Introduction
This presentation, “Hospital Response Following a Terrorist
Incident Involving Radioactive Material,” was prepared as a
public service by the Medical Response Subcommittee of the
Health Physics Society Homeland Security Committee for
hospital staff training.
The presentation can be copied for use by using the tool bar. On
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The presentation can be edited to fit the needs of the user. The
authors request that appropriate attribution be given for this
material and would like to know who is presenting it and to what
groups. That information and comments may be sent to Marcia
Hartman, at [email protected]
Ver 1.5
0
Hospital Response Following a
Terrorist Incident Involving
Radioactive Material
Medical Response Subcommittee of the
Health Physics Society
Homeland Security Committee
1
Emergency Preparedness
• Medical stabilization is the highest priority
– Contamination control should not delay critical medical care
• Be prepared for multiple hazards, including chemical,
radiological and biological hazards
• Be prepared for multiple incidents, e.g., a 1st incident
followed by 2nd incident used to harm the first
responders
• Be prepared for
– large numbers of potentially contaminated individuals
– large numbers of uninjured and uncontaminated but
concerned citizens
2
Emergency Preparedness
• Triage Goals for Mass Casualty
– Evaluate & sort patients by immediacy of treatment
– Do the greatest good for the most people
• In mass casualty incidents, may need to deal with
thousands of persons in need of decontamination and
exposure assessment
• Pre-plan to ensure adequate supplies and survey
instruments are available
• Training and drills are essential to competence and
confidence
3
Radiological Medical Emergency
Response Plan
• Required by The Joint Commission
– EM.02.02.05 Emergency Management - means for radioactive,
biological, and chemical isolation and decontamination
• Information available:
– Radiation Emergency Assistance Center/ Training Site (REAC/TS)
– website and training classes http://orise.orau.gov/reacts/
– NCRP 111, Developing Radiation Emergency Plans for Academic,
Medical or Industrial Facilities
– NCRP 138, Management of Terrorist Events Involving Radioactive
Material
– NCRP 165, Responding To A Radiological of Nuclear Terrorism
Incident: A Guide for Decision Makers
4
Radiological Medical Emergency
Response Plan
• Interim Guidelines for Hospital Response to Mass
Casualties from a Radiological Incident,
http://emergency.cdc.gov/radiation/
• Health Physics Society Homeland Security website
information
– Training presentations: "Emergency
Department Management of Radiation
Casualties "
https://hps.org/hsc/documents/emergency.ppt
5
Visit http://emergency.cdc.gov/radiation/
6
Visit http://remm.nlm.gov/
Mobile REMM Application also available for I-Phone
7
Visit http://hps.org/hsc/responsemed.html
8
Goiânia : Lesson for RDD Preparedness
Number
Total Population
% of Pop’n
1,000,000
100
112,000
11.2
249
0.025
Persons Admitted to Hospital
49
0.005
Persons Needing Intensive Medical Care
22
0.002
Deaths
4
0.0004
Forearm Amputated
1
0.0001
Persons Monitored
Persons with External and Internal Doses
photo credits: IAEA
9
Mass Casualties, Potentially Contaminated but
Uninjured Individuals
• An incident caused by nuclear terrorism may
create large numbers of the public coming to
hospitals:
– potentially contaminated people who are not injured
and
– concerned citizens who may not be injured or
contaminated.
• Measures must be taken to deal effectively with
these individuals while preventing them from
heading to and overwhelming the emergency
department (ED).
10
Assessment Centers
Primary – Hospital
Secondary – Community
• Triage Site
– Medical staff trained in medical radiation emergency
procedures, health physicists, medical physicists & other
staff trained in decontamination and use of radiation survey
meters, psychological counselors and security.
– Screen patients for injury and contamination
– Treat minor injuries (first aid)
– Psychological counseling for staff & victims, as needed
• Decontamination Center
– Perform decontamination and treatment of non-life
threatening injuries
11
Handling of Mass Casualties
Main
Hospital
Near ED
Access for
Self-referred
patients
Controlled
Triage
Site
Access for
Staff, Press,
Officials
Area for
deceased
Serious
Injury/Illness
Triage for Injury &
Contamination
Ambulance
Traffic
Only
Emergency
Department
• Perform first aid
• Perform decontamination
Community
Admit
patients
or treat &
discharge
12
Triage Site
Information
• Develop prepared information packets with Media
Relations in advance with message for incidents
involving radiation.
• CDC website has Emergency Instructions for Individuals
and Families titled, “FAQ About a Radiation Emergency”
Available in
English
Español
Deutsch
Français
Tagalog
Chinese
photo credits: CDC
13
Mass Casualties, Potentially Contaminated but
Uninjured Individuals
14
Systematic Approach
• A systematic approach to
handling large numbers of
potentially contaminated
individuals is necessary.
• Such an approach should
provide for surveying, mass
decontamination, resurveying,
advanced decontamination (if
necessary), resurveying and
additional decontamination or
ED care as indicated.
• Depending on weather,
decontamination sites may
have to be established indoors
or in a temporary shelter.
15
Controlled Triage Site
• A controlled triage site should
be established away from the
ED to intercept the large
numbers of contaminated
people who are not injured and
uncontaminated but worried
people and divert them to
appropriate locations.
• These locations may be
Hospital Reception &
Decontamination Centers
(HRDC) or local reception
centers.
16
Triage Site Control
• Control of movement through the site is necessary to
minimize the potential for contaminating clean areas of the
site.
• Radiation portal monitors should be used to facilitate rapid
screening of large numbers of victims.
• The triage site should be staffed with medical staff,
radiation monitors, social workers and security personnel.
• Precautions should be taken so that people cannot avoid
the triage center and go directly to the ED.
17
Movement Through the
Triage/Decontamination Areas
• The path through the
triage/decontamination
area must be clearly
marked and individuals
assigned to keep traffic
moving in the right
direction and to
prevent potentially
contaminated
individuals from
walking into clean
areas, except by the
designated route.
photo credits: M. Meehan
18
Directions
• Clear directions (in
appropriate
languages) are
necessary to help
individuals understand
what is expected of
them.
19
Decontamination Center
• Establish a Decontamination
Center where staff can
survey people to identify
who are contaminated, but
not significantly injured.
– Center should provide showers
for many people.
– Replacement clothing must be
available.
– Provisions to transport or
shelter people after
decontamination may be
necessary.
20
Contamination Surveys
• Survey with GM survey
meters
• Use nuclear medicine and
radiation therapy
technologists or others
familiar with the use of
radiation detection
instruments
• Goal is no more than 2
times background
• Prepare protocol for
survey & documentation
photo credits: REAC/TS
•
•
•
•
Probe held ~ 1/2 inch from surface
Move at a rate of 1 to 2 inches per second
Follow logical pattern
Document readings in counts per minute
(cpm)
21
Radiation Levels to Initiate Decontamination
• Decontamination (skin and clothing) should always
be performed when the contamination level is:
• >0.1 mR/hr exposure rate (~1 μGy/hr air-kerma
rate) at 10 cm
• >600,000 dpm/cm2 (10,000 Bq/cm2) beta and
gamma surface contamination
• >60,000 dpm/cm2 (1,000 Bq/cm2) for alpha surface
contamination.
• Facial contamination should initiate potential
medical treatment for internal contamination.
22
22
Decontamination Directions
• Clear directions (in
appropriate languages)
are necessary to help
individuals understand
what is expected of them.
23
Surveying After Each Decontamination
Procedure
• Provisions must be
provided for repeat
surveying of individuals
after each
decontamination
procedure to determine
success of efforts and
when individuals can be
routed out of the
decontamination center.
photo credits: REAC/TS
24
Mass Decontamination Facilities
• Where possible, the
decontamination of many
contaminated individuals
should be carried out in
existing shower facilities
(e.g., at a fire house, school
locker room, or public
campground)
• When such facilities are not
immediately available, field
decontamination capabilities
may have to be
implemented.
25
Mass Decontamination
26
• Runoff
Mass Decontamination
– Responders should closely monitor the direction of
runoff to prevent cross contamination between lanes
and between zones. If possible, the decontamination
area should contain a storm water drain or be on a
slope that allows control of water runoff.
• EPA and Runoff
– The EPA has stated that they will not hold responders
liable for run-off in a chemical or biological incident
caused by a terrorist event. (EPA letter dated 9/17/00)
– Your Emergency Management Plan must have a
contingency to contain runoff; the EPA only allows an
exception if you exceed your planned holding capacity.
– Protection of human life and health is primary goal.
27
Second Stage Decontamination
Ambulatory Patients
• When surveying
shows that preliminary
decontamination of
individuals has not
been complete, they
should be sent to a
second stage
decontamination
facility (e.g.,
specialized
decontamination tent).
28
Clothing for Decontaminated Individuals
• Supplies of clean clothing
(sheets, blankets, scrub
suits, etc.) should be
available for individuals
exiting decontamination
stations.
• Provide baggies for
personal items, wallets,
jewelry.
• Maintain a chain of
custody if the incident is
considered a crime scene.
29
Second Stage Decontamination
Non-Ambulatory Patients
• Some specialized
decontamination tents
permit capabilities for
decontamination of
non-ambulatory
patients as well as
those who can walk.
30
Gowning Capabilities
• Patients exiting
second stage
decontamination
facilities need to be
provided with clean
clothes (hospital
gowns, coveralls,
sheets or blankets).
31
Resurveying
• Individuals exiting the second
stage decontamination facility
should be surveyed again to
determine the effectiveness of
decontamination. Individuals
found to be still contaminated
can be rerouted through the
second stage decontamination
effort.
• Refer anyone with
contamination near the nose or
mouth for medical assessment.
32
Unsuccessful Decontamination or First Aid
• When field
decontamination
efforts have failed to
remove adequate
amounts of
contamination or the
individual requires
additional first aid,
they can then be
routed to the ED.
33
Hospital Preparation
• Activate hospital plan
– Alert key personnel
– Obtain radiation
emergency supplies
– Obtain radiation survey
meters
– Call for additional support
• Radiation Safety/ Health
Physics
• Medical Physicists
• Radiation Oncology
• Nuclear Medicine
• Researchers
34
Hospital Preparation
• Treating life threatening injuries is the 1st priority
– Contamination control should not delay critical medical care
• Plan for contamination control
– Ensure staff are properly gowned and remind them to use
standard precautions
– Establish multiple receptacles for contaminated waste
– Protect floor with covering if time allows
– For transport of contaminated patients into ED, designate
separate entrance, designate one side of corridor, or transfer
to clean gurney before entering, if time allows
35
Hospital Preparation
• Assemble radiation
emergency supplies
• Ensure adequate
number of survey
meters
• Check operation of
survey meters
Cesium-137
in lead shield
662 keV
• If available, request
equipment for
identification of
radionuclides
36
Medical Triage
• Follow the REAC/TS
Patient Treatment
Algorithm to triage
patients
• Externally
contaminated
patients follow the
left side of the chart
37
Other Considerations
• Victims may include the terrorist(s)
• In most cases, standard precautions is all that is
necessary to protect the staff
– Risk to caregivers, who would likely receive low doses, is
very small
– Hospital staff doses at Chernobyl < 1 rem
– 25 rem increases the risk of fatal cancer by ~ 1%
– 25 rem increases the risk of severe hereditary effects by ~
0.1%
• Pre-plan who will be given radiation dosimeters
– ED staff, surgery staff
38
Other Considerations
• Larger hospitals or large metropolitan areas
should consider stocking decorporation agents
• Dose rates to first responders 20 cm from patient
with uniform surface contamination:
– Cs-137, 100 µCi/cm2 – 1 rem/hr
– Co-60, 100 µCi/cm2 – 3.9 rem/hr
• Dose rates to surgeon standing 20 cm from patient
with radioactive fragment (0.2 mm long, 0.2 mm
radius, embedded 20 cm deep)
– Co-60, 1 Ci - 2.5 rem/hr
39
Support for Concerned Citizens
• Fear of radiation and misunderstanding of
consequences
• Long term psychological effects could arise hours or
days after an incident
• Counsel on acute and potential long term physical
and psychological effects
• Psychological effects include:
Anxiety disorders
Post traumatic stress disorder
Depression
Insomnia
Traumatic neurosis
Acute stress disorder
40
Support for Concerned Citizens & Workers
• Provide psychological counseling to staff, victims and
their families
• High-Risk groups: emergency workers, children,
mothers w/ small children, cleanup workers
• Provide exposed patients with a “sense of control of
their health”
• Resources: The National Center for Post Traumatic
Stress Disorder
http://www.ptsd.va.gov/
41
Contaminated Corpses
• Disaster Mortuary Operational Response Teams
(DMORT)
• Restrict autopsies of highly radioactive corpses
• No embalming or cremation
• Health Physics assistance for autopsies
– Use contamination control
– Wear protective clothing
42
Key Points
• Medical stabilization is the highest priority
– Lifesaving activities take priority over radiological concerns
• Pre-plan to ensure adequate supplies and survey
instruments are available
• Train/drill to ensure competence and confidence
• Make sure that you have prepared your personal family
plan - http://www.ready.gov/
• Do what works for your facility and available resources
• The first 24 hours are the worst, then many other
experts will be available to help
43
Additional Resources
Agencies that are available 24/7 to assist with medical management:
– Radiation Emergency Assistance Center/ Training Site
(REAC/TS), (865) 576-1005, http://orise.orau.gov/reacts/
– Medical Radiobiology Advisory Team (MRAT)
Forces Radiobiology Research Institute (AFRRI)
295-0530, http://www.afrri.usuhs.mil/
Armed
(301)
Websites:
– Response to Radiation Emergencies by the Center for Disease
Control, http://emergency.cdc.gov/radiation/
– Medical Response information on the Health Physics Society
website, http://hps.org/hsc/responsemed.html
– Disaster Preparedness for Radiology Professionals by American
College of Radiology, http://www.acr.org/, search “disaster”
44
Acknowledgements
The Medical Response Subcommittee members when issued:
Jerrold T. Bushberg, PhD, DABMP, Chair, UC Davis Medical Center
Marcia Hartman, MS, UC Davis Medical Center
Linda Kroger, MS, UC Davis Medical Center
John J. Lanza, MD, PhD, MPH, FAAP, Florida County Health
Department
Edwin M. Leidholdt, Jr., PhD, ABR, Western Region Veterans Affairs
Mark A. Melanson, PhD, CHP, Walter Reed Army Medical Center
Kenneth L. Miller, MS, CHP, CMHP, Hershey Medical Center
45
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Version 1.5
Disclaimer: The information contained herein was current as of August 8, 2011, and is
intended for educational purposes only. The authors and the Health Physics Society
(HPS) do not assume any responsibility for the accuracy of the information presented
herein. The authors and the HPS are not liable for any legal claims or damages that
arise from acts or omissions that occur based on its use.
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Hospital Response Following a Terrorist Incident Involving