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Radiation and radioactive materials have become an indispensable part of today's modern society and industry. With its unique properties, radiation provides benefits in many areas, particularly in energy, industry and health. Some of these uses are: precision clock production, sterilization, DNA sequencing, determination of metal fatigue in aircraft and generation of large amounts of electrical energy. The range of application of radioactive materials is so extensive that modern life is unthinkable without these materials. We benefit from the benefits of this technology as well as the necessary safety during the production, use and storage of these materials. If safety precautions are not taken properly, radiation accidents will be inevitable.
General Preparation in Hospitals to Intervene in Radiation Accidents
Hospitals should regularly assess the risks in the environment they serve and have the necessary personnel and equipment available in accordance with the risk they determine. However, a minimum level of preparation is required in all hospitals. Since hospitals will need to cooperate with the fire brigade, the security forces and the relevant government agencies, it is beneficial to establish a certain level of relationship with these units. It should be kept in mind that decontamination can be completed at the scene to a great extent if the teams performing the first response to the accidents intervene as necessary (1,2).
A planned activity should be initiated when there is a notice that a radiation casualty will be brought to the hospital. The person answering the phone should try to get as much information as possible about:
- Number of wounded,
- The medical condition and the type of injury of each injured,
- whether the survivors were screened for radiation,
- Radiological status of survivor (irradiated?, Contaminated?),
- Material causing contamination,
- Estimated time of arrival.
If there is doubt about contamination, the victim should be considered contaminated until proven otherwise. If the hospital has a special entrance for this type of incident, the ambulance personnel will be warned. If the notification comes from someone other than the emergency response teams, the telephone number to be requested is called back to verify the event before alarming the radiation responding team and starting preparations.
If a hospital is to respond to persons exposed to irradiation or contamination, provision should be made for such a situation. First, a treatment area should be identified. This area should be known by everyone and all the services of the hospital should be easily accessible. The treatment unit should be equipped with facilities to treat life-threatening wounded. Generally, a part of the emergency department will be allocated as “radiation emergency area” (RAA). Some centers have separated the morgue section for this purpose. However, the environment is not suitable for patients and relatives, and the necessary equipment for intervention may not be available in this section. In addition, the media may make inaccurate inferences due to the location of the patients (1).
Ideally, the RAA should have a separate entrance from the emergency room. This prevents entry-exit of other patients. However, this is not an absolute requirement. Access to RAA should be limited to personnel who will intervene in patients. RAA should be considered as a contaminated area. Everyone entering this area should wear protective clothing as if intervening in a septic phenomenon. No one should leave the RAA without a full-body contamination scan. Since the whole body scan will take 10-15 minutes at a time, unnecessary entries and exits to this area should be prevented. Personnel should remain in this area until the intervention is completed (1,3,4).
A region other than RAA is designated as the buffer region. In this zone, there should be a cabinet with all kinds of special equipment that may be needed to intervene in the radiation accident. Entry and exit to this buffer zone is limited to a nurse or staff assigned to this area. This area is considered a potentially contaminated area. The nurse in the buffer zone communicates with other emergency services and transmits any other material that may be needed, such as mobile x-ray, fluid, device or medication, to the RAA. This nurse can also record patient procedures, contamination levels and decontamination procedures, if any. To prevent unnecessary contamination, this area should be closed to personnel and other human traffic (3,4).
If time remains, the RAA and buffer should be covered with floor protection material. For this purpose, waterproof thick plastic material or thick paper can be used. The material should be taped to the floor (Figure 1). Covering the floor is not mandatory, but makes it easier to clean later. Traditionally, RAA is coated with “yellow” and the buffer zone is “green”. Plastic garbage bags should not be used to cover the floor. They are slippery and can cause accidents. Similarly, sheets or other fabric materials are easily folded, making movement difficult. In addition, fabric material is a material that makes it difficult to decontamination and can lead to the transport of radioactive material to shoes in other areas (3,4).
Personnel who will intervene in the patient should be protected from the possibility of contamination. For this purpose, it is enough to wear a double surgical gown and gloves. The double coat is intended to be easily removed when the outer coat is contaminated. Over-dressing can make work difficult if ventilation is not sufficient. To protect the shoes from contamination, plastic shoe covers should be worn on the feet and taped on both the wrist and the middle section (Figures 2, 3).
Dosimeters should be given to each personnel entering RAA. This rule normally includes personnel such as nuclear medicine-radiology technicians and nuclear medicine-radiology physicians who wear dosimeters. The aim of the dosimeter is to measure the radiation dose to which personnel is exposed during the patient intervention. A thermoluminescent (TLD) dosimeter should be fitted to the innermost body. If desired, a ring TLD dosimeter is attached under the gloves. TLD serves to determine the official radiation dose received. A pen dosimeter to be attached to the outermost can read the dose the staff is exposed to at any time. However, pen dosimeters are sensitive to vibrations and impacts may not provide accurate information in determining the exact irradiation dose (1,4).
Personnel Required for First Response
In any case, appropriate and trained personnel are required for on-site intervention. Anyone in this team, which can be defined as a radiation emergency response team, should be familiar with the radiation emergency plans of the hospital and participate in the exercises. For some subgroups in this group (such as decontamination, triage and radiological monitoring teams), the frequency of administration may be increased. Changing personnel are also subjected to the same training to ensure compliance with the team. These trainings should include emergency medical technicians and personnel carrying the wounded from the scene to the hospital. This is because these personnel play important roles in the pre-warning of the hospital and the proper transport of radiation injured (2). The tasks and functions of the radiation emergency response team are presented in a table below (Table 1).
Let us examine in detail the functions of some of the personnel to be employed in the team.
Emergency nurses: Nurses play the most important role in the intervention of many emergency patients. They clean the wounds and make them ready for the intervention of the physician. Emergency nurses are responsible for taking samples from suspected contaminated areas and performing final decontamination. Depending on the size of the accident, 1 or 2 nurses should always be present in the RAA.
Emergency Medical Specialist: Emergency medical doctors are used to respond to casualties. The task of the emergency physician is to stabilize the patient medically. Decontamination is performed after the patient has stabilized. Emergency medical attention always has priority over radiation decontamination. The emergency physician will remain in the RAA until the patient has stabilized and the life-threatening has been eliminated.
Trauma surgeon: Surgery is sometimes necessary to stabilize the victim. This intervention is performed by the surgeon or trauma surgeon. Again, these surgical interventions are performed before decontamination. The trauma surgeon stays in RAA until he no longer needs it. If the trauma surgeon undertakes treatment, the emergency medical practitioner may leave this area.
Nuclear medicine technician or radiation technician: If the patient survives and stabilizes, the areas of contamination should be identified, if any. This is done by a nuclear medical technician or radiation technician (radiation safety officer). These personnel should wait in this area during the patient intervention. If contaminated areas are known when the patient arrives, the technician reminds the patient to intervene to change contaminated gloves and gowns after the intervention. In no event shall this technician prevent or delay the initial medical intervention of the patient.
Security personnel: The presence of security personnel is important for two reasons. The first is the patient's privacy. Only the name of the patient, the time of admission to the emergency department and the general condition can be explained. Any other information to be disclosed is a violation of patient rights. Second, if people potentially enter this area continuously, contamination will be very likely to spread. Security personnel control the entry and exit of this area to prevent the spread of contamination and leakage of unauthorized information.
Public relations: Most of the time, radioactive accidents do not attract much attention and media coverage, but sometimes it can happen in front of everyone. In this case, the hospital should appoint someone experienced in this area to contact the press.
Necessary Staff for Advanced Care and Treatment
Surgeon: A trauma surgeon is often needed as most trauma is accompanied by a certain degree of trauma. This staff member could be called early or later. Surgeons should be aware of contamination control as these personnel intervene in other complications of wounds, burns and trauma, and may be needed at any time during the intervention.
Radiation technician: If there is contamination, the duration of irradiation, the distance to the source, and the amount of shielding and activity, if any, should be known to determine the irradiation that will occur. Dosimeters are read and prepared for complications of radiation. If contamination is present, necessary analyzes should be performed to determine the isotope. If an isotope is identified, appropriate decontamination therapy may also be initiated.
Nuclear medicine and / or radiotherapy specialist: Both of these experts will benefit from the management of radiation accidents. Nuclear medicine specialists are experienced in dealing with internally administered radionuclides. They can apply treatment for internal contamination of different isotopes. Radiotherapy specialists are also experienced in patients exposed to high doses of external irradiation. Their knowledge and experience will be helpful in identifying early and late effects in patients exposed to high dose irradiation.
Oncology / hematology specialist: Radiation casualties are in the high risk group for cancer in the long term, but the oncology / hematology specialist will be useful for other reasons in the early period. The oncology / hematology specialist is experienced in the treatment of immunosuppressed patients. If leukopenia is evident, protective isolation may be required. Bone marrow transplantation may also be a treatment alternative in patients exposed to a dose close to the lethal dose.
Internal medicine specialist: Patients with serious injuries may need to be hospitalized for long periods of time. If surgery is not required, an internal specialist may be required to coordinate the overall treatment of the patient. Liquid electrolyte balance may be impaired in patients exposed to high doses of radiation. The patient may be lost if not treated properly. Infection and other complications due to long-term hospitalization may also require treatment.
Legal adviser: Radiation accidents can also have legal consequences. The hospital and personnel being prepared for this situation will undoubtedly allow for the proper preparation of the necessary materials and documentation.
Emergency Response Team (ADME) Preparation
Protective clothing: Protective clothing is intended to protect bare skin and personnel clothing from contamination. Team members should wear surgical clothing (gowns, masks, caps, eye protection and gloves). Waterproof shoe covers or shoe covers are used. All open areas and floor sections are taped. The end of the tapes is folded for easy removal when necessary. Gloves should be worn in double coats. The first layer of gloves is taped under the surgical gown arm. The second coat must be easily removed and replaced if necessary. The dosimeter to be distributed to each team member is attached around the neck area outside the surgical gown. If available, another type of dosimeter is worn under a surgical gown. Each team member who uses fluids for decontamination should also use a waterproof outer apron.
These protective suits effectively inhibit alpha and some beta particles, but are not useful for gamma rays. Bulletproof aprons that cannot stop most gamma rays are not recommended, as they create a false sense of security.
Preparing the treatment area for contamination control: The treatment room should be prepared , if possible, near the external entrance. Visitors and patients are removed from this area. Equipment that will not be used in emergency response to the victim is either removed from this area or covered. Several large plastic trash cans will be needed.
The treatment table is covered with several layers of waterproof disposable drapes. Plastic waste bags should be available in all sizes.
The devices used in radiation monitoring are checked for batteries and operation. Again, background activity is determined and recorded before patients arrive. The team is prepared to receive the patient by the ambulance.
Covering the floor: Brown wrapping paper is laid out from the ambulance area to the treatment room. Regardless of the material used to cover the floor, it should be fixed with tape on the ground. This path is then separated by safety ropes to prevent unauthorized access. The decontamination chamber and treatment area are also covered with the same material if time is left. This will facilitate subsequent cleaning. The threshold of the decontamination chamber is clearly marked with a thick band to define the boundary of the contaminated and clean zone.
Control of ventilation: It is preferred that the ventilation of the separated section is a separate ventilation from other areas. Or the passage of air in this area to other sections without filtering should be prevented. Contamination is very unlikely to be suspended in the air and into the ventilation system.
Patient Admission
Pre-admission: The most often overlooked issue in hospital preparation is pre-admission to the hospital with the first intervention team. The emergency department team is contacted about patient and injury patterns. The emergency personnel are familiar with respiration, pulse, blood pressure, skin color, pupillary reflex, and other signs and symptoms. However, the average staff does not know enough about the evaluation of radiation data. A description by the on-site radiation technician of 10,000 10,000 hands and 2,000 DPM contamination of the scalp abilir can create hesitation and fear for staff interfering with the patient. If the hospital is close to the facility that uses radioactive material, it is imperative that both the emergency responders and hospital staff understand the radiation language. Drills are an important part of the preparation and should be carried out at least once a year with the participation of the facility using the radiation, the emergency response team and the emergency service team.
As in any accident involving dangerous substances, it would be very useful to know the material causing contamination, the amount of irradiation and the affected body areas. If the accident occurred during the transport of radioactive material, the contents and the amount of activity shall be clearly written on the package.
A common pre-agreed language should be used in pre-acceptance communication. It is not easy to determine the radiation in rad or gray at the scene. Instead, it is easier to express contamination in terms of DPM (counting per minute) or CPM (counts per minute). This data should be provided by persons who are knowledgeable. Information should be provided not only on contamination, but also on the type of the boiler, the material involved and the affected areas, if known.
Clean transfer between teams: When the patient arrives at the hospital, the ambulance / helicopter and personnel should be considered as contaminated. The patient should not be directly admitted to the hospital by a potentially contaminated ambulance gurney or staff. In this case, contamination can spread rapidly throughout the hospital by other unaware staff.
The easiest way to overcome this problem is to perform clean transfers between teams. To perform such a transfer, a potentially contaminated area around the incoming vehicle is determined. The ambulance will approach this area. Ambulance personnel should not leave this area. Ambulance personnel are met by hospital personnel at the border of this region. The ambulance and hospital gurney are brought side by side to this border and the patient is taken to a clean stretcher and transports to the hospital. A similar procedure can be applied for helicopters. The inside of the helicopter runway ring is designated as a contaminated area and transfer is made in this line.
Thanks to the clean transfer, the patient can be taken to the emergency room or the operating room without suspicion of contamination.
Releasing the emergency response team: The team members bringing the patient are checked for contamination by an experienced technician. Until this process occurs, team members are not allowed to eat, smoke or drink liquids. If there is contamination, it will be inevitable that external contamination, which can be treated more easily in this way, will turn into internal contamination, which is more difficult to control.
The whole body scan of the team and the control of the vehicle interior are performed according to the routine procedure. If no contamination is detected or contamination is removed, the team is allowed to leave.
Result
Radiation and radioactive materials have become an indispensable part of today's modern society and industry. So we have to learn to live with them. Increasing use of radiation and radioactive materials increases the risk of accidents with them.
Intervention to radiation accidents should be a multidisciplinary approach. It is of utmost importance to bring the survivor from the place where the incident took place to the health institution, and to train personnel who are conscious about radiation and radioactivity in all the processes up to the discharge of all kinds of interventions there. In addition, health institutions where the first interventions of such victims should be prepared should be made ready for radiation accidents. Consequently, the establishment of a team (ADME) to intervene in possible radiation accidents in each health facility and providing continuous in-service training to this team will also minimize the risk of injury to an accident victim and other personnel in charge.
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