On arrival the engine company finds a male in his 30s, diaphoretic, sitting on the floor of his garage. There is emesis in a garbage can next to him. The patient’s brother, on scene, confirms the patient has no pertinent medical history and just started vomiting repeatedly after lunch. It is cold outside, and the garage door is closed with a heater running. When assessing the scene, the fire captain sees a piece of metal with a yellow label and a faded radioactive trefoil partially visible. Its markings are obscured, but he can see the word Sentinel.
When questioned about it, the brother reports they’d bought the contents of a storage unit at auction. Inside they’d found a locked toolbox that contained something that looked like a “heavy metal lunchbox” and started taking it apart for recycling. The brother says they got it open last weekend and left it on the workbench, where his brother then worked throughout the week. The patient had also spent all morning in the garage today. As Medic 1 arrives and takes over care, the captain orders a radiological survey. A firefighter records a background reading outside and enters the work area to find counts per minute unchanged.
While the scene size-up and history provide information that could indicate carbon monoxide poisoning from the heating source or possibly foodborne illness after eating lunch, it was also concerning that this individual could have been exposed to a radiological source housed inside that “lunchbox,” which was actually an industrial radiography device made to check welds and metal thickness. These devices are ubiquitous in construction and industry and represent only one type of many common radiological sources that exist in our communities. Understanding what common radiological sources may be encountered, the difference between exposure and contamination, common patient signs and symptoms, and how to best protect yourself are important concepts for good prehospital care.
Oak Ridge Facilities
Nearly 80 years ago the U.S. government built the Oak Ridge National Laboratory in secrecy as part of the Manhattan Project, with the hope of developing technology to end World War II. The experience gained by the use of nuclear energy has also expanded our knowledge about its effects and the medical treatment of radiological/nuclear medical emergencies.
The Radiation Emergency Assistance Center/Training Site (REAC/TS) is a world-renowned asset of the U.S. Department of Energy (DOE) and its National Nuclear Security Administration (NNSA) and a leader in emergency medical response to radiological/nuclear medical emergencies. A part of the Oak Ridge Institute for Science and Education (ORISE) in Tennessee, REAC/TS is operated by Oak Ridge Associated Universities (ORAU). ORAU provides innovative scientific and technical solutions to advance national priorities in science, education, security, and health.
REAC/TS responds daily to requests for information, calls for advice, and consultations regarding potential radiological emergencies and also operates a cytogenetic biodosimetry laboratory. Since the launch of the Cassini probe in 1997, REAC/TS has worked with NASA, which uses nuclear technology to power its probes, rovers, and landers, including the Mars rover launched in 2020. The mitigation efforts around launch risks have involved the education of medical and response personnel to identify and treat radiological medical emergencies. “Even during the SARS-CoV-2 pandemic, we were proud to be able to accomplish our mission by being present in the event of an anomaly during the recent Mars Perseverance launch,” says REAC/TS Director Carol Iddins, MD.
The REAC/TS Mission
The REAC/TS mission consists of three primary areas:
Education—REAC/TS provides education to first responders and medical personnel who may be involved in the care of patients exposed to radiation or contaminated with radioactive materials. REAC/TS hosts on-site courses at its Oak Ridge facility in radiation emergency medicine, advanced radiation medicine, and health physics in radiation emergencies. The team also offers customized outreach programs in the U.S. and globally, tailored to meet requesting agencies’ educational needs. Customized outreach can be offered at hospitals, first responder agencies, nuclear facilities, and public health entities. Courses are accredited by the Accreditation Council for Continuing Medical Education and/or the American Academy of Health Physics. Because of the SARS-CoV-2 pandemic, virtual presentations have been made available and further work is underway to expand online course offerings.
Advice and consultation—The REAC/TS team of subject matter experts includes physicians, health physicists, and nurse/paramedics who are on call 24/7 to provide consultation and advice on rapid dose assessment, radiological and medical triage, and diagnosis and medical management of radiological/nuclear incidents. If activated by the DOE to respond to a radiological/nuclear emergency, REAC/TS teams mobilize and deploy. These response teams maintain current advanced medical, cardiac, and trauma life support certifications.
Cytogenetic biodosimetry laboratory—By operating a CBL, ORISE helps DOE close a critical gap in our nation’s ability to respond to radiological and nuclear incidents. The use of radiation for medical, industrial, research, and other applications raises the risk of accidental human exposure. Cytogenetic biodosimetry, specifically dicentric chromosome assay, is the gold standard used to help calculate the absorbed radiation dose in exposed individuals. Information on individualized radiation doses assists in better treatment decisions and management of valuable emergency response resources.
REAC/TS is a unique and valuable resource for those who may be called upon to care for individuals involved in a radiological incident. In addition to the mission areas described, REAC/TS has many other resources, including a brand-new RadMed app. Its website, https://orise.orau.gov/reacts, offers educational videos and free downloadable informational graphics, including patient triage and assessment algorithms, personnel surveys, and guidance for donning and doffing protective clothing.
In the heart of the Tennessee Valley, REAC/TS has a lot to offer in expertise and education.
Sidebar: The Realities of EMS Radiation Response
Our minds have been conditioned by Hollywood. We’ve seen both Mr. Spock and Captain Kirk die from radiation in the Star Trek movies. Newsreels still play out the devastation of the nuclear blasts at Hiroshima and Nagasaki in World War II. While these represent the grave images of force and extremely high levels of radiation, lower doses are all around us and part of our lives. We live in an environment with ionizing radiation. Our natural environment results in dosing from cosmic radiation, material in the soil, and material in our own bodies. Most of us have heard about radon and having our homes tested. Radon can be inhaled, as it comes from radioactive material in the soil.
Medical technology results in additional exposure, primarily from medical tests and treatments. The average dose varies depending upon your residence and where you work. Living near sea level will give you more natural shielding from cosmic radiation than living in the mountains or higher elevations. The same goes for frequent air travelers and those who live in regions where the soil has higher levels of radioactivity. The primary health risk of ionizing radiation is that it can cause cancer.
What we don’t know conclusively is whether exposure to low levels of radiation causes cancer. The majority of data comes from high-dose events experienced by the bombing of Japan in World War II and other nuclear events releasing high doses of radiation. Though experts do not have conclusive evidence, they conservatively speculate that all radiation is cancer-causing. They also believe the risk of cancer is directly proportional to the total radiation dose received.
Keep in mind the radiation dose from contaminated persons is relatively low. The primary risk from contaminated persons is from ingestion and inhalation. The majority of patients in a radiation event have likely been exposed, not contaminated.
In some radiation events radioactive material could be on people, as with a dirty bomb or other dispersal device. The radioactive material spreads similarly to dust and dirt. Patients should be decontaminated as possible, as with any hazmat event. Simple steps like removing their clothing, washing with soap and water when possible, and putting a sheet over them will reduce the spread of radioactive material and contamination. Remember that while chemical decontamination is normally an emergency, radiation decontamination usually isn’t. Most radioactive contamination is detected below levels that are a significant hazard. While we should be cautious around radioactive material, it shouldn’t keep us from providing treatment for medical injuries.
Basic BSI (body substance isolation) precautions, such as wearing disposable gloves, outer clothing, and an N95/N100 mask and following normal PPE (personal protective equipment) hygiene protocols, minimize EMS personnel’s exposure to radiation. Patient treatment should follow established practices. Acute radiation sickness is not a communicable disease—you can’t catch it from someone else. Radiation injuries seen by EMS providers will normally be in the form of radiation burns or trauma from an associated blast. Treatment and triage of these patients should be the same as with any other trauma patient. Should serious exposure be involved, you may want to transport the patient to a hospital with an oncology department, where they are used to dealing with patients who have been exposed to radiation.
In all situations follow your protocols or seek online medical control for any deviation. These patients require the same care and attention as any other. Do not be afraid of them; just be mindful of how to properly care for them and remove or protect yourself and your unit from any potential contamination.
Sidebar: Online Training Resources
John M. Dabbs is a consultant and investigator for the Northeast Tennessee Regional Health Office.