1. Radioactive Material Spill and Decontamination Fundamentals for Emergency Response Professionals Michael A. Charlton, Ph.D., CHP, CIH, CSP, CHMM Assistant Vice President for Risk Management & Safety Adjunct Associate Professor – Radiological Sciences Program The University of Texas Health Science Center at San Antonio San Antonio, TX 78229 Phone: (210) 567-2955 Email: charlton@uthscsa.edu

2. Slide Number 2 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Purpose  Review emergency preparedness methods  Describe a typical treatment layout  Outline key contamination control efforts  Discuss patient management techniques  Identify common medical health physics deficiencies

3. Slide Number 3 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Emergency Preparedness  Anticipate potential emergency situations  Recognize problem areas  Evaluate the potential for emergencies in your area  Control/remedy these potential problems

4. Slide Number 4 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Facility Preparation & Planning  Activate hospital plan –Obtain radiation survey meters –Call for additional support: Staff from Nuclear Medicine, Radiation Oncology, Radiation Safety (Health Physics) –Plan for decontamination of uninjured persons –Establish triage area –Plan for counseling the worried well  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

5. Slide Number 5 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Key Points Contamination is easy to detect and most of it can be removed It is very unlikely that ED staff will receive large radiation doses from treating contaminated patients Contamination Control Universal precautions Survey hands and clothing with radiation detector Replace gloves or clothing that is contaminated Keep the work area free of contamination

6. Contaminated Waste Treatment Area Layout Radiation Survey HOT LINE STEP OFF PAD CONTAMINATED AREA BUFFER ZONE CLEAN AREA Radiation Survey & Charting ED Staff Clean Gloves, Masks, Gowns, Booties Separate Entrance Trauma Room

7. Detecting and Measuring Radiation  Instruments –Locate contamination - GM Survey Meter (Geiger counter) –Measure exposure rate - Ion Chamber  Personal Dosimeters - measure doses to staff –Radiation Badge - Film/TLD –Self reading dosimeter (analog & digital)

8. Slide Number 8 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Patient Management - Priorities Triage  Medical triage is the highest priority  Radiation exposure and contamination are secondary considerations  Degree of decontamination dictated by number of and capacity to treat other injured patients

9. Slide Number 9 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Patient Management - Triage Triage based on:  Injuries  Signs and symptoms - nausea, vomiting, fatigue, diarrhea  Health History - Where were you when the bomb exploded?  Contamination survey

10. Psychological “Triage”  Terrorist acts involving toxic agents (especially radiation) are perceived as very threatening  Mass casualty incidents caused by nuclear terrorism will create large numbers of worried people who may not be injured or contaminated  Provide psychological support to patients and set up a center in the hospital for staff  Establish triage (monitoring and counseling) centers to prevent psychological casualties from overwhelming health care facilities –Staff counseling centers with physicians with radiological knowledge, health physicists with instrumentation and professional counselors

11. Slide Number 11 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Patient Management - Decontamination  Carefully remove and bag patient’s clothing and personal belongings (~95% effective)  Survey patient and, if practical, collect samples  Handle foreign objects with care until proven non-radioactive with survey meter  Decontamination priorities: –Decontaminate wounds first, then intact skin –Start with highest levels of contamination  Change outer gloves frequently to minimize spread of contamination

12. Slide Number 12 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Patient Management - Decontamination 1.Protect non-contaminated wounds with waterproof dressings 2.Contaminated wounds: –Irrigate and gently scrub with surgical sponge –Extend wound debridement for removal of contamination only in extreme cases and upon expert advice 3.Avoid overly aggressive decontamination 4.Change dressings frequently 5.Decontaminate intact skin and hair by washing with soap & water 6.Remove stubborn contamination on hair by cutting with scissors or electric clippers 7.Promote sweating 8.Use survey meter to monitor progress

13. Slide Number 13 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Patient Management - Decontamination  Cease decontamination of skin and wounds –When the area is less than twice background, or –When there is no significant reduction between decon efforts, and –Before intact skin becomes abraded.  Contaminated thermal burns –Gently rinse. Washing may increase severity of injury. –Additional contamination will be removed when dressings are changed.  Do not delay surgery or other necessary medical procedures or exams…residual contamination can be controlled

14. Slide Number 14 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Radionuclide-specific Most effective when administered early May need to act on preliminary information NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides Internal Contamination Considerations RadionuclideTreatment Route Cesium-137Prussian blueOral Iodine-125/131Potassium iodideOral Strontium-90Aluminum phosphateOral Americium-241/Ca- and Zn-DTPAIV Plutonium-239/Cobalt-60

15. Slide Number 15 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Patient Management - Patient Transfer Transporting injured, contaminated patients  Clean gurney covered with 2 sheets  Lift patient onto clean gurney  Wrap sheets over patient  Roll gurney out of treatment room

16. Slide Number 16 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Facility Recovery  Regularly remove radioactive waste from EC and triage  Survey facility for contamination (each shift)  Decontamination procedures –Normal cleaning routines (mop, strip waxed floors) typically very effective –Periodically reassess contamination levels –Replace furniture, floor tiles, etc. that cannot be adequately decontaminated  Decontamination Goal: Less than twice normal background…higher levels may be acceptable

17. Slide Number 17 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Hospital Preparedness Initiatives  Most hospitals required to have written plans  Some hospitals have received preparedness grants  Difficult to test/lack of knowledge  Communication with first responders is improved

18. Slide Number 18 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio National Disaster Medical System  Designed to respond to requests for hospital bed overflow capacity  Joint federal DOD, FEMA, VA, and HHS  1,800 hospitals are member (100,000 acute care beds)  Patients evacuated from disaster scene to remote unaffected city

19. Slide Number 19 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio National Disaster Medical System  NDMS will transport patients  NDMS assists in healthcare costs  In South Texas, the Ft. Sam Houston is the lead Federal Coordinating Center

20. Slide Number 20 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Additional Objectives 1.Staff recall procedure 2.Communications 3.Hospital security 4.ER operations 5.Staff scheduling 6.NDMS bed reporting 7.Decontamination 8.Triage 9.Coordination with outside agencies 10.Medical supply logistics

21. Slide Number 21 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Flow Chart  Patients arrive immediately  Worried well begin after news saturation  Contamination control efforts paramount  Patient counseling for large populations Patient Triage “Frisking” or Survey Area DeconER Admit

22. Slide Number 22 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Communications 1 st Responders City Responders City Emergency Ops Center (EOC) Medical Ops Center (MOC) Hospital EOC Hospital Staff (total time varies)

23. Slide Number 23 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio General Patient Flow PerimeterPatient Triage

24. Slide Number 24 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio General Patient Flow Patient CounselingTwo Frisking Stations

25. Slide Number 25 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio General Patient Flow Ambulatory DeconTwo Decon Stations

26. Slide Number 26 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio General Patient Flow Recording Pt Decon InfoPost Decon Frisking

27. Slide Number 27 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio General Patient Flow Patient VitalsAdmission

28. Slide Number 28 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Common Health Physics Improvements  Training for staff (100%)  Timely/improved communication (100%)  Contaminated patient flow (91%)  Lack of contamination control techniques (83%)  Radioactive waste considerations (75%)  Functional and calibrated equipment (62%)  Lack of equipment knowledge (54%)

29. Slide Number 29 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Other Potential Improvements  Security interactions with ambulatory pts  Clearly defined hot vs cold zones  Improved frisking techniques  Need for general “risk” counseling for walking well  All hospitals received all evaluator comments

30. Slide Number 30 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio References  San Antonio Dirty Bomb Exercise – After Action Review. Federal Coordinating Center, Audie Murphy Veterans Hospital. San Antonio, TX 2003.  Glasstone, S., Dolan, P.J. The Effects of Nuclear Weapons, Third Edition. U.S. Dept of Defense and US Dept of Energy, 1977, US Government Printing Office, Washington, DC, available at www.gpo.gov www.gpo.gov  NCRP Report No. 138 Management of Terrorist Events Involving Radioactive Materials, October 2001. available at www.ncrp.org www.ncrp.org  Landesman, L.Y. Public Health Management of Disasters, The Practice Guide. American Public Health Assoc. 2001, Washington, DC, available at www.apha.org www.apha.org

31. Slide Number 31 RAM Spill and Decontamination Procedures The University of Texas Health Science Center at San Antonio Questions? NHTSA reports 12,713 lives were saved by vehicle safety belt usage in 2009.