Day in the Life of a Nuclear Pharmacist

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Well, I’ve been meaning to do this for quite a while since I’m constantly asked and PM’d with questions regarding nuclear pharmacy. It’s a very specialized niche in our field...and unfortunately, many healthcare professionals (and even other pharmacists) have a very vague understanding of what we do.

So, here it goes...a very thorough description (sorry!) of the world that is nookyoolar pharmacy, and what I go through on a daily basis.

To give you a quick overview of the industry’s current standing: nuclear pharmacies are generally either institutional (and cater to a single medical center), or commercial. Centralized commercial pharmacies are contracted by hospitals/clinics to provide radiopharmaceuticals, and there really are only a few major players out there: GE (FKA Amersham), Triad (FKA Tyco, Mallinckrodt, or Covidien), and Cardinal Health (which bought out Syncor, among others)...and smaller independents.

Moly Generators and Compounding Radiopharmaceuticals

Unlike CT/MRI, nuclear imaging is great at assessing function, as opposed to just structure or anatomy. Technetium (Tc-99m) is by far the predominant isotope used...it’s an ideal diagnostic tracer and we use it to compound the vast majority of our radiopharmaceuticals. I won’t go into the gory details, but Tc is obtained by a eluting a generator: a vial of saline is placed at the entry point with an evacuated vial on the opposite end (encased by a heavy tungsten shield). The negative pressure draws the saline through the generator, and a Tc-99m eluate is produced (think radioactive saline). Depending on the amount of activity needed for the run (and the number of doses the pharmacy puts out), several generators are hit throughout the course of the day. This Tc-99m elution is then used to compound most kits.

In a LAFW with an L-block for protection, multidose vials of the various radiopharmaceuticals (also placed into tungsten vial shields) are compounded using specific amounts of Tc eluate and saline. Each drug kit has particular compounding steps (i.e. some require heating, venting, etc.).

The compounder/pharmacist then hands the prepared multidose vials with corresponding prescription labels to technicians, who (in their own hoods) safely draw up unit doses into syringes with the help of a leaded glass syringe shield. These are actually a little heavy and require a lot of dexterity/practice to use properly. The technician draws the volume indicated on the prescription label, and then verifies the activity by placing the syringe into a dose calibrator. The calibrator will indicate the current activity of the dose, as well as what it will read at the desired assay time indicated by the customer. (i.e. 82 mCi now, and 30 mCi at 08:00).

Each unit dose (syringe) is placed into a lead-shielded “pig”, labeled, capped, and placed into a case to be shipped out to the hospital or clinic. When the dose arrives to the customer, a nuclear medicine technician/physician will verify the dose in their own calibrator, and administer the dose to the patient.

In addition, prior to doses leaving the pharmacy, quality control by chromatography is performed on each and every kit that is prepared to ensure the drug is sufficiently bound to the isotope, there are no impurities, etc. USP sets certain percentage requirements for QC to pass for each drug, and each pharmacy may also set even more stringent internal requirements (i.e. 95% purity or above to pass).

Radiopharmacology

This is what really drew me in to the field. Relatively speaking, there are really only a small number of radiopharmaceuticals and nuclear isotopes used, and this allows us to become experts on a good majority of them. 80% of radiopharmacy is diagnostic; however, there are some fascinating and effective therapeutic drugs that we compound as well. Now, I’m not going to go into each and every drug, but these are the big ones, and it’ll give you a good taste for what’s out there.

• Cardiology: this is the bread and butter of nuke med and the major agents used are Thallium-201, Tc-99m Sestamibi (Cardiolite®) and Tc-99m Tetrofosmin (Myoview™). They’re useful in myocardial perfusion imaging (i.e. comparing a ‘rest’ and ‘stress’ image to identify ischemia/infarction), avid infarct imaging (to detect damaged myocardial tissue post-MI) and cardiac function studies (to determine how well the heart is pumping via LVEF). These studies are a great tool for guiding a patient’s course of therapy...determining whether they may need open heart surgery, cath, or strictly risk management with lipid control, etc.

• Brain imaging: Exametazime (Ceretec™), Bicisate (Neurolite®); these agents can be used to screen for tumors, detect metastases, detect intracranial injury, determine legally defined ‘brain death’, identify seizure foci, etc.

• Skeletal imaging: Tc-99m Medronate (MDP) and Tc-99m Oxidronate (HDP); are radiotracers with a bisphosphonate structure that you’re all familiar with. These can be used to assess trauma (i.e. fracture imaging), distinguishing osteomyelitis vs cellulitis, evaluate bone cancer/multiple myeloma, paget’s disease, etc.

• Treatment of bone metastasis: here’s a good example of where nuke medicine is used for treatment rather than strictly for diagnosis. Sr-89 Chloride (Metastron®) and Sm-153 Lexidronam (Quadramet®) can be far more effective than traditional therapy in helping cancer patients suffering from excruciating pain from bone mets.
  
  
• Liver/Spleen imaging: Tc-99m Sulfur Colloid; used to image for hepatitis/cirrhosis, high LFT’s, liver tumor, trauma, abscesses, etc.; where ‘cold spots’ (dark areas) will indicate an abnormality.

• Lymphoscintigraphy: small doses of Tc-99m Sulfur Colloid are injected during surgery to locate lymphatic drainage patterns, guide oncological surgeons, and to identify the location of a sentinel node. The sentinel node (first node downstream from the tumor) can then be sent for biopsy to determine metastasic status.
  
  
• Hepatobiliary imaging: Tc-99m Mebrofenin (Choletec®) is used for gallbladder imaging to differentiate between acute (oftentimes caused by gallstones) and chronic cholecystitis. In acute cholecystitis, the gallbladder will light up in the scan, but does not for chronic disease.
  
  
• Renal imaging: Tc-99m Pentetate (DTPA) and Tc-99m Mertiatide (MAG-3) are used for renal function imaging (i.e. quantifying GFR or tubular secretion), whereas Tc-99m Succimer (DMSA) is used to assess structure/anatomy of the kidney. These are useful in patients with renal obstruction, renal HTN, tumor, trauma, etc.

• Pulmonary imaging: VQ scans are done to differentiate between a pulmonary embolism (lung clot) and COPD. A perfusion test (using Tc-99m MAA) is done first. If the results are abnormal, the ventilation portion of the study (using radioactive Xe-133 gas or aerosolized Tc-99m DTPA) is performed. Normal ventilation will then indicate that the patient has a PE, whereas abnormal ventilation points to COPD.

• Thyroid imaging and treatment: since the thyroid gland naturally takes up iodine in order to produce thyroid hormones, administering radioactive iodine is a logical step in order to assess function (uptake) of the thyroid, as well as image or treat thyroid cancer. Thyroid uptake/function studies are performed by administering I-123 or I-131 NaI, helping to determine hypo-/hyperthyroidism. Thyroid imaging can also be performed to assess ‘hot’ or ‘cold’ nodules on the thyroid; as well as whole body imaging, to look for metastatic tumors during follow-up of thyroid cancer. Thyroid therapy is a classic example of how nuclear medicine is used for treatment purposes. I-131 NaI is administered in higher activities to treat hyperthyroidism (treatment of choice), as well as ablate the gland after surgery to mop up any remaining cells.

• Infection imaging: Ga-67, which is similar to iron, is passively localized to a site of infection and is the drug of choice for chronic infection imaging. Radiolabeled white blood cells can be used to image acute infection, inflammatory bowel disease, fever of unknown origin, osteomyelitis, soft tissue abscess, skin graft infection, diabetic foot ulcer, etc. A hospital will send us a syringe containing 60 cc of the patient’s blood. In our blood room (a completely segregated area from the remainder of the pharmacy), we use a completely needless procedure, involving centrifuging the sample, to extract the patient’s white blood cells. The WBC’s are then tagged with radioactive In-111 or Tc-99m Exametazime (Ceretec™). The patient’s own radio-labeled WBC’s are then sent back to the hospital, within 5 hours they are re-injected into the patient, and scanned to localize the site of infection. On a busy day, we’ll do anywhere up to 12 - 15 bloods.

• Monoclonal antibody imaging/therapy: this could quite possibly be the future for nuclear medicine, as there are so many possible applications for monoclonals. There are a only a handful of agents available now: In-111 Capromab Pendetide (ProstaScint®) to image prostate cancer, and In-111/Y-90 Ibritumomab Tiuxetan (Zevalin™) or I-131 Tositumomab (Bexxar®); however many more are in production. Zevalin™ and Bexxar® are effective treatment options for patients with non-Hodgkin’s lymphoma.
  
  

• PET: this is actually another fascinating area of nuclear medicine that I could go into a lot of detail, but to keep it simple…FDG (think radioactive glucose), which is produced at a facility with a cyclotron, is used to detect areas of the body undergoing high metabolism (think epilepsy, cancer) relative to normal tissue. Since PET looks at the disease on a chemical level, you can identify the disease much sooner than when using other imaging modalities.

• Adjunctive agents: there are a handful of non-radioactive meds that we dispense a lot of too, and they include pharmacological stress agents which are used when a patient isn’t able to exercise prior to a ‘stress’ portion of a myocardial study (i.e. dipyridamole, adenosine, regadenoson, dobutamine); aminophylline (an antidote used to reverse stress agents); and sincalide (to cause the gallbladder to empty for hepatobiliary imaging).

Authorized Nuclear Pharmacist (ANP) Training

Another common question I get: how to go about getting the training you need to become a nuclear pharmacist. You need about 200 hours of didactic training, and 500 hours of hands-on experience to practice under a pharmacy's RAM license...and there are a few ways to go about doing this to become an “ANP”. 1) Attend a pharmacy school that has a nuclear program, which you’ll complete while working on your PharmD (i.e. Universities of Arkansas, Oklahoma, New Mexico, Purdue, Tennessee). Option 2) Once you’ve already obtained your PharmD, privately pay for training (i.e. through NEO). Option 3) Do a nuclear specialized residency (i.e. SUNY or Walter Reed) or Option 4) and this is probably what most people do...get hired by a nuclear pharmacy company; they will pay you pharmacist salary while you do your training, and provide the training as well.

Typical Day at a Nuclear Pharmacy

Most pharmacies will typically have between 1 – 3 set “runs”. I’ll explain a typical day at a pharmacy, just so you get an idea of how the process goes. The night pharmacist comes in at around midnight and takes any new orders off of the recording. They will then begin to hit the generators and start compounding the first run. Technicians and drivers will begin to trickle in; doses are drawn (including FDG brought in from a cyclotron) and packed up. First run is out the door and on its way to customers between 03:00 – 05:00. The pharmacist and technicians then have some down time to clean up, log all of the kits prepared during the run into the computer, grab a bite to eat, etc. 2nd run then starts at around 06:00; a second pharmacist arrives at around 07:00 as this is when the phones start to pick up with same day add-ons from the customers. 2nd run is out the door by 08:00. A third and fourth pharmacist arrive at 08:30. One of them will generally be designated to work on the bloods; another will help answer the phone, take orders, deal with customer service issues, etc. 3rd run compounding (which is usually pretty light), begins at 10:00 and is out the door by 11:30. I-131 capsules will need to be compounded at some point as well. Throughout the day, we’ll field phone calls ranging from STAT add-ons to clinical questions (i.e. pediatric dosing, altered biodistribution, questions about drug selection, etc.). The rest of the day is generally spent setting up for the next night: order entry, drawing any doses (i.e. Thallium, which has a long half-life) that can be drawn the day prior. Scripts are printed, double-checked and any products needed for the next day are ordered. So, as you can see, the daytime hours are generally spent getting ready for the following night. The last pharmacist locks up sometime around 17:00 and is on call for the remainder of the night.

Radiation Safety

This is always one of the main concerns/questions people ask me about nuclear pharmacy (and rightly so). Radiation safety and proper handling of all RAM is at the forefront of the training you receive. Employees are required to wear ring badges on each hand (to monitor extremity exposure) as well as a body badge at collar/thyroid level (to monitor whole body exposure). Rings are monitored weekly, and badges monthly, to assess each employee’s radiation exposure. The US government has set limits (i.e. 5 REM/year for whole body exposure, 50 REM/year for extremities, etc.). In addition, companies will oftentimes have even stricter limits than these, and will assess each individual as necessary if their exposure approaches action levels. Most of the times, this will entail adjusting ones compounding techniques to ensure practice of “ALARA” principles. Each pharmacy will also have a “Radiation safety officer” (who may or may not be a pharmacist), and they are responsible for overall safety at the pharmacy: monitoring air concentrations, training personnel, and keeping employees under all federal/company radiation guidelines. Pregnant women can officially declare their pregnancy to the company as well, and will receive an additional fetal badge to be worn near the belly. She will have even stricter limitations to restrict the amount of radiation exposed to the child.

Advantages of Becoming a Nuclear Pharmacist:

It’s a very specialized field and there’s a general appreciation for the training/education that you’ve put in. Salary is very good (generally comparable to retail). There’s no insurance to deal with, since the hospital/clinic is responsible for billing the patient. As you saw in my description of a typical day, (barring any problems), the pace is generally pretty relaxed and you’ve got some lag time, especially at night. There’s no dealing with the general public (although this can also be seen as a disadvantage to some people). You become very close with your staff (technicians, drivers, admins). You also get to know your customers very well over the phone; I’ve become good friends with many of the nuclear pharmacy techs and physicians too. You are treated as a professional and they value your input and services. After you’ve gotten enough hours under your belt, you’re also able to become board certified (BCNP) if you so desire; nuclear pharmacy was the first specialty area established by the BPS. There’s definitely opportunity for job growth through management, etc. Nuclear is a neat balance between clinical pharmacy, physics, chemistry, math, management, business/sales, customer service, issues like <797>; there’s a little bit of everything for everyone.

Disadvantages of Becoming a Nuclear Pharmacist:

The reality is, you are dealing with radiation and biohazardous material (i.e. blood). You are however, provided with the training for how to deal with this properly, and it’s in your own interest to do things by the book. Over-night hours are another stickler for some people. A fully staffed pharmacy though, will permit pharmacists to rotate their hours. It may be possible that you will only have to work the opening shift one week out of every two? four? six weeks?..depending on the needs of the pharmacy. Specializing in nuclear also requires you to keep up with “regular” pharmacy. Hospital/retail pharmacists don’t exactly know what Cardiolite® is, but nuclear pharmacists rarely talk about the new factor Xa inhibitor anticoagulant either. I’ve also been asked whether it’s difficult to find a job as a nuclear pharmacist. The answer is: no…it’s not hard to find “a” job; you’re a well-trained specialist and there will always be a demand for you...however, unlike retail pharmacies, you’re not exactly going to find a nuclear pharmacy on every corner. As a result, it may take a little longer to find “the” opening you want, in the specific city/state you’re interested in.

So…if you’ve actually gotten through all of this, I’m highly impressed! And you’ll have a better understanding of what nuclear pharmacy is relative to 99.9% of the general public...because if I tell anyone that I’m a nuclear pharmacist, I generally just get a blank stare of bewilderment. If you’re even remotely interested in the field, I highly suggest taking an elective at your school if one’s offered, sign up for a nuclear rotation, or even contact a nearby pharmacy to shadow someone for a day. I know the ID guys are going to jump on me for this one, but generally speaking...and excluding empiric therapy, you can’t treat a patient unless you know what you have on your hands. I love that nuclear medicine is able to provide some of those answers, and provide some interesting treatment options to patients. It’s an exciting area to practice in!

Even after writing all of this, I’m sure I’ve left some things out...so if you have any other questions, let me know!

Thanks! This is great...can we sticky?

Thank you! You did an awesome job giving me a better understanding of the field as a whole and I feel significantly more informed after reading it than what searching online was giving me. Physics has always been a second love of mine I even graduated with a minor in Biomedical Physics. This stuff has always kept my interest; I love how it is always cutting edge. A few questions...

-Do most facilities have pharmacy students as interns in any respect? I know that we're talking about a very specialized area that most interns would have no training in, but who knows. My school doesn't offer any rotations in the field so I'd probably be finding something in the summer on my own to gain some experience before jumping in after I graduate.

-What's the average burn out rate for Pharmacists you've worked with? I know you had recently posted about looking to leave the field, was is something about the field itself, or a personal matter?

-Can you give me some of your personal pros and cons about working in the field? What aspects drew you to it? What do you wish you'd done/known before applying to work in the field?


Thank you again.

WOW. fantastic! thanks so much! this defintly needs to be a sticky. this is really cool bc not much people know about this and now you have elightened many to a different opportunity and path of pharmacy. thanks for ALL the info and taking the time to write all this. defintly worth the wait. better info then most sites offer on nuclear pharm!

So wait, what does a nuclear pharmacist do again?

Just kidding. I shadowed some pharmacists at a nuclear pharmacy for about a week, and you pretty much summed up what I learned during that time in a few paragraphs. I felt like you were describing the specific pharmacy I was at (minus the FDG) lol

Wow! Thanks for all that crazy insight Spiriva! That's great in-depth coverage of your field and niche. It's given me greater insight to how radiopharmaceuticals are Q/Ced and whatnot.

Question to you though, what's your Total Lifetime Risk of developing cancer as a result of being in such proximity to these drugs? Hopefully it's not as bad as being a toxicologist?

Also does your company QC drugs to greater than 95% purity? The med-chem dept at my company was under pressure to exceed 99.9%. Talk about crazy!

Originally Posted by jasonargos

Thank you! You did an awesome job giving me a better understanding of the field as a whole and I feel significantly more informed after reading it than what searching online was giving me. Physics has always been a second love of mine I even graduated with a minor in Biomedical Physics. This stuff has always kept my interest; I love how it is always cutting edge. A few questions...

-Do most facilities have pharmacy students as interns in any respect? I know that we're talking about a very specialized area that most interns would have no training in, but who knows. My school doesn't offer any rotations in the field so I'd probably be finding something in the summer on my own to gain some experience before jumping in after I graduate.

-What's the average burn out rate for Pharmacists you've worked with? I know you had recently posted about looking to leave the field, was is something about the field itself, or a personal matter?

-Can you give me some of your personal pros and cons about working in the field? What aspects drew you to it? What do you wish you'd done/known before applying to work in the field?

Thank you again.

Yeay, I'm glad it helped! Let's see....

No, I wouldn't say that most pharmacies have interns working with them at any given time, but many do.

Many pharmacies post summer job openings (check company websites for postings prior to the summer for positions). And as you mentioned, a summer internship would be a great way to get your feet wet (and get paid too!).

Average burn out rate: From what I've experienced, it seems like pharmacists realize rather quickly whether nuclear "fits" them or not. To give you a rough estimate of the longevity at my pharmacy: 7 pharmacists and an average of 10.1 years each. And that's including a wave of 2 new pharmacists that were just hired a few months ago (so they each contributed 0 years)! So, people seem to bail within the first year/two and jump ship, or really make a career out of it...

As far as the personal frustrations/concerns that I was voicing...those are strictly aimed at the current situation I'm facing, and the developments occurring here at my lab. And honestly, I think it has a lot to do with growing pains and transitions we're currently going through. So, I wouldn't really apply those across the industry. I wouldn't take the time to promote this field if I didn't feel it was a good area to practice in. There are aspects of "regular" pharmacy (for lack of a better word) that I miss; however, even if I decide to accept another position in an inpatient setting, I'm sure I'll stay active as a nuclear pharmacist in some regard.

Personal/pros cons? I don't really have a lot to add besides the ones I discussed above. Like I mentioned, it was the radiopharmacology and drugs that really drew me in. I had always anticipated doing a PGY1 and 2 residency, but I took the elective nuclear course during pharmacy school...and that sealed the deal. It would have been nice to have gotten some more experience in nuclear pharmacy...but I got a lot good experience in other areas too that I wouldn’t have wanted to pass up. I'm a firm believer in becoming a well-rounded person (both professionally and personally)...as well as an expert/specialist in something you truly enjoy. It's hard to make an impact otherwise.

Originally Posted by AggiePharmer

Wow! Thanks for all that crazy insight Spiriva! That's great in-depth coverage of your field and niche. It's given me greater insight to how radiopharmaceuticals are Q/Ced and whatnot.

Question to you though, what's your Total Lifetime Risk of developing cancer as a result of being in such proximity to these drugs? Hopefully it's not as bad as being a toxicologist?

Also does your company QC drugs to greater than 95% purity? The med-chem dept at my company was under pressure to exceed 99.9%. Talk about crazy!

I have loads of studies that go into the effects of radiation and mutation/sterility/cancer, etc. Most of them are actually from sources such as the Radiation Effects Research Foundation (RERF), which studied 90K + survivors from the bombings in Hiroshima and Nagasaki. Interestingly, these data are what everyone uses to set protection standards. There are also plenty of others from lab animal studies, nuclear workers, survivors of Chernobyl, etc. But the bottom line is, occupational doses received in a nuclear pharmacy (chronic small doses received repeatedly over a long period of time) show no statistical increase in negative health effects. There's actually a theory called 'hormesis' (and forgive me if you're already aware of this term, but for those who aren't...), it claims that something harmful (i.e. radiation), can actually be beneficial in low doses. It's controversial, but some cell culture studies demonstrate increased repair mechanisms after exposure to low doses (low obviously being the key word).

In reality though, we're watched closely on our exposures. Companies have set very conservative limits and action levels...and I feel very safe working within these. X-ray techs for example, get higher exposure than we do.

Since you seem interested QC...I didn't go into too much detail initially, but we use ascending radiochromatography for the majority of our QC'ing. Solvents include polar (distilled water, NS, 20% saline, etc.) and non-polar ones (acetone, ethyl acetate, ethanol, etc.) and then various papers for the stationary phase (silica gel, whatman, silica acid). Chromatography will help determine radiochemical purity (i.e. determine whether the Tc has actually bound to the drug sufficiently). Since you asked about the pressure we feel to pass QC...from my experience, if a kit is going to fail, it is going to fail miserably. Borderline numbers usually indicate a failure in QC procedure (i.e. cutting the paper incorrectly, contaminated solvent, etc.). If the numbers fall between passing USP regs and failing corporate ones, it is the pharmacist's discretion to override the test. Our pharmacy's policy is that if the test fails twice for the technician, the RPh will try a third time. If it fails again, throw the kit away and make a new one. I'd much rather make up a new kit than have 15 hospitals calling with poor scans (and inconveniencing the patient). These are good drugs though, and assuming the pharmacist compounds them correctly, QC numbers should be in the high 90%'s. I don't know about shooting for 99.9%+ every time though.

Originally Posted by OKgirl

Sorry to semi-threadjack....

Do nuclear pharmacies allow people to shadow them? I'm pretty interested in it (from what I've read) and I just want to see if I really do like it. I also have a few other questions.

Originally Posted by FastLane051

Nah its ok because that was my second question acttually!
I Think I will try doing this for 2 weeks during my month long christmas break!

But what does everyone thing, could we just shadow a nuclear pharmacist?
I have working in a hospital in-patient pharmacy for 4 months 40hours a week.

Of course you can shadow, and I'd highly recommend it if you are at all interested. Although, 2 weeks is a little excessive to be "shadowing" a pharmacist in any setting. Try to set something up through your school (i.e. are there any nuclear pharmacy preceptors?). Otherwise, contact a nearby pharmacy (locations: Cardinal Health, Covidien, GE, Independents), explain that you are a pharmacy student and are interested in visiting the lab...they should be happy to accommodate you!

How big is nuclear pharmacy in Canada, Europe and the rest of the world? I wonder how things go over there (do these same companies have international branches)

I'm gonna do a nuclear rotation, but waking up at 2AM really turns me off especially when I want to schedule that rotation in January...ughh...

And thanks for posting that Spiriva!! I know you spent a lot of time on it. We really appreciate it.

Spiriva, thanks for the in-depth review of what nuclear pharmacist do, much appreciated!

Does insurance cover radio-pharmaceuticals or does the hospital pay out of pocket?

Hospitals and clinics view nuclear pharmacies as any other supplier/vendor. We charge each account per dose based on the agreed contract price (if they have one, or, a non-contracted price). The hospital or clinic will then in turn bill the third-party payer. Hospitals are now limited to billing per procedure (i.e. it's bundled into just one code). However, for the time being, outpatient clinics are permited to bill under three codes. As a result, hospitals are limited on the amount they're reimbursed. This is why the person responsible for billing at the hospital has to be extremely careful...there are many codes for each procedure (and it can make or break whether the hospital is reimbursed for each correctly).

So, there's the long-winded answer to your question, but, yes! Insurance companies and Medicare/Medicaid definitely cover nuclear med procedures.

and i thought i really wanted to pursue clinical pharmacy.. until now! thanks so much for allowing us to "online shadow" a nuclear pharmacist. this was an amazing experience and am now aspired to become one! I live in california and found out there are many nuclear pharmacies near my home. again, thank you very much!!

Thanks, this is great information for a pharmacy student (P3)

Awesome to see fellow Pharm.D doing this. I think this is like a mixture of biomed +technology + physics +pharmacy.

How does a nuclear pharmacy get rid of its waste material?

It depends on the type of waste.

The restricted area of the pharmacy has a radioactive waste breakdown room that contains a few large lead-shielded barrels. Bags and ammo cans that return from the customers are brought in each day and broken down. Syringes are segregated into different barrels according to the isotope...short-lived ones (i.e. Tc-99m) in one barrel, longer-lived ones (i.e. Ga-67, In-111, Tl-201) in another, etc.

Once the barrel is full it's sealed and stored in the pharmacy for at least ten half-lives...and then once it has reached background levels (which you determine by using a survey meter), it can be disposed as "regulated medical waste". This is biohazardous material (since the needles have been injected into patients) that we send off to Stericycle.

Other non-biohazardous trash that we produce in the pharmacy during compounding (i.e. gloves, pads) can be thrown in the regular trash as long as it isn't hot.

The generators which we use to obtain Tc-99m are good for 14 days. Lantheus generators are sent to us with lead shielding, and once we buy them, they're ours (i.e. we have to break them down, and store the Mo-99 cores for a few years). Covidien generators are sent out with depleted Uranium shielding (and therefore can ride in passenger aircraft). They can't be broken down, and Covidien provides a return box to send the generator back to them.

The pharmacy produces tons and tons of lead waste too from all the material we receive...which we sell by the pound each month to be recycled.

Another big thing...all radioactive symbols/signs on packaging must be obliterated prior to throwing it out in the trash. We can get audited/fined big time if someone finds that in a dumpster.

I've attempted to explain what goes on in a nuclear pharmacy for months to my family. I think I confused them more than anything.

So, I had them sit down and read your post today. Thanks for making it easy on me! It sums up my experience quite nicely.

Bravo

Originally Posted by Eleen

I've attempted to explain what goes on in a nuclear pharmacy for months to my family. I think I confused them more than anything.

So, I had them sit down and read your post today. Thanks for making it easy on me! It sums up my experience quite nicely.

Bravo

Hah!

It took me a decent amount of time for my fam to get it too...now they're extremely interested and ask me about all of the interesting cases we get (i.e. Down's syndrome child with Graves' who requires I-123, VIP flying in for Zevalin, etc.) - minus the patient details.

So what's your take on nuclear and how does your experience differ (so that others can have a different perspective).

I gather you're doing the AU program at Arkansas? Best of luck!

New commercially available drug just hit the nuclear market: AdreView™ (I-123 mIBG) for detecting pheochromocytomas and neuroblastomas. Prior to this, we used to custom compound it, but will cease doing so now that the FDA approved product is available.

It's a neat time in the industry...the first generic version of Sestamibi (Cardiolite®) just hit the market a few weeks ago. This is big!

Originally Posted by SpirivaSunrise

Hah!

It took me a decent amount of time for my fam to get it too...now they're extremely interested and ask me about all of the interesting cases we get (i.e. Down's syndrome child with Graves' who requires I-123, VIP flying in for Zevalin, etc.) - minus the patient details.

So what's your take on nuclear and how does your experience differ (so that others can have a different perspective).

I gather you're doing the AU program at Arkansas? Best of luck!

Yep, nuclear was my top choice even before I realized that AR had a dedicated program. I lucked out!

Other than a difference in hours and staffing, my experience is pretty much the same.
We opened at 2am (that was great); and only needed two pharmacists, one early, one day shift.

I urge anyone interested in nuclear to do an internship/rotation for sure. It will be difficult to convince me that this is not the best fit for me. I love it!

What do you wear at work in nuclear pharm? Theres a discussion now about what pharmacists should wear at work. Do you wear jeans?

I generally stick to business casual; dress slacks, a nice blouse/collared shirt and heels. Other days, I'll go with scrubs (just ordered a pair of Gator ones! ). Occasionally put on jeans if I'm in the mood for a "casual Friday". I don't visit accounts wearing jeans/scrubs though.

You are required to put on a lab coat to enter the restricted area of the pharmacy though (and this goes for guests too)...allows for quick removal if there's any contamination. When I'm working with bloods, I'm sure to put on Tyvek sleeves too.

Awesome post. I signed up for a nuclear elective a couple months ago... and hoping I get it as a rotation too. Did you make your contacts through a clerkship?
Go Gators!

Originally Posted by ethyl

Awesome post. I signed up for a nuclear elective a couple months ago... and hoping I get it as a rotation too. Did you make your contacts through a clerkship?
Go Gators!

Nice! Definitely hope you enjoy the elective...and hopefully you'll get the rotation too. I took the nuclear elective as a P3 (taught by a practicing ANP), and that's definitely what reeled me in. I made most of my contacts through my professor, and the local pharmacy manager for the company that I knew I wanted to work for.

If/when you get a rotation, be sure to share your experience. Hopefully you'll like it. And yes!! Go Gators!!

Originally Posted by SpirivaSunrise

Nice! Definitely hope you enjoy the elective...and hopefully you'll get the rotation too. I took the nuclear elective as a P3 (taught by a practicing ANP), and that's definitely what reeled me in. I made most of my contacts through my professor, and the local pharmacy manager for the company that I knew I wanted to work for.

If/when you get a rotation, be sure to share your experience. Hopefully you'll like it. And yes!! Go Gators!!

Wahoo! Got my rotation with GE for nuke pharm. I had no idea GE was into nuclear medicine before this thread. I'll be sure to post how things went in a few months

First, how many hours do you work a week? I have heard you get paid a 40 hour work week but only work like 30 hours. Also, can you work part time if you wish?

I'll preface this by saying that I work in one of the busiest pharmacies in the country. Our full-time pharmacists are salaried, and we'll work a minimum of 40 hours/week. Being salaried allows us the flexibility to take a few hours off here and there if we need to pick the kids up early, go to a dentist appt, etc. On the other hand...I won't leave a co-worker swamped with a ton of work, so will more times than not work far more than 40 hours/week. We do have a part-timer on staff too, and she'll usually work 2-3 days/week. So yes, it is possible to find part-time positions in the field as well.

Now, the reason I prefaced this by saying I work at a very busy pharmacy is...yes, there are slower nuclear pharmacies across the country (think the Shreveports, Hattiesburgs, Charlottesvilles, etc.), whose number of hospitals they serve is far far less, possibly allowing them to get the runs out much faster and work fewer hours. So, these are probably the type of pharmacies you've heard of. It all goes into the trade-off of where you like to live, metropolitan vs. rural, the size of the pharmacy, and their staffing situation.

On another topic, I work in the pharmaceutics department at my university. Will having an extended background in compounding help me out at all?

Compounding background of any sort would absolutely help as a nuclear pharmacist. Whether you have background working in the IV room in a hospital, infusion pharmacy, etc...all of those skills would translate well to the "compounding" side of our job, from being able to do all of the calculations, aseptic technique, working with a "recipe" and always thinking one step ahead; planning the run in your head depending on which doses are most critical; this would definitely be a great background. But remember, being a nuclear pharmacist isn't all about compounding in the hood like a robot. You have to be good at everything from the clinical applications, customer service, managing your technicians, drivers, etc....it's a very wide range of duties.

Also, do techs get paid well? I was thinking about trying it out while being in pharm school.

Nuclear pharm techs will generally make $15-20/hour. Students who want to work in a nuclear pharmacy during school will most likely work weekends. To begin with, overnight hours during the week would be pretty hard to pull of while taking classes...and there are no doses drawn in a nuclear pharmacy during the late afternoon. Weekend runs are a great shift to get a taste for work in the pharmacy though, because the pace is much slower.

By all means, if you're interested...contact your nearby pharmacies and see if they have any openings!! You'll just have to be persistent until you find something.

Originally Posted by ethyl

Wahoo! Got my rotation with GE for nuke pharm. I had no idea GE was into nuclear medicine before this thread. I'll be sure to post how things went in a few months

Awesome! Can't wait to hear how it goes.

Originally Posted by ethyl

Wahoo! Got my rotation with GE for nuke pharm. I had no idea GE was into nuclear medicine before this thread. I'll be sure to post how things went in a few months

I am working on setting up a rotation with Cardinal right now... Red tape red tape...

Congrats - definitely let us know how it goes.

~above~

Hi. I recently shadowed a nuclear pharmacist and was wondering how difficult is it starting up your own nuclear pharmacy compared to a retail pharmacy?

Originally Posted by Mwz1024

Hi. I recently shadowed a nuclear pharmacist and was wondering how difficult is it starting up your own nuclear pharmacy compared to a retail pharmacy?

First off, you’re going to have to apply for a RAM license...and this process will differ whether you want to open the pharmacy in an “Agreement State”, (a State where the NRC has granted them authority to regulate the use of byproduct RAM), or an NRC State.

You’re going to have to have the facility in mind and the layout...about 3,000 SF would probably do for a small pharmacy. You’re going to need to submit a diagram detailing everything from where you’ll store generators, waste, the compounding area, restricted/unrestricted areas, hood and filter system if you’ll be compounding iodine (including environmental impact study since you’ll be venting this into the air), airflow patterns, etc. It’s a very exhaustive license/application, but the easiest thing to do is model one after an approved license of an existing, established pharmacy.

Then of course, you’ll have to apply for a pharmacy license in that State, as you would for opening any type of pharmacy. Keep in mind that each State may also have specific requirements specific to nuclear pharmacies as well. For example, here’s Florida’s inspection form, giving you an idea of some of the requirements necessary.

$1 million funding is probably a good estimate to begin with, since you’re going to have to buy all of the equipment to furnish the pharmacy. You’ll also need this to start, since vendors will not supply you with the drugs unless you have the money on hand. Purchasing and overhead is actually not as daunting as with a retail pharmacy however, since the drugs are generally much cheaper.

As with any business, location is key, and you’re going to need to have customers that are committed to moving their business to you before you even open. Best idea is to find an area with hospitals/clinics who are not satisfied with the local business. Can you get the doses to them cheaper? Faster? Find an area with poor service. Logistics is a big issue in nuclear pharmacy because of the time sensitivity of these doses. Hospitals don’t like to call you with stat orders and hear that it’s going to take 3 hours to get them.

Reality is, you’re going to need inside experience before opening a nuclear pharmacy. The majority of indy owners/pharmacists are most definitely trained former employees of the Syncors (Cardinals)/Covidiens, etc. And like any new business owner, don’t expect to make a huge profit right off the bat. You’ll be pulling long hours, making deliveries, and so on. But sooner than not, you can be very very successful. And ultimately your goal will be to get big enough to be bought out by one of the big guys, retire early, and enjoy life.

On a side note...UPPI would be a great resource for those interested in independent nuclear pharmacy.

I'll be doing an internship this summer with GE. I'm a P1, hopefully this experience confirms my choice to pursue nuclear.

Hi there,

First of all, thank you for this awesome subject!

Now, i want to know if i have any chance to do nuclear pharmacy in the USA, knowing that i'm algerian, & i will get my PhD in two years? so please can you clarify this issue for me!
Thanks again!
Zak

Originally Posted by ThisisZAK

Hi there,

First of all, thank you for this awesome subject!

Now, i want to know if i have any chance to do nuclear pharmacy in the USA, knowing that i'm algerian, & i will get my PhD in two years? so please can you clarify this issue for me!
Thanks again!
Zak

I'm presuming you mean as an ANP? Because regardless, nuclear pharmacists are first and foremost...pharmacists. So as long as you can become an RPh in the US, becoming an ANP will be secondary.

Best of luck to you! What are you earning your PhD in?

Wow...when did you do this? You must have a lot of free time!

Wow, impressive explanation of what we do spiriva... I won't hold it against you that you left out the best school for nuclear ;-)

You might do up to 15 bloods a day?!? Holy crap!

Originally Posted by PurduePharmD07

Wow, impressive explanation of what we do spiriva... I won't hold it against you that you left out the best school for nuclear ;-)

You might do up to 15 bloods a day?!? Holy crap!

Seriously? I left out Purdue??

Oooops! And I work with a bunch of you Boilers. Consider it fixed!!!

Yeah; we'll average 8-10 bloods a day...but more when it's busy. You out there working as an ANP?

yep... coming up on 2 years practicing next month, hard to believe!

Originally Posted by ItsOverZyvox

Wow...when did you do this? You must have a lot of free time!

I'm sure it's "work" time!

Can you provide more information about salary of NP? Like promotion, and the highest pay?

Thanks,

Originally Posted by 5minutes

Can you provide more information about salary of NP? Like promotion, and the highest pay?

Thanks,

Generally on the higher end of retail in the same given geographical area...with a slight variance according to the saturation/need of nuclear pharmacists in the area.

Promotion will differ for each company, but from my experience, there is huge room for growth if you work for it.


Posted via Mobile BlackBerry Device

My nuclear rotation was awesome. My first few days consisted of me getting a hang of the regulations and safety training... lots of manual reading. :P Then I got to start eluting generators, making kits, drawing doses, processing pigs in and out, etc.. The really cool part was when I got to make some I-131 capsules using a recently purchased machine that helped to limit exposure. I was still moving 100+ curies around but I did that quickly. I really had no idea how volatile that powder truly was until I surveyed my throwaway sleeves a few times after entering the iodine hood... and they were hot every single time I exited the hood.
I did the 1AM shift for a week and it wasn't that bad. There were so many things to do that it turned 9AM in a flash. It did take a day or two to adjust back to normal sleeping which would be worth it for me not to have to deal with customers and insurance at a retail pharmacy. It was difficult to remember to go to sleep early for those morning shifts so I would sometimes accidentally stay up till 8-9PM.
My only difficulty was visualizing all the math in my head. I've always been horrible with numbers. It's all pretty simple math (blah mCi / blah mL = blahh mCi / x mL) but I would tend to mix up simple things. I got the hang of it by week 4 though.

All in all, it was a lot of fun and I think nuclear could definitely be a career for me. And a useful tip: Offer to help out the couriers and technicians and they'll love you plus you'll always be able to find things to do.

Originally Posted by ethyl

My nuclear rotation was awesome. My first few days consisted of me getting a hang of the regulations and safety training... lots of manual reading. :P Then I got to start eluting generators, making kits, drawing doses, processing pigs in and out, etc.. The really cool part was when I got to make some I-131 capsules using a recently purchased machine that helped to limit exposure. I was still moving 100+ curies around but I did that quickly. I really had no idea how volatile that powder truly was until I surveyed my throwaway sleeves a few times after entering the iodine hood... and they were hot every single time I exited the hood.
I did the 1AM shift for a week and it wasn't that bad. There were so many things to do that it turned 9AM in a flash. It did take a day or two to adjust back to normal sleeping which would be worth it for me not to have to deal with customers and insurance at a retail pharmacy. It was difficult to remember to go to sleep early for those morning shifts so I would sometimes accidentally stay up till 8-9PM.
My only difficulty was visualizing all the math in my head. I've always been horrible with numbers. It's all pretty simple math (blah mCi / blah mL = blahh mCi / x mL) but I would tend to mix up simple things. I got the hang of it by week 4 though.

All in all, it was a lot of fun and I think nuclear could definitely be a career for me. And a useful tip: Offer to help out the couriers and technicians and they'll love you plus you'll always be able to find things to do.

Can you please tell what kind of machine that you use?

Originally Posted by 5minutes

Can you please tell what kind of machine that you use?

I'm not sure. It was an automated machine that goes in the iodine hood where you place the syringe and capsule in particular holders, place the vial in a holder with a venting needle, use the touch screen computer to plug in the amount of iodine you want injected in the capsule.. then let her run.

Originally Posted by ethyl

I'm not sure. It was an automated machine that goes in the iodine hood where you place the syringe and capsule in particular holders, place the vial in a holder with a venting needle, use the touch screen computer to plug in the amount of iodine you want injected in the capsule.. then let her run.

I just finish one class called Instrumental Analysis. I was just wondering if they use any of these machines that I have learned: IR, NMR, and Mass Spectrometer.

Originally Posted by 5minutes

I just finish one class called Instrumental Analysis. I was just wondering if they use any of these machines that I have learned: IR, NMR, and Mass Spectrometer.

Sounds like Organic Chemistry...

I think I may want to go into nuclear pharmacy rather than retail.
Do nuclear pharmacists stand on their feet ALL day?
If so, please tell me that they move more than a retail pharmacist.
I don't want to have varicose veins by standing for too long as a pharmacist!

your information was really helpful and in fact i never even knew that nuclear pharmacy existed..well the problem ia that i am a bachelors student here in india and i am interested in pharm d. but i am unable to find the required info regarding my admission in a university in the US. it would be really great of u if you could let me know what is the procedure for me to enter into this after completing my 4 years graduation .would i have to go in for prepharmacy as well? and here in india we dont have communication as a subject and that is a requirement ..so what should i do?

Tango,

Your first step to applying is to research the US pharmacy schools you want to apply to:
http://www.pharmcas.org/collegesscho...alphastate.htm

Pharmcas is the place where you apply, submit PCAT scores, submit transcripts, submit letters of recommendation, submit your personal statement. It is the centralized location for applying to pharmacy schools (although not all pharmacy schools use pharmcas)

I have included two examples for what is required additionally from international applicants:
http://www.pharmacy.umn.edu/pharmd/a...international/
http://web.pacific.edu/x23355.xml

Notice that they generally require:

• TOEFL (test of english as a foreign language exam,
• Certificate of finances,
• and have your transcript evaluated by an accredited foreign transcript evaluation service)
• and also a visa

In addition to having your TOEFL, finance certificate, foreign transcript evaluation, and visa, you will need to complete standard items:

• PCAT exam (pharmacy college admissions test), sign up at:

http://pearsonassess.com/haiweb/Cult...t/pcathome.htm

• complete all pre-reqs (bio I and II, Chem I & II, Calc I, Speech, etc., Exact pre-reqs depend on school)
• get at least 2, sometimes 3 letters of recommendation from: professors, work supervisors, or pharmacists who are your supervisor
• write a good personal statement describing why you chose pharmacy (you like chemistry, you like helping people, parents told you to, etc.) Of course dont say the last reason.
• get pharmacy experience to see if you like it.

The Fall 2010 cycle opens up in June. You should submit everything by November or you will be rejected for sure. Call up or write to schools you are interested in for more details, or arrange a meeting with an adviser. Thats your best bet.

So in summary you should research which schools you want to apply to: that may depend on which city you want to live in or other factors.

Best of Luck,

--
Regarding communication, Speech 10100 is a required pre-requisite course for 98% of US pharmacy schools, you should take that course at a community college.