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Introduction | Technetium-99 (Tc-99m): A Versatile Isotope
Introduction | Technetium-99 (Tc-99m): A Versatile Isotope
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Technetium 99m and Tc99m Radiopharmaceuticals | Technetium-99 (Tc-99m): A Versatile Isotope
Technetium 99m and Tc99m Radiopharmaceuticals | Technetium-99 (Tc-99m): A Versatile Isotope
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Bone Scan and Indications | Technetium-99 (Tc-99m): A Versatile Isotope
Bone Scan and Indications | Technetium-99 (Tc-99m): A Versatile Isotope
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Lymphoscintigraphy for Breast and Indications | Technetium-99 (Tc-99m): A Versatile Isotope
Lymphoscintigraphy for Breast and Indications | Technetium-99 (Tc-99m): A Versatile Isotope
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Technetium 99m - Sulfur Colloid | Technetium-99 (Tc-99m): A Versatile Isotope
Technetium 99m - Sulfur Colloid | Technetium-99 (Tc-99m): A Versatile Isotope
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Ventilation Perfusion Scan | Technetium-99 (Tc-99m): A Versatile Isotope
Ventilation Perfusion Scan | Technetium-99 (Tc-99m): A Versatile Isotope
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Renal Scans - MAG3 | Technetium-99 (Tc-99m): A Versatile Isotope
Renal Scans - MAG3 | Technetium-99 (Tc-99m): A Versatile Isotope
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Glomerular Filtration Rate - DTPA | Technetium-99 (Tc-99m): A Versatile Isotope
Glomerular Filtration Rate - DTPA | Technetium-99 (Tc-99m): A Versatile Isotope
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Nursing Considerations for Nuclear Medicine Procedures | Technetium-99 (Tc-99m): A Versatile Isotope
Nursing Considerations for Nuclear Medicine Procedures | Technetium-99 (Tc-99m): A Versatile Isotope
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Transcript

So this is my dog, Max. He has a habit of picking up pigeon feathers off the road and he thinks he has the whole pigeon.

Similarly, even though I'm presenting five tests that are most five most common tests that we do with Technetium, it is just a small picture. It is not the big picture. It is a part of what you can do with Technetium. Disclaimer, none.

Objectives, so identifying Technetium diagnostic utility, listing five different radiopharmaceuticals as it is combined for diagnostic tests, mechanisms of action in the scan, explaining the imaging process and the policies and procedures connected to them.

Okay, so at MSK we call our nuclear medicine division Molecular and Imaging Therapy Service. At the main center right now we have eight nuclear medicine registered nurses, 15 technologists, we have three PET CT scanners, seven gamma scanners, one spec CT scanner, and we recently acquired

one MRI PET scanner, that is currently housed in our MRI division. On average, on our main campus, we do about 40 to 50 PET scans, that's about 10,000 to 11,000 PET scans in a year. 10 to 20 bone scans, 10 breast lymphoscintigraphy scans,

four V/Q scans, two to six MIBG, three renal, three cardiac, two GFR, two liver and other miscellaneous scans. I'm not talking about any of the RESA scans that we recently started, like our C11 or dotatate PET scans.

So Technetium, it is not a high energy isotope. It has a half life of six hours. It has intermediate energy, so what that means, that even though it may stay in your system for longer, four days, it is not as strong as FDG, which is used for PET scans.

So it does not require the same kind of precautions. Just like other isotopes, it is also pure gamma radiation, so it does need a specialized scanner. Other thing really cool about Technetium and other nuclear med scans are that they show how the, they show the functioning.

So when we are injecting how the body is functioning, rather than how body looks right now. So CAT scan, when you take the picture, it's how it looks at that point of time. With the Technetium scan it shows how the body is working. So we do flow studies, so as the isotope is going through

the body it can take pictures of that. That's pretty cool. It is Technetium can connect with different carrier, as we call them, such as MDP, sulfur colloid, and allow us to take specialized scan. The carriers will connect to Technetium and take them

to specific areas for those specific scans. Let's see, it is measured in millicuries. So this is a gamma scanner. It is pretty cool. The two plates that you see can move around the table around the patient.

So the table stays still, the patient stays still. It's the camera that's moving. It can go above and below the patient or to the side of the patient, depending on what pictures do we need. So it's an open scanner, as we call it. That's the patient on the scanner, pretty open.

Most patients do not have trouble with that, other good thing about this scanner is you can wear metal clothes so your clothes can have metals in it and it will not effect the scanning. So those are some of the radiopharmaceuticals that are there.

The most common ones that I will be talking about some of them I'm not attempting to pronounce, I'll just use how I use it in daily life. MDP, sulfur colloid, MAA, MAG 3, D.T.P.A, that we do use an aerosol as well as IV form.

I will be talking about bone scan, breast lymphoscintigraphy scan, ventilation perfusion scan, renal study and the GFR study. Also, 'cause breast lymphoscintigraphy's a mouthful, and I trip, I'll use mapping at times. (laughing)

- [Audience] What will you use? - Mapping. - Mapping, okay. - That's the layman's language, I guess, for us. - So breast mapping? - Uh-uh.

So bone scan, we use MDP and it is used to diagnose fractures that are not seen

on plain X-rays, any malignancies, or osteomyelitis. The adult dose is 20 millicuries and for pediatric the dose is based on BSA. Now that scan is actually a normal scan. What I'm highlighting is the joints and the bladder. There's always a little bit of uptake.

So our doctors know that they know how to look for it. Bladder because it does go through the kidney and it can be eliminated through urine. It will not effect the kidneys though. - [Audience] What is mCi? I know that it's measurement, is it like meter cubics?

- Millicuries. It has low sensitivity in detecting osteolytic lesions and as such most of the time our patients get a CT scan with it to eliminate false positives. Usually, we inject the patient, have them look at the CAT scan and then come back for scanning.

The approximate time from start to end for bone scan can take up to three to four hours. That does not mean that the patient is in the scanner for that long. It just start to when it ends. - [Audience] From injection?

- To the point of scan, end of scan. Procedure, we always confirm the patient and the test, like any good nurses, right? For bone scan, 'cause I know we have patients who will be going for probably a CAT scan, so I always like to check if they have CAT scan

with or without contrast, or they have MRI or any other test that will require an IV. I work with cancer patients who have bad veins. If possible, I like to put in an IV, and leave that IV in. So I inject my dose, wrap up the IV,

and let them go to their next scan, if they have anything in between. Patient comes back to us after two to three hours for the scanning part, there is no dietary restriction, we do ask them to drink lots of water. Not only does it help with the hydration,

absorption of the isotope, it also helps get rid of any of the extra isotope that's not, it has not absorbed into their system. The scan time is 30 to 40 minutes, and this is where we make the (mumbles). They're in the scanner for longer.

This is the bone scan, and you can see the bone mets. That's where the cancer is. It's not just, you can see darkness beyond the joints. You can see it in the ribs, you can see it in the sternum, the spine, the femur, and that's how you can see. These are bone positive bone scan.

There's three phase bone scan which is a specialized bone scan. We do everything similar, but it's also considered a flow study. It is used to diagnose bone infection such as osteomyelitis and cellulitis.

The only thing you are doing different for this one is you take the patient, you put the IV in, you get the patient on the scanner, and then in collaboration with the technologist, you say, one, two, three, go, you inject your dose as they're taking pictures

of a specific site that the doctor wants. So it could be the patient is coming in because they have this new pain in the right hip. The technologist will get the camera into the appropriate area, and you inject, you flush, and they take pictures.

The picture is about like a 15-minute picture, patient gets off, they leave, come back in two to three hours for the full body bone scan. It does not replace the full body bone scan. It's just an additional picture that they want.

Moving on to breast lymphoscintigraphy or breast mapping.

We use sulfur colloid for this. Indications for it is the patient's probably getting the surgery, either the day of or the day after and the doctors need to know which sentinel node biopsy do they need to do. It shows the first draining lymph node.

We do two kind of mapping. One is the same day surgery mapping and the second it's a day before as it says, same day is for the patients who are having surgery today and day before is the patients who are having surgery the day, the next day.

Doses, same day surgery at 0.1 millicuries, and day before is 0.5, it's tiny. Yes, we do use that little syringe. For procedure, you confirm the patient, you confirm the order, and the breast laterality, not just with the patient but also their chart.

Because how many times has it happened, the patient is like, "But I'm getting surgery "on both breasts." The order is for right because there is a reason. They're only doing breast biopsy on the right. Also, it can eliminate them of the wrong orders

that might happen in the system. You wanna confirm. We have a tendency at MSK to look at the consents, the mammograms, the CIS order and so this pathology reports just to make sure everything is in order. I like to educate my patients beforehand.

A lot of patients come in, oh it's a test, it's a nuclear medicine test, they have no clue. I like to just go over it. Any patient that come in after I confirm everything with them, I'd tell them, "So today we are doing "breast mapping, I will be injecting

"a little bit of radioactive isotope "right underneath the skin so it's intradermal, "it goes at the six o'clock perioral, sorry, "peri-areolar area." You can show it on yourself and most patients know what six o'clock is, they're adults.

When I inject, there will be a little pinch and a burning stinging sensation. If the patient has had a recent biopsy or a recent radioactive seed placement, they are more sensitive than others, so at that point, if I know they have had it,

or they say, "Oh yeah, I have had this today," we tell them, "Yes you might be more sensitive to it "than a regular patient. "But just be patient, it will pass. "It is not that long." You inject the isotope, it's like I said,

it's intradermal, so even though that's a PPD test, it kinda looks like that. You do see a little bubble as you inject. After the injection, I'd cover it with gauze, put some paper tape on it, because I really don't want anything else, and I use a couple fingers,

put it at the point and start a pointed massage. It doesn't matter which way you move, just as well you keep it moving, so that it facilitates the isotope to go towards the first draining left node. It disperses the isotope.

I show the patient as I'm doing it, this is how you're doing it, and then I wait there for about 30 seconds to a minute to make sure they're doing it. Some patients, as soon as they start doing it, they go like this, they're caressing,

they're not actually moving it. Some people are being really vigilant and they are like just kinda digging it and you don't want them to get tired before the 10 minutes are up. I just make sure they're doing it right,

tell them, if this hand tires, you can use your second hand and then leave the room. We have, thankfully, we have volunteers whom I can say, "Hey, in 10 minutes, "at exactly this time, can you let the patient know "to get dressed and wait in the waiting area

"until one of our technologist bring them back in "for a 10 to 15 minutes scan." If I do not have the volunteers, I have used a timer, because God knows we have all forgotten whether the patient was in there for more than 10 minutes massaging their breast.

Happens, unfortunately it happens. Someone calls you for something else, and you get busy in that. This is the view, and this is actually, I especially chose this one because you can actually see almost three lymph nodes.

The first, the lower part is the point of injection, and there are a couple up there, that's the anterior and the lateral view. The next day, when the patient goes into the OR, their doctors just have to use their wand to see where the radioactive isotope is.

This picture is actually for us to make sure that it has drained into the lymph nodes.

For Technetium, sulfur colloid, there are patients who have sulfa allergies, and they are really worried that they might just have an allergic reaction to this

because they hear sulfur. I have talked to the doctors as well as our pharmacists, and they have said that it's possible but not probable given that the rate of, chance of an allergy to sulfur colloid is less than 10%. We have injected patients who have sulfa allergies

without pre-medicating them without any problems, but you always know those patients were highly anxious, or they pretty much, they give you a full blown allergic reaction to anything, so you can discuss with their MD and give them Benadryl 25 milligrams PO.

V/Q scan. We use MAA for IV and I did not add D.T.P.A in the aerosol form. Indication. Pulmonary embolism for pre-surgical testing or the patient is unable to have a CAT scan

with contrast because either they're allergic to the iodinated contrast or they have a decreased eGFR. V/Q scan has two components, the ventilation, which has aerosol dose of 40 millicuries and then a perfusion dose IV of five millicuries. Sorry, going back, actually those are the containers

that we use to carry those doses. Ventilation, patient either gets an oral, disposable oral mouthpiece or often disposable mask on their face and it can, the radioactive isotope can be infused with either air or oxygen depending on patient's need.

Patient is told to take nice, deep breath through their mouth, not through their nose. We want them to take deep breaths through their mouth for about two to three minutes until the isotope is all gone, and this part is done all by technologist and then they scan them for about 20 minutes.

Those are ventilation pictures. Where the isotope is, you can see all the darkness, because if there's a PE, it won't travel further. It wouldn't travel because there is a clot. The isotope cannot infuse. Perfusion, that's where the nurse comes in.

You confirm the patient, you confirm the allergies, and you inject. Now MAA is always only injected in peripheral IV, central line, because MAA is very concentrated, so if we inject in central line, including PIC lines or Medi-Ports, it can cause a PE.

We don't really want to do that to the patient. Patient is instructed to take deep, even breaths, so when I come in as I'm putting in an IV or assessing their IV if they have one, I usually talk to them about that time period, and I talk, give them the education

that I will be injecting the radioactive isotope, I will be flushing it with two to three normal saline depending on what kind of IV excess it is and varieties and if it has an extension or not. And I want you to do yoga breathing for me. 'Cause I've had patient who have literally

hyperventilated on me, thinking that they're helping me. Yoga breathing is my term, I really love it. Nice, deep, even breaths and it also helps with the stress. Once you're done, just remember to tell them to breath normally, not, don't tell them stop breathing. Done that, didn't go very well.

- [Audience] Don't tell them to hold their breath. - Yeah, so just breath normally. This is the perfusion picture. As per a doctor's, I'm gonna step up here, it didn't prefuse, stop right up here, so they actually found that PE there

because the isotope did not travel to the full lungs. There was a little PE, so it didn't actually trans. - [Audience] Seeing the black in this case is a good thing? - Yes. - [Audience] 'Cause that means it perfuses correctly. - This is another picture.

It's a perfusion. The darkened areas are where it's not going through the isotope. Yeah. Okay so this is another case where the CT was normal, the doctors were still not sure,

they sent it to us, the ventilation scan went great, the pictures looked great. Then, perfusion scan, you can see the little, a big area, that's darkened, the isotope did not go. Right, the colors are amazing. Contraindication.

Patients who are unable to follow instructions, that could be because of altered mental status or sedation. Patients who are in too much pain because they will not hold still for the scan. And pulmonary hypertension. A regular MAA is 0.5 million particles.

It consists of 0.5 million particles. For pulmonary hypertension, we can only inject up to 100, 250,000 particles. If you use 0.5 million particle, a regular MAA dose, you can cause capillary blockage causing a cardiac arrest right there on the scanner.

Not something we do need. We have had patients who are elderly. We do not know their history or they are unsure, so it's always great to have a doctor in the room while you are injecting, just to be on the safe side and we have had that, especially later in the evening,

when we don't have as much help. V/Q scan, this was one where we weren't sure. Actually the lower pictures are of a patient who was in a lot of pain. Upper pictures are normal. As you can see, you don't know if you're seeing

an angel or vulture. Depends on the patient, right? Or the person who's looking at it. Patient kept moving, instead of breathing in through the mouth, they gasped, and they, the radioactive isotope

went into their stomach and we could see esophagus and the stomach and it was just not a happy scan. It's always great to make sure your patient is comfortable before you start doing all of these procedures with them.

Renal scans.

I'll be talking about MAG 3 renal scan. It can use furosemide and captopril. We don't use captopril as much at MSK. I've only used it twice in the two and a half, three years I've been there. I'll just quickly touch on it.

We use captopril to diagnose either renovascular hypertension or renal stenosis. Again, we don't use it as much. Furosemide is our choice of drug that we use. GFR scan that uses D.T.P.A in IV form. Renal scan MAG 3.

This was, when I put it off, Vera went like, "Is this an infection control slide?" It is not an infection control slide. It's just, I though it was really cute, because-- - [Audience] Are those supposed to be kidneys? - Yes, these are two kidneys.

One is kinda healthy, and the second is very sick, and that's what sometimes you find in the renal scans, that one kidney is working great and the second is just, I don't know, feeling all that hot. Indications. For perfusion and, renal perfusion and function,

renal obstruction, renal trauma, or renovascular hypertension. Renal scan is done in three parts, pre-procedure, peri and post, and I'll go over each one of them. Pre-procedure we try to hydrate our patients

with one liter of water as quickly as they can tolerate. If the patient has any contraindication to that much fluid, our doctors change the order for the fluids. Pediatric, the hydration is done on the pediatric floor by their doctors, and the dose is based on BSA. Initial blood pressure is needed on all of our patients

who are going through the renal scan. Again, education, I like to educate my patients before I start doing anything so that they know what we are doing. Most of the patients, as I'm talking to them, that yes, we will be placing an IV,

I would like you to use the restroom before you go on to the scanner. We will be injecting you under the scanner. And someone will take pictures for about 20 minutes before I come in and inject lasix or furosemide. They cannot move after I inject 40 milligrams

of IV furosemide for about 20 minutes. At that point, I offer them a brief. I try not to call it a diaper, because, I mean, come on, how many adults here wants to listen to the fact that, "Hey do you guys wanna wear a diaper?"

- [Audience] Are you hydrating them orally? - Orally. If they can take it, then definitely orally. Another nurse actually calls the diaper a disposable underwear. - Oh, I like that. - Yeah, right?

Education, because as an adult, if I go for a scan, if someone tells me, "Hey, there's a diaper, please wear it," I would not like it. It's just letting them know why you're giving it to them. They don't have to use it, it's just in case,

it's to protect them, because they will not be able to move for about 20 minutes after the furosemide injection. At that point, it might be 40 minutes. They've already had a liter of water in them. Even then, I always tell my patients,

even when you're wearing a brief, we would still want you to hold it. Because it they do void, or if they have an accident, it creates a background radioactive isotope imaging in the scanner, it can get on the scan, and we would rather just avoid all of that.

I'm pretty sure most patients wants to go home in their own clothes, so that's really important. Just in case. Truthfully most of my adult patients opt to wear it. Renal scan for peri-procedure, again, this is a flow study,

so you're talking with a nuclear medicine technologist. Nurse and the technologist have to be on the same page, ready when you inject. So you confirm with the technologist, are you ready, the scanner is in the right place, one, two, three, go.

You inject your dose eight millicuries, and then you flush it with about 50 to 60 milliliters of normal saline. After that, 20 minutes of imaging, the nurse can usually leave, come back in 20 minutes, inject 40 milligrams of furosemide,

which can be based, it can be increased if the createnine is higher. And then flush it with another 10 milliliter of saline. Leave, they do another 20 minutes of pictures, stop, the patient gets off the scanner, uses the bathroom, comes back

for another five minute picture to make sure the bladder did empty out. These are the imaging. As you can see, there's a really cool, and this is as you're injecting the isotope and the saline. It just gives that picture.

See, going back to my kidney slide, we have left kidney that's pretty healthy and the right kidney is not doing so hot. Actually that darkened area up there is the kidney not able to eliminate all of the urine so it's holding on to the isotope.

20 minutes later, as you can see in the end, lasix is given and slowly they're gonna clear out. Post-procedure, you assess the patient, you get another blood pressure, because you really don't want them to tank. I'll make sure they're all great,

the blood pressure is good, you gave them furosemide. Also, assessing, another assessment, that's really important is their ability to ambulate. You don't ask them, "Do you think you can walk fine? "You think you feel safe?" Walk with them for that initial thing,

for the initial walk to the bathroom or to the hallway because I know that if I really have to go, I'm probably not looking very far. (mumbles). You do not want the patient to fall. So just make sure that they are able

to ambulate independently and you're walking with them. You're not just letting them walk by themselves right after the scan.

The next one is GFR, D.T.P.A. That's another sick kidney. Measures function of the kidneys

for patients with chemotherapy, renal transplant, or evaluation of renal donors. It can also assess kidney impairment. Procedure, educate, I love to use that word. We also require a blood draw, a green tube, before we do the injection.

You inject the D.T.P.A, which is adult dose is four millicuries and child dose is based on their body surface area. You have to back flush the primary syringe that had the isotope multiple times. I personally use three to four flushes

just to make every little drop of isotope is in the patient. You do it because you will be getting a residual. After I'm done, I take that syringe that had, that originally house the isotope, cap it, I'd take it to the pharmacy

along with the paperwork and they check the tube to see, the syringe to see how much isotope is still in there. It is really needed for this GFR calculation that we do for this test because suppose they gave me an exact four.

I've taken the syringe back and there's a residual of .1 millicuries. So the calculation that we will do for GFR will be done from the dose of 3.9 millicuries, and not four. This is a back flush. Let's see if it actually works.

The one with the, and I made it kind of, blurry on purpose so that patient identifiers would not show. The one with the sticker, that is the original syringe with the isotope, and the other one is flushed. Let's see if I can, I don't think this goes. Let me just kind of go over here.

So this is stop clock, you lock it to the patient, put saline in there, lock it to the saline, and flush. And you can do it multiple times, three to four flushes are done. Sorry, let me just make sure, okay, I didn't lose anything.

Post-procedure after that's done, you have your residual, the patient can go under the scanner. Scan is mostly to make sure that there is no infiltration, there is no isotope hanging around in their arm, having a party.

Everything has gone in. It's exactly where we want it in the blood stream. Picture is like a five-minute picture. We have had babies do it without anesthesia if the parents will hold them. You get another IV access for blood draws.

If possible, if you can use the other arm, please try to use the other arm, otherwise try to use a different vein for the blood draw, if there's no other choice. We have also used the midlines and the Medi-Ports for, especially for pediatric patients

because no one wants to stick them again. It's just we use a lot more flush after we inject, and if it's, suppose if it's a central line and I've used red port out, tell the nurse, I have used red port,

please do not use that for the blood draw. Use the other colored port, I don't care, just not the same one. For blood draws, we need two more green top tubes at 90 minutes and then 180 minutes. Adults come to us automatically,

the pediatric goes back to the pediatric service to get the blood draws. They hold it, our technologist actually run the labs, and they're the ones who have the calculations done. That's the GFR picture. Again, it's not a proper scanning picture.

We don't really need it except to make sure that everything went in. As you can see, there is no infiltration. Just a background on this one, it's actually a three-year-old with retinoblastoma, and the GFR was 47 milliliters per minute.

For kids, how many kids, if you do a BMP, you actually see anything, it just gives you creatinine, kid is too young to actually have a GFR. Or for adults, you just see more than 60 milliliter per minute. GFR scan is actually very accurate.

For adults, it can go as high as 100 milliliter per minute for a normal GFR, and for kids younger than two years old, there's a whole chart right there.

Policies and procedures in nuclear medicine. Pregnancy and breastfeeding. Pregnancy, we assess every female

from the age of 11 to 50 years old. Adults get a pregnancy questionnaire and pediatric review is done for pediatric patients in the pediatric area. Their doctors do it before they send the patient to us. If the patient has had a sterilization procedure,

they automatically get pregnancy exemption in their chart so that we don't keep asking them for the same thing over and over again. If the patient is not sure, and trust me, this has happened to me multiple times, the patient will come in, "Maybe I'm pregnant,"

just do the test, it's so much easier to just do the test and if they are hesitating, just be like, "Listen, we understand, "but if you have even 1% chance, let's take the test." It's easier than taking, doing this test and then finding out your pregnant, not worth it.

Breastfeeding. MSK policy at this point is to pump and store the milk for 96 hours. You can, after you pump it, you can date it, time it, and remember, these are isotopes. Even if you're not doing anything, they will decay.

So the milk will be good to use in 96 hours. Again, it is also up to mothers how comfortable they feel, but that's a policy.

Nursing consideration. Claustrophobia, needlestick, results, and first experience. Anxiety has its own, again, claustrophobia.

Most patients have come to us after MRI. I understand. And I usually let them take a peek at our scanner and be like, listen, see? Open scanner. Our techs are really good.

They have dimmed the light for some patients, they have turned on the music that the patient likes, it's pretty good. And sometimes if I'm still talking to the patient, and they're like, I'm not sure, and I told them to go to the zen zone,

or as I call it Rainaland, it's the best place to be. It has exactly everything that I like. Because it's my land. It knows what makes me happy, what makes me anxiety-free, it's the best land to be. It helps patients.

You know, you're laughing, but laughing also helps patient. For needlesticks, we always get those patients and they come in and it's obviously it's the big burly guys who are coming in. "Just so you know, I'm gonna faint on you. "I don't like needles."

I'd tell them, "If you faint on me, "I'm putting your picture up on the hall of fainters." Again, they laugh, they let go of that little bit of anxiety, makes my life very easy. Some patients actually have bad pains.

These are breast patients who only have one arm, who have been stuck multiple times, and you just try to be patient with them, warm them up, educate, and then get the IV. Don't hurry, take your time. Results, some of these patients have had chemotherapy,

other treatments, they are coming in to see, do they still have the cancer. What is it gonna say? Has it spread? Just being sensitive to the fact and not trying to rush them through this

can be very helpful. Also, first scan experience. I've had multiple patients who have come in, "I'm having a nuclear medicine scan." Great, I'm a nuclear medicine nurse. You're in a nuclear medicine department.

Which one? They have no clue, except that their doctor told them they're having a nuclear medicine scan. So just educating them at every point of the process while you're with them is really important and really helpful to them.

Infiltration. You can use a warm or a cool compress depending on the patient preference. There's no solid research out there. Isotope will absorb or decay, this is not (mumbles). The Technetium, it's almost fluid-like,

if you have ever seen it, it's almost like saline. It doesn't actually kinda sit there and can harm the tissues. Our problem come from the based dose, so if I've inject, now we are a big pharmacy, we always have extra, so if I see I've injected some

and there's still some in the saline, in the syringe, and IV has infiltrated, I'll stop, I'll cap the syringe, put it in the appropriate container, take it to the pharmacy, and be like, "Hey the IV infiltrated, can you just help me, "how much is in there?"

They'll do the calculations. So I gave you a dose of 20, there's only eight in here. I can go to our MDs and be like, okay, there was an infiltration, there's eight in the syringe, do you wanna write an extra order for eight? 'Cause I cannot reuse that isotope.

I need a new one. And they'll write it, depending on, if they want seven, they want 10, I'd go back, I inject, and the patient can still have the scan. At any point, I mean if they have had an infiltration, it's better for me, especially with our pharmacy

to just then give them the rest of the dose rather than have them not take the test or take the test and not have good pictures later on. Comfort, environment, bladder, positioning. Environment, I already said, our techs are really good with it.

I've had patients who have actually left feeling great because they have taken a nice 20 to 30, 40 minute nap in the middle of the day. They were really happy about it. Especially the in-patients. They come in, they were like, "Wow,

"that was actually quiet. "I've not slept this good since I've been in this hospital." So we're always happy about that fact. Bladder, we like them to use the restroom about five to 10 minute before they go on to the scanner, not just because we don't want them to move

but also if the bladder is full, it can cover the pelvic area and we don't get the great pictures that we do need. Positioning, we have multitudes of pillows and positioning devices. Our technologists make sure that the patient is comfortable

before they start the scanning so that we don't have to move them later on. - [Audience] You don't really need to explain this one. - Radioactivity. Patients, "I'm gonna pee, glow in the dark urine?" No.

All I can say is, yes, if you see something on the seat, you're not sure, clean the seat up, but that's something you should be doing anyways. The family member does not have to use another bathroom, another toilet, or flush it 10 times. We can still use the same bathroom.

Again, it's not glow in the dark. I know we all wish it, but it's not true. No one is also turning into a superhero, unfortunately. Otherwise I'll be first in line, I'll say that. Well, kind of, probably. Actually this happen, I put that picture up

because we had, I was doing another scan injecting a kid, and the kid comes, and he almost goes on to his four trying to look for something. I'm like, "What are you looking for?" He goes, like, "A spider."

I'm like, "Oh God, I know what you're gonna say." But I still have to ask him, like, "Why are you looking for a spider? "We're really clean, we don't "keep those things around here." He's like, "No I have to catch one,

"and as soon as I catch one, I'm gonna have it bit me, "'cause I wanna turn into Spiderman." Again, like I said, if anyone was turning into superhero, I'll be first one in the line. Yeah, yeah, movies. But again, no one is turning into Spiderman there.

So nursing consideration, we have talked about the kids and the adults, and the patients. For yourself, remember the principal of ALARA. Minimize time near the patient, appropriately shield the procedure room, and increase distance from the patient, distance after the injection.

Don't run away from them beforehand. Wait until you have injected. These are clinic patients. They usually leave anyway, so they go to the scan rooms depending on what it is.

Post-procedure, also at MSK, we give them

a radioactivity card, what that card stands for is it has their name, it has a date, up until the time it will be good for. Since Technitium is six hours half life, and it's good for 10 hour half life, it's good for four days.

When I give this card, I tell them this is your get-out-of free jail card only for radioactivity though. If they are stopped by cops or any other security personnel for radiation only, they can use this card. Behind this card, there are a lot of numbers

for, at MSK, if they are not satisfied, they can always give us a call. And we have gotten those calls. Increased fluid intake, again, Technitium does not affect the kidneys, it's only to get rid of any extra isotope

that's hanging around faster than what it usually would go.

Questions? Again, that's Max, that little baby. That's the dose that's in the syringe that the pharmacy gives us. Nothing, only for GFR, but then I talked about the residual.

For most, that's 20, 10% up or down. Their body acts as, almost, kinda a little bit of shield. So if I'm giving 20, in six hours it will be 10. That's the half life. But it won't go anywhere else.

It stays in the system. And again, it does get eliminated through urine, but nothing that fast. Yeah, it's still the same dose. It's not going anywhere else. That's our policy and procedures.

Our doctors have made, I'm not sure if there's a specific reason for that, but that's how, that's what our policy is. As we are injecting, I'm keeping an eye on it. There's always that you don't, I'm not looking at someone else,

I'm looking at the vein as I'm injecting to keep on assessing it as I'm doing it. Also, that eight millicuries that's in there, I take it to the pharmacy because I don't know if it's eight. They calculate that and then our doctors decide

if they want something comparable, if they want eight, or if they wanna add a couple more to it, write a new order, and then whatever is the new order, I inject according to that. It's actually a very small volume.

For, I think, bone scan, we get fresh doses throughout the days, it could be up to one milliliters, maximum. It's very tiny amount. - [Audience] How would you even know if it's a tiny amount that you did infiltrate the line?

- Because you're paying attention, well again, I'm trying to pay attention to the site of injection. No. I personally have not injected a patient who was intubated. Like I said, if they can't follow the instructions,

it's kinda hard to do it. We, about three to four, and there are days we have done more. We also do them for pre-surgical reasons, so there's that. - [Audience] Not necessarily (mumbles). - No more questions?

Okay, thank you.

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