ELECTRICAL SAFETY 332

13 Electrical Safety
Most of the apparatus used in diathermy and electrotherapy is plugged into the mains
supply - 240 volts AC with a frequency of 50 Hz. Any apparatus of this kind represents In Australia, the UK and many
a potential hazard: the risk of electric shock. In this chapter we consider how a shock other countries the mains
can occur, its likely effect and methods of shock protection. supply is 240 volts AC at a
frequency of 50 Hz. Other
It is convenient to distinguish two kinds of shock mechanism; these are macroshock countries (including the USA)
and microshock. use a 120 volts, 60 Hz supply.

* Macroshock: The familiar mechanism which has posed a risk since the advent of
commercially supplied electricity. Here current flows from the body surface, through
the skin and into the body. In order to produce harmful effects a relatively large voltage
and current are needed. A high voltage is needed to produce a sufficiently high
current as the skin offers a high electrical impedance. A high current is needed as
current spreads as it flows through deeper tissues and it is the current density (in A.m-
2 or mA.cm-2) which determines the physiological effects.

* Microshock: As a result of increasing sophistication in medical technology the

patient, in a hospital setting, may be connected to a number of pieces of apparatus For the clinician in an
some of which provide a direct electrical pathway to the heart (for example a intensive-care ward, the risk
myocardial electrode or a transvenous catheter). A very small current applied directly of microshock is an important
to the heart via this pathway can be fatal. Only a low voltage is needed as the consideration. In private
subcutaneous tissues have a low electrical impedance and the current is localized, practice, the potential hazards
resulting in a high current density. are less likely to exist.

How to get a shock

To avoid the risk of electric shock, it is necessary to understand how it can occur. In
order to produce an electric shock two conditions must be satisfied. Firstly the victim
must complete a circuit and secondly the current levels involved must be high enough
to produce an adverse reaction.

ELECTRICAL SAFETY 333

Suppose a person inadvertently contacts one terminal of a battery. In this situation no

shock can occur. A shock current can only flow when the person completes a circuit
and current is able to flow from one terminal through the person and ultimately to the
opposite terminal of the battery. In order for a current to flow the person must
simultaneously contact both terminals of the battery. This is illustrated in figure 13.1.

Figure 13.1
A person must 'complete a circuit' for
shock to occur.

In figure 13.1(a) a shock can not occur, regardless of the size of the battery voltage, as
there is no continuous pathway for the current to travel. In figure 13.1(b) current is able
to flow from one terminal of the battery, through the person, to the opposite terminal:
the circuit is complete and a shock can result if the current flow is large enough.

SIZES OF SHOCK CURRENT

For shock to occur the current flowing through the person must exceed a certain level.
Currents below about 10 mA (0.01 amps) when applied to the whole body via the skin
are unlikely to cause an electric shock. This is because the current is distributed
through the body so that the amount of electrical energy applied to a particular organ
is small. Macroshock only poses a significant risk if the current level exceeds 10 mA.
ELECTRICAL SAFETY 334

By the same token a current in excess of about 100 µA (0.0001 amps) applied directly
to the heart (for example via a myocardial electrode) may be fatal. The microshock
risk threshold is more than 100 times lower than that of macroshock. Shocks are described in
terms of current flow and not
Table 13.1 shows the effect of macroshock, i.e. when current passes through the skin voltage. A shock's effect is
and through the body: that is when the shock is not given directly to vital organs. The determined by the amount of
values quoted refer to mains frequency (50 Hz) AC, since shock via the mains supply current which flows through a
is the greatest hazard in most situations which the physiotherapist will encounter. For particular organ, not the
figures appropriate to DC and other frequencies see Standards Association voltage which produces it.
publication AS/NZS 60479:2002.

Table 13.1
Effects of shock current through body.

While any amount of current over 10 mA is capable of producing painful to severe

shock, currents between 50 and 250 mA are potentially lethal. At values as low as 20
mA breathing becomes laboured, finally ceasing completely even at values below 75
mA: the victim can suffocate due to uncontrollable contraction of the muscles of the
thorax and abdomen.

ELECTRICAL SAFETY 335

If the current exceeds about 50 mA, ventricular fibrillation of the heart is likely to occur -
an uncoordinated twitching of the walls of the heart's ventricles. Once ventricular A fibrillating heart is unable to
fibrillation is induced the heart will not spontaneously revert to its normal pattern of pump blood so the victim will
beating. Normal cardiac rhythm can only be restored by administering a massive die unless first aid (cardiac
current pulse from a cardiac defibrillator. The machine, which should only be massage and artificial
operated by qualified personnel, supplies a short (3-4 ms) current pulse with an respiration) is administered
instantaneous amplitude of up to 40 to 80 amperes. Such high currents forcibly until medical help arrives.
clamp the heart. When the clamping action ceases the heart is more likely to revert to
its normal pattern of contraction.
For shock currents above about 250 milliamps, the muscular contractions are so
severe that the heart is forcibly clamped during the shock. This clamping protects the
heart from going into ventricular fibrillation and the chances of survival are improved.

From a practical viewpoint, after a person is knocked out by an electrical shock it is

impossible to tell how much current passed through the vital organs of his body.
Artificial respiration must be applied immediately if breathing has stopped: if no pulse
is detectable external cardiac massage should also be applied.
An important question is 'how much current will flow if a particular voltage is applied
externally i.e. to the skin surface'. This depends more on the skin impedance than
on the impedance of deeper tissues. The impedance of deeper tissues depends on
their shape and volume, but does not vary a lot. Between the ears, for example, the A useful rule-of-thumb is that
internal resistance at low frequencies (less the skin resistance) is 100 ohms, while in most practical situations,
from hand to foot it is close to 500 ohms. the deep-tissue impedance
is around 200 Ω.
The skin impedance varies much more than that of the underlying tissue. For 50 Hz
AC it can be lower than 1000 ohms for moist skin to higher than 0.5 megohms for dry
skin.
The body current flowing when a person contacts the mains supply (240 volts) is
calculated from Ohm's law to vary between 0.5 mA when the skin is dry and 240 mA
when the skin is moist. If the victim is startled from an initial mild shock, sweating can
ELECTRICAL SAFETY 336

result in a lowering of skin resistance and a rise in current from sub-lethal to lethal
levels in a short space of time. This is one reason why it is essential, in an electric
shock situation, to terminate the shock current as quickly as is safely possible. Perspiration is an unfortunate
accompaniment to pain and
HOW SHOCK CAN OCCUR: MACROSHOCK fright. This lowers the skin
resistance and increases the
To understand the hazards associated with the use of mains powered apparatus we shock current.
need a clear picture of the way in which mains electricity is supplied.
The very high voltage electricity which is generated at power stations is distributed by
cables to electricity substations where step-down transformers reduce the voltage to a
lower value. A single, large step-down transformer may be used to supply the 240
volts to many buildings in a residential neighbourhood. Large buildings in a city (for
example a hospital) may have their own step-down transformers. Figure 13.2 shows
the essential features of the power supply to a building.

Figure 13.2
Mains supply to a building
(schematic)

ELECTRICAL SAFETY 337

One terminal of the stepped-down supply is earthed at the electricity substation. This
is called the neutral line. When the substation serves several buildings the neutral
line is normally also earthed at the fuse box in each building. As we will see later, earthing
the supply affords a simple
240 volts AC is thus supplied to the fuse box in a building using two wires, the active but efficient means of primary
wire and the neutral wire. The neutral wire is nominally at earth potential (zero volts) protection against shock
and the active wire is at a high potential. The active line connects through a power hazard situations.
meter to a switch and fuse or to a circuit breaker. From the fuse box, power wires run
to light switches and power outlets. Power outlets have three terminals; an active, a
neutral and an earth terminal. The earth terminal is connected to a wire which is
physically connected to earth at the building. Figure 13.3 shows the connections of
the active, neutral and earth wires to a power outlet socket.

Figure 13.3
Wiring convention for an Australian
power outlet (viewed from the front).

Both the neutral and earth terminals of a power point are

normally at earth or ground potential. However, it should not
be assumed that the active terminal (on the left in figure 13.3)
is the only hazardous one. For example it is quite possible for
the active and neutral connections to be inadvertently
interchanged when the power point is installed. Mains-
powered equipment will still function normally when plugged
in to the power point: the fault can only be determined by a
specific test.
Even when the power point is correctly wired it is possible for the neutral terminal to
be above ground potential. This happens when appliances which draw a high current
ELECTRICAL SAFETY 338

are connected to the same circuit. A high current flowing in the neutral line will result
in a potential difference between the power point neutral terminal and the connection
to earth at the fuse box. This is because the resistance of the neutral cable, while For these reasons both the
small, is not zero. If the neutral wire has a resistance R and carries a current I, the active and neutral terminals
potential difference produced is given by Ohm's law as V = I.R. of a power point should be
treated with equal respect
In what follows we assume that the power point is correctly wired and consider other when considering potential
hazards associated with the mains supply. shock hazards.

In normal operation, when an appliance is plugged into the mains outlet, current flows
between the active and neutral terminals. The earth wires does not normally carry any
current. The earth connection is only provided as a safety measure.

The advantages of a three-terminal mains supply can be seen by inspecting figure

13.4.

Figure 13.4
Earthing of mains-powered apparatus casing.

The circuitry within the apparatus (represented by an equivalent resistance Re in

figure 13.4) is powered from the active and neutral wires. The earth wire is connected
to the casing of the apparatus to ensure that there is never any voltage on the casing.
The idea is that if the active wire within the apparatus makes accidental contact with
the casing a very high current will flow through the earth wire to ground. The low

ELECTRICAL SAFETY 339

resistance of the earth wire ensures that the current flow will be large enough to blow
the fuse, thus cutting off the active supply. In this way, the casing of the apparatus can
not become 'live' and present an electric shock hazard to anyone touching it. For this reason a fuse should
never be replaced with a
As long as the earth wire and connections remain intact there is no risk of shock from conductor other than a fuse
touching the apparatus. of the same rating.

Some apparatus - electric shavers and hair dryers are examples - is 'double Australian Standard AS3100
insulated'. The casing is usually made of a non-conducting plastic and special requires that double
precautions are taken to ensure that an electric shock is virtually impossible. The insulated apparatus has two
advantage here is that no reliance is placed on an earth wire which could come loose distinct and independent
or break. In fact, no provision at all is made for an earth connection to the apparatus. layers of insulation. Failure of
The use of the double insulation principle is restricted to small and easily insulated both insulating layers is
apparatus. Any exposed metal on double insulated apparatus is not connected to almost impossible without
earth but is doubly isolated from the internal electrical circuitry. complete fracture of the
apparatus' casing.
All apparatus which plugs into the mains, then, is macroshock protected, either by
double insulation or by earthing. Nevertheless hazards remain in the form of faulty or
worn equipment or careless workmanship.

Figure 13.5 illustrates how an electric shock can

result when apparatus is not earthed - because
the earth wire is damaged or disconnected. The
shock hazard in figure 13.5 arises when the
active terminal short-circuits to the casing of the
apparatus. In this case two faults have occurred -
a break in the earth connection and a short circuit
of the active wire to the casing.

Figure 13.5
A person contacts apparatus which is not earthed
and has the active wire touching the casing.
ELECTRICAL SAFETY 340

Since the neutral line is earthed at the fuse box and power sub-station, a person
standing on the ground is effectively connected to the neutral terminal of the mains
supply. To complete the circuit and receive a shock, the person need only touch the
active terminal or something connected to the active terminal. Current flows from the
active terminal through the person to ground and hence to the neutral connection at
the fuse box or power substation.
Two important things should be noted about the situation illustrated in figure 13.5
* A shock has occurred because the earth wire is damaged. If the earth
connection was intact the fuse in the active line (figure 13.2) would blow and
isolate the apparatus from the mains supply.
* The fuse in the active line will not protect the person from receiving an electric
shock. The fuses used for normal apparatus have a rating of several amperes. The fuses used in typical
The person can receive a lethal shock (see table 13.1) without blowing the fuse. apparatus must have high
ratings so they will not blow in
A question which might occur to you is 'do both faults shown in figure 13.5 have to normal operation (where the
exist in order for a shock to result?' The answer is no. A shock can result when the current flowing between
apparatus is not earthed even though there is no direct physical contact between the active and neutral may be
active terminal and the casing. This is because the active wire and the case must measured in amperes).
have a small capacitance associated with them and insulation will not be perfect.
Thus it is possible for small currents to leak via the insulation to the casing. With new
and well looked-after apparatus the insulation impedance will be high and the
maximum leakage current will be very small. Bad design or deteriorating insulation
can, however, increase leakage currents to hazardous levels. Only by earthing the
casing and providing an extremely low resistance pathway to ground can the risk of
shock be minimized.

MACROSHOCK PROTECTION
From the previous discussion it should be apparent that the fuses in the mains supply
serve a protective role only when currents of several amperes are involved. For this to

ELECTRICAL SAFETY 341

happen the active wire must short-circuit to the earthed casing. How then can we
protect against shock involving much lower currents? There are two commonly used
ways - by using a core balance relay or a protected earth-free supply.
Core Balance Relays
Under normal circumstances the currents flowing in the active and neutral wires are
equal. When an electric shock occurs the current in the active wire will be slightly
greater than that in the neutral wire. This is because some current flows from the
active wire through the victim to ground and through the ground to the neutral
connection at the fuse box. Core balance relays are used to detect any imbalance and
disconnect the power supply when the imbalance exceeds a predetermined value.
The arrangement is shown in figure 13.6.
Figure 13.6
Core-balance relay protection.

The active and neutral wires both

pass through a magnetic core
around which a sensing coil is
wound. The currents in these
wires are in opposite directions
and when they are equal no current
is induced in the sensing coil. If
the currents are unequal a current
proportional to the difference in
active and neutral current is
induced in the sensing coil. The
induced current is amplified and
used to operate a magnetic relay
which disconnects both the active
and neutral supply lines.
ELECTRICAL SAFETY 342

Once the core balance relay has been 'tripped', the supply remains disconnected until
the circuit breaker is manually reset.
The response time of core balance relays is quite short (less than 100 ms) and typical
units can be adjusted to trigger on an imbalance of as little as 5 mA. They are
available for permanent installation (usually inside the fuse box) and are also supplied
as portable units suitable for connecting between power points and appliances.
From the foregoing description it should be apparent that these units protect against
the 'normal' situation where a shock current flows through a person's body to earth.
They will not protect against the more unusual situation where a person inadvertently
contacts both the active and neutral lines simultaneously.
Earth Free Supplies
In the situation shown in figure 13.5
the person receives an electric shock
because his hand makes contact with
the active line and his feet are in
contact with the ground to which the
neutral is connected. A question
which might occur to you is 'would it be
safer if the supply neutral was not
earthed?' In this case the earthed
person could not complete a circuit by
touching the active line and so would
not receive a shock. The answer to the
question is a qualified 'yes'.

Figure 13.7 shows how the normal

mains supply can be rendered earth-
free by using an isolating transformer.
If neither side of the transformer Figure 13.7
secondary is earthed a person can Isolation with a transformer.

ELECTRICAL SAFETY 343

touch both earth and one transformer terminal without receiving a shock.
At first glance it would seem that a person can only receive a shock if both transformer
secondary terminals are contacted simultaneously. Unfortunately this is not the case
in practice and the reasons are twofold:

* If a piece of apparatus plugged into the power point should develop a short circuit
to earth no fuses will blow. The fault can remain unnoticed indefinitely. In the
meantime the earth free supply has been converted to an earthed supply and we
have no knowledge of which side of the transformer has become 'active' and
which 'neutral'.

* If faulty or poorly designed

apparatus is plugged into the
power point the insulation
impedance between either
supply terminal and earth can
be reduced to the extent that
the supply is effectively
earthed: again with no
knowledge of which terminal
is at earth potential.

The system can be rendered safe

by adding an earth leakage
detector between the mains earth
and the two transformer secondary
wires as shown in figure 13.8.
In normal operation a negligible
amount of current flows through
the leakage detector. If, however,
apparatus with a short circuit or Figure 13.8
defective insulation is plugged into Isolation with earth leakage detection.
ELECTRICAL SAFETY 344

the power point a current will flow through the detector and activate the alarm.

Of the two systems the protected earth free supply is somewhat safer than an earthed When earth free supplies are
supply fitted with a core balance relay. Unfortunately the isolation transformers and used an earth leakage
leakage detection circuitry needed are both bulky and expensive. For this reason detector system is
protected earth free supplies are only found in areas of high shock hazard. Core mandatory. The combination
balance relays which are relatively cheap and easy to install are considered adequate provides a high degree of
for more general use such as in physiotherapy clinics and the physiotherapy electrical safety.
departments of hospitals. Whichever method of protection is used it is important that
the system be checked at regular intervals to ensure that the protection mechanisms
are operating correctly.
MICROSHOCK
The use of electronic monitoring and measuring
devices in the hospital setting has proved of
immense value for patient monitoring and
assessment. It has, however, also introduced
some special risks of which the modern member
of the health care team must be aware.
Consider the patient in an intensive care unit. In
some cases the patient may have apparatus
connected by a direct electrical pathway to the
heart. One such situation is illustrated in figure
13.9. Here a very special hazard exists because of
the low current needed to cause ventricular
fibrillation. Even if all the equipment is earthed the
patient can still be electrocuted unless adequate
precautions are taken.

Figure 13.9
A microshock hazard situation.

ELECTRICAL SAFETY 345

The patient, in this situation, is connected to two pieces of apparatus: an

electrocardiograph (ECG) machine and a blood pressure monitor. For simplicity only
the earth wires are shown. The patient is connected to earth by two pathways: the
electrode connected to the right leg is earthed via the ECG machine and the fluid filled
catheter is connected to a pressure transducer which is earthed via the blood
pressure monitor.
The risk of shock arises when a potential difference exists between the earth
terminals on outlets 2 and 3. If a current I flows along the earth wire connecting the For example, if the resistance
of the earth wire is 0.1 Ω, and
two outlets a potential difference V will result. V is given by Ohm's law V = I.R where R a spike of leakage current of
is the resistance of the earth wire between the outlets. Although R is very small it is
100 mA flows, a potential
not zero. If I is large enough the potential difference produced will be sufficient to
difference of 10 mV is
electrocute the patient - remember that currents in excess of 100 microamperes or so produced. If the resistance of
flowing through the patient's heart may be fatal.
the tissue is 100 Ω, a current
of 100 µA will flow.
Normally, of course, little or no current flows in the earth wire - it is only there to carry
leakage current from the apparatus plugged-in. If, however, an appliance with a high
leakage current, such as a vacuum cleaner, is plugged into outlet 1 a dangerous
situation can result.

Vacuum cleaners are notorious for producing large leakage currents (particularly at
switch-on) because the motor is continually exposed to dust and moisture which
lower the insulation impedance. Visualize the situation where the patient in figure
13.9 is connected as shown and a cleaner, working his way down the corridor, plugs
a vacuum cleaner into outlet I (on the corridor outside) and switches it on. The
instantaneous leakage current flowing in the earth wire could raise the potential at the
earth terminal of outlet 2 to a sufficiently high value (relative to outlet 3) to electrocute
the patient.

The solution, in this case, is to plug all apparatus around the patient into a single
power outlet or to interconnect the earth terminal of each outlet with heavy gauge
copper wire. It is also necessary to ensure that the wiring for the power outlets in the
patient's room does not connect to the power outlets in adjacent rooms or corridors.
ELECTRICAL SAFETY 346

A further precaution which must be taken is to ensure that any apparatus which is
used in the patient's room has been tested for earth leakage and meets the
appropriate safety standards. This last criterion would
exclude most domestic and
PATIENT TREATMENT AND ELECTRICAL SAFETY industrial vacuum cleaners
and many domestic
From the foregoing considerations of shock and shock protection it is apparent that appliances.
there are three levels of risk associated with patient treatment. The greatest risk is to
patients coupled to apparatus which may have a direct electrical connection to the
heart. A lower level of risk exists when there are no invasive electrical connections;
however we should distinguish the patient who is coupled to electromedical
apparatus by surface electrodes from the patient who is not electrically connected to
any piece of apparatus. The reason is that if a patient is connected by electrodes to,
say, an electrocardiograph the potential for a shock to occur is increased by the
deliberate electrical connection. In addition the skin resistance has been minimized
by cleaning and application of a conductive electrode gel. In this case the voltage
needed to produce a fatal shock current is reduced.
Protection is afforded at two levels:
* by using apparatus which meets appropriate safety standards and
* by appropriate protection built into the mains supply.
We consider each factor in turn.

Protection and the Mains Supply

Patient treatment areas in hospitals are distinguished according to the kind of
procedures or treatment being used and different safety standards apply to the mains
supply in each case. Three types of treatment area are distinguished:
* Cardiac protected electrical areas. These are areas which are suitable for
carrying out procedures which involve direct electrical connection to the heart.
The safety requirements for both the electrical supply and apparatus to be used
in such areas are stringent (see SAA Standards AS 3200 and AS 3003). These

ELECTRICAL SAFETY 347

are described as 'Type CF' or simply 'cardiac protected' areas. In Australia and
some other countries, these used to be described as 'Class A' treatment areas.
* Body protected electrical areas. These are areas which are suitable for
carrying out procedures which do not involve direct electrical connection to the
heart but which do involve the patient being in direct electrical contact with
electromedical apparatus. Safety requirements are more stringent than those
applying to areas where no electrical connection between patient and apparatus
is necessary. Such areas are described as 'Type BF' or simply 'body protected'
areas. They used to be known as 'class B' treatment areas.
* Other patient areas. These are areas which are not specifically suited to
'cardiac type' or 'body type' procedures. Apparatus which is not electrically
connected to the patient can be used. Apparatus which is intended to connect
electrically to the patient can be used in these areas, but only if the apparatus
itself meets stringent safety requirements (equivalent to those of a cardiac
protected or body protected treatment area).
When direct electrical connection is made to the heart, shock currents as low as 100
µA can be fatal. For this reason cardiac-protected treatment areas are designed to If the maximum potential
minimize this risk. The earth wiring in these areas is constructed from heavy gauge difference is kept below 100
copper wire so that even when substantial currents (up to 1 ampere) flow in the earth mV then the maximum patient
wire the potential difference between different earth terminals is kept below 100 mV. current will be below 100 µA
An area which meets this and other requirements (see SAA Standard AS3003) is (assuming a minimum
described as an equipotential earth (EP) area. patient resistance of 1000
ohms).
In addition to the requirement for equipotential earth wiring, cardiac protected areas
must also have core-balance relay protection or have a protected earth free supply.

Body protected areas are those designed to protect patients who may be connected
directly to electromedical apparatus from macroshock currents. It is not necessary for
the area to have an equipotential earth system but the supply must have core-balance
relay protection or a protected earth free supply.
ELECTRICAL SAFETY 348

Best protection is afforded by a protected earth free supply but such installations are
expensive. Core-balance relay protection can be provided economically and gives an
adequate level of safety. Body protected areas which have appropriate core-balance
protection will have the mains supply disconnected within 60 milliseconds of the
active and neutral current imbalance exceeding 10 mA (SAA Standard AS3003).

Class CF (cardiac protected) and BF (body protected) treatment areas are normally
identified by signs displayed in, or on the doors of, the area. The signs have an
identifying symbol and the words 'CARDIAC PROTECTED ELECTRICAL AREA' or
'BODY PROTECTED ELECTRICAL AREA' printed in white letters on a green
background. The symbols for these areas are shown in figure 13.10.

Figure 13.10
Symbols used to identify different classes of
equipment or treatment area. (a) class CF
(microshock protected) (b) class BF (body protected).

Patient areas which are not designated class A or B

have no 'special' safety requirements other than those
which apply to commercial, industrial and domestic
supplies (SAA Standard AS3000). This means that the
area does not provide protection if contact is made
(either directly or indirectly) between the active supply
wire and earth. It is recommended, though not
mandatory, that such areas be provided with core-
balance relay protection. The recommendation should
be considered seriously since normal protective
devices (fuses or circuit breakers) can allow currents
of up to 150 times the macroshock hazard level without
operating to cut-off the supply.

ELECTRICAL SAFETY 349

Protection and Electromedical Apparatus

Electromedical apparatus used for patient treatment falls into one of two categories. Both kinds of apparatus must
In the first category we have apparatus which does not have a deliberate and direct meet certain safety standards
contact with the patient, such as an infrared or ultraviolet lamp. In the second category specified in terms of the
we have apparatus which requires deliberate electrical connection with the patient; for amount of leakage current
example, apparatus for delivering interferential or conventional TENS currents. In this which can flow under different
case the apparatus has a patient circuit. conditions. Apparatus which
has a patient circuit must
Consider first electromedical apparatus which does not have a patient circuit. In this meet additional safety
case the significant risk to the patient is if the patient inadvertently contacts the standards.
apparatus casing. If the maximum contact current which can flow is below a specified
value (10 µA through a 1000 ohm load) and the earth leakage current is less than 100
µA then the apparatus is designated class CF. This is the safest kind of
electromedical apparatus. Other electromedical apparatus must have a maximum
casing-contact current below 100 µA: this is considered to offer adequate protection
when the patient has no possibility of direct electrical connection to the heart. Class
CF equipment can easily be recognized by the 'heart in the square' symbol (figure
13.10a). This is normally displayed on the rear panel of the equipment, near where
the power cord enters.

When a piece of electromedical apparatus has a patient circuit then the patient circuit
itself can be either class CF, BF or B.

* A class CF patient circuit is the most safe. If the leakage current to the patient
circuit is normally below 10 µA and below 50 µA even when a fault condition
exists (when the earth lead is broken or the patient inadvertently contacts the
active terminal of the mains supply) the patient circuit is designated class CF. A
class CF patient circuit affords microshock protection.

* A class BF patient circuit is macroshock protected. The normal leakage current

is below 100 µA and the current which can flow when the earth lead is broken is
below 500 µA. To comply with class BF specifications the fault current which can
ELECTRICAL SAFETY 350

flow from the patient circuit through the patient to the active terminal of the mains
supply (in the event of the patient accidentally contacting the mains active lead,
either directly or indirectly) must be below 5 mA. In other words a class B patient
circuit has adequate isolation from the mains supply to minimize the risk of
macroshock.

* A class B patient circuit affords a minimum level of macroshock protection. This

kind of patient circuit may have one terminal earthed. Such a circuit must have
leakage currents below those needed to represent a macroshock hazard when
the apparatus is operating normally or when the earth lead is broken. However,
no protection is offered against the situation where the patient inadvertently
contacts the mains active lead.

Class CF and BF patient circuits are identified by the symbols shown in figure 13.10.
The appropriate symbol is prominently displayed immediately adjacent to the patient
circuit output sockets of the machine. If no symbol is found, the patient circuit should
be assumed to be class B.
Protection in Summary
It should be apparent, from the foregoing description, that electrical safety is only
ensured if:
* the equipment meets appropriate safety standards for the treatment procedures
involved;
* the electrical supply meets appropriate safety standards for the treatment
procedures involved.
Figure 13.11 shows a flowchart summarizing the requirements for earthed mains-
powered apparatus and the class of area in which it can be used.
The flowchart is based upon those of Australian Standard AS3200 and figure 5.3 of
AS2500.

ELECTRICAL SAFETY 351

START

Procedure must be carried YES Is there a possibility of an NO Does the equipment have a NO
out in a class CF area. intra-cardiac conductor patient circuit?
(class CF procedure)?

YES

All mains powered

equipment must: NO Does the mains supply have
* be connected in the class CF or class BF
same equipotential area. protection?
* meet relevant safety
standards. YES
Use class CF or BF Use class CF, BF or No special
patient circuit. B patient circuit. precautions

Will individual patient circuits NO

(if any) have possibility of
intra-cardiac connection?

YES

Patient circuit must be Use class CF, BF or B

class CF. patient circuit.

Figure 13.11
Flowchart for the safe application and use of electromedical equipment.
ELECTRICAL SAFETY 352

The strictest safety standards are mandatory when the patient has apparatus
connected directly to the heart. In this case the mains supply should be that provided
in a Class CF area and electromedical apparatus with a patient circuit should not be
used unless either the patient circuit is class CF or there is no possibility of a direct
electrical connection with the heart. In this way the risk of microshock is minimized.

When there is no direct electrical connection to the heart it is sufficient to protect

against the risk of macroshock. This can be achieved either by using equipment with
a class CF or BF patient circuit or by treating the patient in a class CF or BF area. If the
electrical wiring in a patient treatment area is class CF or BF then patients can be
safety treated with apparatus which has a class CF, BF or B patient circuit. If the
electrical wiring in a patient treatment area is not class CF or BF then the patient
circuit must be class CF or BF. In other words if the mains supply is of the normal
household variety then electromedical apparatus should have either a class CF or BF
patient circuit.
When there is no patient circuit and no possibility of intra-cardiac connection,
electromedical equipment may be used on a normal earthed (but unprotected) mains
supply.

EXERCISES
1 (a) What is meant by the terms 'macroshock' and 'microshock'?
(b) Electric shocks are always described in terms of shock current rather than
voltage. Why is this so?

2 (a) Consider macroshock and list the factors which will determine the size of
shock current when a person accidentally contacts the mains supply.
(b) Table 13.1 shows the effect of different sizes of shock current. Explain why
shock currents in the range 50-250 mA represent a greater hazard than
shock currents above 250 mA.

ELECTRICAL SAFETY 353

3 A person accidentally contacts the mains supply (240 volts). Given that the skin
resistance may vary from 1000 Ω to 0.5 MΩ calculate the possible range of shock
currents which may result.
What is the practical significance of this in terms of terminating the shock as
quickly as possible?

4 Figure 13.3 shows the wiring convention for a power outlet. Given that the neutral
and earth terminals are grounded (earthed) at the fuse box in a building
according to figure 13.2, does this mean that the neutral and earth terminals are
'safe'? Explain.
5 (a) Figure 13.2 is a schematic diagram of the mains supply to a building. The
neutral line is earthed at the electricity sub-station. Why is it an advantage to
also earth the neutral line at the fuse box?
(b) The neutral line of the mains supply is normally earthed at the fuse box.
Even so, this does not mean that the neutral terminal of a correctly wired
power point is at earth potential. Explain.
6 Consider figure 13.4 and explain what would happen if:
(a) the active line accidentally makes contact with the apparatus casing
(b) the neutral line accidentally makes contact with the apparatus casing.
Would this blow the fuse? Could a short-circuit of the neutral line to the
casing pose a shock hazard? Explain.
7 (a) What is meant by the term 'double insulated' as applied to electrical
apparatus?
(b) What is the principal advantage of double insulation for electrical safety?
(c) Explain the relative merits of double insulated apparatus and earthed
apparatus as far as leakage currents are concerned.
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8 (a) Figure 13.5 shows a person receiving an electric shock because two faults
have occurred. What are they?
(b) Is it possible for a person to receive a shock from apparatus in which only
one of these faults has occurred? Explain.

9 It has been said that fuses are included in the mains supply line only to protect
the apparatus. Is it possible for a fatal shock to be delivered without blowing the
fuse in the following two cases:
(a) when the earth wiring is damaged?
(b) when the earth wiring is undamaged?
Explain.
10 (a) Describe the principles of operation of a core balance relay (as shown in
figure 13.6).
(b) The fuses included in the mains supply must have a rating of several
amperes and so can not protect against macroshock, yet a core balance
relay can have a 'rating' of a few milliamperes but will not disconnect the
mains supply in normal operation. Explain.
(c) Under what circumstances is a core balance relay unable to protect against
macroshock (even involving shock currents of several hundred
milliamperes)?

11 Figure 13.7 shows an isolating transformer used to generate an earth-free

supply.
(a) Could a person receive a shock by contacting any one of the terminals of the
power outlet?
(b) Under what circumstances could a person receive a shock from an earth-
free supply (assuming no faults in the wiring)?
(c) What is the principal disadvantage of the simple earth-free supply shown in
figure 13.7?

ELECTRICAL SAFETY 355

12 (a) Explain why earth-free supplies can only be regarded as safer than a
normal earthed supply if an earth leakage detector (figure 13.8) is included
in the circuitry.
(b) Why is a protected earth-free supply preferable to a core balance relay
protected supply for areas of high shock hazard? Are there any
disadvantages associated with the installation of protected earth-free
supplies?
13 Consider figure 13.9 where the patient is connected to (i) the supply earth of a
blood pressure monitor via a transvenous catheter and (ii) the supply earth of an
ECG machine via an electrode attached to the right leg.
Explain how a shock hazard situation arises as a result of the ECG machine and
blood pressure monitor being connected to separate power outlets.

14 A microshock of only 200 µA flowing directly through the heart can be fatal.
(a) Given that the resistance of the patient's tissues between the catheter and
the electrode applied to the right leg in figure 13.9 is about 1000 Ω, calculate
the potential difference needed to produce a fatal shock current.
(b) The resistance of the earth wire connecting mains outlets 2 and 3 in figure
13.9 is 4.0 Ω . Calculate the current flowing through the earth wire
connecting the outlets which would be sufficient to cause electrocution of
the patient.
(c) A cleaner plugs a vacuum cleaner into mains outlet 2 (see figure 13.9). The
leakage current of the vacuum cleaner is 70 mA. Does this represent a
microshock hazard?
15 Consider the microshock hazard situation shown in figure 13.9.
(a) How might the microshock hazards be minimized?
(b) What are the implications of this situation for the use of electrotherapy
apparatus on or near the patient?
ELECTRICAL SAFETY 356

16 (a) What is the difference between a class CF and a class BF treatment area?
(b) How are class CF and class BF treatment areas identified?
17 (a) How would you recognize equipment with a class CF or class BF patient
circuit?
(b) A piece of equipment has a class Z patient circuit. Under what
circumstances should the equipment be used for patient treatment?
(c) What class of patient circuit should apparatus have if it is to be used in a
patient's home?
18 Suppose you have (a) an ultrasound machine and (b) an interferential therapy
machine which are to be used with an unprotected mains supply. What electrical
safety standards apply to each machine?