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					   Emergency Department


   Preparation for Receiving
          Radiation
Exposed/Contaminated Patients
 Radiation Exposure/Contamination
• Accidents
   •   Nuclear reactor
   •   Medical radiation therapy
   •   Industrial irradiator
   •   Lost/stolen radioactive sources
   •   Transportation

• Terrorist Event
   • Radiological dispersal device (dirty
     bomb)
   • Attack on or sabotage of a nuclear
     facility
   • Low-yield nuclear weapon
                 Scope of Event

  Event          Number of Deaths               Most Deaths Due to

 Radiation           None/Few                       Radiation
 Accident

 Radioactive        Few/Moderate                   Blast Trauma
                    (Depends on size of
  Dispersal        explosion and proximity
   Device                of persons)


  Low-Yield              Large                    Blast Trauma
                  (e.g., tens of thousands in
Nuclear Weapon     an urban area even from       Thermal Burns
                        0.1 kT weapon)          Radiation Exposure
                                                (Depends on Distance)
       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.
 Be prepared for multiple events, e.g., a 1st event
  followed by 2nd event used to take out first
  responders if terrorists are involved.
 Be prepared for:
    Large numbers of potentially contaminated individuals.
    Large numbers of uninjured and uncontaminated but
     concerned and frightened individuals.
         Emergency Preparedness

   Triage Goals for Mass Casualty
     Evaluate and sort patients by immediacy of treatment.
     Do the greatest good for the most people.

 In mass casualty event, may need to deal with
    thousands of persons in need of contamination
    and exposure assessment.
 Pre-plan to ensure adequate supplies and
    survey instruments are available.
 Training and drills are essential to competence
    and confidence.
         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 medical care
 as indicated.
• Depending on weather, decontamination sites
 may have to be established indoors or in a
 temporary shelter.
Contaminated but Uninjured and Worried Well

  • An incident caused by nuclear terrorism may
    create large numbers of contaminated people
    who are not injured and worried people who
    may not be injured or contaminated.

  • Measures must be taken to prevent these
    people from overwhelming the emergency
    department.
         Controlled Triage Site

• A controlled triage site
 should be established
 away from the
 emergency department
 to intercept the large
 numbers of
 contaminated people
 who are not injured and
 people who are
 uncontaminated but
 worried and divert them
 to appropriate locations.
              Triage Site Control
• Control of movement through the site is
    necessary to minimize the potential for
    contaminating clean areas of the site.
•   The triage site should be staffed with medical
    staff, radiation monitors, and security personnel.
•   Precautions should be taken so that people
    cannot avoid the triage center and go directly to
    the emergency department.
           Decontamination Center
• Establish a decontamination center for people 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.
   •   Staff the center with medical staff with a radiological
       background, health physicists or other staff trained
       in decontamination and use of radiation survey
       meters.
   •   Psychological counselors available
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          photo credits: M. Meehan



 into clean areas, except
 by the designated route.
                Directions

• Clear directions (in
 appropriate
 languages) are
 necessary to help
 individuals
 understand what is
 expected of them.
       Handling of Mass Casualties
                                                                   Access for
                                                                   Staff, Press,
                                                                   Officials
                                                       Main
             Near Emergency                           Hospital
               Department
Access for                                             Area for
Self-                                                 deceased    Ambulance
               Controlled
referred                               Serious                      Traffic
                Triage
patients                            Injury/Illness                   Only
                  Site
              Triage for Injury &                    Emergency
               Contamination                         Department

        • Perform first aid
        • Perform
          decontamination                              Admit
                                                      patients
               Community                             or treat &
                                                     discharge
              Facility Preparation


• Activate hospital plan:
   • Obtain radiation survey meters.
   • Call for additional support: Staff from Nuclear
       Medicine, Radiation Oncology, Radiation
       Safety (Health Physics).
   •   Establish area for decontamination of
       uninjured persons.
   •   Establish triage area.
               Facility Preparation

• Plan to control contamination:
   • Instruct staff to use universal precautions and
       double glove.
   •   Establish multiple receptacles for
       contaminated waste.
   •   Protect floor with covering if time allows.
   •   For transport of contaminated patients into the
       emergency department, designate separate
       entrance, designate one side of corridor, or
       transfer to clean gurney before entering, if time
       allows.
               Treatment Area Layout
                                                              Separate
                                                              Entrance
CONTAMINATED                                       ED
                Radiation                         Staff
                 Survey
    AREA
                   &
                Charting


                              Trauma Room
               Contaminated
                  Waste                                       HOT
                                                              LINE
                                 STEP             Radiation
                Waste
BUFFER




                                 OFF               Survey
 ZONE




                                 PAD
CLEAN
 AREA




                                         Clean
                                        Gloves,
                                        Masks,
                                        Gowns,
                                        Booties
      Additional Considerations

• Develop prepared information packets
 with Media Relations in advance with
 message for incidents involving radiation.
• CDC Web site (www.cdc.gov) has
 Emergency Instructions for Individuals
 and Families
        Available in
          English
         Español
         Deutsch
         Français
         Tagalog
         Chinese                 photo credits: CDC
                        Health Physics Society
Disclaimer: The information contained herein was current as of 13 Aug 2008 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.


*The Health Physics Society is a nonprofit scientific professional organization whose
mission is to promote the practice of radiation safety. Since its formation in 1956, the
Society has grown to approximately 6,000 scientists, physicians, engineers, lawyers,
and other professionals representing academia, industry, government, national
laboratories, the Department of Defense, and other organizations. Society activities
include encouraging research in radiation science, developing standards, and
disseminating radiation safety information. Society members are involved in
understanding, evaluating, and controlling the potential risks from radiation relative to
the benefits. Official position statements are prepared and adopted in accordance
with standard policies and procedures of the Society. The Society may be contacted
at 1313 Dolley Madison Blvd., Suite 402, McLean, VA 22101; phone: 703-790-1745;
fax: 703-790-2672; email: HPS@BurkInc.com.