Lessons from the Accident at Yanango (192Ir, 1999)

Luis Enrique Barriga MD
Director Ejecutivo, Centro de Radioterapia de Lima SA
Coordinador Emergencias Radiologicas
Mayer Zaharia MD1, Luis Pinillos MD2, Alfredo Moscol MD2, Adela Heredia MD2, Oscar Barriga MD1, & Gustavo Sarria MD2
1Centro de Radioterapia de Lima
2Instituto Nacional de Enfermedades Neoplasicas
Lima Peru

Abstract

Since discovery of ionizing radiation, radioactive sources have been used in medicine, research, agriculture and industry. Safety precautions are essential to limit the exposure of persons to harmful radiation. Radiation accidents are rare, often not immediately recognized and have a very low reproducibility rate. When they do happen, damage has particular features which may delay recognition of the accidental situation that can result in severe injuries and even deaths. A serious radiological accident occurred on February 20, 1999 at Yanango hydroelectric power plant in Peru (San Ramon district 300 km east of Lima). A welder found an 192Ir industrial source on the ground and placed it in the back pocket of his trousers where it remained for several hours thereby receiving a very high dose from the source. As patient arrived at the hospital, his dose was calculated by the Medical Physics Department of the National Cancer Institute of Peru (INEN) based on information provided regarding the time the source was in his pocket. The results were extremely high and led Peruvian doctors to raise the possibility of a hemipelvectomy as a treatment, however a decision was made to delay the procedure and to graft over the lesion in an attempt to save the irradiated limb. Some Peruvian authorities requested foreign assistance and the patient was hospitalized in France where the grafting techniques failed and the limb was amputated a few months later. It has been more than 12 years since the accident and the patient is practically abandoned to their fate and with a great psychological deficit. Common sense could have prevented many severe accidents that resulted in serious injuries or deaths. Delay in identifying the type of accidents results in severe consequences not only for the patient but also for their families. Radiography cameras need to be designed and constructed in a way that prevents unauthorized access to the radioactive source. Persons not directly working with radiation sources, but working nearby, should be given appropriate information and may require training. National authorities must stop being bureaucratic entities and engage in education and supervision.