Managing the medical response (A8 elements)

(1) To ensure that medical practitioners or other responsible parties make appropriate notification and implement response actions after the presentation (observation) of medical symptoms of radiation exposure or other effects indicating a possible radiological emergency (4.74).

(2) To provide appropriate specialized treatment to any person who receives a dose that could potentially result in severe deterministic health effects (4.75).

(3) To detect any increase in the incidence of cancer among emergency workers and the public resulting from radiation exposure during a radiation emergency and provide appropriate treatment (4.76).

A8 - MANAGING THE MEDICAL RESPONSE Threat category Responsibility

Elements I II III IV V O L N

A8.1 Arrange to make medical personnel, both general practitioners and emergency staff, aware of the clinical symptoms of radiation exposure and of the appropriate notification procedures and other immediate actions warranted if a radiological emergency is suspected (4.77).

9 9 9

This can be accomplished by distribution of information similar to the IAEA/WHO poster “How to

recognize and initially respond to an accidental radiation injury”. 9 9 9

A8.2 Arrange for treatment of a limited number of contaminated or overexposed workers, including provisions for first aid, the estimation of doses, medical transport, and initial treatment of contaminated or highly exposed individuals in local medical facilities (4.78).

9 9 9 9 9

Arrange to gather information needed to reconstruct the dose promptly following a serious exposure in order to determine the course of treatment. This information should include: estimates of the dose received to the whole body or tissues; photograph/diagrams of the facility/practice and activities involved; a description of the source of exposure (e.g. activity, radionuclide, dose rate at 1 metre); a detailed description of circumstances of the exposure (e.g. location of person as a function of time);

readings of all personal dosimeters (all staff members) or other monitoring devices; samples of items

9 9 9 9 9 9³²

32 Medical facility

75

A8 - MANAGING THE MEDICAL RESPONSE Threat category Responsibility

Elements I II III IV V O L N

worn by the overexposed person; a full description and time of onset of any early clinical symptoms (e.g.

vomiting); results of a general medical examination of all systems and organs, including the skin, visible mucosa; and total blood counts in order to detect the first occurrence of symptoms related to exposure (see Ref.[ 28]).

Arrange for a local medical facility (the “designated hospital” – see Appendix 14) to be used for initial treatment (see Element A4.7). This facility should have the capability to: treat and decontaminate contaminated patients, identify radiation exposures needing specialized treatment, control the spread of contamination and prepare patients for transport to a facility (the ”referral hospital” – see Appendix 14) that can treat severe overexposures consistent with Refs. [28, 29]. Train/inform the facility medical staff on control of their exposure (the staff should be considered emergency workers, see Element A6.2), the risks of treating contaminated and exposed patients, contamination control, and handling of contaminated waste or samples. One aim of this training is to overcome staff fears that may interfere with treatment.

(See Element A10.6).

9 9 9 9 9

A8.3Establish a medical management plan for emergency zones, which should include operational criteria for

performing triage and assigning any highly exposed members of public to appropriate medical facilities (4.79). 9 9 The triage and treatment system should be consistent with Refs. [28,29]. Identify facilities to treat

overexposures of up to 5% of the population in the PAZ. The operational criteria (triage criteria) for determining which level of treatment people receive should be based on estimated exposure or onset of clinical symptoms consistent with Ref. [28, 29].

9 9

A8.4Arrange, at the national level, treatment for people who have been exposed or contaminated. Include guidelines for treatment; a list of medical practitioners trained in the early diagnosis and treatment of radiation injuries and the selection of approved institutions to be used for extended medical treatment or follow-up of persons subjected to radiation exposure or contamination. Include arrangements for consultation with medical practitioners experienced in dealing with such injuries on treatment for any exposure that could result in severe tissue damage or other severe deterministic health effects (4.80).

9 9

Inform agencies that may be notified of a radiation injury of these arrangements. Use existing medical

facilities and brief the medical staff on the limited risks from treating contaminated and exposed patients 9 9

A8 - MANAGING THE MEDICAL RESPONSE Threat category Responsibility

Elements I II III IV V O L N

facilities and brief the medical staff on the limited risks from treating contaminated and exposed patients, precautions they should take, contamination control, and handling of contaminated waste or samples. See information for Element A10.6 on how to characterize risk. Ensure that medical staff will not let fear interfere with treatment of contaminated patients. Establish a procedure and system of organization and notification of appropriate medical staff and support personnel. Diagnosis and treatment guidelines should be consistent with Refs. [28,29]. Attempt to minimize psychological suffering (for example, by treating the patient near home if possible). Consult experienced physicians on the treatment of severe deterministic health effects through the IAEA or WHO using the procedures in Ref. [23]. See the first information item under Element A8.2 on the information to be gathered to estimate dose.

Be prepared for three waves of people arriving at a hospital from a radiation emergency with mass-casualties: 1) Wave 1: worried-well, who are not injured but worried and get to the hospital on their own and fast. If the staff is not prepared for them, they can clog the hospital and interfere with the treatment of the truly injured that will arrive later. 2) Wave 2: the injured that are rescued by the public – bystanders.

These arrive next and, while injured, they may not be the most severely injured and 3) Wave 3: the injured that are rescued by the emergency response personnel. These will be the last to arrive and will typically be the most severely injured. Note Wave 1 and 2 could contain people who have not been monitored or decontaminated.

9 9 9 9 9 9 9

Have arrangements to dispatch an emergency medical response team to co-ordinate the medical response to a radiological emergency at any location. This team should be prepared to prepare and use local medical resources. (see Appendix 7 for typical responsibilities)

9 9

A8.5 Arrange for identification, tracking and long term medical follow-up and treatment of the health effects of people in those groups that are at risk of sustaining a detectable increased incidence of cancer from radiation exposure or in effects from prenatal exposure (e.g. mental retardation). The criteria for determining who should receive long term medical follow-up should have the aim of detection of radiation induced cancers or mental retardation at an early stage to allow more effective treatment (4.81).

9 9 9 9

A registry should be established of persons to be tracked and to receive long term medical follow-up.

These arrangements should include identification of the responsible organization, criteria for inclusion in 9 9 9 9 9 9

77

A8 - MANAGING THE MEDICAL RESPONSE Threat category Responsibility

Elements I II III IV V O L N

the registry and information to be obtained that ensures that the correct identity of persons in the registry can be confirmed over time (see Element A7.5). Base inclusion in the registry on objective criteria that indicate a potential for an increase in the incidence of radiation induced cancer or mental retardation from prenatal exposures (e.g. 50 mSv to the thyroid, 200 mSv [41] whole body and 100 mSv foetus [40]).

Include those who were children at the time of exposure and who may have received sufficient dose from radioiodine to result in a detectable increase in thyroid cancer (e.g. 50 mSv) risk. Inform people included in the register of their risk level and of the purpose of the register. (See Element A10.6.)