Training: Medical Management of the Contaminated Patient

Recent training drills have indicated most hospital Emergency Departments are poorly trained to manage patients who are contaminated with radioactive materials or exposed to significant quantities of ionizing radiation. Once a patient has been identified as being contaminated with normal form (loose) radioactive materials, the following activities should occur rapidly:

1. Control Line. A control line (reverse isolation) must be set up to contain the contamination within a predefined area of the ER, typically a treatment room. Everyone leaving the room must be surveyed with appropriate survey equipment. Operation of this control line is technically simple but logistically complex given the heavy traffic in most Emergency Departments. Recognize that the staff may not realize the patient is contaminated until they are already in the ER. Failure of the control line in the ER can lead to rapid contamination of the hospital. While many think federal or state agencies will help the hospital staff with contamination control, it is most unlikely. The large DOE response team stationed in Las Vegas generally cannot arrive for 48 to 72 hours, and few states have sufficient personnel or equipment to help the area hospitals. Hospitals must be able to control contamination using in-house staff and equipment.

2. Radiochemistry. Samples of the contamination from nasal smears, clothing, or bioassay samples must be rushed to a radiochemistry lab with the appropriate high resolution gamma and alpha spectrometers to identify the offending radionuclide(s) and determine the activity on the nasal smears or bioassay samples. Radiochem labs are uncommon (RSE has the only commercial radiochem lab in Arizona), and none work 24/7. The hospital should have a prearranged contract with one to handle the samples on an emergency basis if needed, and this capacity should be tested during drills. Speed is of the essence. In many cases the contaminating radionuclide can be determined from a shipping manifest in a transportation accident, or from plant safety personnel in industrial or nuclear power plant accidents. The radiochem lab still must evaluate the nasal smears and other bioassay samples needed for definitive treatment of the patient.

3. Dosimetry. An estimate of the radiation dose the patient has or will receive from the inhaled or ingested radionuclides (internal dosimetry) must be made, along with an external dose estimate, and an estimated dose to the basal epithelium from skin contamination. The hospital radiation physicist should perform these tasks. Since this is a rare occurrence, most hospital physicists will not have the skin dose code (Varskin) or the internal dosimetry code (DCAL or IMBA) necessary to perform these estimates. This should be addressed in your emergency planning. Call lists of all personnel who must respond to this type of emergency should be in every ER.

4. Definitive Treatment. Medical subspecialists with experience in treating radiation injuries are available to guide local physicians in the treatment of the patient with radiation injuries, and the CDC has stockpiled most of the drugs that will be needed. Physicians from the REAC/TS site in Oak Ridge, TN (see training section below) are available 24/7 to guide patient care. The REAC/TS physicians, of course, cannot measure radiation from their offices in Oak Ridge, so the radiochemistry lab and physicist must relay isotope and dosimetry data to them for each patient.

5. Training. The federal government has provided abundant training opportunities for hospital personnel who must manage the control line and for physicians who will treat the patient. All of the training is heavily subsidized or free. For the staff involved in the care of the patient, Oak Ridge Associated Universities offers several classes in the care of patients with radiation injuries. Please see the web site below for their current offerings.

These classes are taught by the same subspecialists referenced above who will be guiding the patient care.

For the staff that will be obligated to run the control line, DOE offers free training at the Nevada Test site near Las Vegas. Please see the website below for the listing of these classes.

Since the number of personnel necessary to run a control line can be large, it is common to send some staff (e.g. Nuclear Medicine Technologists) to the free training and then have the trained staff members and the local physicists that have had advanced training in emergency response, train the bulk of the personnel that will manage the control line(s). The number of control lines you will need to operate simultaneously can be determined from your emergency response plan. A control line will be needed for each isolation area in the ER and every OR where contaminated patients will be treated.

The federal government has also provided grant monies to cover the cost of the additional radiation survey equipment needed, although the grant application process is quite convoluted.

If you have any questions regarding any of the above issues, please feel free to call us at (480) 897-9459 or (800) 477-8691.