RESPONSE TO A MEDICAL EMERGENCY INVOLVING RADIOACTIVE MATERIALS

RESPONSE TO A MEDICAL EMERGENCY INVOLVING RADIOACTIVE MATERIALS

BY ANTHONY M. GAGLIERD AND RICHARD K. HILINSKI

At 0847 hours on July 14, 1994, McCandless Township dispatch was called to respond to a construction accident at the intersection of McKnight Road and Arcadia Drive. (McCandless is a suburb of Pittsburgh in Allegheny County, Pennsylvania.) The weather was overcast with numerous heavy rain showers. Units from the Peebles Volunteer Fire Department of McCandless Township and the Franklin Park Ambulance Authority were dispatched to the scene. They arrived at the scene at 0851 hours and found a severely injured construction worker. He had been using a testing machine containing a radioactive material to measure soil moisture and compaction (Troxler Moisture-Density Gauge).

The worker was struck and run over by a large earth grader and sustained amputation of one arm, near amputation of both legs, and crushing trauma to the abdomen. He was in shock. His blood pressure was falling rapidly; he was in critical condition.

At 0907 hours, McCandless Township dispatch requested a hazardous-materials team respond to the scene because first responders determined–from radioactive markings on the damaged gauge and the yellow-and-white shipping label on the yellow plastic shipping container nearby–that radioactive materials were at the accident site. The North Hills Response Team (NHRT), under the direction of Richard Hilinski, was dispatched. This prompted notifications of Allegheny County Emergency Management, the Allegheny County Health Department, and the U.S. Nuclear Regulatory Commission.

The medical units on scene were awaiting the arrival of the NHRT but, due to the patient`s condition, opted to transport the victim to Allegheny General Hospital, a Level 1 Trauma Center. The crew notified the hospital, and the ambulance left the scene at 0913 hours and arrived at Allegheny General at 0926 hours.

The director of the Allegheny County Emergency Medical Services was advised of the incident and informed that an ambulance was transporting a critically injured patient who may be contaminated with radioactive materials to the Allegheny General Hospital. On receipt of the notification, the Allegheny County Emergency Management Agency dispatched Anthony Gaglierd, the county`s radiological officer, to the scene. All key personnel responding were provided updated information by radio while en route.

ASSESSING THE PROBLEM

Although there was only one injury, the possibility that construction workers who had rushed to the injured man`s aid might have been contaminated by radioactive materials was a concern. Gregory Potts, chief of the Peebles Volunteer Fire Department, the incident commander, kept all nonessential personnel a safe distance from the accident site. Firefighters did not enter the exclusion (hot) area but directed the construction workers who may have been exposed or contaminated to the southmost of two construction trailers, which provided shielding from the radiation source, about 20 feet from the trailer. (Shielding is a radiation protection factor based on the principle that the denser a material, the greater its ability to stop the passage of radiation.) The workers were to be detained in the trailer, to prevent the spread of possible contamination, until such time as they could be safely moved and monitored.

Potts at this time still was unable to exactly identify the material(s) involved. Gaglierd, en route, contacted Potts for information about the circumstances involved. Knowing that there usually are only two activities for which radioactive materials are used at construction sites–radiography and soil moisture/density gauging–and knowing the work taking place when the accident occurred, Gaglierd was able make an educated guess as to the radioactive isotope being used. He also asked other questions to assess the situation and advise the incident commander. Based on the information he received, Gaglierd believed the device was a soil density gauge and contained Cesium 137 and Americium 241. He did not know the exact amount but did know they were not dealing with a highly radioactive source. Gaglierd shared this information with the incident commander, the hospital via Medic Command, and the director of emergency medical services.

At 0919 hours Hilinski, the NHRT commander, arrived on scene. Potts briefed him on the situation. Haz-Mat Command was established. The consensus was that all of the individuals with immediately life-threatening injuries had been transported and that no personnel in the designated exclusion zone would be permitted to leave the zone without being checked for contamination.

The NHRT arrived on scene at 0930 hours and was briefed by Hilinski. A command post was established approximately 1,000 feet from the two construction trailers. The cold zone was marked with yellow barrier tape. Command contacted the engineering firm that employed the victim who had been operating the radiation device. The firm positively identified the device as a Troxler brand gauge, used to measure soil moisture and density. Command requested a representative of the engineering company respond to the scene.

In a radiation incident, a one milliRoentgen (mR/hr) perimeter, which becomes the hot line, is established. The area inside this line is the exclusion zone. As a rule of thumb, if the one mR/hr perimeter is less than 100 feet, the hot line is set at 100 feet, to give responders room to work. The first- responding units and the haz-mat team set the command post at a distance of 1,000 feet from the incident; this was the cold zone. The exclusion zone was set at about 500 feet from the scene and was delineated with red barrier tape. Since no entry was made and no readings were taken, these distances were chosen based on guidance of stopping 500 feet upwind from an unknown radiation incident.

The incident scene was visually surveyed using both binoculars and a spotting telescope. The damaged Troxler gauge was located in the exclusion zone, approximately 20 feet south of the construction trailers. Visual inspection showed it appeared to have been compressed. The upper arm of the instrument was broken off and the yellow casing appeared to have been crushed in the middle.

ENTRY OPERATIONS

Gaglierd arrived on scene at approximately 0958 hours and was apprised of the situation. A plan of action was formulated. Four personnel–donning personal protective clothing consisting of Tyvek® coveralls, boot covers, and latex gloves and carrying a pocket dosimeter and a CD-V 700 survey meter (covered to keep the rain from affecting them) and an intrinsically safe radio–would operate as two teams.

Entry team 1 was assigned to monitor the scene and check the instrument for damage and any release of radioactive material. Team 2 was to survey the individuals detained in the trailer inside the exclusion zone for possible radioactive contamination. In accordance with our standard operating procedures, a backup team stood by in readiness near the command post.

Entry team personnel determined that radiation levels outside the trailer at a distance of 20 feet from the damaged gauge were 0.03 mR/hr, within normal background radiation levels. The actual hot zone–or the area where readings were greater than one mR/hr–was 10 feet around the gauge. Team 1 notified the command post that it was getting readings of 13 mR/hr in close proximity to the damaged gauge. According to the owner of the gauge, readings of 10 to 15 mR/hr should be expected.

The radiological survey indicated that conditions were such that detainees in the construction trailer could be sent to the control point (the only point of entry and exit into the exclusion zone) for questioning and a brief medical examination. Nineteen individuals were surveyed and evaluated. No contamination was found. The workers then were given their lunch buckets and sent to a nearby conference room where representatives of their employer and county and state radiological specialists/officers briefed them on their status and safety. The Allegheny County Mental Health Critical Incident Stress Debriefing Team debriefed the workers.

At this time, command was notified that Allegheny General Hospital found no con-tamination on the victim, the ambulance crew, and the ambulance. It was later learned, sadly, that the victim`s injuries had proven fatal.

Further survey by Entry Team 1 conveyed that the Troxler gauge suffered a direct blow to its casing. The immediate concern was whether the radioactive source was intact and, if so, whether it was in the shielded or unshielded position.

During Team 1`s entry, two representatives of the Pennsylvania Department of Environmental Resources Bureau of Radiation Protection arrived on scene. Outfitted in protective clothing, they entered the hot zone with additional metering devices. Their surveys confirmed the initial readings. Swipes (paper filters) were collected. Members wiped a four-inch-square area of the damaged gauge to determine if there was any release of radioactive materials. (Swipes distinguish between fixed and removable contamination. Removable radioactive material will adhere to the swipe and can be detected and measured.) The swipes were counted (or checked for contamination) in the second trailer. The results were negative, and as such the swipes did not have to be sent to the laboratory for more precise analyses of the amount of radioactive material and specific isotopes present.

Based on the readings, which were within DOT guidelines for radiactive material transportation, the representatives from the Bureau of Radiation Protection gave engineering firm representatives permission to place the damaged gauge into its shipping container. The county radiological officer, a state radiation protection specialist, and a representative of the engineering company reentered the exclusion zone to assist in and oversee the placing of the damaged gauge into its shipping container. When the gauge was lifted, a reading of 300 mR/hr was recorded. The gauge was immediately placed back in its original position. It was hypothesized that the Cesium source–sealed into the end of a rod that is surrounded by a Tungsten shield–was not completely in the shielded position. To perform a test, the “source rod,” as it is called, is unlocked from the shielded position and forced out and into a predrilled hole (the unshielded position). Approximately one inch of the source rod was exposed outside the shield. The damaged gauge could not be placed into its shipping container because of the excessive radiation levels. A health physics specialty company was contacted to remove the device. Its members placed the gauge in a lead-lined, 55-gallon steel drum. The incident was terminated at 1416 hours.

LESSONS LEARNED AND REINFORCED

Irrational fears of radiation exposure and contamination should not deter the responder from administering aid–the fear is out of proportion to the risks in most foreseeable accidents involving radioactive materials. The majority of radiation incidents to which public fire/EMS personnel will respond are low-level releases involving small quantities of material. Using the radiation protection factors of time, distance, and shielding (described below), responders can rescue, stabilize, and remove victims from a radiation area with minimal or no measurable exposure. (This is another good reason for having fire, EMS, and haz-mat personnel get at least basic-level radiation training and for carrying meters and dosimeters on their apparatus. Field courses are available. The resident course “Radiological Emergency Response Operation” is conducted by FEMA in Berryville, Virginia.) Life-threatening medical emergencies supersede concerns about radiation monitoring, contamination control, and decontamination. At this incident, since the victim was seriously injured, the medical team correctly transported him to the Allegheny General Hospital E.D. before the haz-mat response team arrived at the scene.

The emergency medical responder should always use proper emergency priorities in caring for accident victims where radiation hazards exist. When performing emergency medical stabilization or rescue procedures, use good judgment to protect yourself and keep radiation exposure as low as reasonably achievable (ALARA).

When adequate personnel are on the scene, police, firefighters, and other personnel should isolate and secure the area while emergency medical actions are being carried out. Boundaries for controlled and noncontrolled areas should be established in the same manner as for nonradiological hazards.

The medical team alerted the hospital E.D. in advance–while en route to the hospital–of the victim`s condition/status, enabling the hospital`s emergency team, including a health physicist, to meet the ambulance outside the emergency entrance to assess the patient`s medical condition and perform a radiation survey.

Normally, the medical team would include in its alert the number of victims being transported, the medical status of each victim, the number of contaminated victims, and the following if known: the extent of contamination, the body areas subjected to the greatest contamination, the identity of radionuclides and their chemical forms, and any available information on exposure to nonradiological hazards.

After transport of the last contaminated patient, the transporting ambulance is locked and kept at the hospital until it can be surveyed for contamination and decontaminated if necessary. The ambulance crew is given a radiation survey, takes a shower, and changes into clothing made available by the hospital. During this time, no eating, drinking, or smoking is allowed.

Uninjured victims as well as all other persons in the controlled area should be detained for radiological monitoring, identification, and possible decontamination. If any doubt about contamination exists, it should be assumed that contamination has occurred. The IC, in this case, had no information about the radioactive material(s) involved initially. He, therefore, relocated personnel who could have been exposed to or contaminated by the radioactive source (the gauge) from the immediate area of the damaged gauge to a “distant” area and confined them to a construction trailer that was shielded by a second trailer.

Distancing and shielding are radiation protection factors based on the following principles: (1) The level of radiation exposure is always greatly reduced by moving away from the radioactive materials (distancing), and (2) The denser a material, the greater its ability to stop the passage of radiation (shielding). In emergency situations, shielding often is limited or not practical. Time is another radiation protection factor that can alter radiation dose; the principle involved here is that the shorter the time spent in a radiation field, the less radiation will be accumulated.

The command post–established 1,000 feet from the scene–was shielded by two construction trailers.

Command was able to determine the type of radiation device involved by contacting the victim`s employer. Relaying that information to the radiological officer while en route to the scene enabled Command to have the radioactive materials identified in a timely fashion and relayed to Allegheny General Hospital. Consultation with the owner of the gauge also made it possible to ascertain that the initial reading of the gauge by Team 1 was within normal limits.

Communication and obtaining good information can be major problems at any emergency. In Allegheny County, everybody in the emergency services is on a different radio frequency. Major medical emergencies are run through the City of Pittsburgh`s Med 2 channel, since it operates Medic Command from Presbyterian Hospital. This channel was cleared for use during this emergency. Since this was a channel available to most of those involved in the emergency, we used it. Gaglierd had to switch to a different channel to talk to County Emergency management. He used Med 2 to talk to Allegheny General Hospital via Life Flight Command. Driving, talking on the radio, and keeping track of to whom he was talking made the operation more complex.

This type of coordinated effective response does not just happen. It is the result of planning and training. It results from teamwork that develops from a mutual respect and understanding of the abilities, duties, and responsibilities of those involved. It results from doing what you were trained to do.

Preplanning is the recognized key to rapid and efficient disaster control and recovery. Unfortunately, it is psychologically impossible to motivate personnel to devote the amount of time to think, organize, train, and equip themselves for some vague disaster they believe will never occur when real problems and work assignments are at their fingertips daily. Most individuals cannot gear themselves for preplanning until they have personally experienced a major accident.

* * *

The successful conclusion of this incident does not imply that there were no problems, difficulties, or confusion. They always will be factors in an emergency. Planning, training, teamwork, mutual respect, and understanding, however, will keep them to a manageable minimum. n

References

Crockett, C.E., J.D. McClure. Transportation Accidents/Incidents Involving Radioactive Materials. Sandi National Laboratories, 1971-1993.

Hilinski, Richard K., “Report of Hazardous Materials Incident,” July 14, 1994, North Hills Response Team.

Manual of Protective Action Guides and Protective Actions for Nuclear Incidents. U.S. EPA 400-R-92-001, May 1992.

Personal Communications U.S. NRC Division of Radiation Safety and Safeguards. Aug. 3, 1994.

Recommendations on Limits for Exposure to Ionizing Radiation. National Council on Radiation Protection and Measurements, Report No. 91, June 1, 1987.

Ricks, R.C., Ph.D. Prehospital Management of Radiation Accidents. Oak Ridge Associated Universities, Feb. 1984, ORAU-223.

Roberts, M.C., D. White. “Portable Density Gauge Operator Killed in Construction Accident,” U.S. NRC NMSS Licensee News Letter, Sept./Oct. `94, NUREG/BR-0117, No. 94-3.

The command post was established approximately 1,000 feet from the radiation source, well beyond minimum safe radiation response distances. In general, apparatus responding to a possible radiation emergency should be positioned outside a 500-foot radius from the contamination source or occupancy. (Left photo courtesy of authors; right photo courtesy of Bradford Communications Corporation.)

(Left, middle) These photos show the front and rear views of the damaged soil moisture-density gauge, with the handle broken off. With instrumentation, responders could clearly see the crushed unit and warning markings. (Right) Properly equipped entry teams identified the true hot zone–a 10-foot perimeter in which readings were one mR/hr or greater. (Photos courtesy of authors.)

RADIOACTIVE INCIDENT PROTOCOLS

Accidents involving radioactive materials generally can be grouped into six categories, based on where the accident occurs:

1. nondestructive testing (industrial

radiography, soil testing),

2. radionuclides in medical facilities,

3. isotope production facilities,

4. radionuclides in research facilities,

5. nuclear reactor sites, and

6. transporting radioactive materials.

Incidents involving radioactive materials occur most frequently during transportation. The Radioactive Materials Incident Report (RMIR) database lists 1,620 incidents that involved radioactive materials during the period 1971 to 1993; 103 were in Pennsylvania.

The other most common radiation incident involves the use of sealed sources for nondestructive testing, such as industrial radiography or soil-density gauging.

TYPES OF RADIATION INJURY

An accident involving radioactive materials can result in external irradiation or contamination (external or internal) or both.

External irradiation occurs when all or part of the body is exposed to penetrating radiation from an external source.

Contamination occurs when radioactive materials in the form of solids, liquids, or gases are released into the environment. External contamination involves exposure of the external surface of the body. If radioactive materials get inside the body through the lungs, digestive tract, skin, or wounds, the contamination can become deposited internally.

(Editor`s note: For more information, see the following articles by Anthony M. Gaglierd: “Training for Radiation Accident Response,” September 1990, 57-61, and “Response to Radiation Emergencies,” February 1991, 61-68. n

TRANSPORTING CONTAMINATED VICTIMS

The victim should be brought to the control line where a clean stretcher has been covered with a sheet or blanket. The victim is then transferred to the covered, clean stretcher, and the sheet or blanket folded to securely “package” the victim. An arm can be extended through an opening in the sheet to measure vital signs or administer intravenous fluids. The attendants can wear gloves to protect their hands and, as an additional precaution, the floor of the ambulance can be covered with securely taped plastic or a sheet. Deceased accident victims should remain at the scene until the usual investigation is completed. Public health officials, assisted by health physics personnel, should direct the handling and transporting of contaminated human remains. n

(Top left) A control point, from which all individuals enter and exit the exclusion zone, must be established for radiation emergencies. Personnel and civilians must not pass this point without monitoring for possible further action. (Top right) The victim is brought to the control point for “packaging” and transport, where a stretcher covered with a clean sheet or blanket is prepared. (Bottom left) The victim is transferred to the clean stretcher and (bottom right) the blanket is folded securely around him for proper “radiation packaging.” (Photos courtesy of Bradford Communications Corporation.)

ANTHONY M. GAGLIERD is the radiological officer for the Allegheny County (PA) Emergency Management Agency, team leader for the East Boroughs Hazardous Materials Unit, and an emergency medical first responder. He is an adjunct instructor at the Federal Emergency Management Institute, Pennsylvania State Fire Academy, Allegheny County Fire Academy, and Point Park College. Gaglierd has a bachelor`s degree in behavioral science and chemistry from Point Park College.

RICHARD K. HILINSKI has served more than 20 years in the fire and emergency services, 15 of them as a paramedic in the City of Pittsburgh (PA) Bureau of EMS. He is assistant director for medical programs at the Community College of Allegheny County, Public Safety Institute; deputy haz-mat commander for the North Hills Response Team; deputy EMS coordinator for Allegheny County, Pennsylvania; and assistant fire chief of the Sharps Hill Volunteer Fire Department of Shaler Township, Pennsylvania. Hilinski has a bachelor`s degree in public administration from the University of Pittsburgh.