Australian Clinical Guidelines for Radiological Emergencies - September 2012

Hospital Response to Radiological Events

Page last updated: 07 December 2012

Introduction

An incident involving even a single casualty from an incident involving radiological materials is likely to trigger concern amongst other casualties, bystanders, emergency responders, treating staff and potentially the broader community. Significant numbers of individuals may seek assessment and reassurance about potential health effects, from hospitals and other clinical providers.

The nature of radiation is frequently poorly understood, and this may create anxiety even amongst health professionals. The principles of ionising radiation, its health effects and treatment should be included in clinical education to address knowledge deficits. Enhanced understanding is relevant, not just in preparedness for radiological incidents, but also to the concept of justification in the use of diagnostic radiology. Justification is the principle of minimising exposure to ionising radiation unless the benefit outweighs the risk of harm.

Organisationally, a structured approach to the management of radiological incidents is essential to ensure occupational safety of personnel, and appropriate allocation of resources. Preparedness for radiological events is a component of the all hazards approach that hospitals must address as part of emergency planning. Planning must consider both mass casualties and the hazardous nature of radioactive substances. Procedures should be documented as part of emergency response plans, taught and exercised.

Basic Principles

An all hazards response should be implemented initially. Until it is confirmed that radiation is the only hazard, it must be assumed that potential hazards include chemical, biological and radiological agents, as well as explosives and attackers. Hospital responders should implement their chemical procedures, including wearing Level C personal protective equipment for reception and initial triage of casualties, prior to their decontamination. Procedures should be down-graded, and appropriate personal protective equipment worn, when information is received that radiation is the only hazard.

In a radiological incident, the medical stabilisation of casualties has first priority and takes precedence over any radiological consideration. Radiation does not cause immediate death, burns or wounds. Only in extremely high dose, does exposure to radiation cause incapacitation. Irradiation or contamination alone are not medical emergencies. Irradiation may not cause manifest illness for hours, days or weeks and does not make casualties radioactive. Efforts to control and contain external contamination are chiefly directed at avoidance or minimisation of internal contamination. However, traumatic injuries associated with an explosive radiation dispersal device may be life-threatening and require immediate intervention to stabilise. Concern about radiological contamination should not delay these interventions, as delay may result in preventable deaths due to trauma.
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In the event of a mass casualty explosion of unknown or suspicious origin, it is advisable to screen casualties for possible radiological contamination. Basic radiation detection equipment is simple to operate and maintain. Where radioactive materials are known to be involved in the incident, it is important to monitor casualties for contamination (after stabilising life-threatening medical conditions) to ensure that radiation doses to both casualties and medical staff are kept as low as reasonably achievable. This is the ALARA principle.

Radiological contamination on casualties can be controlled and contained. “The only survivors of a radiation accident who have been so badly contaminated as to be a threat to those involved in treating them were some of those involved in the accident at Chernobyl. No other accident victims, including those at Goiânia, Brazil, where gross contamination of the victims occurred, have presented ANY threat to responders, due to the precautions and procedures they followed in managing those victims.” (Medical Management of Individuals Involved in Radiation Accidents. ARPANSA; 2000.) Simple measures such as the establishment of control lines, use of personal dosimeters, rotation of treating personnel, appropriate personal protective equipment, and casualty decontamination will minimise risk to healthcare workers from radiological contaminants.

Reduction of radiation levels to background is not always possible. Decontamination should be as thorough as practical. However, radionuclides may chemically incorporate into the stratum corneum, leaving detectable residual superficial contamination. Additionally, if there has been internal contamination via inhalation, ingestion or via wounds, the incorporated radionuclide will be detectable externally if it emits gamma, x-ray or energetic beta radiation. Vigorous decontamination of the skin may cause abrasions, resulting in increased absorption of superficial radionuclides, potentially up to one hundredfold.

Provide psychological support for casualties throughout their care. In addition to distress from the circumstances of their exposure, casualties are likely to experience fears regarding potential radiation exposure and its perceived health effects, and stress due to uncertainty. Good risk communication will help to alleviate this by the timely provision of accurate information and straightforward explanation of procedures.

Hospitals are likely to see large numbers of people who have concerns about their exposure to radiation as a result of a radiological incident. This is not panic, but an over-response to a perceived health threat. They may exhibit a range of symptoms as part of a physiological response to stress. This somatisation may present a diagnostic challenge in the context of the non-specific symptoms of prodromal radiation sickness. Such people will request assessment of physical concerns, information and reassurance, perhaps in overwhelming numbers. Hospitals must plan for this surge in concerned individuals. These persons deserve someone to respectfully listen to their concerns, evaluate whether there is any evidence of toxic effect, provide information and reassurance, as well as offer information on possible psychological reactions to an incident of this nature. A duty of care is owed to them, even if resources must be carefully husbanded to meet the needs of all presenters. Failure to address their concerns empathetically is likely to increase their perceived sense of injury and aggravate later psychological disturbance.

Radiation Monitors for the Emergency Department

Basic radiation safety equipment will include personal dosimeters to monitor staff exposure, and assist with appropriate staff rotation planning if required. It is preferable to have electronic dosimeters that provide immediate readings of dose-rate and cumulative dose. Film badges and thermo-luminescent dosimeters are not able to be read without processing, and will not assist with management of staff safety during the event.

Portable contamination monitors, such as Geiger-Müller counters, are used in the evaluation of external radiological contamination. (See Contamination Monitoring Procedure on page 42.) Frequently, these can be located in the nuclear medicine department, and occasionally in the pathology department.

Area radiation monitors are wall or ceiling mounted units designed to alarm on detecting a significant amount of radioactivity in the vicinity of the monitor. The detector or probe of the area monitors is attached to the body of the monitor via an extendable cord. The probe may be used to measure levels of contamination on persons involved in radiation incidents. As such, it is an adjunct to the contamination monitor used by the health physicist or radiation safety officer of the hospital. (See Obtaining Specialist Advice on page 46.)
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Portal radiation monitors are designed to resemble doorways with radiation detectors usually at 1.2 to 1.5 metres above floor level. The area and portal monitors will probably not passively detect casualties with lower levels of radioactive contamination, except where the probe of the area monitor is used, and will not alarm in this situation. However, these monitors are likely to detect patients who have recently had nuclear medicine investigations, so they are fairly sensitive.

In this situation, the only way that ED staff will know that casualties have been involved in a radiation incident is if they have been so advised by either emergency response agencies or those responsible for the incident. ED staff should have a high index of suspicion in assessing victims of any blast, and include assessment for possible radiological contamination.

The following section describes:
  • The set up for receiving contaminated patients
  • Personal protective equipment
  • Triage of casualties involved in a radiation incident
  • Casualty follow up and counselling
  • Contamination monitoring procedure
  • Area radiation monitor / portal monitor procedure
  • Decontamination procedures
  • Waste management
  • Obtaining specialist advice
  • Role statements:
    • Radiation safety officer
    • Medical health physicist
    • Haematologist / oncologist

Set Up For Receiving Contaminated Patients

Two areas should be established to receive patients: a treatment area for potentially contaminated patients requiring resuscitation or immediate care, and an assembly area for screening ambulatory casualties for radiological contamination.

Triage post

Establish conventional triage at the initial contact point external to the hospital to ensure patients in need of resuscitation are promptly identified and only stable patients are allocated to the assembly area. Also, set up for quick radiological triage, to scan briefly for any high activity shrapnel fragments that may pose greater risk for staff.
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Arrange for the hospital entrances other than the emergency department entrance(s) to be secured.

Treatment area

  • Set up a controlled area large enough to hold the anticipated number of victims
  • Establish control lines and prevent the spread of contamination
  • Temporary barriers should be erected to exclude others entering the designated corridor and treatment area
  • Floor of corridor to treatment area, and treatment area itself, should be covered with heavy-duty paper or plastic to minimise spread of radioactive material. The covering materials should be secured to the floor with tape
  • Large bins lined with disposable plastic bags are to be provided for the disposal of contaminated waste such as clothing, linens, dressings, etc. Bags to be sealed and tagged for subsequent monitoring by hospital health physicist or radiation safety officer (RSO)
  • Non-essential equipment should be covered or removed from the controlled area
  • There is no need to control air ventilation of areas receiving contaminated casualties as there is minimal aerosolisation of radioactive material
  • A decontamination table or trolley with a waterproof cover, or a burn trolley provides a suitable treatment surface
  • Small lead-lined storage containers (pigs) for holding any radioactive foreign bodies removed from wounds
  • Swabs for sample collection and ‘radioactive ‘ labels for specimens
  • Patient chart with outline of body (front, back and sides) for recording areas of contamination and wounds
  • Decontamination materials
    • Soap, shampoo
    • Soft scrubbing brushes, sponges
    • Sterile water / saline for irrigation of wounds and mucosal surfaces
Notes: Special floor covering is not necessary for treatment of casualties contaminated with radioactive material. The sole purpose of placing floor covering down is to make clean-up of contamination easier afterwards. Medical treatment must not be delayed because there is no floor covering in place.

External assembly point

An assembly point for the purpose of monitoring of ambulatory casualties for radiological contamination (radiation monitoring point) should also be set up external to the hospital, with access to the decontamination facilities.

Personal Protective Equipment (PPE)

Normal clothing used in operating suites will provide sufficient protection for personnel treating patients who are contaminated with radioactive material:
  • Dress in normal surgical scrubs, reserving normal work attire to be worn later.
  • A gown with a waterproof apron.
  • Cover all hair with a theatre cap.
  • Waterproof shoe covers.
  • Two pairs of surgical gloves. Single-use nitrile gloves are worn as the inner layer, with the cuffs under the gown sleeves. Tape the gown sleeves to the inner gloves. An outer pair of gloves is then donned, with the cuffs over the gown sleeves. The outer gloves can be changed as necessary during patient care.
  • Surgical mask.
  • Eye protection / goggles.
top of pageLead aprons are ineffective against gamma radiation as the thickness of lead in the apron does not provide sufficient shielding against ionising radiation of this energy level. They should only be worn as needed to protect against (lower energy) x-rays, during diagnostic radiology procedures required to stabilise the patient. Unnecessary use of lead aprons is likely to increase fatigue.

Personal radiation dosimeters are to be worn outside clothing, by key treating personnel in closest proximity to casualties. Ensure the dosimeter is correctly oriented. It is suggested that dosimeters with alarm functions be set to alarm at 100 µSv/hour, which would permit up to 20 hours exposure at that dose rate before exceeding the average annual background exposure level. If personal dosimeters alarm, rotate staff to keep doses to a minimum and seek advice from the hospital health physicist or radiation safety officer. The health department radiation adviser is able to provide advice also.

Removal of PPE

  • Remove protective garments and gloves standing adjacent to the control line, on the contaminated side. Bag and tag collected waste.
  • Remove outer gloves, turning them inside out, and deposit into a lined bin.
  • Remove the dosimeter and deposit into a bag held by another staff member, avoiding contaminating the outside of the bag.
  • Remove all tape and deposit into a lined bin.
  • Remove the gown, turning it inside out. Minimise shaking of the gown. Deposit into a lined bin.
  • Remove cap, mask and goggles. Deposit into a lined bin.
  • Stand or sit adjacent to the control line on the contaminated side. Remove one shoe cover and deposit into lined bin. The sole of the inner shoe should be scanned for contamination before placing on the floor / ground on the clean side of the control line. Repeat for the other side.
  • Remove inner gloves and deposit into lined bin.
  • The staff member should be scanned for contamination prior to showering. Staff members should be instructed not to eat, drink or smoke until after they have been surveyed and showered.

Triage of casualties involved in a radiation incident

Please see the algorithm on the next page.
  • Provide triage outside the ED entrance and direct:
    • casualties with life threatening conditions to the prepared treatment area; and
    • other casualties to the radiation monitoring point.
  • Scan briefly to identify any high activity shrapnel fragments that may pose greater risk for staff. Utilise time, distance and shielding to minimise staff exposure to high activity fragments during resuscitation.
  • Stabilise life-threatening medical conditions of casualties.
  • Ambulatory casualties who have recently entered the hospital, and have been at the site of the incident, should be advised to assemble at the radiation monitoring point for radiation monitoring by the hospital health physicist or RSO. (See Contamination Monitoring Procedure on page 42.)
  • Decontaminate contaminated individuals as appropriate.
  • Implement definitive medical treatment.

Casualty follow up and counselling

  • Order IMMEDIATE full blood examination (FBE) and differential and follow with absolute lymphocyte counts every 6 hours for 48 hours when history indicates possibility of total-body irradiation.
  • Identify casualties with potential internal contamination:
    • contamination of the face and nares is suggestive of inhalational exposure
    • contaminated wounds
  • Conduct bioassays and whole body or lung scans as appropriate to assess internal contamination.
  • Consider decorporation treatments early. (See the section on Internal Contamination on page 91.)
  • Casualties who have been involved in radiation incidents should be followed up for a week, with particular reference to the development of nausea and vomiting, areas of otherwise unexplained erythema, conjunctival redness, epilation, and changes in full blood and lymphocyte count.
  • Casualties who have been or think they have been exposed to radiation may need psychological support to help alleviate any anxiety.
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Image displays Radiation Accident with Trauma or IllnessD

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Contamination monitoring procedure

Portable contamination monitors are usually located in nuclear medicine departments of major hospitals for management of spills. However, it is recommended that emergency departments should acquire at least one Geiger-Müller counter in order to ensure ready access to this equipment at all times.

Skin and Clothing


  • Cover the probe, with a surgical glove or plastic bag to prevent inadvertent contamination of the probe. The glove can be changed if contamination occurs.
  • Ensure that the instrument is used in fast response mode, where this is possible.
  • Set the instrument selector switch to the most sensitive range of the instrument.
  • Measure background radiation prior to commencing survey of the patient.
  • Holding the probe approximately 1 to 2 cm from the person’s skin and systematically survey the entire body from head to toe on all sides.
  • Move the probe slowly (a few cm per second).
  • Do not let the probe touch anything.
  • Try to maintain a constant distance.
  • Pay particular attention to body orifices, skin folds, hands, face and feet.
  • An increase in count rate or dose rate above background indicates the presence of radiation.
  • Document areas of contamination on a body map together with monitor details, monitor readings for the various body areas that are contaminated, and details of the casualty.
  • When necessary, adjust the range of the instrument by moving the range selector switch.
Note that some instruments cannot detect alpha radiation and some low-energy beta radiation. Because alpha radiation is non-penetrating, it cannot be detected through even a thin film of water, blood, dirt, clothing, or through the probe cover.

Body Orifices and Wounds

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  • Nasal and oral swabs should be collected using moist, clean cotton tipped applicators.
  • Any sputum, vomitus, or tissues from nose blows should be collected.
  • Any initial wound dressings should be collected
  • Swabs, dressings, etc. should be placed in separate plastic bags and labelled with patient details, site, and time for later analysis.



This picture shows the procedure for personnel monitoringD

Source of graphic: Radiation Emergency Assistance Center / Training Site (REAC/TS); Guidance for Radiation Accident Management. Available from ORISE website.

Area radiation monitor / portal monitor procedure

Selected hospitals may be equipped with area radiation monitors or portal monitors positioned at the ambulance and ambulatory entry points to the emergency departments. They have adjustable alarm settings to allow for different doorway configurations. In general these monitors may be set to alarm at a threshold of 20 microsieverts per hour ( µìSv/h).
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They are designed to detect significant amounts of radiation, such as that from a part of a radiological source contained in a casualty as a shrapnel fragment, and will NOT detect low-level radiation from diffuse superficial contamination from a radiological dispersion device (“dirty bomb”). The threshold is sensitive enough to detect some nuclear medicine patients, however.

If alarm of area radiation monitor sounds:

  • Turn alarm off by pressing “HIGH ALARM” button.
  • If unsure as to who set the alarm off, detach probe at right side of the area monitor and use this to determine who set the alarm off. If the portal monitor alarmed, use a portable contamination monitor instead.
  • Question to determine if person has had a nuclear medicine scan, radio-pharmacotherapy or radiotherapy implant recently.
  • If not and there are suspicious circumstances:
    • Isolate the person until radiological triage completed.
    • Key ED staff involved in patient treatment should wear personal dosimeters.
    • Holding the monitor probe 30cm from the casualty, conduct a radiation survey to establish the maximum dose rate.
    • If the maximum dose rate 30 cm from casualty is less than 1 millisievert/hour (mSv/H) as indicated on area monitor display there is no need for rotation of staff, as the annual occupational dose limit (20 mSv) would not be exceeded for at least 20 hours.
    • If the maximum dose rate 30 cm from casualty is greater than 1 mSv/h as indicated on area monitor display - staff to rotate when cumulative dose indicated by dosimeter is 20 mSv.
    • Provide treatment and care to patient whilst observing these exposure guidelines for the treating staff.
    • Contact: (1) hospital Radiation Safety Officer via hospital switchboard, and (2) health department radiation adviser.
    • Using the portable contamination monitor establish the extent and bodily location of contamination.

Hospital decontamination procedures

The medical stabilisation of casualties has first priority and takes precedence over any radiological consideration, including decontamination.
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Decontamination should only be as thorough as practical. Reduction of radiation levels to background is not always possible. Careful removal of clothing will reduce contamination by about 90%. Avoid unnecessary exposure of the face as clothing is removed, in order to minimise further internal contamination.

Collect samples from the nose, mouth and wounds. Ensure all samples are bagged, labelled and marked as a radiation hazard.

Ambulatory patients

Small areas of superficial contamination can be decontaminated using a sink or basin. If extensive body areas are contaminated, the patient can be showered under the direction or with the assistance of the hospital health physicist or radiation safety officer. Caution the patient to avoid splashing water into the eyes, nose, mouth, or ears. Repeated showers might be necessary, and clean fresh towels provided for drying after each shower.

Stretcher patients

Decontaminate open wounds first

  • Remove temporary dressings, place in a plastic bag and label
  • Change outer gloves
  • Survey the wound with the Geiger-Müller counter and record the results on the chart
  • Drape wound with waterproof material
  • Gently irrigate with saline or water
  • Remove any visible foreign bodies with long-handled forceps, if clinically appropriate to do so. Take care not to touch or handle metallic foreign bodies
  • Remove contaminated drapes and dressings as necessary as decontamination proceeds
  • Repeat until there is no further reduction in radiation level
  • If radiation level cannot be reduced to near background levels, debride wound, if clinically appropriate, and bag and label debris
  • Change outer gloves and re-dress wound

Decontaminate body orifices

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  • Oral cavity - encourage brushing the teeth with toothpaste and frequent rinsing of the mouth.
  • Pharyngeal region - gargling with a 3% hydrogen peroxide solution is suggested in some texts. Evidence for this recommendation is not cited.
  • Radioactive material swallowed – gastric lavage is unreliable, with negligible benefit if performed more than one hour after ingestion.
  • Eyes - rinse by directing a stream of water from the inner canthus to the outer canthus of the eye while avoiding contamination of the nasolacrimal duct.
  • Ears - external rinsing; an ear syringe can be used to rinse the auditory canal, provided the tympanic membrane is intact. Caution: detonation of an explosive device to disperse radioactive material carries the risk of barotrauma to the ears.

External decontamination of intact skin

  • Wash under a stream of water, gently scrubbing at the same time with a soft disposable brush or surgical sponge. Special attention should be given to nails, skin folds and hair
  • Use gentle, neutral pH soap if required
  • Scrub for 3 – 4 minutes, rinse for 2 – 3 minutes and then dry
  • Monitor
  • Repeat if necessary
  • Decontamination stops when no further significant reduction in radiation level can be achieved
top of pageAvoid excessive scrubbing. Even minimal abrasions may result in a greater than ten-fold increase in incorporation of radioactive material.

After decontamination

Replace the sheet beneath the patient. Move casualties from “contaminated” stretcher to a clean stretcher across control line for transport of casualty to definitive treatment area.

Waste management

Waste Water

Ideally waste water from decontamination procedures would be collected. However, this is unlikely to be practical. The installation of a holding tank is almost certainly not justified because of the infrequency of this event. Any radiation hazard to the public or the environment from the comparatively small volume of waste water will be massively diluted in the sewer system.

Bagged Waste

At the conclusion of the decontamination of the patient soiled linen, dressing materials, etc. should be surveyed by the hospital radiation safety officer for residual contamination. Contaminated linen and waste should be double-bagged and labelled “radioactive”. Bagged contaminated waste should then be stored in a secure, isolated area, free from human interference, until decay has occurred naturally, rendering the waste no longer radioactive. The time for this to occur is dependent on the specific radioisotope. In the case of waste with a long half-life, contact the radiation regulator or the health department radiation adviser in your state or territory for advice on arrangements for the proper disposal of the waste.

Contaminated Buildings and Equipment

Cleaning staff should wear the same PPE as the decontamination team. Disposable floor coverings and other coverings should be rolled up and placed in plastic bags. The entire area should then be thoroughly surveyed for residual contamination. In most cases, normal cleaning methods will remove the material. Vacuum cleaners that can handle wet material and have high efficiency filters are useful. Some surfaces may require repeated scrubbing and vacuuming before they are free of contamination.

Disposal of Waste

All waste materials should be disposed in accordance with prescribed procedures. Hospital radiation safety officers can obtain further advice from the health department radiation adviser.

Obtaining specialist advice

  • Contact the hospital on-call health physicist or radiation safety officer (RSO) to attend at the ED.
  • Contact the health department radiation adviser in your state or territory for advice and to ensure notification of the incident has occurred. Whilst the regulation of radiation may not rest with State or Territory health departments in every jurisdiction, health departments will provide initial public health advice, links to appropriate radiation expertise and overall coordination of health resources in emergencies.
  • Clinical advice on the care of victims with acute radiation injury or illness can be obtained from radiation oncologists in each State and Territory. The Peter MacCallum Cancer Centre, Melbourne, is the clinical part of the Australian Collaborating Centre for Radiation Protection and Radiation Emergency Medical Assistance, and a member of the World Health Organisation Radiation Emergency Medical and Assistance Network.
    • Contact Peter MacCallum switchboard on 03 9656 1111. Request the on call radiation oncologist.
  • Inpatient care may require the coordination of a multidisciplinary team of medical and support specialists including, but not limited to:
    • Medical health physicist
    • Nuclear medicine physicians
    • Radiation oncologists
    • Haematologist / oncologist
    • Intensivist
    • Trauma surgeon
    • Clinical toxicologist
    • Infectious control specialist

Role Statement: Radiation Safety Officer

Often, the hospital radiation safety officer is a member of the diagnostic radiology department. Occasionally this role is fulfilled by the occupational health and safety unit. The radiation safety officer supports safe operations in a radiological emergency, assisting responding staff to ensure their doses are as low as reasonably achievable, and providing technical support and documentation.

Responsibilities pre-event

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  • Advise management on matters relating to radiation safety including:
    • Radiation monitoring programs.
    • Condition of and need for radiation monitoring and protective equipment.
    • Action to be taken to reduce the radiation exposure of employees or members of the public to as low as reasonably achievable.
    • Action to be taken in the event of an emergency or accidental exposure.
    • Prescribed standards for discharge of radioactive waste.
  • Prepare safe working procedures with respect to radiation protection for use in routine operations or in an emergency or accidental exposure.
  • Be responsible for instruction of employees in radiation hazards, safe working procedures to ensure radiation protection, the proper use of radiation monitoring and protective equipment, and measures to limit radiation exposure.
  • Maintain sufficient radiation monitoring and radiation protection equipment and ensure that equipment is calibrated and in a ready and working condition.
  • Ensure that prescribed radiation signs are maintained in good condition and located in places where they will be easily seen.
  • Investigate sources of radiation exposure, the radiation protection equipment and working procedures and recommend any change that would reduce exposure to employees and members of the public.
  • Maintain detailed records on all the above matters.

Responsibilities during event

  • Ensure that appropriate radiation protection monitoring surveys are carried out as required.
  • Implement personal monitoring systems for the determination of effective doses for any employee or class of employees as required.
  • Assess accumulated effective dose and committed effective dose of any employee or class of employees.
  • Ensure compliance with prescribed standards for radioactive waste handling.
  • Ensure that radiation signs are located in places where they will be easily seen.
  • Monitor transport containers and ensure they comply with the Code of Practice for the Safe Transport of Radioactive Material (2001) or later as amended.
  • Maintain detailed records on all the above matters.

Role Statement: Medical Health Physicist

Medical health physicists work in the areas of radiography, nuclear medicine, or radiation oncology. They can provide advice to clinicians managing radiological casualties.

Responsibilities pre-event

  • Contribute to the development of radiological emergency response plans for their hospital, based on health physics principles. Ensure these are consistent with local state and territory arrangements.
  • Contribute to staff development, training and exercising for radiological emergencies. Coordinate activities with the radiation safety officer.
  • Through professional bodies such as Australian Radiation Protection Society (ARPS), Australian and New Zealand Society of Nuclear Medicine (ANZSNM), Australian and New Zealand Society of Nuclear Medicine Technologists (ANZSNMT), the Australian Institute of Radiography (AIR), Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) and others, develop mutual aid arrangements and consensus educational and operational guidelines for radiological emergencies.
  • Nuclear medicine physicians and technologists should familiarise themselves with Anigstein R, et al. Use of radiation detection, measuring, and imaging instruments to assess internal contamination from inhaled radionuclides; part 1: feasibility studies. 2007. Available from CDC web site.

Responsibilities during event

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  • Orient medical staff with the principles of dealing with radiological contaminants.
  • Evaluate the level of external or internal contamination of casualties.
  • Assist clinical staff to evaluate and understand the significance to patient and staff of the levels of radiological contamination with which they are dealing,
    • Particularly with respect to the stabilisation of life-threatening injuries in a timely way consistent with safety of personnel.
    • Assist with advice regarding special precautions required to provide patient care where there are shrapnel fragments with significant radiological activity.
  • Provide guidance on the decontamination of casualties, facilities and the vehicles involved in transporting casualties to hospital.
  • Oversee the recalibration of hospital gamma cameras, thyroid cameras, etc for use in evaluating internal contamination.
  • Make preliminary dose estimates and communicate these to treating clinicians. Include an explanation of the uncertainty in the dose estimate.
  • Inform communications with patients, staff and management on radiological issues.
  • Assist public health authorities in monitoring people who are not injured but are concerned they have been exposed to radiation or radiological material.

Role Statement: Haematologist / Oncologist

A consequence of exposure to high dose radiation is myelosuppression. Experience from radiation accidents, shows that it is possible to salvage casualties with myelosuppression under the care of a haematologist / oncologist.

Responsibilities pre-event

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  • Contribute to the development of radiological emergency response plans for their hospital.
  • Through professional bodies such as the Royal Australasian College of Physicians (RACP), Haematology Society of Australia and New Zealand (HSANZ), Medical Oncology Group of Australia (MOGA) and others, develop consensus guidelines for the evaluation and clinical management of myelosuppression in radiation exposure casualties.

Responsibilities during event

  • Make a preliminary dose estimate utilising available clinical information for each individual. See Radiation Dose Assessment on page 75.
    • Establish the symptom and location history.
    • Assess the degree of myelosuppression based on lymphocyte depletion kinetics.
    • Seek the advice of a health physicist in interpretation of bioassays and dicentric analysis, when these results are available.
  • Stratify casualties into risk groups:
        1. Will not require medical intervention
        2. Could benefit from supportive care with G-CSF or GM-CSF to facilitate autologous marrow recovery.
        3. Needs further evaluation for haematopoietic stem cell transplant.
        4. Not able to be salvaged.
  • Provide ongoing clinical management of patients with myelosuppression in conjunction with the multidisciplinary management team.
    • Implement colony stimulating therapy in eligible patients as early as feasible, ideally in the first 24 hours.

References

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    1. Anigstein R, Erdman MC, King SH, Mauro JJ, Miller KL, et al. Use of radiation detection, measuring, and imaging instruments to assess internal contamination from inhaled radionuclides; part 1: feasibility studies. 2007. Available from CDC website.
    2. Armed Forces Radiobiology Research Institute. Medical management of radiological casualties handbook, military medical operations. 2nd ed. Bethesda: Armed Forces Radiobiology Research Institute; 2003.
    3. Miller CW, Whitcomb RC, Ansari A, McCurley C, Guinn A, et al. The roles of medical health physicists in a medical radiation emergency. Operational Radiation Safety. 2007; 93(s3): S187-S190.
    4. Radiation Safety Program, Department of Human Services. Radiation safety officer typical duties. 2009. Available from Department of Health Victoria website.
    5. Solomon S, McKean N, Drummond R, Tai KH (editors). Medical management of individuals involved in radiation accidents, technical report series no. 131. Australian Radiation Protection and Nuclear Safety Agency (ARPANSA). Yallambie. 2000.
    6. Victorian Government Department of Human Services. Decontamination guidance for hospitals. Victorian Government Department of Human Services, Melbourne. 2007.
    7. Victorian Government Department of Human Services. Health services personal protective equipment and decontamination hospital staff training course presenters guide. Victorian Government Department of Human Services, Melbourne. 2006.
    8. Weinstock DM, Case C, Bader JL, Chao NJ, Coleman CN, et al. Radiological and nuclear events: contingency planning for hematologist/oncologists. Blood. 2008; 111(12): 5440-5445.
    9. Raphael B. CBRN safe, psychosocial guidelines. Psychosocial guidance for emergency workers during chemical, biological, radiological and nuclear incidents.
    10. Weisdorf D, Apperley J, Courmelon P, Gorin N-C, Wingard J, et al. Radiation emergencies: evaluation, management, and transplantation. Biology of Blood and Marrow Transplantation. 2007; 13: 103-106.
    11. Wingard JR, Leahigh AK, Confer D, Edwards J, Billups RL, et al. Preparing for the unthinkable: emergency preparedness for the hematopoietic cell transplant program. Biology of Blood and Marrow Transplantation. 2006; 12: 1229-1238.
    12. Mettler FA. Medical resources and requirements for responding to radiological terrorism. Health Physics. 2005; 89(5):488-493.
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