chapter 5 radiological and nuclear response for...

46

The threat of use of radiological materials or nuclear weapons is at its highest point since the end of the Cold War. This chapter summarizes the environment, dangers, planning recommendations, and response techniques for dedicated EMS personnel when in-volved as providers or victims in a radiological or nuclear event. Selected resources are identifi ed.

RADIATION: DEFINITION AND EFFECTSRadiation consists of subatomic particles and electro-magnetic waves that can interact with matter. Non-ionizing radiation causes excitement of atoms and molecular structures, and ionizing radiation can re-move electrons from an atom and break interatomic and molecular bonds, including single- and double-strand breaks of DNA chains. Ionizing radiation has the capability to cause gross surface and subsurface damage, and incrementally impairs the ability of the body to repair those injuries. The latter effect, typi-cally called a “radiation burn,” requires a different medical response than is typical for thermal burns.1 Ionizing radiation materially damages the immune system, with permanence depending on radiation dose and probabilistic long-term effects, and requires a multifaceted care environment for the injury and re-covery.

Ironically, medical personnel, who have ample sci-entifi c training beyond that of the general public, are not immune to fear of the effects of radiation created by the entertainment industry. This was confi rmed at

a major “dirty-bomb” drill in north Texas in 2004.2 In that exercise, a large sports venue held 2,500 volun-teers and the number of EMS personnel as would be present for an event with capacity of 275,000. State authorities secreted minor radiation sources, com-monly available at sporting goods stores, on “trauma victims” with moulage wounds. When patients ar-rived at the 35 participating hospitals with varying levels of trauma, and hospital personnel detected the radiation sources, all closed temporarily (went to ‘Di-vert’ status) due to contamination. The local public health authority made a decision to require contami-nated hospitals to continue to accept contaminated patients, because the authority had received radiation training a few weeks prior to the exercise. In a real-life scenario, fear of radiation can negatively affect operations due to reluctance of medical personnel to handle exposed or minimally contaminated patients. In addition, emergency facilities are likely to be over-whelmed with terrifi ed but uninjured citizens.

NORMAL RADIATION ENVIRONMENTThe human species developed in a radioactive world. Ionizing radiation from the sun, rocks, cosmic rays, and from naturally occurring radioisotopes in the environment has continually bathed all life on Earth since life began. The background radiation level of the Earth is actually less now than at the generally accepted date of Homo sapiens fi rst appearance. Ap-proximately 0.05% of the potassium on the Earth is

5 Radiological and Nuclear Response for Emergency Medical Personnel

John C. White

CHAPTER

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CHAPTER 5 Radiological and Nuclear Response for Emergency Medical Personnel 47

potassium-40, a radioactive isotope with a half-life of 109 years, which decays while emitting powerful gam-ma rays. Since K-40 is ubiquitous, any foods that con-tain potassium are radioactive, and human bodies are radioactive as well. We live in a constant bath of ion-izing radiation, and DNA strand breaks and radiation-generated chemically active free radicals result from this radiation. In addition, granite, which is widely found on the Earth’s surface and used in buildings, contains small amounts of uranium, which generates many radioisotopes as it decays. Radon, a radioactive inert gas—accounting for over half the background radiation exposure in the United States—is a prod-uct of uranium decay. Ionizing radiation is simply everywhere in our existence. Excessive amounts of radiation are problematic because the physical re-pair mechanisms we have developed to cope with the background radiation on planet Earth become over-whelmed.

RADIATION THREATSAlthough the Cold War has ended, the threat of nu-clear weapons has not. A number of governments and terrorist organizations have clearly stated the intent to acquire and use such weapons as necessary.3 In addition, the proliferation of radioisotope sources in medicine and industry has provided targets for terror-ist organizations. A substantial effort is underway by responsible governments to protect and secure these sources, but it is possible that a determined group could acquire either a nuclear weapon or radioactive materials suffi cient to cause massive destruction, or chaos and panic, with resultant societal disruption and signifi cant expense. In addition, routine uses of radiopharmaceuticals in medicine involve transpor-tation of smaller amounts.4 Accidents happen and emergency medical personnel could easily be called on to treat accident victims or receive them at their facility.

TYPES OF IONIZING RADIATIONThe main types of ionizing radiation are alpha, beta, gamma (and x-ray), and neutron. Each type has spe-cifi c penetration, and therefore detection, characteris-tics. Figure 5.1 shows the penetrating capabilities of each in relation to human tissue.

WHAT RADIATION DOES NOT DOMuch has been made by the entertainment industry of the effects of radiation. Spontaneous immediate mutations, burns, and insidious unknown and scary effects are legion in movies, television, and novels. It is important to understand that immediate, dramatic mutations of anatomy do not occur, and that strange genetic anomalies are seen only in successive gen-erations with large population-level doses. Radiation levels in the global environment were higher in the distant past due to naturally occurring radioactive ele-ments, and recent atmospheric nuclear weapons test-ing raised the radiation background only slightly. The medical worker responding to a radiological incident may be exposed to a high-radiation environment for a short time, but the somatic effects should be similar to a short period of exposure to other physiological stressors such as heat, chemicals, or other repairable phenomena. Long-term effects of lower doses of ion-izing radiation are generally probabilistic, and the im-mediate needs of a population exposed to radiological weapons or contaminants are evacuation, clean-up, and emergent care.

RESOURCES FOR THE RESPONDERSince the emergency worker has a basic scientifi c education, understanding of the effects of radiation is somewhat easier to impart than to the general public. It is critical to remember that the effects of radiation are not magic, but are well understood after many years of scientifi c research. The emergency worker and

1 m Concrete

Alpha

Beta

Neutron

Gamma

FIGURE 5.1. Relative Penetration in Human Tissue of Ionizing Radiation.

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48 SECTION A Incident Planning and Response

emergency manager should identify trusted people in the facility or system who can provide accurate and useful evaluation of the risk and give concrete recom-mendations to ameliorate the radiation effects, while allowing the responder to perform duties. These re-sources—people whose livelihood depends on the un-derstanding of radiation and its effects—are available in most communities, hospitals, and government en-tities. Immediate resources include nuclear medicine personnel who handle isotopes, detection equipment, and isotope clean-up on a daily basis, and are required to have detectors in their facility. Others immediately available include well-trained hazardous-materials response personnel, who have extensive training and hands-on experience with detection equipment. They may also have detection equipment in mobile units. Well-trained incident management personnel with radiation training who have participated in numer-ous local, regional, and national exercises may also be available. The second line of resources consists of knowledgeable technical specialists such as the local radiation safety offi cer or radiological incident man-ager who have more in-depth knowledge of radiation detection and effects, but may not be immediately available.

Resources in ReserveManagement of a radiological incident requires un-derstanding of the true threat to emergency person-nel. An unreasoned response calling for immediate withdrawal of all emergency personnel to extreme distances is unwarranted and possibly negligent. Since fear of radiation is ubiquitous, a reserve ra-diation specialist may be called on to provide guid-ance and reasoned response. Such person(s) may not be immediately available, but may be summoned or contacted. It is critical to note that radiation profes-sionals are essential to response organizations when faced with a radiological response. In-depth under-standing of radiological science and knowledge of resources available can save time, money, and pos-sibly lives.

Resources to ContactEvery emergency service supervisor should have a list of immediately available contacts who can give concrete applicable advice and information to a re-sponder. Techniques to protect a responder can be simple to implement with available equipment, and

responders should be trained in these at every oppor-tunity. Preparation for a radiological emergency is not necessarily an expensive, long-term process, but rather a matter of standard practice modifi ed to fi t an additional stressor. Reliable equipment to detect radiation is readily available, portable, and relatively inexpensive. Local medical use of isotopes requires knowledgeable personnel to handle, administer, and detect the isotope. Transportation requires drivers with an understanding of exposure limits and the materials that are being transported. In a massive in-cident, massive resources must be brought to bear, but immediate local response will be responsible in the fi rst contact with any radiological threat. Local responders must be given clear and proper instruc-tion and training in how to work with and around ra-diation. Many professional organizations, web sites, and agencies provide detailed information, such as Health and Human Services’ http://www.remm.nlm.gov, and the U.S. Department of Energy, Oak Ridge National Laboratory, maintains the Radiation Emer-gency Assistance Center/Training Site (REAC/TS) (http://orise.orau.gov/reacts/), which has expert as-sistance available year-round, 24 hours a day (call 865-576-1005, and ask for REAC/TS).

HOW TO PROTECT YOURSELFExposure to ionizing radiation is manageable. A basic understanding of the radiation environment and the dangers therein is your primary tool to manage how you and those you supervise can perform with mini-mal risk.

Radiation effects can be summarized simply by considering three elements of exposure:

• Irradiation—Radiation enters and passes through the body as a fi eld

• Contamination—Radioactive materials collect on the outside of the body

• Internal exposure—Radioactive materials enter the body

Each of the three have different causes and dif-ferent effects.

IrradiationIrradiation means that a person or an object is in a fi eld of radiation, and the effects of that radiation can be reduced by the following three methods.

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Time—Obey the ClockRadiation effects are linearly cumulative. In a uniform fi eld and at a steady distance, 10 minutes of exposure totals twice as much total effective dose equivalent as 5 minutes of exposure. It is important for emergency responders to understand the radiation fi eld emitted by each victim. U.S. Environmental Protection Agen-cy (EPA) guidelines for exposure of emergency re-sponders are shown in Table 5.1.

If a patient is emitting a radiation fi eld of 100 mil-lirem per hour (1 milliSv), the responder may spend 50 hours on that patient, or work on 50 patients for 1 hour each. For patients with higher radiation fi eld readings, less time is allowed. Obviously, decontami-nation of the exterior of the patient can reduce the fi eld, but if radioactive shrapnel is present in the pa-tient, danger for surgical teams may exist.

Distance—Radiation MagicEvery person has at some time cupped his or her hand around a candle fl ame or come near a hot light bulb. At a short distance, the fl ame or bulb feels hot. At a 10-cm distance, the heat is greatly reduced, and at 20 cm, may be imperceptible. This principle, known as the inverse square law, applies to ionizing radiation (Figure 5.2). Radiation received by any object decreases as the square of the distance from the source. So moving away from the patient, or staying at a distance if your imme-diate presence is not required for a procedure, dramati-cally reduces your dose. Combining distance and time planning can extend your time to work on an emergent patient, allow you to work on more patients, and in-crease the resources for responding to an incident.

Shielding—The Thicker, the BetterFor most radiation sources, dense materials provide more shielding than light materials. Alpha particles will not penetrate skin or clothing or paper. Betas can penetrate approximately 1 cm of fl esh, but are stopped by most fi refi ghter protective gear. In the event of high-energy neutron radiation, quantities of plastic and water are required for shielding. Shielding against gamma ray penetration requires substantial quantities of concrete, lead, or water. But in an emergent situa-tion, the person of your co-worker, who is 90% water, may be somewhat of a shield. So, standing behind a co-worker when you are not needed at the immedi-ate site can help lower your dose. Since shielding for many radiation sources is bulky, shielding is usually the least available tool for protection, unless the char-acteristics of a shield, such as a wall, are known.

ContaminationRadioactive materials that collect on the outside of a person (“contamination”) may be removed by simple

Dose Limit (Whole Body) Activity Performed

5 rem (5.000 mrem) (0.05 Sv)

All activities

10 rem (0.1 Sv) Protecting major property

25 rem (0.25 Sv) Life saving or protection of large populations

�25 rem (�0.25 Sv)

Life saving or protection of large populations, only by volunteers who understand the risks

rem, Roentgen equivalent in man/mammal, a measure of expo-sure; Sv, Sievert. 1 rem � 10 milliSievert (0.01 Sv); 1 Sievert � 100 rem.

EPA Emergency Action Dose Guidelines

TABLE 5.1

1.1 mrem/hr

30 Feet

2.5 mrem/hr

20 Feet

10 mrem/hr

10 Feet

40 mrem/hr1000

millirem/hr

5 Feet

5X5=25

FIGURE 5.2. Distance Causes Decrease in Radiation Exposures Exponentially.

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mechanical means. Test data from people accidentally exposed to fallout from a nuclear detonation in the Pacifi c demonstrate that most of the material was re-moved by disposal of/changing clothing.5

Exposed skin may be cleaned with any mechani-cal cleaning agent, such as soap and water or other surfactants or chelating agents. It is important to keep radioactives from gaining entrance into the body dur-ing the decontamination process. Exposed body sur-faces such as hair, head and shoulders, hands, arms and legs, and moist areas under clothing should be treated as contaminated and washed with copious amounts of mechanical cleaning agent. Of paramount importance is prevention of ingestion of radioactives through any pathway, particularly the respiratory and gastrointestinal tracts. Note that unlike some materi-als, radiation cannot be “denatured” or “sanitized” by use of any chemical. Decontamination occurs only through mechanical removal.

IngestionThe most dangerous exposure route by far is inges-tion of radioactive materials. The materials ingested by inhalation, drinking, eating, or through a wound are translocated to specifi c organ systems, depending on the radioactive element, and signifi cant damage can oc-cur to the organ system. The body is an effi cient physi-ological bioconcentrator of many elements. Iodine is preferentially taken up by the thyroid gland, calcium by the bones, sulfur by the liver and gonads, and so on. When an organ system takes a radioactive element into its physiologic pathway, the damage to that organ system can be amplifi ed by the concentration in that system. For this reason, any emergency responder is advised to wear respiratory protection whenever the possibility of an airborne radioactive contaminant ex-ists. The minimum protection used should be an N-95, R-95, or equivalent mask, but any reduction in the in-take of radioisotopes is benefi cial. Although there are now pharmaceutical intervention compounds that can remove certain radioactive elements from the body or block the initial uptake by an organ system, the prefer-ential approach is clearly to prevent ingestion.

Effects on Emergency PersonnelIt is diffi cult for patients presenting in an emergency to have enough radioactive material on their clothes or on their body to deliver a harmful irradiation dose

to an emergency worker. Doses to response personnel are limited by regulation to certain specifi c levels. Be-low the upper limit of these levels, modern radiation science can not detect somatic effects of radiation. There may be statistical chances of effects later in an individual’s life, but it is unlikely that a responder will suffer an effect. Table 5.2 summarizes the anticipated effects of radiation exposure.

The greater threat to an emergency response work-er is the possibility of ingestion of radioactive materi-als. It is critical that all emergency response personnel become accustomed to immediately donning an N-95 or greater respiratory protective mask when respond-ing to an unknown situation. This may be diffi cult, since masks hinder communication, particularly for those who need to talk to victims, victims’ families, or numbers of persons. But the lethal ingestion dose for some highly unusual radioisotopes is relatively low. In the recent poisoning of the Russian spy Litvenenko, the estimated quantity of the polonium-210 delivered was less than a grain of salt.6 And there are certain non-lethal but common isotopes such as iodine, routinely shipped on trucks in most cities, that should be suspect-ed if any detection equipment shows a reading higher than background. Consequently, the inconvenience and communication hardship generated by the mask is far outweighed by the respiratory protection provided. In addition, if the worker or possible victim needs to drink liquids, a straw should be used to prevent washing con-taminants from the lips into the body.

Radioactive materials for medical use in diag-nostic tests are transported in low quantities through-out the world. Shipments occur daily in most major metropolitan areas. The quantities in these ship-ments are usually not an immediate danger to life and health (IDLH), and there is ample documenta-tion with each shipment. In the event of a terrorist attack to intercept a shipment, it would be diffi cult to acquire suffi cient quantity of medical isotopes to cause signifi cant harm. Most medical isotopes are of the short half-life variety, can be detected eas-ily by radiation detection equipment, and are trans-ported in well-marked vehicles. Iodine is used for medical activities, but dispersal of this isotope may reduce its effectiveness for injury. In the event of a transportation accident, detection equipment should be used prior to approaching the scene, emergency personnel should don a mask, and information on the vehicle or shipment should be acquired as soon as possible.

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DIRTY BOMBS, EXPOSURE BURNS, AND INGESTION INJURYThe deliberate spreading of a radioactive material could happen in several ways. A radiological disper-sal device (RDD) could spread isotopes over a large area. Other means of dispersing radioactive materials could be used with the sole purpose of spreading the material over a wide area. By defi nition, dispersing a radioactive material means that it is less concentrated; therefore, the radiation fi eld is reduced by distance. The major medical impact of a “dirty bomb” would be the physical trauma associated with the bomb por-tion of the device. The medical impact of the radiation from such a device may be minimal, since it is diffi -cult to deliver a harmful external dose with dispersed

material. The danger would be from the ingestion of radioisotopes. It is certain that this type of incident would cause fear responses by a large number of citi-zens from this type of incident. During an incident in Goiania, Brazil, a city of 1 million people, four people died as a result of breaking open a radiother-apy capsule, and 249 persons were contaminated.7 A number of persons presented with symptoms of radia-tion poisoning such as nausea and vomiting. Of those, none were contaminated. But 12% of the population showed up at a local soccer stadium to be checked for contamination. As with a radioisotope transport ac-cident, the number of “worried-but-well” people who are fearful of the effect on themselves or their fami-lies could be orders of magnitude above the number of actual victims.

Trauma from the explosion of a dirty bomb could be signifi cant, and the victims could be signifi cantly

Whole-Body Radiation from External Exposure or Internal Absorption

Subclinical Range Clinical, Sublethal Range Lethal Range

0–100 rad

100–200 rad

200–600 rad

600–800 rad

600–3,000 rad

�3,000 rad

Nausea, vomiting

None 5–50% 50–100% 75–100% 90–100% 100%

Time of onset

3–6 hours 2–4 hours 1–2 hours �1 hours Minutes

Duration �24 hours �24 hours �48 hours �48 hours Not avail-able

Lympho-cyte count

Unaffected Minimally decreased

�1,000 at 24 hours

�500 at 24 hours

Decreases within hours

Decreases within hours

Central nervous system function

No impair-ment

No impair-ment

Routine task perfor-mance

Cognitive impair-ment for 6–20 hours

Simple and routine task per-formance

Cognitive impair-ment for �24 hours

Rapid inca-pacita-tion

May have a lucid interval of several hours

Summarized from Department of Veteran Affairs Pocket Guide, Terrorism with Ionizing Radiation General Guidance. Bethesda, MD: Armed Forces Radiobiology Research Institute, 2003.

Signs and Symptoms of Radiation Exposure

TABLE 5.2

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contaminated. For this reason, it is recommended that any EMS personnel responding to an explosion of any sort, or receiving patients who have been affected by an explosion, immediately don a mask. Ingestion could lead to signifi cant internal exposure, and reme-dial pharmaceuticals may be required on an emergent basis. The use of radiation detectors by response per-sonnel would be mandated, both in the fi eld and in a receiving facility. Because the radiation environment could change rapidly, alarm-equipped detectors with reasonable pre-set levels may be required. Radiation readings taken with calibrated equipment, typically carried by most fi re department hazardous materi-als units, can determine the actual radiation fi eld in the area, and access by emergency personnel can be planned. In the event of the presence of a radiation fi eld, exposure limitations would be enforced. Unusu-al exposures could be allowed for specifi c personnel for life-saving and retrieval of injured persons in the radiation fi eld.

A far greater hazard may be signifi cant numbers of fearful citizens who feel the need to be “checked out” by a competent medical person, or who feel the need for decontamination. Medical facilities should be prepared for large numbers of citizens demanding attention if reporting of a traffi c accident mentions associated radioactive materials. If there is a possi-bility of contamination, a simple means to deal with worried but well people would be to establish sig-nage at a medical facility for people to decontaminate themselves while surrendering their clothing, and then donning a paper gown and being examined by a trained professional with a radiation detector. Per-haps the best recommendation to be made with a low possibility for contamination would be for persons who wish to be checked to stay home, remove their clothes and place them in a plastic bag, and then take a shower, put other clothes on, and bring the bag of clothes to a check station, which could be located at an area fi re or police station or large gathering ven-ue. An incentive for people to decontaminate them-selves would be that clearance by authorities is faster. Persons who need assistance with decontamination would proceed through a controlled decontamination stream, which would be much slower and monitored closely by response personnel. Materials required for this include heavy-duty plastic bags for clothing, re-closeable freezer-strength plastic bags for valuables, and temporary clothing for decontaminated persons.

The fi nancial impact of a dirty bomb might be signifi cant in the short term, because of the need to

clean the area for routine use. Natural phenomena such as weather may reduce the long-term impact of the isotopes, but uptake of biologically active isotopes such as iodine-131 (half-life of 8 days) or cesium-137 (half-life of 30 years) by crops and food animals could prolong the impact of an event.8 It is important that contaminated areas are controlled and adequately evaluated for realistic decontamination levels. Sig-nifi cant fi nancial resources may be required to “nor-malize” an area for use. Without question, national resources would be brought to bear on control and clean-up of any area involved in such an incident.

Exposure BurnsExposure burns are generally caused by irradiation, that is, exposure to a radioactive source of activity suffi cient to damage cells. This source could be a strong, concentrated “capsule,” or contamination of the skin over a signifi cant period of time. The burn is not perceived by the individual at the time of occur-rence, because humans are not equipped to directly perceive ionizing radiation. The effect of irradiation is to damage the ability of cells to regenerate, which presents at some time after exposure with symptoms similar to a thermal burn. Typically, the burn decreas-es in severity with distance from the point of exposure on the skin, but the burn can be extremely deep. An exposure burn does not present until weeks or months after the incident, due to the increasing failure of cells to regenerate. Examples are radiological burns from the x-rays during multiple cardiac catheterizations 18 to 21 months postexposure, and a beta burn from an overnight exposure to a radioisotope thermoelectric generator 6 weeks postexposure (see Figure 5.3).

Ingestion InjuryThe extremely dangerous impact of ingestion of ra-dioactive materials was highlighted in 2006 in the case of Lieutenant Colonel Aleksandr Litvenenko of the Russian FSB (Federal Security Service, successor to the Soviet-era KGB secret police and intelligence organization). Litvenenko was poisoned with polo-nium-210, an alpha emitter with an extremely high specifi c activity (the ability of an isotope to produce radiation), while eating at a London restaurant. Po-lonium is a metal that binds to the heme portion of hemoglobin, so all tissues in Litvenenko’s body were bathed in high-level radiation (Figure 5.4). His death occurred 3 weeks after the ingestion.

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Although the isotope in this quantity is rare and the ingestion deliberate, this incident should serve as a warning to be suspicious of the potential to ingest radioisotopes in an unknown environment such as responding to an explosion or treating patients who present to EMS personnel after an explosive or con-tamination event.

NUCLEAR WEAPONSThe return of the threat of nuclear weapons has re-newed many efforts to prepare for a catastrophic event. The impact of a nuclear detonation of any size would be signifi cant, challenging the resources of any nation to respond. The uncertainty of the location of 50 to 100 “backpack nukes,” 1-kiloton weapons manufactured by the KGB for the Soviet Union,9 and the efforts by states such as Iran to develop weapons, along with the questionable reliability of certain na-tions that possess nuclear weapons, makes a nuclear detonation in a city somewhere in the world more likely than not. The detonation of any nuclear weapon would produce destruction and injury in the immedi-ate area and downwind threats due to fallout.

Blindness, Burns, Blast, and RadiationThe detonation of a nuclear device produces a signifi -cant amount of radiation in the visible spectrum. The net effect of this phenomenon is a long-range fl ash that can permanently blind people who inadvertently look at the fl ash or at a refl ection of the fl ash. Those

who throw their arms in front of their eyes may actu-ally see their bones through their fl esh, and may still have permanent damage due to the physical response time for protective actions. The blink refl ex takes ap-proximately 200 milliseconds, which may be enough time for permanent injury from the light.10 The ther-mal pulse generated by the detonation fi reball, which produces energy in the infrared spectrum, comprises 35% of the energy from a nuclear detonation. Any sur-face exposed to the thermal pulse will experience heat at a rate of 10 calories/cm2, which can cause spon-taneous combustion.10 Half of the energy generated by a nuclear weapon is expended in displacement of the atmosphere, which is the blast from the weapon. Atmospheric tests on buildings, steel ships, soil, hard rock, water, and all other physical structures demon-strate that there is little that can withstand a nuclear detonation. However, the range of such a blast is en-tirely dependent on the power of such a device, and the Earth’s atmosphere provides a damping effect. But projectiles thrown by a nuclear blast can travel signifi -cant distances. Last, the ionizing radiation produced

FIGURE 5.3. Radiation-Induced Skin Injuries from Fluoroscopy. Brian Dodd, “The IAEA and the Control of Radiation Sources”. U.S. Food and Drug Administration Offi ce of Science and Technology, Center for Devices and Radiological Health. Presenta-tion at Health Physics Society conference, College Station, Texas, April 2006.

FIGURE 5.4. Litvenenko at University College Hospital, central London, November 20, 2006. (Photo courtesy of Litvenenko family.)

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immediately by the detonation comprises a relatively small proportion, 5%, of the energy released. This so-called prompt gamma, or immediate release, is a high-energy pulse that irradiates any object according to the inverse square law.

The remaining 10% of the energy released by a nuclear weapon is in the form of fallout, which is re-

sidual radioactive materials that are thrown into the atmosphere by the blast, and fall out of the atmo-sphere over a period of time. Initial fallout, which de-scends to Earth in the fi rst 24 to 48 hours, comprises 50% to 70% of the total radioactivity from the detona-tion, and is comprised of a mixture of radioisotopes of relatively short half-life and high energy. This early fallout is extremely dangerous due to high radioactiv-ity, and people should avoid exposure to this in any form. Sheltering-in-place at a point as far as possible from the external surface of a building is the primary means of protection, but should be augmented by air fi ltration.10 Later fallout, which may descend over days or weeks, or may remain in the upper atmosphere for years, comprises 30% to 50% of the radioactivity released. This occurs primarily in the form of small particles, and may be longer half-life isotopes with lower radioactivity. Respiratory protection is advised for anyone downwind of a detonation. For this reason, it is critical to know and understand the “wind rose” for your location. Knowing the direction of travel of the wind could mean the difference between life and death. If patients are received who have been in a fall-out area, or a patient is irradiated by a large source, use the Andrews Lymphocyte Nomogram to deter-mine the level of exposure (Figure 5.5).

Note that if a person is exposed to radiation, a major factor in his or her recovery is prevention of infection. In Figure 5.6, a general hemogram shows maximum vulnerability at 30 days postexposure.

Another effect of a nuclear weapon is the ra-dio fl ash, or electromagnetic pulse (EMP). When

NORMALRANGE

MODERATE

SEVERE INJURY

VERYSEVERE

LETHAL

3000

2000

1000

AB

SO

LUT

E L

YM

PH

OC

YT

ES

500

100

0 1DAYS

2

FIGURE 5.5. Andrews Lymphocyte Nomogram. Andrews GA, Auxier JA, Lushbaugh CC. The importance of dosimetry to the medical management of persons exposed to high levels of radiation. In Personal Dosimetry for Ra-diation Accidents. Vienna: International Atomic Energy Agency, 1965.

DAYSEXPOSURE

14

12

10

8

6

4

3

2

1

2

16

12

8

4

0

2 20

LATENTPHASE

RECOVERYPHASE

BONEMARROW

DEPRESSIONPHASE

PR

OD

RO

MA

LP

HA

SE

10 4030 50

PLATELETS NEUTROPHILS

HEMOGLOBIN LYMPHOCYTES

60

HE

MO

GLO

BIN

(gr

ams

x 10

5 )

LYM

PH

OC

YT

ES

and

NE

UT

RO

PH

ILS

(x

105 )

PLA

TE

LET

S (

x 10

5 )

FIGURE 5.6. REACT/S Hemogram Showing Effects of Exposure of 300 rad (300 cGy) Total Body Irradiation.

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a nuclear weapon is detonated, the large number of gamma rays released has enough energy to actually knock electrons from atoms of gases such as oxygen and nitrogen in the atmosphere. These free electrons spin in the Earth’s magnetic fi eld, and give off en-ergy in an intense fl ash. This EMP has the potential to cause damage to any electronic circuit.11 An EMP could damage any communication device, control circuits for medical equipment, computers, network-ing equipment, power systems, and vehicles. Refrig-eration of medicines and electrical support of pa-tients could be damaged, for a short time to months. Planning for this possibility consists of installing power generation equipment in shielded areas, treat-ing penetrations for transient suppression, and other technologically complex procedures, but can also be as simple as removing antennas from radios when in a charging cradle and contingency planning if all power, communications, and vehicular transport are unavailable. The extent of EMP damage would de-pend on the size of the weapon and the altitude at which detonation occurs.

IMPACT ON MEDICAL CAREIt is clear from numerous drills that the medical com-munity suffers from many of the same fears that are widespread among the general population. Often, when radioactive contamination is detected in even low levels, medical facility administrators assert that their facility is “contaminated,” and thus closed to new patients, including formal declarations of diversion. Minimal levels of radiation exposure necessitate only minimal disruption to facility operations or person-nel activities, and understanding by managers of such levels is critical. In a radiological event, it is possible and even likely that emergency facilities, ambulances, and other response equipment will become slightly contaminated. The high sensitivity of radiation detec-tion devices produces highly audible readings from even minimal contamination that is not a threat to emergency workers. Radiation safety professionals or other trained workers must accurately evaluate the threat to emergency medical personnel.There are three myths that can paralyze medical response.12

The fi rst is that radioactive contamination is high-ly dangerous and requires extraordinary measures. The facts are these: Radioactive contamination is not immediately dangerous to life and health, is easily

managed and contained using airborne and contami-nation infection control practices, and, unlike biologi-cal or chemical agents, presents little hazard to medi-cal staff, unless inhaled or otherwise ingested.

A second myth is that decontamination of the patient is the highest medical priority. The facts are these: There are few, if any, legitimate reasons for withholding treatment due to radioactive contami-nation. Radioactive contamination may present is-sues over the long term (years), but is not usually an immediate threat to life and health. If the patient requires immediate treatment, treat the patient while protecting yourself. Later you can decontaminate the patient and yourself. The key is to understand radiation levels and to avoid ingestion of radiologi-cal materials.

A third myth is that you need special skills to handle radioactive patients. The facts are these: Ra-dioactivity cannot be sensed by the human body, so radiation meters (e.g., Geiger counters) are needed. They are easy to use, and most larger fi re departments now have meters. Contamination surveys are easily learned and performed. Decontamination is essen-tially a soap-and-water clean-up (in many cases as simple as a sponge bath).

The Greatest Hazard: Overwhelming Public DemandIt is worth reiterating that the public demand for emer-gency services to ameliorate fear is likely to be the greatest challenge to EMS in any minor radiological event, and an exacerbating condition in a major event. A large percentage of the population in your area may present to emergency departments, ambulances at or near the scene, or even your on-scene command post, with emotional demands to receive your services im-mediately. Security of emergency personnel must be maintained to allow successful treatment of truly in-jured persons.

SUMMARY

Radiation Effects Are Science, Not MagicThe cultural fear of radiation is global. Emotional responses from the public can obscure the knowl-edge base about radiation physics, and drive soci-

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etal and political activities that have no basis in sci-ence. The effects of radiation on humans are well understood. Even more important is the understand-ing of what radiation does not do. Exaggerations of radiation effects for entertainment purposes have encouraged the public to expect dramatic and fi c-tional responses rather than measured, understood effects.

Simple, Clear StepsEMS workers can take simple, clear steps to detect the presence of radiation, protect themselves from the radiation, and reduce the impact of radiation expo-sure and contamination on facilities and co-workers. Radiation detection instruments work well, and in the hands of trained personnel, are dependable and effec-tive. Protection is simple:

1. Prevent ingestion of radioisotopes at all costs, even at the cost of communication.

2. Focus on time, distance, and shielding when responding to any radiological incident.

3. Remember that time of exposure is linearly cu-mulative, but exposure is reduced by the square of the distance.

4. Simple decontamination means mechanical removal of materials, and most comes off the patient or the worker with removal of clothing.

PharmaceuticalsFortunately, compounds are available that can be used to reduce the total effective dose equivalent that the worker or patient receives from ingested radioiso-topes, if administered in time. The National Institutes of Health list an excellent reference paper,13 and the Centers for Disease Control and Prevention maintain an excellent web site.14 Pharmaceutical compounds corresponding to certain isotopes are available. The critical factor in most of these treatment regimens is timely administration. Stockpiles should be present, and most have a long shelf life.

CONCLUSIONProviding an effective medical response to a radio-logical or nuclear incident is possible for the EMS responder. Education and training are important in overcoming fears of the effects of radiation. Tools are available that must be used, and resources from ex-perts in radiation protection are available.

REFERENCES 1. Boudagov RS, Oulianova LP, Tsyb AF. The pathogenesis

and therapy of combined radiation injury. Report A394754. Washington, DC: Defense Threat Reduction Agency, U.S. Department of Defense, October 2006.

2. Jisha R. Texas Motor Speedway Exercise Summary. Austin: Incident Investigation and Environmental Program, Texas Department of State Health Services, November 2004.

3. Statement of Paul M. Longsworth, Deputy Administrator for Defense Nuclear Nonproliferation, National Nuclear Security Administration, before the Senate Armed Services Committee, March 10, 2004.

4. U.S. Department of Energy, Health, Safety, and Security Division. Nuclear Safety and Environment. Washington, DC: Department of Energy, June 2008.

5. Berger ME, Leonard RB, Ricks RC, Wiley AL, Lowry PC, Flynn DF. Hospital triage in the fi rst 24 hours after a nuclear or radiological disaster. Oak Ridge, TN: Radiation Emergency Assistance Center/Training Site (REAC/TS), U.S. Department of Energy, Oak Ridge National Laborato-ries.

6. U.S. Nuclear Regulatory Commission, Offi ce of Public Affairs. Polonium-210 Fact Sheet. Washington, DC: NRC, December 19, 2006.

7. International Atomic Energy Agency. The radiological ac-cident in Goiania, Brazil. Vienna, Austria: IAEA, 1988.

8. Lawrence Livermore National Laboratory. Marshall Islands Dose Assessment and Radioecology Program. Livermore CA: LLNM, 2003

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9. The Threat of Nuclear Diversion. Statement for the Record by John Deutch, Director of the Central Intelligence Agency to the Permanent Subcommittee on Investigations of the Senate Committee on Government Affairs, March 20, 1996.

10. Glasstone S, Dolan PJ. The Effects of Nuclear Weapons, 3rd ed. Washington, DC: U.S. Government Printing Offi ce, 1977.

11. Foster JS, Gjelde E, Graham WR, et al. Report of the Commission to Assess the Threat to the United States from Electromagnetic Pulse (EMP) Attack. Volume 1: Executive Summary, report to Congress, July 22, 2004.

12. McBurney R. EMS: State of the Science. Presentation at Health Physics Society conference, Dallas, Texas, January 2005.

13. Marcus CS. Administration of decorporation drugs to treat internal radionuclide contamination. Radiation Prot Manag 2004; 21(6):26—-31.

14. Centers for Disease Control and Prevention. Emergency Preparedness and Response. Radiation Emergencies. Avail-able at: http://emergency.cdc.gov/radiation.

ADDITIONAL RESOURCES 1. Armed Forces Radiobiology Research Institute. Emergency

Response Resources. Available at: http://www.afrri.usuhs.mil/outreach/emergency_response.html.

2. Armed Forces Radiobiology Research Institute: Medi-cal Management of Radiological Casualties Handbook, 2nd ed., April 2003. Available at: http://www.afrri.usuhs.mil/outreach/pdf/2edmmrchandbook.pdf.

3. Oak Ridge Institute for Science and Education, Radia-tion Emergency Assistance Center/Training Site. Web site. Available at: http://orise.orau.gov/reacts/.

4. U.S. Department of Health and Human Services. Radiation Emergency Medical Management. Web site. Available at: http://www.remm.nlm.gov/.

5. National Council on Radiation Protection and Measure-ment. Management of Persons Accidentally Contaminated with Radionuclides, 1979, report 65, and Management of Terrorist Events Involving Radioactive Material, 2001, report 138. Available at: http://www.ncrponline.org/.

6. Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry. Toxicological Pro-fi le for Ionizing Radiation. Available at: http://www.atsdr.cdc.gov/toxprofi les/tp149.html.

7. Centers for Disease Control and Prevention. Acute Radia-tion Syndrome: A Fact Sheet for Physicians. Available at: http://www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp.

8. Conference of Radiation Control Program Directors. Hand-book for Responding to a Radiological Dispersal Device: First Responder’s Guide—The First 12 Hours. Available at: http://www.crcpd.org/RDD_Handbook/RDD-Handbook-ForWeb.pdf.

9. Health Physics Society. Emergency Department Manage-ment of Radiation Casualties. (Powerpoint fi le. Click on Medical Response.) Available at: http://www.hps.org/hsc/.

10. U.S. Department of Homeland Security. Domestic Nuclear Detection Offi ce, Joint Analysis Center. Available at: http://www.dhs.gov/xabout/structure/gc_1192453282596.shtm.

11. U.S. Nuclear Regulatory Commission. Emergency Pre-paredness and Response. Available at: http://www.nrc.gov/about-nrc/emerg-preparedness.html.

12. U.S. Department of Energy, National Nuclear Security Administration. Radiological Assistance Program. Available at: http://nnsa.energy.gov/emergency_ops/1709.htm.

13. Oak Ridge Institute for Science and Education, Radiation Emergency Assistance Center/Training Site. REAC/TS Electronic Library References. Courses: Emergency Re-sponse. Available at: http://www.orau.org/ptp/New_Folder/new/library/Cdlinks/Topics_EResponse.htm.

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