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 metros In 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

Thank You