1. NMDP Basic Radiation Training
Presenters name
Date

2. Why learn about radiation?
Many agencies think that there will be a radiological incident in our lifetime
U.S. government
Independent nuclear watch groups
(Nuclear Threat Initiative)
(Monterey Institute for International Studies)
International Atomic Energy Agency (IAEA)
Every year hundreds of radiological sources are stolen worldwide
Between , over 612 radiological devices were stolen or lost around the world. Fewer than half were recovered 1. In 2006 alone, 85 incidents were reported to the International Atomic Energy Agency (IAEA), 75% of which had not been recovered at the time of the IAEA report 2. And this is only what is reported to the IAEA.
Less than 10 kg of Plutonium is required to create a 10 kiloton Improvised Nuclear Device (IND). If such as device was detonated in a major city, there could be hundreds of thousands of casualties, including more than 30,000 potential patients with a marrow toxic injury 3. As a hematologist, oncologist or transplant physician, you would be called upon to play a vital role in caring for victims with a hematologic toxic injury.
References:
1 Dainiak, Nicholas, et al. The Hematologist and Radiation Casualties, American Society of Hematology: Hematology 2003, p
2 IAEA, Preliminary 2006 Report from IAEA Illicit Trafficking Database, February 1, 2007
3 Casualty predictions derived from Draft: National Planning Scenarios, April 2006, Department of Homeland Security

3. Goals of this Presentation
Basics of radiation: sources, types, units of measurement
Biological and clinical effects of radiation
Symptoms of Acute Radiation Syndrome (ARS)
Exposure and contamination
Protection against radiation exposure: time, distance, shielding
Preparedness planning and our role with RITN
Between , over 612 radiological devices were stolen or lost around the world. Fewer than half were recovered 1. In 2006 alone, 85 incidents were reported to the International Atomic Energy Agency (IAEA), 75% of which had not been recovered at the time of the IAEA report 2. And this is only what is reported to the IAEA.
Less than 10 kg of Plutonium is required to create a 10 kiloton Improvised Nuclear Device (IND). If such as device was detonated in a major city, there could be hundreds of thousands of casualties, including more than 30,000 potential patients with a marrow toxic injury 3. As a hematologist, oncologist or transplant physician, you would be called upon to play a vital role in caring for victims with a hematologic toxic injury.
References:
1 Dainiak, Nicholas, et al. The Hematologist and Radiation Casualties, American Society of Hematology: Hematology 2003, p
2 IAEA, Preliminary 2006 Report from IAEA Illicit Trafficking Database, February 1, 2007
3 Casualty predictions derived from Draft: National Planning Scenarios, April 2006, Department of Homeland Security

4. Section 1: Radiation Basics

5. Types of Radiation Natural Man made
Many more sources of natural radiation
Insignificant risk associated with typical exposure
Man made
Fewer sources of exposure
BUT…potentially deadly if misused
Ionizing radiation is focus of this course

6. Sources of Radiation Exposure in the U.S. Population
Natural (82%)
Radon
Cosmic (outer space)
Terrestrial
Rocks/Soil
Internal
Inside human body
Stress that Radon is the largest source of natural radiation.
Radon is the result of radioactive decay of minerals deep in the earth.
Internally there are multiple sources of radiation: all humans have potasium-40 (K-40) inside their cells, this is harmless radiation that naturally occurs which has a half-life of 1.26 billion years. The second most active radionuclide in the body, carbon-14 (5,730 yr half-life), but it can not be detected easily because it is a beta emitter.

7. Natural Background Radiation
Cosmic
Sun (much of this radiation is shielded by Earth’s atmosphere)
Terrestrial Sources
Materials in soil
Break down into radon gas
Radioactivity in the Body
Very minute quantities
We are constantly exposed to radiation.
This exposure can increase when at higher altitudes such as being in Denver or when flying in a comercial aircraft.

8. Sources of Radiation Exposure in the U.S. Population
Man Made (11%)
- Medical
X-rays
CT scans
- Nuclear medicine/
radiation oncology
- Consumer products
- Other
Man made radiation is a small percentage of the total sources of exposure, yet much more dangerous.
Provide specific examples of man made radiation:
Diagnostic radiation:
Xrays
Bone scans
Treatment radiation:
Cancer treatment (total body irradiation prior to transplant)
Radiation sources placed inside the body, wafers for brain cancer or pellets for prostate cancer
Consumer products:
Tritium causes the illumination in watch faces
Americium is used in smoke detectors

9. Atomic Structure (a VERY basic one)
Protons
Positive charge
Neutrons
No charge
Electrons
Negative charge
To understand how radiation is hazardous we need to review a bit of high school physics.
An atom is the smallest particle of an element, smaller than an atom and it no longer can be connected to a specific material (like Hydrogen, etc…).
An atoms basic composition includes protons, electrons and neutrons.
Ionizing radiation is produced by radioactive decay of atoms, also by nuclear fission and fusion…. aka nuclear reactor or a thermonuclear device such as a nuclear bomb.

10. Radioactivity and Ionizing Radiation
Radioactivity or radioactive decay:
Emitting excess energy from the nucleus of an unstable atom
Radioactive decay results in the decrease of radiation levels over time
Ionizing radiation: Energy released from unstable (radioactive) atoms
NOTE: Radioactive Atoms Emit Radiation

11. Three Main Types of Ionizing Radiation Emitted from Radioactive Atoms
Alpha
Beta
Gamma
When you think of Alpha particles, think inhalation/ingestion/injury hazard. The particles have to be inside the body to do significant damage.
In 2006, Alpha particles resulted in the death of Alexander Litvinenko, a Russian dissident, who was poisoned with Polonium-210.
Had he not ingested the radioactive material he would have most likely survived, external contamination at best would result in a burn similar to sunburn.
Additional sources of Alpha particles include:
americium-241
radon
plutonium
radium
thorium
Uranium
An alpha particle can be stopped by one sheet of paper.

12. Ionizing Radiation Alpha Particles
Heaviest and most highly charged ionizing radiations
Energy is used up quickly; low penetrating ability
Cannot travel more than 4 to 7 inches
Stopped by a sheet of paper
Not a serious hazard outside the body
Can be most damaging if inside the body (e.g., ingestion, inhalation)
When you think of Alpha particles, think inhalation/ingestion/injury hazard. The particles have to be inside the body to do significant damage.
In 2006, Alpha particles resulted in the death of Alexander Litvinenko, a Russian dissident, who was poisoned with Polonium-210.
Had he not ingested the radioactive material he would have most likely survived, external contamination at best would result in a burn similar to sunburn.
Additional sources of Alpha particles include:
americium-241
radon
plutonium
radium
thorium
Uranium
An alpha particle can be stopped by one sheet of paper.

13. Ionizing Radiation Beta Particles
Smaller and travel much faster than alpha
Physically similar to electrons, but do not orbit around an atom
Travel faster with less charge than alpha and penetrate further
Major hazard when emitted by internally-deposited radioactive material
Beta particles are similar to Alpha particles in that while outside the body they are not powerful enough to cause significant damage.
These radionuclides all release Beta particles:
cesium-137
cobalt-60
iodine-129 &-131
strontium-90
Tritium
A beta particle can be stopped by one sheet of aluminum foil.

14. Ionizing Radiation Gamma Rays Similar to medical x-rays
Short wavelength and high frequency
Most hazardous from sources outside the body
Can travel up to a mile in open air
All tissues and organs can be damaged by sources outside the body
Gamma rays are the most powerful ionizing radiation we will discuss here today (instructors note: Neutron radiation is a very powerful ionizing radiation that is limited to specific nuclear fission reactions and therefore outside the scope of a potential radiological incident).

15. Ionizing Radiation Alpha and beta radiation: both are PARTICLES
Gamma radiation: is a form of electromagnetic radiation, transmitting energy in the form of WAVES
Gamma rays are the most powerful ionizing radiation we will discuss here today (instructors note: Neutron radiation is a very powerful ionizing radiation that is limited to specific nuclear fission reactions and therefore outside the scope of a potential radiological incident).

16. Electromagnetic Radiation
Transmitted in the form of waves
Generally higher in energy
Originate in the nuclei of atoms
Types of electromagnetic radiation include television and radio waves, microwaves and visible light.
Gamma radiation, to the far right is a very powerful form of electromagnetic radiation that is also ionizing radiation.

17. Radiation Penetration Into Skin
Exposure to alpha & beta from outside body is slight hazard
Long periods of exposure can cause “heat burns”
Significant hazard if ingested, inhaled or contaminates a wound
Since alpha and beta are not powerful enough to penetrate deeply, they are primarily a hazard only when ingested, inhaled or when in an open wound.
Beta particles can cause a nasty skin burn if exposed for a long enough period; and beta particles are extremely hazardous to the unprotected human eye.
Where gamma radiation can pass through a human with ease, and therefore interact with sensitive internal organs.

18. Ionizing Radiation Gamma rays - deadly Beta particles
There are three (3) types of ionizing radiation that we will discuss today.
Alpha, Beta and Gamma….
We will show you that all are hazardous and can kill a human, but some are significantly more dangerous than others.
Beta particles
– internally a bit more hazardous
Alpha particles – hazardous internally

19. Shielding
Gamma rays pass through you and keep going.
You will not be radioactive after being exposed to gamma radiation. Just like you are not radioactive after having an xray.
This doesn’t mean it is safe. As it passes through your body it causes significant damage to cell structures.
2-1/2 inches of dense concrete will absorb approximately 50% of typical gamma rays
Five inches of water is just as effective

20. When you are exposed to radiation, your body absorbs a measurable dose
Exposure vs. Dose
When you are exposed to radiation, your body absorbs a measurable dose

21. Measurement of Radiation Dose
Today we will discuss three (3) ways to measure radiation.
Roetegen, rad and rem.
All measure radiation, yet each have a specific use.
What needs to be known for medical treatment
Intensity of exposure
Time or duration of exposure

22. Roentgen
The Roentgen is used to express the amount of gamma radiation exposure
Abbreviated with a capital “R” after the amount of gamma radiation received
Independent of the time of exposure
This measurement is not very useful in determining the biological effects on a human since it only states the amount of radiation exposure, not what was absorbed into the body. Therefore it does not lend to quantifying the potential level of cell damage.
For instance, if a man is exposed to 5 R of gamma rays on one occasion, and 6 R on another, the sum of the two, 11 roentgens, is his cumulative gamma radiation exposure.

23. Rad (radiation absorbed dose)
Relates different types of radiation (alpha, beta, gamma and neutron) to the energy they impart
Basic unit of absorbed dose of radiation
One roentgen of gamma radiation exposure results in about one rad of absorbed dose
A rad as well as a gray are very important in determining the impact of radiation exposure.
Both directly correlate to the potential impact on cells since both rads and grays measure how much radiation was absorbed in the body.
1 rad = 0.01 Gy or 100 rad = 1 Gy

24. Rem (roentgen equivalent man)
Relates the dose of any radiation to the biological effect of that dose
For gamma rays and beta particles, 1 rad of exposure results in 1 rem of dose
For alpha particles, 1 rad of exposure results in ~20 rem of dose
Rem takes into account that different radiological materials impact the body with a variety of effectiveness.
Definition from Rem relates the absorbed dose in human tissue to the effective biological damage of the radiation. Not all radiation has the same biological effect, even for the same amount of absorbed dose.
Therefore, 1 rad from an alpha particle source is not the same as 1 rad from a beta or gamma source. The measurement may seem counterintuitive since alpha particles result in a higher rem dose. This is because alpha particles exposed to human tissue are slow clumsy particles that will collide with human cells, where some beta particles and many gamma rays will pass through the body not impacting any cells.

25. Exposure Rate The rate at which an individual is exposed to radiation
Expressed in terms of roentgen or milliroentgen per hour

26. International System of Units (SI)
SI uses gray (Gy) instead of rad
- 1 Gy = 100 rad
SI uses sievert (Sv) instead of rem
Sv = 100 rem
SI units must be used on labels to identify radioactive materials during transport

27. Section 2: Biological Effects of Radiation

28. Biological Effects
Dependent upon type of exposure (duration of exposure)
Acute (limited time of exposure)
Chronic (extended or repetitive exposure)
Level of exposure (intensity)
Certain biological factors
For biological effects think:
Time
Intensity
And, everyone really is special. Meaning we are all different, no one responds to radiation exposure the same way (except for extremely high doses).

29. Ionizing Radiation Radiation is a form of energy in motion
When alpha, beta and gamma radiation enter the body, some or all of their energy is lost in collisions with the body’s cells
Collisions strip away electrons from atoms in the body
Removal of electrons is called ionization
These collisions with the body’s cells results in damage that make humans sick… Acute Radiation Sickness.

30. Biologic Effects Damage DNA and other structures inside cells
Could result in cell death
Incorrect repair, resulting in mutations that could cause cancer

31. Biological Effects Acute Exposure Chronic Exposure
Significant dose of radiation over a short period of time
Radiation sickness or death shortly after exposure
Long-term effects (possibly cancer years later)
Chronic Exposure
Small dose of radiation continuously or over many years
No immediate observable effects
May result in long-term effects
Acute exposure resulting in sickness is from high level of exposure over a short period of time.
Chronic exposure sneaks up on you over many years of minor exposure.

32. Biological Factors
Each person differs in their biological response to a given dose of radiation
Age
Sex
Diet
Body temperature
Overall medical health

33. Acute Radiation Sickness
Occurs when an individual is exposed to a large amount of radiation in a short period of time
Occurs at doses greater than 100 rem
(1 Sv), which would be 100 rad (1 Gy) for gamma rays

34. Acute Radiation Sickness
Manifestations
Changes in blood cells (lymphocytes decrease first)
Vascular changes
Skin irritation
GI effects (nausea, vomiting, diarrhea)
Fever
Non specific “flu”-like symptoms
Hair loss

35. Acute Radiation Sickness
Severity and course depends on
How much total dose is received
How much of the body is exposed
Sensitivity of exposed individual to radiation
May appear shortly after exposure, then disappear for a few days only to reappear in a much more serious form in a week or more (related to amount of exposure)

37. Four Stages of ARS Prodromal phase (within 48 hours)
Latent Phase (days to weeks)
Manifest Illness (weeks to months)
Recovery or Death

38. Four Stages of ARS Prodromal phase (within 48 hours)
Nausea/vomiting
Headache
Fatigue
Fever, diarrhea
Anorexia
Fluid shifts
Electrolyte imbalance
Latent Phase (days to weeks)
Temporary improvement
Common initial signs of ARS are:
Nausea/vomiting
Headache
Fatigue
Fever, diarrhea

39. Four Stages of ARS Manifest Illness (weeks to months)
Intense immunocompromise and symptoms specific to 4 major organ systems (heme, GI, skin, neurovascular)
Recovery or Death
Note: After lethal dose, victims may go through these phases in a period of hours resulting in early death

40. Severity Levels Delayed effects after sublethal dose
(<250 rem*) may be non-specific
Fever
Abdominal pain
Insomnia
Restlessness
Blisters
Malaise
Fatigue
Drowsiness
Weight loss
* For gamma and beta radiation, 1 rem = 1 rad

41. Delayed effects after potentially
Severity Levels
Delayed effects after potentially
lethal dose (250 to 650 rem*)
Significant reduction in production of blood cells
Nausea/vomiting which appears to get better in 3 days
WBC greatly reduced
After two weeks: chills, fatigue, ulceration of the mouth
* For gamma and beta radiation, 1 rem = 1 rad

42. supralethal dose (>650 rem*)
Severity Levels
Delayed effects after
supralethal dose (>650 rem*)
Damage to the stomach lining and/or intestine
Causing decreased absorption, ulceration and dehydration
Seven Days After Exposure
Severe infection, fluid loss, blood loss or collapse of the circulatory system and may result in death
* For gamma and beta radiation, 1 rem = 1 rad

43. Severity Levels Acute Doses over 1000 rem*
Irreparable damage to the brain and spinal cord
Symptoms
Agitation
Lack of coordination
Breathing difficulty
Occasional periods of disorientation
Death occurs within hours to days
* For gamma and beta radiation, 1 rem = 1 rad

44. Key Symptoms of ARS Reduced number of platelets Nausea Vomiting
Itching or altered sensation in the skin
Swelling and Edema
Diarrhea
Fatigue
Nausea
Vomiting
Anorexia
Reduced number of white blood cells (lymphocytes, granulocytes)

45. Severity of Radiation Injury
Dose Range (Gy)*
Prodrome
Manifest - Illness
Prognosis
(without therapy)
Mild
Slight decrease in
blood cell counts
Almost certain survival
Mild to Moderate
Early signs of BM
damage
Highly probable survival
(>90% of victims)
Moderate
Moderate-severe BM
Probable survival
Severe
Severe BM damage;
mild GI damage
Death within weeks
(50% of victims)
Pancytopenia and
moderate GI damage
Death probable
within 2-3 weeks
Marked GI and BM
damage; hypotension
Death probable within 1-
2.5 weeks
Severe GI damage,
pneumonitis, altered
mental status
Death certain within 5-12
days
CV collapse; fever;
shock
Death certain within 2-5
Abbreviations:
Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI).
Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko
* 1 Gy = 100 rad

46. What is the standard dose of total body irradiation (TBI)
irradiation used for
total body irradiation (TBI)
in clinical BMT?

47. Severity of Radiation Injury
Dose Range (Gy)
Prodrome
Manifest - Illness
Prognosis
(without therapy)
Mild
Slight decrease in
blood cell counts
Almost certain survival
Mild to Moderate
Early signs of BM
damage
Highly probable survival
(>90% of victims)
Moderate
Moderate-severe BM
Probable survival
Severe
Severe BM damage;
mild GI damage
Death within weeks
(50% of victims)
Pancytopenia and
moderate GI damage
Death probable
within 2-3 weeks
Marked GI and BM
damage; hypotension
Death probable within 1-
2.5 weeks
Severe GI damage,
pneumonitis, altered
mental status
Death certain within 5-12
days
CV collapse; fever;
shock
Death certain within 2-5
Abbreviations:
Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI).
Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko
12 Gy: TBI dose for clinical BMT

48. - the lungs are usually given a lower
The standard dose of irradiation used for total body irradiation (TBI) in clinical BMT is 12 Gy (1200 rad), but….
- this total dose is administered in
multiple fractions over several days
to allow repair of normal cells and
tissues
- the lungs are usually given a lower
total exposure (e.g., 9 Gy) to reduce
risks of pulmonary toxicity

49. Treatments
Exposure results in a full range of injuries, from changes in the blood cells to skin burns to serious radiation sickness
Analysis of peripheral blood may diagnose exposure before other effects appear
Treatment depends upon the nature and severity of the injury

50. Long-Term Effects Probability increases as level of exposure increases
Three most notable effects
Cancer
Cataracts
Acute exposure of 200 rads (2 Gy)
Chronic exposure (months) of 1,000 rads (10 Gy)
Shortening of lifespan
Although widely thought of as a cause of cancer, acute radiation exposure only marginally increases cancer risk. For example, Japanese atomic bomb survivors who received and average of approximately 28 rads (0.28 Gy), only 0.2 percent experienced a radiation-induced cancer.
Fibers that comprise the lens of the eye are specialized to transmit light. Damage to these fibers, and particularly to the developing immature cells that give rise to them, can result in dark spots in the lens called cataracts that interfere with vision.

51. Long-Term Effects Animal experiments
Same disease, earlier age
Data from populations of Hiroshima and Nagasaki
Very slight risk (i.e., <1 years per 100 R)

52. Long-Term Effects

53. Section 3: Exposure versus Contamination

54. Contamination versus Radiation
Contamination: the deposition of radioactive material in undesired locations
NOTE: one can be exposed to radiation without becoming contaminated (e.g., radiation therapy treatments)
Radioactive contamination on a surface does not make the surface itself radioactive
- Remember that radioactive materials emit
radiation
- Once the contaminated surface is cleaned of the
radioactive material, there is no longer a threat of

55. Sources of Radioactive Exposure
and Contamination
Direct radiation
Inhalation
Skin contamination
Direct ingestion
Radiation from
contaminated surfaces
Secondary ingestion
(e.g., food, water, milk)
Briefly discuss these means of exposure to radiation:
Direct radiation: exposed like in radiotherapy
Inhalation: as a result of a radioactive plume (cloud containing radioactive particles), plumes are associated with fallout, nuclear power plant releases, and dirty bombs
Skin contamination: radioactive particles that are temporarily deposited on the skin, once washed off during decontamination the radiation will be gone
Direct ingestion: if there are radioactive particles on food or in a beverage they can be very dangerous once ingested (this is how Litvenenko received a lethal dose of Polonium-210)
Radiation from contaminated surfaces: radioactive particles on surfaces emit radiation that can be harmful to the body
Secondary ingestion (e.g., food, water, milk): If a cow ingests radioactive particles, some of these will be transferred to the milk which can be dangerous if ingested

56. Control of Radiation Exposure
Protective Measures
Time
Less time = less exposure
Distance
Further away = less exposure
Shielding
Intensity is reduced by absorption and scattering by the material between you and the source
These should all make sense.
Time- You want to be exposed to the radiation for a short a period of time as possible. Less time means a lower absorbed dose at that exposure level.
Distance- Would you want to be next to a nuclear detonation or in the next state over? The farther away the lower the exposure level.
Shielding- Would you rather hide behind a fence or a 4 foot thick concrete wall? The more material between you and the source the less radiation that will get to you.

57. Section 4: Preparedness Planning

58. Types of Radiological Incidents
Orphaned source
Lost/stolen radiation source that exposes people
Can be purposely placed to injure
Radiological Dispersal Device
a.k.a. “dirty bomb”
Improvised Nuclear Device (IND)
a.k.a. “terrorist nuke”
could fit into a suitcase

59. Orphaned Source Case Study

60. Dirty Bombs
Conventional bomb attached to a source of radioactivity (e.g., Cobalt-60)
Explosion spreads radioactivity resulting in widespread contamination
Result in few casualties
Public panic is greatest danger
Economic impact is far reaching when compared to INDs or military weapons

61. Radiological Dispersal Device Case Study
No explosion, but it is an excellent example of how the public would react in response to the potential contamination.
Anxiety and panic.

62. Improvised Nuclear Device (IND)
Estimates based on a 1 kiloton or 10 kiloton IND
Worst case scenario: Victims will outnumber BMT community resources

63. Improvised Nuclear Device (IND)
INDs are not only in James Bond (Goldfinger) and George Clooney (Peacemaker) movies.
The left picture is an example of what a IND could look like when created to fit in a briefcase.
On the right is a US Military SADM man portable nuclear device. The US and Russian military both had “backpack” nukes in their arsenals (they weighted upwards of 150 lbs, but were still easily maneuverable by military ground and Airborne units).

64. Contingency Planning
The Radiation Injury Treatment NetworkSM (RITN) provides comprehensive evaluation and treatment for victims of radiation exposure or other marrow toxic injuries. RITN develops treatment guidelines, educates health care professionals, works to expand the network, and coordinates situation response. RITN is a cooperative effort of the National Marrow Donor Program® (NMDP) and The American Society for Blood and Marrow Transplantation (ASBMT).

65. RITN Centers RITN provides:
Existing facilities with practicing specialists for intensive supportive care and treatment
Infrastructure and process for transplant if needed
Training of physicians and other health care workers
Assistance during an emergency
Donor search support
IRB - approved data collection plan
Increases transplant community awareness about potential need of their services in time of crisis
Involves transplant community in emergency preparedness

66. Available through RITN Website
RITN Acute Radiation Syndrome treatment guidelines
RITN center standard operating procedure templates
Donor selection criteria
NMDP data collection protocol
Training resources
Pertinent publications

67. What is RITN Doing to Prepare?
Standard Operating Procedures
Basic radiation training completed by staff
Grand rounds presentation in development
Additional training resources provided on RITN Web site
Conduct an annual tabletop exercise
Emergency communications tests
GETS cards and satellite telephones
Coordinating with government (DHHS-ASPR)

68. RITN Distribution Across USA
UMC

69. What if there is a disaster?
If an improvised nuclear device (terrorist nuclear bomb) is detonated, what will happen?
The federal government will:
Setup outside the hazard area
Receive, decontaminate and triage victims
Forward them on for appropriate care
Any victim with trauma or burns would be treated for that before being evaluated for treatment due to marrow toxicity
This leaves a smaller subset for marrow reconstitution
Stress that:
Unless it is your city that has the incident all patients will be decontaminated prior to presenting for treatment.

70. Possible Casualty Levels
The U.S. government is planning to respond to a 10 kiloton improvised nuclear device (terrorist nuclear bomb)
There most likely will not be many transplants as a result of a terrorist nuclear device detonation.
Low level exposure victims will self recover with minimal medical support.
High level exposure victims will die no matter what care they are given.
Between these two extremes will be many patients that require intensive medical support.

71. Timelines for Activity - Transplants
Not all of these patients will be ready for treatment at day one.
It will take time to evacuate, decontaminate and triage all the victims involved.
Even if there is a small chance of requiring a transplant the NMDP expects and is prepared for a significant initial load of search activity, this will result in many matches but as stated previously it is expected that there will be many less transplants.

72. RITN Centers
Admission to RITN several days after event (unless hospital is in the vicinity of the event)
Initial triage and decontamination is completed by first responders
Identifying a destination for each victim
Health & Human Services working with RITN
Initial treatment and diagnosis
Conducted by RITN, NCI and NDMS centers
NDMS – National Disaster Medical System: hospitals that signed agreements with HHS to receive patients resulting from a mass casualty event

73. Urgent BMT Small subset of patients will require transplantation
Expediting the evaluation of donor(s) is key
Housing needs for donors and patients
Expect that altered standards of care will be implemented by the Dept. of Health and Human Services during this time to facilitate treatment

74. “By failing to prepare you are preparing to fail.”
Contingency Planning
“By failing to prepare you are preparing to fail.”
Benjamin Franklin

75. Some Online References
RITN:
HHS Radiation Event Medical Management (REMM):
CDC:
Radiological Terrorism: Medical Response to Mass Casualties:
Radiological Terrorism: Just in Time Training for Hospital Clinicians:
Medical Response to Nuclear and Radiological Terrorism:
The Role of Public Health in a Nuclear or Radiological Terrorist Incident:
National Planning Scenarios: earlywarning/NationalPlanningScenariosApril2005.pdf