My first day in radiotherapy physics: reflections of a medical physicist

NHSIn 2010 Karen Goldstone was awarded the MBE for her services to healthcare. Here she reflects on the primitive tools used for radiotherapy patient outlines back in the 1970s and remembers the wise advice she was given on her first day as a radiotherapy physicist.

BIR

I started work in the NHS as a Hospital Physicist in 1970. Prior to that I did the MSc in radiation Physics based at Middlesex Hospital. When doing a placement in nuclear medicine, computer tapes had to be taken to University College about a fifteen minute walk to the other side of Tottenham Court Road and fetched the next day hopefully having run successfully.

In my first post I expected to be doing mainly diagnostic radiology physics but discovered that that was rather a luxury field and so most of my time was spent doing radiotherapy physics. Those were the days when patient outlines were taken using a strip of lead or a flexicurve and planning was done using tracing paper and coloured pencils or biros. There was no computer planning of course and we only had one calculator with a paper roll print out so slide rules were in constant use. The main piece of advice I remember receiving on my first day was that if I discovered I had made a mistake I should own up to it straight away and not seek to cover it up – very wise words.

When not doing radiotherapy physics many hours were spent reading out film densities produced using our homemade “Ardran Cassette” in order to check kVp. This was the beginning of setting up a quality control programme for X-ray units. Another time-consuming activity was sealing lithium borate powder into plastic capsules in order to measure dose to radiologists, carrying out various procedures under fluoroscopic control, and subsequently reading the doses received.

Although diagnostic radiology physics was not seen as important it was an exciting time and I was fortunate enough to hear Godfrey Hounsfield give the 1972 MacRobert Award lecture on “Computerised Transverse Axial Tomography” – an invention that has revolutionised diagnostic imaging.

I started my second post in 1974 in a smaller department but with responsibilities in other, far-flung, hospitals. Here I was the radiotherapy physicist (the only one) and also covered diagnostic radiology and radiation protection, but because it was a smaller department and staff had to be versatile I also did some nuclear medicine and even once some ultrasound.

In the peripheral hospitals in my patch one was still using wet developing, one using just a fluorescent screen for fluoroscopic procedures and one an image intensifier viewed not via a camera but via a mirror arrangement.

How times have changed!


About Karen Goldstone MBE

I worked for forty years in the NHS, in radiotherapy physics, diagnostic X-ray physics and all aspects of radiation protection. In 1983 I set up the East Anglian Regional Radiation Protection Service (EARRPS) based at Addenbrooke’s Hospital in Cambridge, and ran it for almost 30 years. I was both a Radiation Protection Adviser and Laser Protection Adviser. I gave physics lectures to radiologists and was a physics examiner for FRCR both in the UK and Malaysia. With colleagues in EARRPS and Cambridge University I ran a number of Radiation Protection Supervisor courses and gave countless IRMER courses to reluctant clinical staff. I was exceedingly surprised to be awarded the MBE in 2010 for services to healthcare.

Since retiring I have taken up rowing and become a Level 2 rowing coach; I have given two courses on Radiation and Health to the University of the Third Age in Cambridge and am otherwise kept busy with my garden, allotment, grandchildren and church activities. I am still involved on one or two committees for medical physics and radiological protection.

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My first radiology job in the NHS

NHS

What does a jazz band, a ghost train and a figure in dark goggles have in common? They are all part of the NHS 70 memories of Professor Ralph McCready.

Ralph McCready

As a houseman I had the privilege of working for Professor Frank Pantridge, inventor of the defibrillator. I was fascinated by his catheter lab with the combination of physiology and radiology. So I decided to become a radiologist but was advised to go to England (from Northern Ireland) and obtain an impressive degree so that I could return if I wished. So I went to Guy’s Hospital, London to study for an MSc in Radiation Physics and Biology and the Diploma in Medical Radiodiagnosis (DMRD), paying my own fees.

Guy’s Radiology Department was interesting. The radiology chief was Dr Tom Hills who smoked cigars, had a tiny lead apron over the appropriate parts and had made an automatic wet X-ray film processing system.

It was obvious I would never get a radiology job at Guy’s coming from Belfast, speaking strangely, and not having the MRCP (Membership of the Royal College Physicians examination) so I applied for a Senior House Officer (SHO) position at the Hammersmith Hospital London where everybody was equal.

At the Hammersmith I was told by the other applicants that I would not get the job as I had come from Belfast. However I was determined to leave the interview with my head held high. I was first in to the SHO interview and was amazed to see a long row of people on the other side of the table headed by Professor Robert Steiner. He opened the questioning by asking why I was a member of the Musician’s Union. I explained that all my colleagues in the White Eagles Jazz Band had failed their exams, left the University and turned professional. To continue to play with them I had to join the Union. Then I was asked what else I had done, so rising to the occasion I told them I had been the ghost in a ghost train in an Amusement Park. I was bored so I connected the light over the skeleton to be permanently on. The little children came out saying that there was a ghost reading the Daily Telegraph beside the skeleton. Of course nobody believed them and the people outside poured in to see what was going on.

I emerged from the interview after forty minutes to tell the other candidates how awful the interview had been. I was appointed to the position! Professor Steiner used me to do all the odd jobs in the X-ray department for the next two years. As the junior doctor I worked in the dark with the oldest Watson X-ray set. Every time I took an erect X-ray the large steel edged cassette containing the film would slide across and usually fall out of the carriage landing on the floor with a loud crash frightening everybody in the darkened room.

It was a time of great innovation at the Hammersmith: the first renal transplant was carried out; micturating cystograms were started. After initial problems with old ladies standing up in the dark being unable to ‘pee’ when the urine hit the steel bucket with a tinkle, the problem was solved by lining the bucket with sound deadening polythene. Friday was ladies’ day when I was the only radiologist who performed Hysterosalpingography. It was done in a small room with a boiling water sterilizer in the corner. When I came out to view the films the steam poured out of the door and I would appear in a cloud of steam as a fearsome figure wearing large dark goggles and a long lead apron to the consternation of the waiting mixture of NHS and private practice ladies.

Professor Steiner was a great leader and inspiration. I will always be grateful to him appointing me to a job in the Hammersmith to start my career in the NHS. https://www.rcr.ac.uk/college/obituaries/professor-robert-steiner


About Ralph McCready

I graduated in Medicine from Queen’s University Belfast and then worked as a Houseman in the Royal Victoria Hospital. When I came to England I studied for the MSc in Radiation Physics and Biology and the Diploma in Radiodiagnosis at Guy’s Hospital London. After working as an SHO in Radiology at the Hammersmith Hospital I was appointed to a research position at the Institute of Cancer Research in Sutton, Surrey. With the development of a Nuclear Medicine Department at the Royal Marsden Hospital I became the consultant in charge for over 40 years. In 1987 I was awarded a DSc by Queen’s University Belfast, the British Institute of Radiology Barclay Prize in 1973, an Hon. FRCR in 1975, an Honorary Fellowship of the Faculty of Radiologists Royal College of Surgeons, Ireland in 1992 and made an Honorary Member of the Japanese Radiological Society also in 1992. I was appointed to a personal chair in Radiological Sciences in the Institute of Cancer Research in 1990.

As a founder member of the British Nuclear Medicine Society I have recently co-edited a book celebrating the 50th Anniversary of the Society and the development of radionuclide studies in the UK.https://link.springer.com/book/10.1007/978-3-319-28624-2

When MRI created excitement in the air

NHS

Dr Adrian Thomas shares his experience of working as a radiologist and how excited he was to see the EMI/CT scanner for the first time. 

 

adrian thomas

Dr Adrian Thomas

In my time as a radiologist I have seen the amazing growth and flowering of radiology. I entered medical school in 1972, which was the year that the CT/EMI scanner was announced by Godfrey Hounsfield and James Ambrose at the BIR Annual Congress; and I started radiology at Hammersmith Hospital in 1981, which coincided with the opening of their MRI scanner. I don’t think that either of these events were connected!

 

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X-ray Television at Farnborough Hospital in 1970

When I started medical school everything looked so advanced and exciting to my young eyes. As I look back now it all seems rather primitive. Computers were in their infancy, and imaging was almost all traditional. However, I liked the X-ray departments that I saw, and was taught by Peter Bretland at the Whittington Hospital, and by the great George Simon who was a pioneer chest radiologist. Both were inspirational teachers.

OLYMPUS DIGITAL CAMERA

Old X-ray cassette, pre-digital

The juniors today will find it difficult to understand how very different things were. As a junior doctor, practising emergency medicine or surgery with only minimal imaging was not easy. Many assumptions were made. So for example, an older person with left iliac fossa pain and fever was assumed to have acute diverticulitis. They were treated with intravenous fluids, antibiotics and a nasogastric tube; a barium enema was then arranged as an outpatient. Many exploratory laparotomies were performed for undiagnosed acute symptoms, and the surgeon had only a limited idea as to what would be found. We had plain films, contrast studies and nuclear medicine, but no CT and only limited access to ultrasound. I can remember patients who would have been managed entirely differently today with modern imaging. In particular, an accurate diagnosis made by CT or ultrasound may preclude the need for invasive surgery.

5 Store for conventional film packets

Store for conventional film packets. Large storage rooms were needed for storing X-ray film packets, with many filing clerks

I was a surgical houseman in 1978-9, and I recollect one particular patient that had done something that you should never do, that is to polish the floor  underneath a carpet. He had come downstairs, and had stepped onto the carpet. The carpet had slid forwards, and he fell backwards hitting himself hard on the occiput. He presented with a severe headache, but no neurological signs. His skull plain film X-ray showed no fracture, and I admitted him for neurological observations. After 24 hours he remained well, but still had his severe headache. The surgical team decided to keep him in  hospital for further observation. We kept him for well over a week, and he remained well although with a persistent headache. We then finally sent him home. I had a phone call some days later from another hospital. My patient had unfortunately died, and the other team wanted to know what we had been doing. I explained what had happened, and the voice on the ‘phone said that this was all very reasonable and we could not be criticised. Today the patient would have been scanned, a potentially treatable lesion could have been found, and this young man could be alive today.

3 Traditional cassette opened to show intensifying screens and film

Traditional cassette opened to show intensifying screens and film

I had first seen the EMI/CT scanner when my consultant took his firm of neurology students to see the new scanner at the National Hospital in Queen Square, where he had clinical sessions. I was fascinated by the images we saw, and the radiologist Ivan Moseley showed us the capability of the scanner. I could feel the excitement in the air, and a knowledge as to how much we could learn about the natural history of various diseases. I was also aware of the excitement in the air when I was at Hammersmith Hospital as a registrar  in Radiology. We were being taught tradition imaging – plain films, barium meals and enemas, and IVPs. I became quite good at TLAs (trans-lumbar aortograms), when a long needle was passed into the prone anaesthetised patient, and contrast injected to show the peripheral vessels. However, whilst I was learning the traditional techniques, Graeme Bydder, from the MRI Unit, used to join us for our lunchtime meetings and show us the recent scans hot off the printer. This was long before the days of digital transfer of images and PACS. I remember being excited by the images of NMR as it was called then, and realising how the neurosciences would be revolutionised.

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Bags of films for reporting. Once a common scene in reporting rooms

Imaging has utterly transformed both the practice of medicine, and also how we look at ourselves. It is all too easy to be cynical about the modern world and whist things may always improve major advances have been made. However, all of these changes were quite unpredictable when the NHS was set up, and it is a major achievement that these new imaging techniques have been introduced. Modern imaging is readily available for our patients, and has transformed untold numbers of lives. Godfrey Hounsfield was always very humbled by the many letters that he received from patients and relatives thanking him for his invention.


About Dr Adrian Thomas

Adrian Thomas is a radiologist, and visiting professor at Canterbury Christ Church University. He has been President of the Radiology Section of the Royal Society of Medicine, and of the British Society for the History of Medicine. He is the Honorary Historian to the British Institute of Radiology. Adrian has written extensively on the history of radiology writing many papers, books and articles. He is currently, with a colleague, writing a biography of the first woman radiologist and woman hospital physicist.  He has had a long-term interest in role development in radiography, and teaches postgraduate radiographers.

 

A revolution in imaging: radiology memories for #NHS70

NHS

Professor Adrian K Dixon was born in the same year that the NHS began. Here he reflects on what the NHS has given him and the revolution he has experienced in the world of radiology.

 

Adrian Dixon

Professor Adrian K Dixon

I was born in 1948 and, 70 years on, I remain one of the most passionate supporters of the NHS. Like many of my generation, I have received huge personal benefit from the NHS over the years; both my elbow fractures were brilliantly treated in Accident and Emergency Units; joint replacements for osteoarthritis have provided renewed mobility latterly; audiology services have looked after my long-term inherited deafness and allowed me to function reasonably well so far.

Training in medicine in Cambridge (1966–9) and London (St Bartholomew’s Hospital, 1969–72) was very different from nowadays. On hour one, day one, as a young houseman, sister said to me: “There are three patients for myelography today –  there are three trays set up for lumbar puncture – all you have to do is to send some cerebrospinal (CSF) fluid off to the lab and instil the Myodil before they go down to radiology where Professor du Boulay will be waiting….!” I had not even seen a lumbar puncture at that stage but I learnt quickly at the hands of an excellent registrar. Then I went off for training in General Medicine at Nottingham General Hospital in the excellent Professorial Unit led by Professor Mitchell and Dr (later Professor) Hampton. Any patient over 65 then was ‘geriatric’. I well remember one elderly lady recovering from a cardiac event who was not quite well enough to go home where she lived alone – I said: “I think you need a few days in our convalescent home in Cleethorpes (yes, the NHS provided such things in those days!)”. Her reply: “Oh lovely; I have never seen the sea”. No package holidays or low-cost flights back then!

I was extremely lucky to train in radiology during the 1970s and to be involved with the beginning of the revolution in imaging, namely the introduction of ultrasound, CT and MRI. These advances were truly miraculous compared with the fluoroscopic techniques of old. Indeed image intensification was only just becoming sophisticated while I was training and I did my fair share of barium work using direct fluoroscopy following dark adaptation with red goggles! This even persisted after my move to Cambridge when I was given responsibility for imaging services at the local geriatric hospital where the ageing equipment was nearly as old as some of the patients!

Picture1

After a brief spell in paediatric radiology, I became fascinated by Computed Tomography and I was lucky to be appointed as a Research Fellow at St Bartholomew’s Hospital. There, Dr Ian Kelsey Fry had the foresight to install one cranial and one whole body CT systeminto 2 standard X-ray rooms (an excellent strategy – replacing old technology rather than merely adding on the new). This gave me the experience to be appointed as a young lecturer/Honorary Consultant at the newly emerging Clinical School in Cambridge (thanks to the risk taken by my lifelong friend Professor Tom Sherwood).

In partnership with NHS radiological stars in Cambridge (Desmond Hawkins and Chris Flower, to name but two), Tom Sherwood forged a highly successful combined University/NHS Radiology Department which continues to this day. I was fortunate to be given free rein to develop Body CT and the townspeople generously raised the money for a machine which was opened by HRH the Prince of Wales in 1981. But the NHS was not quite ready for CT! Not only did the town-based charity have to pay for the building, it also had to provide running costs for the first five years; we only received subsequent NHS funding in 1986 after a thorough Department of Health Audit of our work. Even then the local NHS was sceptical; the local oncologists saved the day by suggesting that they could manage more of their patients as outpatients if CT was available. The outstanding local fundraisers were so successful that the charity was able to fund top-of-the range MRI systems in Cambridge for some decades thereafter. Although there was one generous distribution of NHS funding for CT systems on the back of Sir Mike Richards’ cancer initiatives, NHS funding for high-end equipment has never really been properly addressed.


About Professor Adrian K Dixon

BIR Toshiba Mayneord Adrian Dixon 4

Professor Adrian K Dixon

Professor Dixon is Emeritus Professor of Radiology at the University of Cambridge and a retired Consultant Radiologist. He has published extensively on Computed Tomography and Magnetic Resonance Imaging and has edited several textbooks. He was Warden of the Royal College of Radiologists (Clinical Radiology, 2002–2006) and MR Clinical Guardian to the UK Department of Health (2004–2007). He has been awarded honorary Fellowship/Membership of Radiological Societies in Austria, Australia & New Zealand, France, Hungary, Ireland, Sweden, Switzerland and the USA. He was Editor-in-Chief of European Radiology 2007–12 and was awarded the Gold Medal of the European Society of Radiology in 2014. He has been awarded Honorary Degrees by Munich and Cork. He was Master of Peterhouse, University of Cambridge 2008–2016.

On foot through Chernobyl with Medical Physicists

Katharine Thomson shares her experience of visiting the abandoned exclusion zone Chernobyl.

Picture1It’s a two hour drive to Chernobyl from the Ukrainian capital, Kiev, through mile after mile of flat, pine-covered countryside. There’s no indication that we’re approaching the site of the worst nuclear power disaster in history; even when we reach the edge of the Exclusion Zone, 30km from the ruined reactor, there’s nothing visible beyond the checkpoint except the long, flat road between the trees.

Soldiers check each passport carefully and wave us through. As our minibus crosses into the Zone, our guide reminds us of the rules: no eating, no touching, no souvenirs.

If the destination is unconventional, our group is equally eccentric. We’re a group of nine: eight British physicists, for whom the prospect of visiting a nuclear disaster zone is not bizarre but compelling, and one game partner. Our visit was organised by Henry Lawrence and the UK Monte Carlo Radiation Transport User Group; most of us work in hospital radiology and radiotherapy departments, and we’re used to dealing with low level radiation incidents, from faulty x-ray equipment to spilt radioactive drugs. Chernobyl, however, is on another scale.Picture5

The first thing that strikes you is the trees: all we can see above three decades of forest are the tops of apartment blocks and the uppermost yellow carriages of a Ferris wheel. We park on the empty road and step into thick undergrowth, passing in single file down tracks that were once highways.

It’s a changeable day, sunny with sudden showers. Yellow butterflies dance around us, and the air is heavy with the smell of pine trees in the heat. Away from the derelict buildings and rusting industrial junk, this is a strangely pleasant place for a walk.

Picture12Our guide sweeps his Geiger counter slowly near the ground; the clicking accelerates as it passes over “hotspots”, otherwise indistinguishable from surrounding earth. I think we’re less impressed than he hoped – many of us do something similar at work, detecting small radioactive spillages.

A dilapidated building looms out of the trees.

“No touching,” our guide reminds us. “Your feet can touch the ground – that’s all.”

We peer through dirty windowpanes. The floorboards have collapsed in splinters and books spill out onto the damp earth, Cyrillic lettering still clear. They look like science schoolbooks, rejected by looters. We step around them carefully – it feels wrong to tread on books. A brightly coloured calendar still hangs on one wall, with drummers marching beneath the date – 1986.

The Accident and Aftermath

1986: in the early hours of the 26 April, Chernobyl Nuclear Power Plant’s Reactor 4 exploded during a safety test. The fire raged for days, releasing clouds of radioactive material into the atmosphere. This fell largely on surrounding countryside and towns, with some carried further across Ukraine, Belarus and Russia, and beyond.

One of the most significant contaminants was iodine-131, a radionuclide which is taken up by the human thyroid. This process is used in hospitals under carefully controlled conditions to treat thyroid conditions including cancer, usually with excellent results. Its half-life is eight days; 31 years on, we have nothing to worry about, but uncontrolled ingestion soon after the accident would lead to a huge increase in thyroid cancer across Ukraine, Belarus and Russia, particularly in children.

Also affected were the plant workers and “liquidators” brought in to battle the fire and contain the spread of contamination; many received very high radiation doses, and 28 died of radiation sickness within three months. The longer term impact, however, is harder to assess, given the hundreds of thousands of evacuees and liquidators, and the delay of years or decades before radiation-induced cancers can occur. However, the UN Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) has concluded that, with the notable exception of thyroid cancer, “there is no clearly demonstrated increase in the incidence of solid cancers or leukaemia due to radiation in the exposed populations”. The enormous psychological stress of evacuation, however, is not in doubt.
Picture9What about the risk to visitors? Our radiation doses were surprisingly small. Our guide’s personal monitor recorded 10µSv over our two day visit, which might translate, given generally used estimates, to a cancer risk of very roughly 1 in 2 million. I have some scepticism about this measurement – background radiation in the UK is about 7µSv per day, so I apparently received a lower dose in Chernobyl than I would have got sitting on my sofa at home. There’s also the risk of contamination, for which we were checked every few hours. However, the biggest radiation dose from this trip probably came from my flight to Kiev.

Picture10Pripyat and the Nuclear Power Plant

We tramp on through the overgrown outskirts of Pripyat, the Soviet city purpose-built for plant workers and their families. This was once a good place to live; the streets were spacious, with a striking range of amenities: a Cultural Palace, swimming pools, gyms and a supermarket where dusty signs still hang above the aisles. A shop we pass is full of cracked televisions, huge and box-like; the one next door houses dozens of upright pianos.

Picture13We are visiting not just another time, but a country that no longer exists: the Ukrainian Soviet Socialist Republic, gone since 1991. Trees grow so dense that sixteen-story apartment blocks are barely visible until we get close, their empty windows gaping black. Broken glass crunches under our feet. We are surrounded by the effects of abandonment, but without our Geiger counter clicking in excited bursts it would be impossible to guess why these people left so suddenly.

Outside Pripyat stands what’s left of Chernobyl Nuclear Power Plant: an unfinished cooling tower, industrial buildings and, most prominently, the smooth white semicylinder of the new sarcophagus concealing the remains of Reactor 4.

The dose rate here, about 100 yards from the sarcophagus at the only permitted photo spot, is 1µSv/hr – remarkably low considering what’s hidden underneath. For comparison, in hospital nuclear medicine departments, staff might come into (brief) contact with levels at least ten times higher, from patients having radionuclide therapy.

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Duga-1 Radar Station

Back in the minibus, we drive on in search of the most mysterious place within the Zone: the abandoned Soviet radar station, Duga-1.  Part of an early-warning system for anti-ballistic missiles, this colossal array of caged radar transmitters is vast almost beyond comprehension, stretching hundreds of metres up and as far as the eye can see. Despite this, it’s almost invisible until you are right upon it, carefully hidden from the road by forest.

The station and attached settlement went unmarked on maps, passed off as a children’s holiday camp complete with fake, brightly-muralled bus stop. The school is real, though; toys and gas masks litter the ground beneath posters of great classical composers still hanging on the walls: Tchaikovsky, Beethoven, Rimsky-Korsakov.

Thirty-one years ago Duga-1 would have been closely guarded, with soldiers on watch while in the school their children learned classical music. Now, no one protests as British physicists with cameras walk past.

Picture4Our minibus is waiting beyond the checkpoint, but first we are checked one last time for contamination, stepping in turn between detectors. All clear: the turnstile clicks open and we’re through. With a last look back, we climb into the minibus, shaking the dust of Chernobyl from our feet.

 

The Future

What does the future hold for Chernobyl? As the Zone enters its fourth decade, the need for a long term plan is ever more pressing. Decontamination work continues, but the buildings are now so dilapidated that they present a real hazard, and a decision must be made soon on whether they should be pulled down. That would be a complicated process, potentially releasing large quantities of radioactive dust.

These same buildings also provide an unlikely source of income for the Ukrainian government. Since its opening in 2011, thousands of visitors have entered the Exclusion Zone annually, drawn by professional curiosity, historical interest or the lure of the unusual. Visitors must be part of accredited tours and entry is strictly controlled. Tourists usually visit Kiev too, bringing much needed income to an industry badly hit by the fighting in eastern Ukraine.

The Ukrainian government faces a quandary: entering abandoned buildings is officially forbidden, but it is an open secret that visitors want to do more than peer through broken windows. As buildings crumble, it’s only a matter of time before someone is injured by collapsing walls or falls through floorboards. On the other hand, will tourists still come if all they can see are pine trees?

There are possibilities, however, for Chernobyl’s future. One is to make some of the more impressive structures safe for authorised visits while others are demolished. Over the border, the Belarusian share of the Exclusion Zone is now a huge wildlife reserve, the Polesie State Radioecological Reserve. Research into environmental effects of radiation continues, and there is even talk of inclusion on the UNESCO World Heritage List. Others have mooted using the Zone as a huge solar farm: a fitting future for energy production’s most notorious disaster site.


 

Sources

https://www.iaea.org/sites/default/files/strategy_for_recovery.pdf 

http://www.unscear.org/docs/reports/2000/Volume%20II_Effects/AnnexJ_pages%20451-566.pdf

http://www.who.int/ionizing_radiation/chernobyl/backgrounder/en/

http://www.who.int/ionizing_radiation/chernobyl/20110423_FAQs_Chernobyl.pdf?ua=1

http://www.brogers.dsl.pipex.com/Wpecker5.html

http://www.unis.unvienna.org/unis/en/pressrels/2011/unisinf398.html

 


 

About Katharine Thomson

Katharine Thomson is a member of the BIR Radiation Safety Special Interest Group (SIG) and also represents the BIR at the Society of Radiological Protection’s International Committee, which connects the UK radiation protection community with the worldwide scene. She is Principal Physicist at Derriford Hospital, Plymouth.

 

 

 

Radiotherapy – learning about the HERO project

Head of Radiotherapy PhysicsThe Health Economics in Radiation Oncology (HERO) project was set up by the European Society for Therapeutic Radiation Oncology (ESTRO) in order to gain a better understanding of the availability and need for radiotherapy in Europe. It also provides health information to inform decision makers on the costs and cost effectiveness of radiotherapy services. Dr Keith Langmack, member of the BIR Oncology and Radiotherapy Special Interest Group (SIG), reports on a recent meeting in Brussels where a new costing model was introduced. He makes the case for multidisciplinary teams to work together to use the model in the UK.

“I was invited to represent the BIR at the ESTRO headquarters on 5 December 2017, one of many representatives from all over Europe all very excited to see the newly developed costing model for radiotherapy and then to go to the European Parliament to discuss the gap in radiotherapy provision across Europe.

The day started with an overview of the HERO project from Professor Cai Grau (Professor of Radiation Oncology at the Institute of Clinical Medicine at Aarhus University, Director of the Danish National Centre for Interventional Research in Radiation Oncology and Chair of the HERO project). He told us that the HERO project had 4 phases: to define the need for radiotherapy, evaluate the current access to radiotherapy, to calculate the cost of radiotherapy, and finally to determine the cost-effectiveness of radiotherapy at a European level. He presented some of the results from phases 1 and 2 [1-4]. These included the conclusion that radiotherapy is only given to around 70% of the patients who could benefit as defined by current guidelines and best-practice, and that socio-economic factors play a big role in the provision of radiotherapy across Europe.

RadiotherapyMost of the rest of the day was taken up with an introduction to the newly developed costing tool by Noémie Defourny, the health economist who has had a major input into developing the model. She explained that this model has been designed to take national level data (e.g. staffing, equipment profile, fractionation) and predict the cost of external beam radiotherapy at a national level. Once base-line data is in place then the effect of changing the parameters on cost (e.g. dose-fractionation, provision of equipment) can be predicted. The cost of brachytherapy and chemotherapy are not included in the model. She then demonstrated the model using a fictional country, Europalia. We then had an opportunity to run the model for ourselves.

The final part of the workshop consisted of presentations from Drs. J F Daisne (Belgium) and Zoltán Takácsi-Nagy (Hungary) to illustrate how they had been piloting the model in their respective countries. This involved a large amount of work collecting the data, however progress was being made. This part of the day was concluded by Professor Josep M. Borras (Director of the Regional Government of Catalonia’s Cancer Plan and Scientific Coordinator of the Spanish Ministry of Health’s Strategy on Cancer) summarising the need for producing national level cancer plans and linking this to the need for effective economic modelling.

We then travelled to the European Parliament for a meeting entitled “Radiation oncology cures cancer today – Help us close the gap in access to radiotherapy and make a difference!” hosted by Mrs Lieve Wierinck MEP (member of the MEPs Against Cancer group). This consisted of a number of presentations from the HERO project. There was then a panel debate chaired by Peter O’Donnell (Associate Editor, European Voice) where a number of learned academic and industry speakers from across Europe talked about meeting the need for radiotherapy in the region.

So what next? As a participant in the workshop it means the BIR has access to the costing model. In the UK we have good data to put into the model. However it would require a multi-professional team to populate all the required data fields. The next step would be looking at the best way to tackle this collaboratively. Having talked with the people involved in developing the model, I am sure ESTRO would be supportive of the implementation of the model at the UK level. It is a very interesting enabler for research on the effects of changes in service delivery. It would be timely to use it with a new radiotherapy service specification being introduced in England.”


Dr Keith LAngmack is Head of Radiotherapy Physics at Nottingham University Hospitals NHS Trust.


References

  1. Lievens Y and Grau C. Health Economics in Radiation Oncology: Introducing the ESTRO HERO project. Radiotherapy and Oncology 103 (2012) 109–112.
  2. Grau C, Defourny N, Malicki J, et al. Radiotherapy equipment and departments in the European countries: Final results from the ESTRO-HERO survey. Radiotherapy and Oncology 112 (2014) 155–164.
  3. Dunscombe P, Grau C, Defourny N et al. Guidelines for equipment and staffing of Radiotherapy facilities in the European countries: Final results of the ESTRO-HERO survey. Radiotherapy and Oncology 112 (2014) 165–177.
  4. Lievens Y, Defourny N, Coffey M, et al. Radiotherapy staffing in the European countries: Final results from the ESTRO-HERO survey. Radiotherapy and Oncology 112 (2014) 178–186.

Remembering Baby exhibition highlights role of MRI in foetal and neonatal post-mortem

Dr Elspeth Whitby reflects on the changing shape of her clinical practice, after a research project and the curation of an exhibition which has opened up new ways to engage the public with her work and medical imaging.

RB-PR sheet8This month I am involved in the launch of a new exhibition, Remembering Baby: Life, Loss and Post-Mortem which opens in London (3-14 November 2017) and then in Sheffield (5-14 December 2017). The exhibition is a result of the “‘End of’ or ‘Start of’ Life’” research project which explores how Magnetic Resonance Imaging (or MRI) techniques are starting to be applied to post-mortem practice – including pregnancy loss and neonatal death. This is an important initiative as it is a technique which is less invasive and arguably less distressing for all involved.

This interdisciplinary collaboration has provided an insight into aspects of my work as a radiologist that I would never normally be aware of, and it has highlighted the importance of understanding parents’ needs at a time when they may be anxious, upset, stressed, concerned and affected by a whole range of emotions. I have learnt how ‘little’ things mean so much to families who experience baby loss, and that these can have a huge impact on how they live with their child’s death.

Making visible the often hidden care practices enacted by health professionals who look after babies and their families following a foetal or neonatal death, is a key aim of the Remembering Baby exhibition. Our research team has worked in collaboration with the BIR artist in residence, Hugh Turvey and sound artist Justin Wiggan, to create exhibits related to early-life loss.

remembering-baby-exhibition-workshop-imagesbanners2 (1)Remembering Baby seeks to make these encounters more visible and features a collection of visual images, physical objects and sound installations that sensitively explore what happens when a baby dies, from both parental and professional perspectives. By talking with Hugh about our study, he has been able to interpret and creatively represent some key themes and findings from the research – including MRI’s role in the developing landscape of minimally invasive post-mortem for babies. In the pieces there is also a broader focus on care practices and memorialisation.

As part of the research project we ran a Lasting Impressions workshop. We invited bereaved parents and relatives from the local area to bring along items that were precious to them and related to their baby. The individuals who came were amazing. They talked very openly to us and to each other about their babies and the memory objects they had bought. Guided by Hugh the participants made paper impressions and rubbings of their items and donated their work to us for the exhibition. Those that came to the workshop were at different stages of their bereavement – for some the loss was very recent, for others it was many years ago – and they all had very different experiences. There was not a single person in the room who did not have tears in their eyes at some point during the workshop, but they were not all sad tears.

HughTurvey_WP_20170912_09_55_03_Pro_LIIt made me realise that as professionals we have improved greatly over the years in terms of how we include families in decision-making and with regard to the support we provide, but we can still do more. During the workshop a parent shared how one item held sad memories for her because it was associated with seeing a spot of blood on her child’s Babygro as they were preparing for the memorial service. This is something I will never forget, and something that could have been avoided. I now look at things in detail beyond the medical side, and consider if there is there anything more we can do to ensure that we avoid additional sadness however small it seems.

In my blog The Role of a Radiologist when a Baby Dies I mentioned the difference between what I understood by the question “what happens to my baby?” and what the parent really wanted to know. We now have leaflets in all our patient packs explaining who looks after the baby, who dresses it, cares for it and where. The midwives have the information for parents when they ask and some of the uncertainties have been removed.

Volunteers have been linked with professionals and support groups so that the items they create meet the needs of all these groups.
Where next? We plan to run educational events for health professionals and support groups, and to continue to work in collaboration and extend our work to looking at consent.

Throughout my career I have been taught that experience is the most important learning tool. This work has highlighted that it is not just the medical experience but my journey with each individual patient, what their needs are and what they can teach me for my future interactions with other patients and relatives.

For more information: https://www.rememberingbaby.co.uk/
Details of the exhibition workshops: https://www.rememberingbaby.co.uk/workshops/

This project is funded by the Economic and Social Research Council (ESRC) and is a close collaboration with colleagues in Sociological Studies at the University of Sheffield – Kate Reed (project lead) and Julie Ellis (researcher)

Images courtesy of Hugh Turvey


ew2Dr Elspeth Whitby is a senior lecturer at the University of Sheffield and an honorary consultant at Sheffield teaching Hospitals NHS Foundation trust. Her clinical and research interests are based around MR Imaging of the foetus and neonate. She provides a national service for foetal MRI and is an integral part of the team at Sheffield Children’s hospital, which has set up the world’s first clinical service for minimally invasive autopsy for the foetal and neonatal age group. Her research provides the necessary data to assess the value of new MRI techniques and then to support the transitions from research to service. The multidisciplinary nature of her more recent work is changing her as well as influencing clinical practice.

She was the ex-Vice President for Education at the BIR. Whilst in this role Elspeth helped to improve the educational scope and methods of delivery of educational events for all BIR members.