Nuclear Medicine Trainee Manual
A structured route into nuclear medicine for the new technologist, radiographer or registrar: what to learn first, in what order, and how to know you’re ready. Work through the sections in order; each ends with what “competent” looks like.
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Orientation & safetyPhysics you needInstruments & QCRadiopharmacy & injectionFirst studiesInto PETTherapy basicsCompetency checklist- From day one, work by time, distance, shielding and containment: wear your dosimeter every shift, monitor hands and bench after every manipulation, and know the spill procedure before you need it.
- Run the daily flood and dose-calibrator constancy checks before imaging; if QC fails, the camera is down until physics clears it, so never work around a failed flood.
- QC Tc-99m kit preparations for radiochemical purity (e.g. ITLC) as kit instructions and local policy require, since free pertechnetate or hydrolysed Tc spoils the image; then measure the dose in the dose calibrator, decay-correct to injection time and shield the syringe.
- Before injecting, check patient ID, study, activity and laterality against the request; avoid extravasation and document it if it happens, and record the net injected activity (pre-injection minus syringe residual).
- For FDG PET, prep is the study: fast 4–6 h, control glucose, keep the patient warm and rested to avoid brown fat and muscle uptake, and log injection and scan times precisely because SUV depends on standardised uptake timing.
Explain it simply
- From day one, limit time near radioactive material, keep your distance, use shields and keep sources contained. Wear your radiation badge every shift, check hands and bench after each task, and learn the spill plan early.
- Check the camera and the dose meter every day before scanning patients. If a check fails, the camera stays out of use until the physics team clears it; never work around a failed check.
- Test prepared tracers as the kit instructions and local rules require, to confirm the radioactive part has attached, or the scan can fail. Then measure the dose, correct for decay and shield the syringe.
- Before injecting, check the patient’s identity, the test, the dose and the correct side against the request. Avoid the dose leaking outside the vein, note it if it does, and record how much actually went in.
- For FDG PET, prep decides the result: fast 4–6 hours, control blood sugar, keep the patient warm and resting so fat and muscle don’t take up tracer, and log exact timings, which the uptake value depends on.
A guide only: follow your departmental protocols and regional requirements.
Week 1 · Orientation & radiation safety
Before you touch activity, learn the geography and the rules. Nuclear medicine is the one imaging discipline where the patient becomes the radiation source, so containment and contamination control sit alongside the classic time/distance/shielding.
Learn the department layout
- Controlled/supervised areas: hot lab, injection room, imaging rooms, therapy suite, waste store. Know the boundaries and the signage.
- Where the kit lives: dose calibrator, survey meter, contamination monitor, spill kit, decay store, PPE.
- Flow of a patient: reception → screening → injection → uptake wait → imaging → release.
The safety habits from day one
- Time · Distance · Shielding · Containment. Work efficiently, step back between tasks, use syringe/vial shields, keep sources contained.
- Wear your dosimeter (body ± ring) every shift; know your finger doses come from drawing up + injecting.
- Monitor hands + bench after every manipulation; know the spill procedure before you need it.
- Never eat/drink in the hot lab; gloves for everything; label everything with isotope + activity + time.
Competent when you can walk the patient pathway, name every controlled area, use a survey meter + contamination monitor correctly, and run the spill procedure from memory.
Week 1–2 · The physics you use
You don’t need the whole textbook to start; you need decay, energy, and why the camera “sees” what it sees. The Physics & Artifact Atlas covers it in depth; here’s the working minimum.
Decay
Activity halves every half-life. Tc-99m 6 h, F-18 110 min, I-131 8 d. You’ll decay-correct doses constantly. Learn to estimate in your head (one half-life = half left).
Emissions
γ for imaging (Tc-99m 140 keV), β⁺→511 keV pairs for PET, β⁻/α for therapy. The emission dictates collimator, shielding and whether the patient needs release rules.
Energy window
The camera only counts photons near the photopeak (e.g. 140 keV ±10%); this rejects scatter. Set the right window for the isotope.
Attenuation & scatter
Deep photons are absorbed (false cold areas); scattered photons blur contrast. Hybrid CT provides the attenuation map; scatter is corrected separately (energy-window or model-based methods). Closer detector = sharper image.
Competent when you can decay-correct an activity, pick the right collimator + energy window for an isotope, and explain why a central “defect” might just be attenuation.
Week 2–3 · Instruments & daily QC
The scan is only as good as the daily QC. Learn to run it, read it, and know what a failure looks like before you image a patient on that camera.
Gamma camera / SPECT QC
| Test | Typical frequency (follow your manufacturer, physicist and national guidance, which differ) | Checks |
|---|---|---|
| Uniformity (flood) | Daily | Even response across the field; spots = PMT/crystal fault |
| Centre of rotation (COR) | Periodic (weekly to quarterly, by programme) | SPECT alignment: error → blurred tomographic images |
| Resolution + linearity (bar phantom) | Weekly to quarterly, by programme | Spatial resolution + straight-line fidelity |
| Energy peaking | Daily | Photopeak centred in the window |
PET QC & the dose calibrator
- PET: daily normalisation/blank + periodic calibration and NEMA performance.
- Dose calibrator: constancy (daily), linearity (quarterly), accuracy (annual), geometry (setup) in one common (US-style) schedule; intervals differ by country and manufacturer (the US NRC now defers to the manufacturer’s instructions or national standards), so follow your local QA programme. This is the legal measurement of what the patient gets; treat it seriously.
Competent when you can run daily flood + dose-calibrator constancy, recognise a failing PMT on a flood, and know which QC gates a study.
Week 3–4 · Radiopharmacy & injection technique
From generator to syringe
- Elute the Mo-99/Tc-99m generator; record eluate activity + time.
- Reconstitute the cold kit (MDP, MAG3, MAA…) per instructions; note tagging + expiry.
- QC the product: radiochemical purity (ITLC) confirms it tagged; free pertechnetate/hydrolysed Tc fails the image.
- Draw + measure the patient dose in the dose calibrator; decay-correct to injection time; shield the syringe.
- Check patient ID, study, activity, laterality against the request (and, for therapy or higher-activity sodium iodide I-131 in the US, the prescription or written directive).
Injecting well
- Good IV access; avoid extravasation. A paravenous dose ruins quantitation (and lymphoscintigraphy) and is a contamination + dosimetry issue. Document if it happens.
- Flush; record site + time; note any residual activity in the syringe (net injected = pre − residual).
- Right tracer, right patient, right time before imaging (uptake time matters: FDG 60 min, bone 2–4 h).
Competent when you can dispense + QC a Tc-99m kit, measure/decay-correct a dose, safely inject without extravasation, and cross-check ID/activity against the request.
Week 4–6 · Your first studies
Start with the high-volume planar/SPECT studies. For each, learn the prep, the timing, the positioning and the one thing that ruins it. Full protocols live in the Study & Protocol Explorer.
Bone scan
MDP (activity set by your local authorised protocol), image 2–4 h, hydrate + void. Whole-body ± SPECT/CT. Ruined by: urine contamination, poor hydration.
Renal (MAG3)
Activity set by local protocol; dynamic 20–30 min, hydrate + empty bladder. Diuretic for obstruction. Ruined by: dehydration, full bladder.
Myocardial perfusion
Gated SPECT, stress + rest, nil caffeine. Some departments give a fatty meal, milk or water to reduce liver and gut activity; evidence is mixed, so follow local protocol. Ruined by: breast/diaphragm attenuation; check gated wall motion.
Lung V/Q
MAA perfusion + ventilation, recent CXR. Reduce the number of MAA particles in pulmonary hypertension, right-to-left shunt, pneumonectomy or single-lung transplant, and in children (EANM 2019). In pregnancy, EANM recommends a reduced-activity, perfusion-first protocol; follow your department’s protocol. Ruined by: clumped MAA hot spots.
Thyroid
Pertechnetate or I-123, stop interfering iodine. Ruined by: recent contrast/amiodarone.
Hepatobiliary (HIDA)
Fast 4–6 h, no opioids, dynamic 60 min ± morphine/CCK. Ruined by: recent opioid, over-fasting.
Competent when you can set up, position and acquire the six core studies unsupervised, spot an inadequate study, and know when to add SPECT/CT.
Week 6–7 · Into PET/CT
What changes with PET
- 511 keV photons penetrate: more shielding, more distance, tighter time discipline; a PET patient is a bigger external source than a Tc-99m one.
- FDG prep is the study. Fast 4–6 h, control glucose, keep the patient warm + rested (brown fat + muscle uptake wreck the scan), quiet uptake room.
- Uptake timing is standardised (~60 min for FDG) because SUV depends on it; log injection + scan times precisely.
- CT component for attenuation + localisation; understand the added dose + breath-hold/arms-up positioning.
Competent when you can prep + position an FDG patient correctly, handle 511 keV safely, and explain why glucose, warmth and timing protect the SUV.
Week 7–8 · Therapy, safely observed
You won’t run therapy solo early, but you must understand the governance and the aftercare, because release + contamination control involve the whole team.
The therapy mindset
- Every therapy needs your jurisdiction’s authorisation (in the UK an ARSAC practitioner licence and employer licence under IR(ME)R 2017, in the US a written directive under 10 CFR 35.40), plus a specialist prescription and, often, dosimetry.
- Patient release is calculated (e.g. US NRC: dose to others below 5 mSv, with activity-based release criteria for I-131 in NUREG-1556 Vol. 9; other countries set their own rules) with written radiation-protection instructions.
- Excreta are a major contamination hazard for unsealed therapies: contamination control (Lu-177/I-131 urine, Ra-223 faeces; I-131 also saliva and sweat); and the gamma emissions of I-131 and Lu-177 add external exposure to others.
- Know the common agents: I-131 (thyroid), Lu-177 DOTATATE/PSMA, Ra-223, Y-90 SIRT.
Competent when you can explain the release process, give correct discharge instructions under supervision, and manage therapy contamination safely.
The competency checklist
Sign off with your supervisor as you go. This is a learning aid, not a formal competency framework. Map it to your local/professional-body requirements.
Safety & QC
- Uses dosimeter, survey meter + contamination monitor correctly
- Runs and interprets daily flood + dose-calibrator constancy
- Executes the spill/decontamination procedure independently
Radiopharmacy & injection
- Elutes generator, reconstitutes + QCs a Tc-99m kit
- Measures + decay-corrects a patient dose; records net injected
- Injects safely; recognises + documents extravasation
Acquisition
- Sets up + acquires the six core planar/SPECT studies unsupervised
- Preps + positions an FDG PET/CT patient correctly
- Recognises a non-diagnostic study + common artifacts
Governance
- Cross-checks ID/activity/laterality against the request (and, for therapy, the prescription or US written directive)
- Explains patient-release + discharge instructions
- Knows escalation + incident-reporting routes
Structured logbook + assessments
Pro will turn this checklist into a signable logbook with per-study assessment forms, a QC troubleshooting flowchart, and exam-mapped revision for NMTCB / ARRT(N) / ASMIRT / CAMRT.
High Yield Imaging · Trainee Manual. Educational orientation aid. Your departmental protocols, professional-body competencies and ARSAC/NRC authorisation are authoritative. Never work outside your assessed competence or supervision.
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Educational reference for imaging professionals. It does not replace local policy, manufacturer labelling or clinical judgement.