Safety Checks of X-Ray Units Fall Far Behind

Inspections of radioactive material users and X-ray machines--the cornerstone of government efforts to protect the public from the hazards of radiation--are seriously behind schedule in California and there is little prospect that the backlog will soon be eliminated, The Times has learned.

The findings, garnered during interviews and a review of official records, come at a time when authorities in the last several weeks have carried out two highly publicized enforcement actions against USC and the University of California, San Francisco, on grounds that they violated radiation safety regulations.

Staff Shortage

But state and county officials said that those actions belie a breakdown in radiation safety inspections in Los Angeles County and other areas of the state because of what they call a “chronic” staff shortage.

Nearly 100 medical, research and business users in Los Angeles County of such radioactive materials as Cesium-137, Strontium-90, Cobalt-60 and Iodine-125 are overdue for inspection--at times years behind schedule--even though documents show that some licensees have a history of violating radiation safety regulations.

More than 8,400 medical and dental diagnostic X-ray machines in the state are also overdue for inspection, about 3,200 of them in Los Angeles County, 230 in Orange County and 690 in San Diego County, according to state records.

For every X-ray machine that is overdue for inspection, Los Angeles County officials believe that there are at least an equal number of machines that have gone undetected--and uninspected--because they have never been registered with the state, a misdemeanor offense. Los Angeles County officials said they do not have the time or personnel to find those machines.

While there have been no reports that anyone has suffered any adverse effects from overexposure to diagnostic X-rays, state and county officials said they are concerned that the unmet inspection schedules will contribute to a breakdown in radiation safety and unnecessarily increase the risk of radiation-induced cancer.

“The value of radiation materials program and X-ray program to protect the public and workers is being undermined by the fact that we do not have adequate staffing to do the job,” Joseph Karbus, chief of the Los Angeles County Health Service Department’s radiation control unit, said in an interview.

An additional 214 industrial X-ray machines in the state, which are 10 times as powerful as diagnostic machines and can be lethal to workers, are also overdue for inspection by the California Division of Occupational Safety and Health, again because of a shortage of personnel.

One state official, who asked to remain anonymous, observed: “You can’t do the kind of shadowing, surveillance or close monitoring that maybe you want to have. The (licensees)) read you like a book--you don’t have the time. They cut a few corners on procedures, and you’d never be the wiser. Suppose you took away every Highway Patrol officer on the road? You know what’s going to happen.”

Medical physicists say that X-ray machines should be checked every six months to a year to make certain that patients are not being overexposed to radiation.

Los Angeles County health physicists have found that virtually every facility they inspect is exposing patients to higher doses of radiation than needed for a good X-ray because of violations of one or more radiation safety regulations governing the equipment and its use. But records indicate that some Los Angeles County machines have not been checked for 25 years. Inspectors report that they routinely find X-ray operators failing to shield the reproductive organs of patients when taking X-rays of other parts of the body. In other cases, X-ray beams irradiate wider areas than the area of clinical interest.

“I have seen a chest X-ray of a baby” that included everything “from the top of the head to the tip of the toes,” Los Angeles County health physicist Kathleen Kaufman said.

The diagnostic and therapeutic use of radiation in dentistry and medicine is the single largest man-made source of radiation exposure to the public, outstripping fallout from nuclear weapons testing, authorities say.

Generally, the risk to an individual posed by X-ray examinations can be slight compared to the medical benefits of detecting and correctly diagnosing and treating a health-threatening condition. On the other hand, a routine chest X-ray when there is no previous pathology may not be worth the risk. Authorities say that the risk and benefits of each examination must be considered individually.

Medical authorities generally agree, however, that the lower the X-ray dose, the lower the risk of eventually developing cancer.

The developing backlog of inspections in Los Angeles County is blamed by its radiation management office on the county’s refusal to raise salaries to attract needed inspectors, even though the state is willing to pick up the cost. The county is under contract with the state Department of Health Services to oversee most X-ray and radioactive materials inspections in the county. County salaries are 8.5% to 11.1% lower than the state’s.

The county has maintained that if it raised the salaries of its radiation inspectors, it would have to also raise the salaries of other county employees who are in the same bargaining unit but whose pay increases would not be covered by the state.

County radiation officials are given high marks by state and federal authorities for their competency and expertise. But there is only one full-time, permanent health physicist, one temporary full-time health physicist and their immediate supervisor, Albert A. Ferguson, who are responsible for overseeing 480 radioactive materials licensees.

There are five X-ray inspectors for 14,000 registered X-ray machines. State and county officials said 10 are needed.

Karbus said there is little likelihood that significant inroads will be made in reducing the backlog. State officials offered a similar assessment of the X-ray inspection backlog in other areas of the state.

The backlog was considered serious enough several months ago for the state to temporarily reassign several of its own inspectors to help Los Angeles County take up the slack.

The 179-count criminal complaint brought against the USC health sciences campus and 10 of its researchers last month was the result of an inspection by state authorities, even though the county had that responsibility.

County officials said they did not have the time or the personnel to inspect USC, despite the fact that the university has been repeatedly cited for violating safeguards.

Some users of radioactive materials with a history of violations have not been inspected since 1983, even though the county’s own priority system sometimes requires an annual inspection.

A 1983 inspection of Harbor-UCLA Medical Center in Torrance, for example, found “evidence of a general overall loss of control of the use of radioactive material.” The hospital promised in writing that it would comply with regulations, and the county closed the case with one observation.

“Your compliance with these items will be reviewed during the next inspection (then due in September, 1984),” officials wrote the hospital.

To date, the hospital apparently has not been re-inspected by the county, according to available records.

Even when X-ray machines are operating as designed, there is no guarantee that a patient will be receiving the lowest necessary dose of radiation, authorities said.

Roland A. Finston, director of health physics at Stanford University, said that doses from perfectly functioning machines can vary widely because of differences in the training, competency and techniques of those who take the X-ray and because of differences in equipment, film, filters, screens and image-quality preferences of the health-care provider.

Hospital radiology departments get far better reviews, in part because they must be accredited every three years by the Chicago-based Joint Commission on Accreditation of Hospitals.

In Los Angeles and Orange counties, inspectors have said that the dose of radiation for an identical X-ray can vary as much as 25 times because of differences in equipment and operator technique. Canadian studies have found that some X-ray machines are giving doses from two to 100 times the dose needed for a good examination.

Unlike Washington state, there is no law in California that sets any standard for developing X-ray film. Unlike Vermont or Illinois, California sets no enforceable limit on doses for various X-ray examinations--just recommendations.

For example, Finston said, dentists have been known to use higher levels of radiation than may be necessary in order to shorten the time it takes to develop the film while the patient is waiting. Officials in Los Angeles and Orange counties say that remains a widespread practice.

Because the state does not have enforceable regulations limiting doses for various kinds of X-ray examinations or mandatory rules for assuring quality development of X-ray films, inspectors say their visits are all the more important.

“Often our recommendations can have a greater impact on patient exposures than our notices of violations,” Kaufman said.

Jim Hartranft, program chief for the Orange County Health Care Agency’s radiologic health section, said there should be a law regulating X-ray film developing facilities and techniques. Lower speed film and old chemicals can result in either higher radiation levels to compensate for the slow film or re-takes of the same X-ray until an acceptable picture is produced. In both cases, patients and X-ray operators are subjected to higher doses of radiation.

For the time being, however, he said he can only make recommendations.