Radiation exposure is an unusual occurrence in the ED, and because of this emergency physicians are unfamiliar with management. Below are some quick questions to help you review.

1. Security informs you that the radiation detectors at the ambulance entrance have alarmed after the last patient came through. You should:

A. Immediately flee

B. Don a lead apron

C. Take potassium iodide

D. Ask the patient if they have recently had any medical therapy or imaging studies in the last few days

Answer D – The vast majority of alarms occur due to patients coming through the entrance who have recently had radioactive treatments (implants or etc.) or studies (like a VQ scan) involving radioactive tracers. Our alarms (located at the ambulance entrance, triage entrance to the ED and in the decontamination room in the ceiling) can detect beta or gamma radiation and alarm at levels >200 counts/minute, which is a very low level. There are algorithms in the HAZMAT radiation cupboard for your information if this isn’t the case or doesn’t fit the situation – which would be rare, and would usually imply an unrecognized exposure (legal or illegal) or, if the patient is a former KGB agent, perhaps they are being slowly and silently poisoned.

2. What is the biggest problem with a ‘dirty bomb’?

A. High levels of radiation

B. Increased severity of injuries

C. Effects on providers

D. Tons of people descending on the hospital worried that they have been exposed to radiation

Answer: D – A dirty bomb, which is a standard bomb plus some radioactive elements thrown in for increased terror effect is really a radiation nuisance more than a threat. Only in the remotest possible situation (person at just the right distance from a solid Cobalt source to be embedded with a small fragment of source material for example) would we have a ‘hot’ patient in the ED (similar to non-radiation days, really). Injuries are basically treated the same as non-dirty bomb injuries – there may be some contamination, but this usually is addressed with basic clothing containment and soap and water decontamination. There is minor risk to victims of getting radioactive materials in their bodies via inhalation or in their wounds which, depending on the agent may require a countermeasure be given – but the risk to healthcare providers is essentially zero. The nice thing about radiation is that we can measure the exposure rate and determine how long we are safe to work in a given area for. The biggest problem an RDD creates is a ton of people who are worried, but well – community reception centers and good community risk communication are a key to keeping the hospital from receiving too many of these ‘patients’ but we will see them.

3. What resources should be available for a radiation response?

A. Geiger counters

B. Ion chamber meters

C. Dosimeters

D. All of the above

Answer: D. We have counters (both standard Geiger counters and newer yellow ‘friskers’ that are very easy to use), an ion chamber meter that nuclear medicine staff can use to determine the likely agent involved (counters just count activity which helps with decontamination and assessment, but the ion chambers look at the emitted spectrum and help identify the likely agent involved – which drives treatment decisions). Dosimeters are available that measure the rate of exposure for providers – the SOR/T meter is the size of a credit card and shows digital rate information, we also have the ‘film badge’ dosimeters that can be worn by decon personnel during an incident and developed later to show cumulative exposure. Nuclear medicine should always be paged if you are using it as they have additional meters, lead ‘pigs’ for isolating active fragments (lead aprons aren’t helpful, FYI as they don’t block gamma) and also know a lot more than we do about the equipment and screening.

4. After a dirty bomb explodes at the county government center, hundreds flood to your hospital seeking care. You should:

A. Place them all in triage

B. Make sure everyone is decontaminated before caring for them

C. Tell them to go to Abbott

D. Screen them by walking them under the portal counter in the decontamination room or EMS entrance

Answer: D – You can screen people for contamination by walking them into the decon room or in through the EMS entrance to the ED and watching the meter on the wall by ambulance entrance which is helpful when you have more than 50 victims (or so). Counts over 100/minute over background (which is usually about 12cpm) or 1mrem/h warrant decon (but if they have no injuries they should go home if possible and shower there and bag their clothing up). BUT before walking people through make sure to put plastic down on the floor or as soon as the first person who has contaminant on their shoes walks through, you’re pretty much done as the floor now has contaminant on it. Unlike most chemicals, radiation injured victims get emergency medical interventions FIRST, then decontamination. When decontaminating blast victims, after they are stabilized decon the wounds first. Wound decon involves draping off the wound, then using a McGill forceps and wet fluffs, swiping the wound once and discarding it, and repeating this until counts are <2x background (all this is in the radiation portion of the HAZMAT plan on the wall by the decon room).

This is obviously a really brief summary and NOT a summary of radiation events and decontamination – some good resources are:

REMM – this awesome on-line resource also has apps for iPhone and Android and can be downloaded to run locally on your computer as well. Very comprehensive! – http://www.remm.nlm.gov/ (also, if you want to get all geeked out on apps try WISER for hazardous materials reference information).

CDC – good information including information for patients and also short videos on decontamination of radiation – http://emergency.cdc.gov/radiation/

Compiled by Dr. John Hick, Medical Director for the Office of Emergency Preparedness with the Minnesota Department of Health.