Manual of the Medical Department (NAVMED P-117): Chapter 15: Medical Examinations: Special Duty

15-68 Occupational Exposure to Ionizing Radiation

Department of the Navy
Bureau of Medicine and Surgery

(2) Command Responsibility. The commanding officer or officer in charge of each naval facility will ensure that personnel have a radiation medical examination prior to being occupationally exposed to ionizing radiation. If it is known that a visitor is to perform duties requiring a radiation medical examination, the visitor's parent command must determine the visitor's physical qualifications.

(3) Responsibility of Individual. All personnel assigned to duties involving occupational exposure to ionizing radiation will report the following to their supervisor a Medical Department personnel in a timely manner:

(a) Any physical condition which they feel affects their qualification to receive occupational exposure.

(b) Any radiation therapy treatment received.

(c) Any radiopharmaceutical received for diagnosis a

(d) Any occupational radiation exposure received from secondary or temporary employment.

(e) Any open wounds or lesions.

(4) Types of Ionizing Radiation Medical Examinations

(a) Preplacement Examination (PE). Personnel who are being considered for routine assignment to duties requiring occupational exposure to ionizing radiation will be given a radiation medical examination, defined as a preplacement examination, prior to assignment a transfer to those duties.

(1) Personnel who are not routinely exposed to ionizing radiation as a result of their normal duties or occupation and who are not likely to exceed 0.5 rem (0.5 centisievert) per year (e.g., visitors, including messengers, servicemen, and delivery men; emergency response personnel; dentists, dental technicians, and other dental paraprofessionals; explosive ordinance disposal team members; and certain crew members or employees whose exposure is truly sporadic) are not required to have a preplacement examination (see appropriate radiological controls manual for specific program).

(2) Individuals in this category (i.e., not required to have a preplacement examination) who exceed 0.5 rem (0.5 centisievert) exposure in a calendar year, must have a preplacement examination within 1 month of the time they exceed 0.5 rem (0.5 centisievert) or as soon thereafter as operational requirements permit.

(b) Reexamination (RE). Personnel who are to be continued in routine duties requiring occupational exposure to ionizing radiation must have a radiation medical examination, defined as a reexamination, at the periodicity listed in article 15 11. The reexamination is required to be performed no later than 1 month following the anniversary date (month and year) of the previous radiation medical examination or other medical examination accepted and documented as a radiation medical examination, e.g., for an examination performed on the 15th of February 1985, the reexamination must be completed by 31 March 1990.

(c) Situational Examination (SE). Any individual who has exceeded the radiation protection standards for occupational exposure per chapter 4 of NAVMED P 5055, or has ingested or inhaled a quantity of radioactive material exceeding 50 percent of the maximum permissible body burden (MPBB) or as deemed necessary by the responsible medical officer must be given a radiation medical examination, defined as a situational examination. MPBBs are listed in the National Council on Radiation Protection and Measurements (NCRP) Report No. 22 (NBS Handbook 69). MPBBs for commonly used isotopes are found in Appendix A of NAVMED P 5055. The medical history must contain summary statements which provide the basis for performing the examination.

(d) Termination Examination (TE). Reasonable efforts will be made to ensure that a worker receives a termination examination. If a termination examination is not completed or not performed (e.g., due to lack of employee cooperation, etc.), a SF 88 will be completed to the maximum extent practicable. The reasons why the form is incomplete will be recorded in block 73 of the SF 88. Personnel will be given a radiation medical examination, defined as a termination examination, it they satisfy one of the following conditions:

(1) Upon separation or termination of their active duty or employment if they received a preplacement radiation medical examination, have documented occupational radiation exposure (including personnel monitored for exposure but who received 00.000 rem), and have not had a TE.

(2) When permanently removed tram the radiation health program.

(3) When assigned or transferred to duties no longer involving occupational exposure.

(5) Other Examinatlons. Medical examinations other than radiation medical examinations and results of consultations fa individuals physically qualified for routine assignment to duties requiring occupational exposure to ionizing radiation will be reviewed by a medical officer or Medical Department representative for findings a evaluations affecting continued qualifications fa duties involving occupational exposure. The scope of other medical examinations need not be expanded to cover the requirements of this article unless the examination is to be used as a radiation medical examination. Medical examinations performed outside the Department of Defense are not to be requested for routine review. Individuals may submit medical information from their private physicians for consideration by the responsible medical officer. In these cases, the Navy remains solely responsible for determining whether the medical information from the private physician will be accepted or rejected.

(6) Scope of Examination. The medical examination will place particular emphasis on determining the existence of malignant and premalignant lesions and other conditions which could be related to radiation exposure. A medical officer with knowledge of the potential biological effects of ionizing radiation will review any medical history or presence of disease states or abnormalities related to the following: History of occupational exposure to ionizing radiation in excess of that allowed by current directives; history of radiation therapy; a medical conditions which may be associated as having been caused by exposure to ionizing radiation. The radiation medical examination will include, but not be limited to, a careful medical history, physical examination, complete blood count (CBC), urinalysis, and other clinical laboratory studies or procedures, and bioassays, as indicated.

(a) Medical History. A complete medical history on an SF 93 will be obtained. In addition, medical histories will include:

(1) History of occupational or accidental exposure to ionizing radiation.

(2) History of cancer or precancerous lesions.

(3) History of anemia.

(4) History of cataracts.

(5) History of radiation therapy.

(6) History of radiopharmaceutical received fa therapeutic or experimental purposes.

(7) History of work involving the handling of unsealed radium sources a other unsealed sources.

(8) Family history of cancer, anemia, or cataracts.

(b) Medical Examination. The examination will consist of the items described in blocks 18 through 43 of the SF-88 with the following modifications fa civilian personnel:

(1) Pelvic examination (SF 88, block 43) is not required. Breast examinations are required for females age 36

or older. The anus/rectal examination is only required to' male examinees age 36 or older. For personnel who are less than 36, the above examinations may be offered but are not required.

(2) Medical examinations of civilian personnel will be documented on a SF 88 and will include a SF 78, or copy of the front side of the SF 78, with Parts A, B, and C completed as an attachment to the SF 88. The reverse side of the SF 78 need not to be completed. Locally generated items that contain the pertinent identifying data and functional and environmental factors may be used in lieu of the SF 88.

(c) Special Studies. The required special studies are a CBC, with differential, and a urinalysis. In addition, the following special studies may apply:

(1) Internal Monitoring. All personnel assigned to duties involving the handling of radioactive material in a form such that they could reasonably be expected to exceed 10 percent of a MPBB through inhalation, ingestion, or absorption will be evaluated for evidence of a partial body burden before and after assignment to such duties, e.g., at the start and completion of a tour involving these duties. Periodic monitoring will be conducted as deemed necessary by the responsible medical officer or radiation health officer. Additional requirements to perform internal monitoring due to specific work environments will be issued in applicable program radiological contra manuals with BUMED concurrence or as conditions of radioactive material permits.

(2) Radon Breath Analysis. All personnel assigned to duties involving the handling of radium, or its compounds, not hermetically sealed such that they could reasonably be expected to receive 10 percent of a MPBB will have radon breath analysis at the beginning and end of such assignment or following personnel contamination incidents involving loose surface contamination of radium compounds such that the individual could have received 10 percent of a body burden. NAVMED P 5055 provides guidance for obtaining a radon breath analysis. Other methods of determining internal radium deposition may be used if approved by BUMED.

(3) Bioassay. When deemed necessary by the responsible medical officer or radiation health officer bioassays may be performed on body tissues, secretions, and excretions to estimate an exposure from internal contaminates. It a command lacks the capability to perform appropriate bioassays, a request will be submitted to one of the support facilities designated in the NAVMED P 5055.

(4) Additional requirements to perform special examinations due to specific work environments can be provided in the applicable program radiological control manual with BUMED approval.

(7) Standards. The general requirements are those for active duty in the military service or in civil service employment, as amended by this article. Individuals disqualified based upon these requirements may be reevaluated at a later date. The following will be cause for rejection or disqualification:

(a) History of systemic malignancy.

(b) History of radiation therapy which may have compromised bone marrow reserves.

Blood Parameter	Male	Female
Hematocrit (Hct)	40-52%	37-47%
Hemoglobin (Hgb)	13.5-48g/dl	12.5-16g/dl
White Blood Count (WBC)	4,000-12,000/cubic mm
Platelet Count	150,000-400,000/cubic mm

Differential Count

There are two acceptable laboratory methods for determining differential count, manual and automated machine.

Manual	Male & Female
Neutrophils (N) Lymphocytes (L) Bands (BF) Eosinophils (E) Basophils (B) Monocytes (M) Atypical Lymphocytes (ATL)	40-80 percent 20-50 percent 0-10 percent 0-10 percent 0-3 percent 0-10 percent 0-10 percent

Automated

Lymphocytes Monocytes Granulocytes (Neutrophils) Large unstained cells

20.5 51.1 percent 1.79.3 percent 42.2 75.1 percent less than 4 percent

Any clinically acceptable automated blood count method suffices for the needs of the radiation health program. However, it the categorization differs from either of those provided above the normal ranges to the machine used must be recorded along with the results of the study.

Table II

	Male & Female
Hematocrit	35-56 percent
Hemoglobin	11 g/dl-19g/dl
White Blood Count	3,500-14,000/cubic mm
Platelet	less than 100,000 or greater than 500,000/cubic mm

(c) History of polycythemia vera

(d) Cancerous a precancerous lesions.

(e) A family history of cancer which is suggestive of clustering or a genetic tendency toward a specific lesion.

(f) Open lesions or wounds (including lacerations, abrasions, and ulcerative, eruptive, or exfoliative lesions) are disqualifying either on a temporary or permanent basis, depending on the condition, for individuals who handle radioactive material which is not hermetically sealed, until such time as the Medical Department representative or medical officer considers the wound to be adequately protected from, radioactive contamination.

(g) Abnormal blood count

(1) Any deviation outside the ranges of the values in Table I must be evaluated by a medical officer and a determination made as to whether the individual is CD or NCD. The responsible medical officer will comment in item 73 of the SF-88, when the values are not within the ranges of Table I.

(2) Values which persist outside the ranges in Table 11 will be CD until further review. The medical officer's evaluation of the CBC and the requests for other studies or consultations must be directed toward the determination of malignant w premalignant conditions and hematopoietic system reserve.

(h) Urinalysis. Red blood cells (RBCs) in the urine (greater than 5 RBCs per high power field) persisting on repeat urinalysis, will be CD, pending definitive determination of other than a malignant condition. Other abnormal urinalysis results may be of clinical significance (e.g., low specific gravity, positive sugar or albumin, WBCs, or casts) dictating follow-up evaluation at the discretion of the examiner. They are not, however, in themselves disqualifying to occupational exposure to ionizing radiation.

(i) It an individual exceeds 50 percent MPBB the individual must be disqualified from duties involving occupational radiation exposure pending BUMED review. (MPBBs are listed in NCRP Report No. 22 (NBS Handbook 69).)

(j) Other detects which pose a health or safety hazard to the individual, coworkers, or degrade the safety of the work place.

(8) Special documentation Requirements. in addition to the requirements for completing the SF 88 and 93, as listed in MANMED, the following specific requirements will be adhered to:

(a) Use of an overprint or rubber stamp on the SF 93 for the required supplemental history questions is acceptable. Instructions in blocks 19 and 21 of the SF 93 require certain additional information be provided for a positing answer, for the purpose of radiation medical examinations, the name of the doctor, clinic, a hospital is not needed.

(b) All radiation medical examinations require a medical officer's signature in block 82 of the SF 88. This medical officer is responsible for reviewing the complete medical examination including laboratory and other information to determine qualification. The reviewing medical officer may be the same as the examining medical officer. The SF-88 block 82 entry will include the date of final review in the margin immediately below the signature of the reviewing official.

(c) The medical history will be signed by the examining medical officer.

(d) SF 88s and SF 93s performed by PAs or nurse practitioners must be countersigned by a physician.

(e) For block 74 of the SF 88 and block 25 of the SF-93 any entry concerning an abnormal finding will have an indication of NCD a CD per article 15~.

(f) Noncompletion of a radiation medical examination must be documented in block 73 of SF-88 with specific reasons for noncompletion.

(g) Radiation medical examinations will clearly state whether the individual is PC or NPO for occupational exposure to ionizing radiation.

(h) The tact that a termination medical examination is required will be entered on the front of the individual's Health Record jacket or employee medical file as Termination Radiation Medical Examination Required.

(i) Medical examinatians conducted for a purpose other than occupational exposure to ionizing radiation may be amended per anicle 15-10 at the discretion of the responsible medical officer. It a previous medical examination is accepted the date of the required reexamination will be based on the original date (month and year) of the accepted examination.

(j) Results of bioassay, internal monitoring, etc., which document monitoring for internally deposited radioactivity, will be documented as required in NAVMED P 5055.

(9) Reporting Requirements. The following Health Records must be submitted to BUMED (MED 21) for review. The transmittal letter must include the reason for submittal, total lifetime exposure of the individual, summary of the individual's duties, and, if appropriate, the current or disqualifying diagnosis.

(a) Findings on a radiation medical examination which disqualify an individual from receiving occupational exposure to ionizing radiation.

(b) Findings on a medical history or medical examination of:

(1) History of occupational radiation exposure or internal deposition in excess of that allowed by NAVMED P5055.

(2) History of radiation therapy

(3) An excess of 10 percent MPBB of radioactive material not intentionally administered for medical diagnosis or treatment. A description of the analysis technique must be included with the submission.

(4) Abnormal personal u family history of cancer, it family history then the submission must include the family pedigree using standard genetic symbols.

(c) Results of medical examination for which the requirements are not explicit.

(d) Any medical examination or condition which the responsible medical officer or commanding officer recommends for BUMED review. Such request for review will not be denied by any member of the chain of command.

(e) All situational radiation medical examinations.

(f) Allegations or claim by a service member or employee that their physical condition was caused by exposure to ionizing radiation.