Emergency Department

1. Emergency Department Preparation for Receiving Radiation Exposed/Contaminated Patients

2. Radiation Exposure/Contamination • Accidents • Nuclear reactor • Medical radiation therapy • Industrial irradiator • Lost/stolen radioactive sources • Transportation • Terrorist Event • Radiological dispersal device (dirty bomb) • Attack on or sabotage of a nuclear facility • Low-yield nuclear weapon

3. Scope of Event Event Number of Deaths Most Deaths Due to Radiation None/Few Radiation Accident Few/Moderate Radioactive Blast Trauma (Depends on size of explosion and proximity of persons) Dispersal Device Low-Yield Large Blast Trauma (e.g., tens of thousands in an urban area even from 0.1 kT weapon) Nuclear Weapon Thermal Burns Radiation Exposure (Depends on Distance)

4. Emergency Preparedness • Medical stabilization is the highest priority. • Contamination control should not delay critical medical care. • Be prepared for multiple hazards, including chemical, radiological, and biological. • Be prepared for multiple events, e.g., a 1st event followed by 2nd event used to take out first responders if terrorists are involved. • Be prepared for: • Large numbers of potentially contaminated individuals. • Large numbers of uninjured and uncontaminated but concerned and frightened individuals.

5. Emergency Preparedness • Triage Goals for Mass Casualty • Evaluate and sort patients by immediacy of treatment. • Do the greatest good for the most people. • In mass casualty event, may need to deal with thousands of persons in need of contamination and exposure assessment. • Pre-plan to ensure adequate supplies and survey instruments are available. • Training and drills are essential to competence and confidence.

6. Systematic Approach A systematic approach to handling large numbers of potentially contaminated individuals is necessary. Such an approach should provide for surveying, mass decontamination, resurveying, advanced decontamination (if necessary), resurveying, and additional decontamination or medical care as indicated. Depending on weather, decontamination sites may have to be established indoors or in a temporary shelter.

7. Contaminated but Uninjured and Worried Well • An incident caused by nuclear terrorism may create large numbers of contaminated people who are not injured and worried people who may not be injured or contaminated. • Measures must be taken to prevent these people from overwhelming the emergency department.

8. Controlled Triage Site A controlled triage site should be established away from the emergency department to intercept the large numbers of contaminated people who are not injured and people who are uncontaminated but worried and divert them to appropriate locations.

9. Triage Site Control Control of movement through the site is necessary to minimize the potential for contaminating clean areas of the site. The triage site should be staffed with medical staff, radiation monitors, and security personnel. Precautions should be taken so that people cannot avoid the triage center and go directly to the emergency department.

10. Decontamination Center • Establish a decontamination center for people who are contaminated, but not significantly injured. • Center should provide showers for many people. • Replacement clothing must be available. • Provisions to transport or shelter people after decontamination may be necessary. • Staff the center with medical staff with a radiological background, health physicists or other staff trained in decontamination and use of radiation survey meters. • Psychological counselors available

11. Movement Through the Triage/Decontamination Areas The path through the triage/decontamination area must be clearly marked and individuals assigned to keep traffic moving in the right direction and to prevent potentially contaminated individuals from walking into clean areas, except by the designated route. photo credits: M. Meehan

12. Directions Clear directions (in appropriate languages) are necessary to help individuals understand what is expected of them.

13. Handling of Mass Casualties Access for Staff, Press, Officials Main Hospital Near Emergency Department Area for deceased Access for Self-referred patients Controlled Triage Site Triage for Injury & Contamination Ambulance Traffic Only Serious Injury/Illness Emergency Department • Perform first aid • Perform decontamination Admit patients or treat & discharge Community

14. Facility Preparation • Activate hospital plan: • Obtain radiation survey meters. • Call for additional support: Staff from Nuclear Medicine, Radiation Oncology, Radiation Safety (Health Physics). • Establish area for decontamination of uninjured persons. • Establish triage area.

15. Facility Preparation • Plan to control contamination: • Instruct staff to use universal precautions and double glove. • Establish multiple receptacles for contaminated waste. • Protect floor with covering if time allows. • For transport of contaminated patients into the emergency department, designate separate entrance, designate one side of corridor, or transfer to clean gurney before entering, if time allows.

16. ED Staff Radiation Survey & Charting Contaminated Waste Radiation Survey STEP OFF PAD Waste Treatment Area Layout Separate Entrance CONTAMINATED AREA Trauma Room HOT LINE BUFFER ZONE Clean Gloves, Masks, Gowns, Booties CLEAN AREA

17. Additional Considerations Develop prepared information packets with Media Relations in advance with message for incidents involving radiation. CDC Web site (www.cdc.gov) has Emergency Instructions for Individuals and Families Available in English Español Deutsch Français Tagalog Chinese photo credits: CDC

18.  Health Physics Society Disclaimer: The information contained herein was current as of 13 Aug 2008 and is intended for educational purposes only. The authors and the Health Physics Society (HPS) do not assume any responsibility for the accuracy of the information presented herein. The authors and the HPS are not liable for any legal claims or damages that arise from acts or omissions that occur based on its use. *The Health Physics Society is a nonprofit scientific professional organization whose mission is to promote the practice of radiation safety. Since its formation in 1956, the Society has grown to approximately 6,000 scientists, physicians, engineers, lawyers, and other professionals representing academia, industry, government, national laboratories, the Department of Defense, and other organizations. Society activities include encouraging research in radiation science, developing standards, and disseminating radiation safety information. Society members are involved in understanding, evaluating, and controlling the potential risks from radiation relative to the benefits. Official position statements are prepared and adopted in accordance with standard policies and procedures of the Society. The Society may be contacted at 1313 Dolley Madison Blvd., Suite 402, McLean, VA 22101; phone: 703-790-1745; fax: 703-790-2672; email: HPS@BurkInc.com.