Australian Clinical Guidelines for Radiological Emergencies - September 2012

Paramedic Response to a Radiation Dissemination Device

Page last updated: 07 December 2012

The aim of this chapter is to provide a general overview of the recommended paramedic response to a radiological mass casualty incident. The most likely scenario to challenge paramedics in Australia is the dissemination of radiological material or a radiological “dirty bomb” with multiple contaminated casualties. Events that irradiate casualties without associated contamination do not require special precautions, as there is no residual hazard once the source is rendered safe. The recommended operating procedures included in this chapter represent world’s “best practice” for the management of contaminated casualties. Specific information on local arrangements should be sought from the appropriate authorities in the State or Territory in question.

The importance of timely management of trauma victims to avert preventable deaths is well understood. By following the procedures within this chapter, paramedics will be able to mitigate the radiological contamination hazard whilst providing clinical care to trauma victims.

Role

The role of the paramedic in Australia varies slightly between jurisdictions, but it can be generally summarized as the following:
  • Provide initial assessment and pre-hospital treatment of illness and injury
  • Provide transport to an appropriate care facility, where required
Paramedics are trained to different skill levels and have access to a variety of equipment and pharmacological regimes, but the basic goal of assess, treat and transport is a constant throughout the country.

History

Fortunately, ambulance services in Australia have never been exposed to a mass casualty incident as a result of a “dirty bomb”. The type of event paramedics have been exposed to has generally been single patients who have been contaminated or potentially irradiated as a result of a manual handling incident or traffic accident.

International and domestic police and military intelligence agencies are on alert for possible terrorist incidents occurring on Australian soil. Whilst there has yet to be any attacks of this nature in this country this century, the current global environment we endure suggests that we must remain vigilant. Preparedness to respond to mass casualty incidents is high on the agenda of all levels of government and all response agencies across the country. It is therefore paramount for jurisdictions to prepare a response for all conceivable types of terrorism. Authorities around Australia have developed sophisticated procedures for responding to an accidental or deliberate chemical release. There are also detailed and well-rehearsed plans for managing the consequences of an incendiary explosion. In recent times a significant focus has centered on influenza pandemic planning. These plans may possibly be adapted to other biological hazards.

Planning for a response to mass casualties contaminated from a radiological “dirty” bomb may require further development; this is possibly due to a variety of reasons:
  • Widespread community misconceptions regarding radiological contamination/irradiation and its health effects
  • Lack of experience with radiological incidents
The pre-hospital environment largely reflects the views of the wider community. Subject awareness saturation will be the most effective tool in combating the misconceptions prevalent in the emergency services community.

Response

Ambulance response to a radiological incident will be as a support to a control agency, however paramedics may be the first emergency responders to arrive. As with any incident, paramedics should consider and be aware of any potential dangers present before entering the scene. If other emergency services are present, a situation report should be sought from the incident controller. If ambulance is first on scene, a thorough scene assessment should be undertaken and reported to the communications centre. Key fire service responders, who may carry portable radiation monitors, should be requested to attend the scene urgently.

Radiation Risks

A credible “worst case” scenario would involve an intact industrial radiography source. Based on the (gamma) dose rate at 3 metres from an unshielded 1.85 TBq iridium-192 source, it would take about 5 minutes to receive a radiation dose equal to the annual natural background dose received by individuals living in an Australian capital city (2mSv)a. It would take about 50 minutes to receive a dose equal to the annual limit for persons occupationally exposed to radiation.

In a credible scenario involving dispersal of radioactive contamination from a dirty bomb with contaminated casualties, the radiation dose received in one hour in close proximity to a highly contaminated casualty would be about 15% of total annual background radiationb and the dose in one hour at 1 metre would be about 0.15%c. Injured people at the scene of the emergency are only likely to have very small amounts of radioactive contamination on their clothing and bodies.

As can be seen from the above figures, the hazard to attending ambulance paramedics would be minimal, so that first aid can be administered safely to casualties.

Standard Operating Procedures for Ambulance Service Paramedics for Suspected Radiation Emergencies

  • Consider all potential scene hazards
  • When attending an event that seems out of the ordinary or suspicious for any reason, approach from upwind with caution
  • If the emergency involves an explosive device, consider the possibility of a secondary device and approach with caution, noting any nearby vehicles or objects that could contain a secondary device
  • If hot/warm/cold zones have been established by other Emergency Services at the incident, pregnant or potentially pregnant paramedics must remain in the cold zone
  • Avoid inadvertent internal contamination by using PPE and avoiding hand-to-mouth activities such as eating, drinking and smoking until personally decontaminated and in the cold zone. PPE required to enter the scene of a radiological incident is disposable gown or overalls, shoe covers, standard clinical use gloves, safety glasses and P2 (N95 equivalent) mask
  • The medical stabilisation of casualties has first priority and takes precedence over any radiological consideration
  • Request appropriate support resources from other ESOs e.g. portable radiation monitors, decontamination facilities, etc.
  • Request appropriate resources from your own organisation, including a management structure
  • If there are injured persons in the affected area requiring urgent medical care, administer treatment and evacuate as quickly as possible in order to keep exposure time as short as possible
  • Prior to re-entering ambulance vehicle, remove disposable gown or overalls, shoe covers, gloves and mask; don fresh gloves. Double bag used garments and leave for monitoring by the Control Agency
  • Record the time spent in the hot zone
  • Transport to hospital, advising en route details of patient with possible radioactive contamination and appropriate vital signs
  • Prior to being re-dispatched for duty, paramedics are to ensure that they and their vehicle and equipment are checked by a hospital health physicist or radiation safety officer (RSO) for any possible contamination
  • If contaminated, shower and get checked for any residual contamination
  • Don fresh clothing when satisfactorily decontaminated

Decontamination at the incident scene

  • Emergency decontamination of persons with actual or suspected contamination should be considered.
  • The medical stabilisation of casualties has first priority and takes precedence over any radiological consideration
  • If the patient has life threatening injuries, he/she should be transported directly to hospital by ambulance without decontamination
  • If possible, remove the patient’s clothing and double bag and tag. This will remove 75 to 90 % of the contamination. This should be performed in the warm zone as for all decontamination procedures
  • Place non-absorbent material, e.g. polythene sheet, on the ambulance stretcher prior to placing patient on stretcher
  • Place the patient on top of cotton sheet on ambulance stretcher and wrap sheet around the patient so that a cocoon is formed. This will contain any residual radioactive material on the casualty, minimising transfer of the material to ambulance personnel and the vehicle
  • Advise hospital that patient will have to be monitored by a hospital health physicist or RSO to determine need for decontamination post stabilisation
  • Patients without life threatening injuries may be decontaminated at the scene if this will not cause deterioration in the condition of the patient
  • Decontaminate PPE as per standard CBR/HAZMAT processes
Note: Personal property such as wallets and purses may be placed in plastic bags and taken with the casualty.

    a. Based on the (gamma) dose rate at 3 metres from an unshielded 1.85 TBq (50 Ci) iridium-192 source.
    b. Based on the (gamma) dose rate at 10 centimetres from an unshielded 37 MBq (1 mCi) caesium-137 source.
    c. Based on the (gamma) dose rate at 1 metre from an unshielded 37 MBq caesium-137 source.