All emergency patients at our clinic receive a CT scan for treatment planning.

It is preferable that
a therapist perform the CT and a dosimetrist be available for any questions that may arise, but
there are times when the dosimetrist does the scanning as well as the planning of the patient if a
therapist is not available. Even in emergency situations, proper identification of all patients is
crucial. In a study done by Ekaette and Lee et al,1 it was found that patient misidentification was
the most probable incident to occur during the simulation process. Our facility has a “red rule”
that must be followed prior to any procedure for every patient; the red rule requires that two
forms of identification must be verified with no exceptions.

After a plan is completed, MU second checks are performed by dosimetry and a physics check is
also done prior to any treatment being given. One step in our normal process that can be delayed
with emergent cases is the check that is normally done by the therapists prior to scheduling the
treatment. This is done as a third check after the plan leaves dosimetry and physics and before
the patient is scheduled. Generally, this check is there to catch any scheduling processes that
may have slipped through the cracks such as coordinating with chemo, pacemaker check prior to
treatment, proper imaging being scheduled, etc. With emergency cases this check is generally
delayed until the next day.

In some cases our doctors will have dosimetry do a “quick” 3D plan on Trilogy to get the patient
started and then the following week will ask that the patient be switched over to our
Tomotherapy machine for IMRT. In these cases it is extremely important to ensure there is
proper communication and documentation. Many times when planning a 3D plan there will be
shifts made from the marks that were placed in CT. It is practice to remove the CT marks after
the patient has had their verification simulation prior to their first treatment; however, if the
patient is going to be switching over to our Tomo machine the plan will have been created from
the CT marks. It is important to communicate this to the therapists so they know to keep the
initial marks placed in CT so they will have them to set-up from for the IMRT treatments.
Because much of our process is kept the same for emergency patients, it is in the instances where
a patient will switch machines after a few treatments that provide the most potential for error.

1. Ekaette E, Lee RC, Cooke DL, Iftody S, Craighead P. Probabilistic fault tree analysis of a
radiation treatment system. Risk Analysis: An International Journal. 2007;27(6):1395-1410.
http://dx.doi.org/10.1111/j.1539-6924.2007.00976.x