Presentation on theme: "NMDP Basic Radiation Training"— Presentation transcript:
1NMDP Basic Radiation Training Presenters nameDate
2Why learn about radiation? Many agencies think that there will be a radiological incident in our lifetimeU.S. governmentIndependent nuclear watch groups(Nuclear Threat Initiative)(Monterey Institute for International Studies)International Atomic Energy Agency (IAEA)Every year hundreds of radiological sources are stolen worldwideBetween , 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, p2 IAEA, Preliminary 2006 Report from IAEA Illicit Trafficking Database, February 1, 20073 Casualty predictions derived from Draft: National Planning Scenarios, April 2006, Department of Homeland Security
3Goals of this Presentation Basics of radiation: sources, types, units of measurementBiological and clinical effects of radiationSymptoms of Acute Radiation Syndrome (ARS)Exposure and contaminationProtection against radiation exposure: time, distance, shieldingPreparedness planning and our role with RITNBetween , 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, p2 IAEA, Preliminary 2006 Report from IAEA Illicit Trafficking Database, February 1, 20073 Casualty predictions derived from Draft: National Planning Scenarios, April 2006, Department of Homeland Security
5Types of Radiation Natural Man made Many more sources of natural radiationInsignificant risk associated with typical exposureMan madeFewer sources of exposureBUT…potentially deadly if misusedIonizing radiation is focus of this course
6Sources of Radiation Exposure in the U.S. Population Natural (82%)RadonCosmic (outer space)TerrestrialRocks/SoilInternalInside human bodyStress 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.
7Natural Background Radiation CosmicSun (much of this radiation is shielded by Earth’s atmosphere)Terrestrial SourcesMaterials in soilBreak down into radon gasRadioactivity in the BodyVery minute quantitiesWe 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.
8Sources of Radiation Exposure in the U.S. Population Man Made (11%)- MedicalX-raysCT scans- Nuclear medicine/radiation oncology- Consumer products- OtherMan 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:XraysBone scansTreatment radiation:Cancer treatment (total body irradiation prior to transplant)Radiation sources placed inside the body, wafers for brain cancer or pellets for prostate cancerConsumer products:Tritium causes the illumination in watch facesAmericium is used in smoke detectors
9Atomic Structure (a VERY basic one) ProtonsPositive chargeNeutronsNo chargeElectronsNegative chargeTo 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.
10Radioactivity and Ionizing Radiation Radioactivity or radioactive decay:Emitting excess energy from the nucleus of an unstable atomRadioactive decay results in the decrease of radiation levels over timeIonizing radiation: Energy released from unstable (radioactive) atomsNOTE: Radioactive Atoms Emit Radiation
11Three Main Types of Ionizing Radiation Emitted from Radioactive Atoms AlphaBetaGammaWhen 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-241radonplutoniumradiumthoriumUraniumAn alpha particle can be stopped by one sheet of paper.
12Ionizing Radiation Alpha Particles Heaviest and most highly charged ionizing radiationsEnergy is used up quickly; low penetrating abilityCannot travel more than 4 to 7 inchesStopped by a sheet of paperNot a serious hazard outside the bodyCan 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-241radonplutoniumradiumthoriumUraniumAn alpha particle can be stopped by one sheet of paper.
13Ionizing Radiation Beta Particles Smaller and travel much faster than alphaPhysically similar to electrons, but do not orbit around an atomTravel faster with less charge than alpha and penetrate furtherMajor hazard when emitted by internally-deposited radioactive materialBeta 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-137cobalt-60iodine-129 &-131strontium-90TritiumA beta particle can be stopped by one sheet of aluminum foil.
14Ionizing Radiation Gamma Rays Similar to medical x-rays Short wavelength and high frequencyMost hazardous from sources outside the bodyCan travel up to a mile in open airAll tissues and organs can be damaged by sources outside the bodyGamma 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).
15Ionizing Radiation Alpha and beta radiation: both are PARTICLES Gamma radiation: is a form of electromagnetic radiation, transmitting energy in the form of WAVESGamma 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).
16Electromagnetic Radiation Transmitted in the form of wavesGenerally higher in energyOriginate in the nuclei of atomsTypes 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.
17Radiation Penetration Into Skin Exposure to alpha & beta from outside body is slight hazardLong periods of exposure can cause “heat burns”Significant hazard if ingested, inhaled or contaminates a woundSince 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.
18Ionizing 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 hazardousAlpha particles – hazardous internally
19ShieldingGamma 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 raysFive inches of water is just as effective
20When you are exposed to radiation, your body absorbs a measurable dose Exposure vs. DoseWhen you are exposed to radiation, your body absorbs a measurable dose
21Measurement 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 treatmentIntensity of exposureTime or duration of exposure
22RoentgenThe Roentgen is used to express the amount of gamma radiation exposureAbbreviated with a capital “R” after the amount of gamma radiation receivedIndependent of the time of exposureThis 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.
23Rad (radiation absorbed dose) Relates different types of radiation (alpha, beta, gamma and neutron) to the energy they impartBasic unit of absorbed dose of radiationOne roentgen of gamma radiation exposure results in about one rad of absorbed doseA 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
24Rem (roentgen equivalent man) Relates the dose of any radiation to the biological effect of that doseFor gamma rays and beta particles, 1 rad of exposure results in 1 rem of doseFor alpha particles, 1 rad of exposure results in ~20 rem of doseRem 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.
25Exposure Rate The rate at which an individual is exposed to radiation Expressed in terms of roentgen or milliroentgen per hour
26International System of Units (SI) SI uses gray (Gy) instead of rad- 1 Gy = 100 radSI uses sievert (Sv) instead of remSv = 100 remSI units must be used on labels to identify radioactive materials during transport
28Biological EffectsDependent upon type of exposure (duration of exposure)Acute (limited time of exposure)Chronic (extended or repetitive exposure)Level of exposure (intensity)Certain biological factorsFor biological effects think:TimeIntensityAnd, everyone really is special. Meaning we are all different, no one responds to radiation exposure the same way (except for extremely high doses).
29Ionizing 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 cellsCollisions strip away electrons from atoms in the bodyRemoval of electrons is called ionizationThese collisions with the body’s cells results in damage that make humans sick… Acute Radiation Sickness.
30Biologic Effects Damage DNA and other structures inside cells Could result in cell deathIncorrect repair, resulting in mutations that could cause cancer
31Biological Effects Acute Exposure Chronic Exposure Significant dose of radiation over a short period of timeRadiation sickness or death shortly after exposureLong-term effects (possibly cancer years later)Chronic ExposureSmall dose of radiation continuously or over many yearsNo immediate observable effectsMay result in long-term effectsAcute 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.
32Biological FactorsEach person differs in their biological response to a given dose of radiationAgeSexDietBody temperatureOverall medical health
33Acute Radiation Sickness Occurs when an individual is exposed to a large amount of radiation in a short period of timeOccurs at doses greater than 100 rem(1 Sv), which would be 100 rad (1 Gy) for gamma rays
34Acute Radiation Sickness ManifestationsChanges in blood cells (lymphocytes decrease first)Vascular changesSkin irritationGI effects (nausea, vomiting, diarrhea)FeverNon specific “flu”-like symptomsHair loss
35Acute Radiation Sickness Severity and course depends onHow much total dose is receivedHow much of the body is exposedSensitivity of exposed individual to radiationMay 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)
37Four Stages of ARS Prodromal phase (within 48 hours) Latent Phase (days to weeks)Manifest Illness (weeks to months)Recovery or Death
38Four Stages of ARS Prodromal phase (within 48 hours) Nausea/vomitingHeadacheFatigueFever, diarrheaAnorexiaFluid shiftsElectrolyte imbalanceLatent Phase (days to weeks)Temporary improvementCommon initial signs of ARS are:Nausea/vomitingHeadacheFatigueFever, diarrhea
39Four Stages of ARS Manifest Illness (weeks to months) Intense immunocompromise and symptoms specific to 4 major organ systems (heme, GI, skin, neurovascular)Recovery or DeathNote: After lethal dose, victims may go through these phases in a period of hours resulting in early death
40Severity Levels Delayed effects after sublethal dose (<250 rem*) may be non-specificFeverAbdominal painInsomniaRestlessnessBlistersMalaiseFatigueDrowsinessWeight loss* For gamma and beta radiation, 1 rem = 1 rad
41Delayed effects after potentially Severity LevelsDelayed effects after potentiallylethal dose (250 to 650 rem*)Significant reduction in production of blood cellsNausea/vomiting which appears to get better in 3 daysWBC greatly reducedAfter two weeks: chills, fatigue, ulceration of the mouth* For gamma and beta radiation, 1 rem = 1 rad
42supralethal dose (>650 rem*) Severity LevelsDelayed effects aftersupralethal dose (>650 rem*)Damage to the stomach lining and/or intestineCausing decreased absorption, ulceration and dehydrationSeven Days After ExposureSevere 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
43Severity Levels Acute Doses over 1000 rem* Irreparable damage to the brain and spinal cordSymptomsAgitationLack of coordinationBreathing difficultyOccasional periods of disorientationDeath occurs within hours to days* For gamma and beta radiation, 1 rem = 1 rad
44Key Symptoms of ARS Reduced number of platelets Nausea Vomiting Itching or altered sensation in the skinSwelling and EdemaDiarrheaFatigueNauseaVomitingAnorexiaReduced number of white blood cells (lymphocytes, granulocytes)
45Severity of Radiation Injury Dose Range (Gy)*ProdromeManifest - IllnessPrognosis(without therapy)MildSlight decrease inblood cell countsAlmost certain survivalMild to ModerateEarly signs of BMdamageHighly probable survival(>90% of victims)ModerateModerate-severe BMProbable survivalSevereSevere BM damage;mild GI damageDeath within weeks(50% of victims)Pancytopenia andmoderate GI damageDeath probablewithin 2-3 weeksMarked GI and BMdamage; hypotensionDeath probable within 1-2.5 weeksSevere GI damage,pneumonitis, alteredmental statusDeath certain within 5-12daysCV collapse; fever;shockDeath certain within 2-5Abbreviations: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
46What is the standard dose of total body irradiation (TBI) irradiation used fortotal body irradiation (TBI)in clinical BMT?
47Severity of Radiation Injury Dose Range (Gy)ProdromeManifest - IllnessPrognosis(without therapy)MildSlight decrease inblood cell countsAlmost certain survivalMild to ModerateEarly signs of BMdamageHighly probable survival(>90% of victims)ModerateModerate-severe BMProbable survivalSevereSevere BM damage;mild GI damageDeath within weeks(50% of victims)Pancytopenia andmoderate GI damageDeath probablewithin 2-3 weeksMarked GI and BMdamage; hypotensionDeath probable within 1-2.5 weeksSevere GI damage,pneumonitis, alteredmental statusDeath certain within 5-12daysCV collapse; fever;shockDeath certain within 2-5Abbreviations:Bone marrow (BM); Cerebrovascular (CV); Gastrointestinal (GI).Modified from RI Walker and RJ Cerveny, eds.(reference 21); provided by Dr. J. Waselenko12 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 inmultiple fractions over several daysto allow repair of normal cells andtissues- the lungs are usually given a lowertotal exposure (e.g., 9 Gy) to reducerisks of pulmonary toxicity
49TreatmentsExposure results in a full range of injuries, from changes in the blood cells to skin burns to serious radiation sicknessAnalysis of peripheral blood may diagnose exposure before other effects appearTreatment depends upon the nature and severity of the injury
50Long-Term Effects Probability increases as level of exposure increases Three most notable effectsCancerCataractsAcute exposure of 200 rads (2 Gy)Chronic exposure (months) of 1,000 rads (10 Gy)Shortening of lifespanAlthough 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.
51Long-Term Effects Animal experiments Same disease, earlier ageData from populations of Hiroshima and NagasakiVery slight risk (i.e., <1 years per 100 R)
54Contamination versus Radiation Contamination: the deposition of radioactive material in undesired locationsNOTE: 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 emitradiation- Once the contaminated surface is cleaned of theradioactive material, there is no longer a threat of
55Sources of Radioactive Exposure and ContaminationDirect radiationInhalationSkin contaminationDirect ingestionRadiation fromcontaminated surfacesSecondary ingestion(e.g., food, water, milk)Briefly discuss these means of exposure to radiation:Direct radiation: exposed like in radiotherapyInhalation: as a result of a radioactive plume (cloud containing radioactive particles), plumes are associated with fallout, nuclear power plant releases, and dirty bombsSkin contamination: radioactive particles that are temporarily deposited on the skin, once washed off during decontamination the radiation will be goneDirect 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 bodySecondary 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
56Control of Radiation Exposure Protective MeasuresTimeLess time = less exposureDistanceFurther away = less exposureShieldingIntensity is reduced by absorption and scattering by the material between you and the sourceThese 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.
58Types of Radiological Incidents Orphaned sourceLost/stolen radiation source that exposes peopleCan be purposely placed to injureRadiological Dispersal Devicea.k.a. “dirty bomb”Improvised Nuclear Device (IND)a.k.a. “terrorist nuke”could fit into a suitcase
60Dirty BombsConventional bomb attached to a source of radioactivity (e.g., Cobalt-60)Explosion spreads radioactivity resulting in widespread contaminationResult in few casualtiesPublic panic is greatest dangerEconomic impact is far reaching when compared to INDs or military weapons
61Radiological 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.
62Improvised Nuclear Device (IND) Estimates based on a 1 kiloton or 10 kiloton INDWorst case scenario: Victims will outnumber BMT community resources
63Improvised 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).
64Contingency PlanningThe 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).
65RITN Centers RITN provides: Existing facilities with practicing specialists for intensive supportive care and treatmentInfrastructure and process for transplant if neededTraining of physicians and other health care workersAssistance during an emergencyDonor search supportIRB - approved data collection planIncreases transplant community awareness about potential need of their services in time of crisisInvolves transplant community in emergency preparedness
66Available through RITN Website RITN Acute Radiation Syndrome treatment guidelinesRITN center standard operating procedure templatesDonor selection criteriaNMDP data collection protocolTraining resourcesPertinent publications
67What is RITN Doing to Prepare? Standard Operating ProceduresBasic radiation training completed by staffGrand rounds presentation in developmentAdditional training resources provided on RITN Web siteConduct an annual tabletop exerciseEmergency communications testsGETS cards and satellite telephonesCoordinating with government (DHHS-ASPR)
69What 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 areaReceive, decontaminate and triage victimsForward them on for appropriate careAny victim with trauma or burns would be treated for that before being evaluated for treatment due to marrow toxicityThis leaves a smaller subset for marrow reconstitutionStress that:Unless it is your city that has the incident all patients will be decontaminated prior to presenting for treatment.
70Possible 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.
71Timelines 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.
72RITN CentersAdmission to RITN several days after event (unless hospital is in the vicinity of the event)Initial triage and decontamination is completed by first respondersIdentifying a destination for each victimHealth & Human Services working with RITNInitial treatment and diagnosisConducted by RITN, NCI and NDMS centersNDMS – National Disaster Medical System: hospitals that signed agreements with HHS to receive patients resulting from a mass casualty event
73Urgent BMT Small subset of patients will require transplantation Expediting the evaluation of donor(s) is keyHousing needs for donors and patientsExpect 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
75Some 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