transport logistics• Only Mumbai & Delhi cyclotron facilities are ideally located & able to supply FDG through air
• Nearby facilities (Hyderabad, Chennai & Bangalore) have no ideal air connectivity in terms of aircraft size, departure time etc.
• Only AI & Jet carry radioactive consignments (DGR)
• So only one (Monopoly) Mumbai supplier
Problems faced by our PET CT centre in FDG supply and
transport logistics• Cyclotron breakdown
• QC failure
• Pilot on flight not DGR certified
• Any security alert
• Any transport delay
• Ultimately leads to postponement of scheduled patients for the day
Possible Solutions
• Regional cyclotrons in Govt & Public/Private sectors so that affordable FDG available
• All private carriers should carry radioisotopes routinely with commitment
• Ensure DGR certified pilots available on specific routes & flights carrying radioactive substances
• Sensitisation of all personnel involved in FDG transport logistics
Conclusion
Molecular Imaging - future of cancer imaging
94 % success rate in patient scheduling Be a Project management professional yourself
Sensitise your health management professional
Ultimately Be an optimist