On September 11, 2001, our own planes were used as missiles against our own city causing death, panic, and mass disruption as well as economical stress. There have been many incidents where terror groups have tried to use radioactive sources such as a particular isotope of cesium (cesium-137) as a dirty bomb. Unfortunately there are still many radioactive irradiators using cesium presently exist in many hospitals that could be used as dirty bomb against our own populated densely cities if they get to a wrong hand. The incident in Guainía of Brazil in 1987 showed that 80 grams of cesium created 40 tons of radioactive waste with 4 deaths and 112,000 people had to be surveyed for radioactive contamination. The Brazil incident was not a malicious attack; otherwise the incident may have been much worse. In addition, according to a Homeland Security Scenario, one would expect about 10,000 people to become lightly contaminated from a large dirty bomb.  The question is how you prepare the hospital, how you assess the patient injuries, and how you mange the radioactive contamination and recover the facility.

Although there are three kinds of particles that could be emitted from radioisotopes (alpha, beta, and gamma), we have simplified this scenario by assuming that the most likely isotope that a terror group would use is cesium-137, which emits gamma radiation.

Hospitals should be able to assess the radiation injuries of the patients and to manage the influx of patients contaminated with radioactive materials. Having knowledgeable staff on board, such as radiobiologists or health physicists, would be an asset to the hospital. These individuals could help to assess the health effects of patients by consulting their knowledge of concepts such as radiation exposure, absorbed dose, radiation units, properties of common radioisotopes, and annual radiation exposure limits.

The hospital should review the hazard vulnerability analysis of where they are located and how many underground train entrances located around the hospital within what distance and what to expect in a real emergency. Is there any area that could be used as the triage area next to the emergency room of the hospital?

In such cases, time is of the essence. Hospitals must be able to quickly detect an event and activate access control to prevent contamination of the Hospital.  Patients, visitor and staff would require screening and need to have access to decontamination areas before entering the facility.  How would the hospital know if the people coming to the hospital are contaminated? Radiation area monitors could be installed at the entrances and the security guards with dosimeters could act as portable portal monitors but would need to be trained by the health physics professionals to check if the incoming persons are merely patients who have had medical procedures with radioactive pharmaceuticals or do a risk assessment for an individual who is determined to be contaminated with a radioactive source. If the radiation alarm goes off too many times in a short time, it is an indication of a mass influx of contaminated individuals to the hospital. In such an incident, the hospital management may consider locking down the hospital to prevent the spread of contamination inside the hospital.

Radioactive incidents are not well understood by the public and in many cases where the public believes they may think they require immediate evaluation to determine if they are affected they present to hospitals and emergency departments to be assessed.  During the Iraqi scud missile attack on Israel, more than half of the people who ran to the emergency room were not hurt, but rather were in psychological shock. Having a mechanism to assess the uninsured and worried with appropriate support needs to be incorporated into in a plan in addition to public messaging to give instructions to remain safe and when to seek medical care. The message should be coordinated with the local health departments.”

It is recommended for the hospital to have decontamination showers external to the hospital and with easy access to the emergency department for those who need care but also easy access to additional areas for those who only need shelter and reassurance. Most hospitals have areas identified to provide ambulatory and non ambulatory decontamination which are used for patients for contamination with radiological, biological and chemical incidents. These areas need to provide shelter from the environment, need to allow patients to safely disrobe or have clothing removed and either shower or be cleaned by a team in a temperature controlled location.    Exercises for radioactive contamination should include a multidisciplinary group which at a minimum includes radiation safety staff and emergency staff in addition to other departments in the hospital but should also coordinate with external emergency response agencies such as fire department and police department to learn from such drills.  There should be some sort of pre-arranged plan between the hospital and local Law Enforcement Agencies (LLEA) as who will do what in a real emergency.

The hospital should have on hand and maintain proper equipment for identifying and quantifying radioactive material. Such equipment may include a portable Geiger-Muller counter for detecting contamination, pocket dosimeters for recording real time radiation dose, and radioisotope identifiers for indicating the type(s) of radioactive material that is/are present.

Hospital staff should separate children and pregnant individuals from the rest of population to be surveyed for radioactive contamination because young individuals are more radiation sensitive. Processes need to be designed to single out individuals for decontamination.  Although a GM counter could be used to survey a mass influx of people, there are other tools that might be employed to survey patients, a portable portal monitor, which is used in nuclear power plants, will be very effective at singling out contaminated individuals. Various tools can also be used to detect and estimate the presence of radioactive materials inside the body which pose an internal radiation hazard. This could, for example, involve the analysis of nasal swabs or urine of exposed individuals. Staff education, should also emphasize that in radiological contamination of patients the priority even before decontamination is life saving medical interventions, it is safe for care providers to render emergency care to contaminated patients.  No healthcare provider has ever died from helping a contaminated individual. Therefore, the presence of contamination on the victims should not prevent the hospital staff to take care of a contaminated patient. Staff should protect themselves from contamination by using universal precaution such as gloves and lab coat and check their hands with a Geiger counter and replace the glove if it is contaminated.

During decontamination procedures, one has to remember that most of the contamination will be removed by just by removing the outer clothes. It is very important to decontaminate the victim from head to toe. Depending on the location, some states require collecting radioactive wash water but in reality this is simply unrealistic.    It may be necessary to monitor a patients for their potential contamination through blood and other body fluid sampling which should be coordinated with Radiation Safety and Nuclear Medicine experts.

If there is an incident where radioactive shrapnel is inside the injured individual, it is recommended that a designated room be identified for operation with the radioactive victim. There has to be a mechanism to contain or to collect radioactive waste from this operation and radiation safety will dispose such waste properly.

For internal exposure to radioactive material, various treatments exist depending on the radioisotope and length of time since the exposure. Assuming cesium is used in a dirty bomb, the potassium iodide pills would be useless and in such cases the physician may prescribe the Prussian blue orally.

In conclusion, the top priority should be saving lives. No one has ever died from helping to decontaminate a contaminated individual. Contamination should not prevent medical stabilization of the injured. The help of a psychological support and public communication will be very beneficial during such a crisis to calm people down. Drills with local emergency responders to build up confidence and competence are very helpful. A pre-plan to ensure proper equipment, survey meters and supplies available is necessary. Precautions should be used to minimize the exposure and risk of contamination. Finally remember the first 24 hours are the worst and additional resources most probably will arrive.