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CLINICAL REVIEW: István Turai, Katalin Veress, Bengül Günalp, and Gennadi Souchkevitch Medical response to radiation incidents and radionuclear threats BMJ 2004; 328: 568-572 [Full text]

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Safety In Radiation Incidents

Jonathan R Benger   (9 March 2004)

Do we face a radionuclear threat?

John R Buscombe   (9 March 2004)

Radiation Incidents

Michael J Tidd   (11 March 2004)

1) Safety In Radiation Incidents

Istvan Turai, Katalin Veress, Semmelweis University, Budapest, Hungary   (12 March 2004)

Do we face a radionuclear threat?

Istvan Turai, Katalin Veress, Semmelweis University, Budapest, Hungary   (12 March 2004)

Medical Response to Radionuclear Threats

Douglas J Holdstock, Elizabeth Waterston   (12 March 2004)

Radiation Incidents

Istvan Turai   (12 March 2004)

Medical response to radiation incidents and radionuclear theats

Nicholas J Lewis   (25 March 2004)

Reply to Dr Nicholas J. Lewis

Istvàn Turai, Katalin Veress, Semmelweis University, Budapest, Hungary   (29 March 2004)

Safety In Radiation Incidents 9 March 2004
Jonathan R Benger, Consultant in Emergency Medicine Emergency Department, Bristol Royal Infirmary, Bristol. BS2 8HW Send response to journal: Re: Safety In Radiation Incidents	Editor, Whilst the review by Turai and colleagues [1] is generally interesting and informative, it contains the very puzzling statement that "Providing care for a patient in a life threatening condition always has priority over decontamination from radioactive materials or those actions required for the safety of others involved (medical staff, emergency rescue teams) or related to the wider public and environment." I entirely disagree. This statement will encourage inexperienced personnel to disregard the safety of themselves and others in a "heroic" attempt to treat the ill and injured. The latest edition of the Major Incident Medical Management and Support Course [2] rightly emphasises self and scene safety over that of survivors. Indeed, experience has shown again and again that well-meaning but poorly trained or equipped rescue and medical personnel are highly likely to become further victims.[3] As an example, the article points out that some of the 28 radiation deaths from the Chernobyl disaster of 1986 were amongst fire fighters. Medical treatment should only be given when it is safe to do so: poorly-considered and risky actions will only serve to lengthen the list of casualties. Jonathan Benger. 1. Turai I, Veress K, Günalp B, Souchkevitch G. Medical response to radiation incidents and radionuclear threats BMJ 2004;328:568-572. 2. Hodgetts TJ, Mackway-Jones K (Eds). Major Incident Medical Management and Support. 2nd edn. London, BMJ Publishing Group, 2002. 3. Cone DC, Weir SD, Bogucki SB. Convergent volunteerism. Ann Emerg Med 2003;41:457-62. Competing interests: None declared
Do we face a radionuclear threat? 9 March 2004
John R Buscombe, Consultant In Nuclear Medicine Royal Free Hospital, Pond Street, London NW3 2QG, UK Send response to journal: Re: Do we face a radionuclear threat?	Sir I read with professional interest the excellent review by Turai et al (1). Clearly they have put much thought into how the medical community should deal with radiation exposure. I agree with the authors that injury could occur by accident in those countries where disintegrating political entities such as the USSR saw fit to leave the debris of their nuclear programmes lying around for an unsuspecting public to pick up (2). However I am less sure of the real, as against hysterical, threat, in Western Europe and the North America. Outside of closely guarded nuclear power stations, weapons establishments and waste stores the most available stores of radioactive materials is either in hospitals or industry. There are however significant obstacles in the way of a potential terrorist trying to actually kill people with a radiological bomb instead of just causing public panic. Radioactive sources come in two main forms solid sources used in industry and radiotherapy. These are well shielded and sealed. If one could break these seals the most likely person injured would be the terrorist themselves. Once the terrorists tried to use such a devise, the radiation would have to be dispersed, presumably by an explosive device. However this would not ensure ingestion, the best way to get a lot of radiation into someone and would be easily detected. Also once dispersed the activity per person would drop. These sources could be used to target an individual but again a cheap radiation detector as used in airports or banks would pick up such a source which may itself be quite bulky. This would leave us with unsealed sources mainly from hospitals. Here the problem is that most hospitals will simply not have enough on site even to kill one individual. The most likely radioisotope would be I- 131 and to give a 2Gy dose 32GBq of I-131 would need to be administered (3). It is very unlikely that such an activity, much greater than used to treat patients, would be left in a site where it can be easily obtained. Whilst we may all face dangers from terrorist action it is important to see risks in the scale of actual possible harm. Whilst grabbing headlines, radiological bombs are probably much less dangerous than explosive, chemical or microbiological attacks and it is to these threats that countermeasures should be concentrated. John Buscombe Nuclear Medicine, Royal Free Hospital, London NW3 2QG 1) Turai I, Verees K, Gunlap B, Souchkevitch Medical responses to radiation incidents and radionuclear threats Br Med J 2004; 328; 568-72 2) Search Begins for Missing Radiation Sources in Republic of Georgia http://www.iaea.or.at/NewsCenter/PressReleases/2002/prn0208.shtml 3) Administration of Radioactive Substances Advisory Committee: Notes for guidance on the clinical administration of radiopharmaceuticals and use of sealed and unsealed sources. London 1998 Competing interests: None declared
Radiation Incidents 11 March 2004
Michael J Tidd, Retired 319 County Road 33, Norwich, NY 13815 USA Send response to journal: Re: Radiation Incidents	Sir, The Clinical Review of Turai et al. while excellent, leaves some important stones unturned. The authors appear to write mainly from the perspective of exposure primarily from gamma ray sources. Although direct terrorist attacks on nuclear power plants may appear unlikely, at least one attempt was made by el Quaeda operatives on a University operated research reactor in Sydney, Australia, during the concurrency of the Olympic Games. They were well prepared with documents detailing security operations at the reactor site. A 'dirty bomb', as well as a reactor accident, could release radioactive material derived from reactor fuel rods. In this instance there would be exposure to alpha particles, beta particles and neutrons, from such materials as plutonium, americium and shorter lived beta- emitting isotopes. The latter may cause radiation damage to the skin. Decontamination of skin, is mandatory to prevent contamination of staff and facilities. The immediate administration of potassium iodide is indicated, particularly in children, unless Iodine 131 is known for sure not to be present. Inhalation of particulate plutonium and other alpha-emitters, and ingestion of Iodine 131, strontium 90 and caesium 137 carries long term potentially serious consequences, including lung cancer, leukaemias and thyroid cancer, indicating the need for long-term follow up. Michael J. Tidd B.Sc., M.B. Competing interests: None declared
1) Safety In Radiation Incidents 12 March 2004
Istvan Turai, WHO 20 Av Appia, CH-1211 Geneva 27, Switzerland, Katalin Veress, Semmelweis University, Budapest, Hungary Send response to journal: Re: 1) Safety In Radiation Incidents	Safety In Radiation Incidents Jonathan R Benger BMJ, 9 Mar 2004 http://bmj.com/cgi/eletters/328/7439/568#52727 We thank Dr Benger for his remarks as it gives us an opportunity to re-emphasize the key message of our article. We believe in the section of our paper titled "Early management of contaminated patients" we provide all the necessary information on how to prevent radioactive contamination of emergency medical personnel and others in case of known or suspected radioactive contamination of patients with no severe combined injuries and/or life-threatening conditions. Nevertheless, as we summarize in the "Strategy and safety aspects..." closing section, saving life of patient(s) with life-threatening conditions should always have a priority, as providing emergency medical care of a contaminated with radioactive materials patient cannot pose significant threat to medical personnel. Let us refer here to the most severe ever nuclear accident, "When workers at Chernobyl who were in the reactor area at the time of the nuclear accident were decontaminated, the medical personnel at the site received less then 10 mGy of radiation." [1] Let us also refer to the recently republished Handbook of AFRRI [2] stating "Surgical priorities for acute or life-threatening injury must preceed any treatment priority for associated radiation injury" and "Radiological decontamination should never interfere with medical care. Unlike chamical agents, radioactive particles will not cause acute injury and decontamination sufficient to remove chemical agents is more then sufficient to remove radiological contamination." Let us reiterate that a person exposed to radiation or contaminated with radioactive materials does not present a direct health risk to the doctor or other rescue personnel. Therefore, "Remembering the essentials of first response, that is, treat the patient, not the poison, by addressing the ABCs of airway, breathing, and circulation, is critical to appropriate treatment of radiation exposure." [3]. [1] Mettler F.A. Jr, Voelz G.L. Current concepts: Major radiation exposure - What to expect and how to respond. NEJM, 2002;346:1554-1561. [2] Armed Forces Radiobiology Research Institute (AFRRI) Military Medical Operations. Medical Management of Radiological Casualties. Handbook, 2nd edn. AFRRI, Bethesda, MD-20889-5603, April 2003 (page 35 & page 53) [3] Leikin J.B. et al. A primer for nuclear terrorism. Dis.mon. 2003;49:485-516. Competing interests: None declared
Do we face a radionuclear threat? 12 March 2004
Istvan Turai, WHO 20 Av Appia, CH-1211 Geneva 27, Switzerland, Katalin Veress, Semmelweis University, Budapest, Hungary Send response to journal: Re: Do we face a radionuclear threat?	Do we face a radionuclear threat? John R Buscombe BMJ, 9 Mar 2004 http://bmj.com/cgi/eletters/328/7439/568#52768 Let us thank Dr Buscombe for his opinion and useful amendments to our paper. We agree with him that radionuclear threats are of low probability, however, cannot be singled out. As for the individual risk, radioactive materials pose presumably the highest threat to the terrorists themselves making the "dirty bombs". Accepting that terrorist contamination of central water supply may lead to significant threat in the affected population group via ingestion, however, we wish to underline that inhalation of radioactive aerosols produced by a "radiological dispersion device" seems to be the most probable contamination pathway for a terrorist threat. [1] We may agree that hospital sources and radioactive materials used in nuclear medicine are of less significance for terrorist use. [2] The radiotherapy sources when stolen and dismantled, however, may cause severe overexposure to those individuals having direct contact with them (as presented e.g. in the section on "Typical exposure scenarios..." in our paper). [1] Mettler F.A. Jr, Voelz G.L. Current concepts: Major radiation exposure - What to expect and how to respond. NEJM, 2002;346:1554-1561. [2] Hogan D.E., Kellison T. Nuclear terrorism. Am J Med Sci 2002;323:341-9 Competing interests: None declared
Medical Response to Radionuclear Threats 12 March 2004
Douglas J Holdstock, Nuclear Hazards Group, Medact Medact, The Grayston Centre, 28 Charles Square, London N1 6HT, Elizabeth Waterston Send response to journal: Re: Medical Response to Radionuclear Threats	From: Douglas Holdstock and Elizabeth Waterston, Nuclear Hazards Group, Medact, The Grayston Centre 28 Charles Square London N1 6HT Email: info@medact.org CLINICAL REVIEW István Turai, Katalin Veress, Bengül Günalp. Gennadi Souchkevitch Editor: We welcome István Turai and colleagues’ valuable overview of the medical response to radiation incidents (1), and are reassured that the United Kingdom has a well-developed system of public protection(2). We agree that both health professionals and the public should be better informed on both the threats and the response. While we also agree with Turai et al (Box 1) that the use of nuclear weapons, at any rate in the UK, is currently unlikely, we are concerned that recent developments could lower the nuclear threshold worldwide. Despite the end of the Cold War, there are some 20,000 active nuclear weapons today, many on high alert. The yield of each of these is several times that of the Hiroshima bomb, of which the British Medical Association wrote that its use on a major city would overwhelm medical services in the UK (3). The current United States administration is considering the introduction of “bunker-busters” or “mini-nukes”, correctly known as “Low- Yield Earth-Penetrating Weapons”. The advocates of these claim that their use would cause less “collateral damage” from blast or heat than existing nuclear weapons; nevertheless, “venting” would produce major fallout over several square kilometres downwind, causing many hundreds of the cases Turai et al describe if an urban area was affected (4). We would like to suggest an initiative that both health workers and the public can support towards reducing this particular radiation hazard. In just over a year’s time the five-yearly Review Conference of the Nuclear Non-Proliferation Treaty will take place at the United Nations in New York. Under Article VI of this treaty, as interpreted by the International Court of Justice, the nuclear-weapon-states are under an obligation to achieve nuclear disarmament by negotiation at an early date. The UK government should be urged to undertake not to replace Trident (a decision on this will be needed in the next Parliament). The UK has already renounced chemical and biological weapons; a similar step in the nuclear field could lead to a major reduction in the threat of nuclear war (5). DOUGLAS HOLDSTOCK and ELIZABETH WATERSTON 1. Turai I, Veress K, Günalp B, Souchkevitch G. Medical response to radiation incidents and radionuclear threats. BMJ 2004; 328: 568-572 (6 March 2004). 2. Kalman CJ. How would the United Kingdom cope? BMJ 2004; 328: 571 (6 March 2004). 3. BMA Board of Science and Education. The Medical Effects of Nuclear War. Chichester: John Wiley, 1983: 124. 4. Sidel VW, Geiger HJ, Abrams HL, Nelson RW, Loretz J. The threat of low- yield earth-penetrating nuclear weapons to civilian populations: nuclear “bunker busters” and their medical consequences. Cambridge, MA: IPPNW, 2003. 5. Pease RS. An end to British nuclear weapons? In: Holdstock D, Barnaby F, eds. The British Nuclear Weapons Programme 1952-2002. London: Frank Cass, 2003: 131-6. Competing interests: None declared
Radiation Incidents 12 March 2004
Istvan Turai, WHO 20 Av Appia, CH-1211 Geneva 27, Switzerland Send response to journal: Re: Radiation Incidents	Radiation Incidents Michael J Tidd BMJ, 11 Mar 2004 http://bmj.com/cgi/eletters/328/7439/568#52923 Let me thank Dr M.J. Tidd for his useful technical amendments to our paper [1]. I believe, safety precautions and awareness of a possible terrorist attack to a nuclear power plant (NPP) do enhance the security and safety of these potentially dangerous but very useful, necessary and reliable - in case of complience with safety regulations - installations. I wish to mention, it is difficult to imagine that a `dirty bomb` could cause release of radioactive materials from reactor fuel rods of an NPP. Let me agree that decontamination of the skin is important and may be mandatory. However, would there be a severe combined injury (eg. arterial bleeding of a victim) the responsibility of the emergency medical team must be the life saving first (as there is certainly no need to decontaminate a dead, exsanguinated patient!) and only then to think about decontamination of the radiation emergency victims or of the medical personnel. Here I wish to underline that no case of significant radioactive contamination of the medical personnel is known due to emergency care of exposed to radiation and/or contaminated patients! It is the primary objective of our paper: to assist physicians in the recognition of radiation injuries and their proper decision making when urgent treatment may be required for life saving due to non-radiogenic damage in the most probable combined injuries. Dr Tidd is correctly emphasizing the importance of the immediate administration of the stable iodine what is necessary in all nuclear accidents as the radioactive iodines are produced at high yield in the fission process and can easily escape to the environment due to their volatility [2]. Sheltering (or staying indoors for the period of presence of the radioactive plume formed by a nuclear accident at a site) and evacuation for the necessary time (as advised by the national radiation safety authority) are important countermeasures - besides the iodine prophylaxis - that can significantly reduce the early and late health consequences of a radiation accident [3]. [1] Turai I, Veress K, Günalp B, Souchkevitch G: Medical response to radiation incidents and radionuclear threats. BMJ 2004; 328: 568-572 [2] WHO: Guidelines for Iodine Prophylaxis following Nuclear Accidents. WHO/SDE/PHE/99.6, Geneva, 1999 (www.ki4u.com/WHO/guide_contents.htm) [3] Turai I, Crick M, Nogueira de Oliveira C, Ortiz Lopez P, Wrixon A. Response to radiological accidents: the role of the International Atomic Energy Agency. Radioprotection, 2001; 36: 459-471 Competing interests: None declared
Medical response to radiation incidents and radionuclear theats 25 March 2004
Nicholas J Lewis, Chief Medical Officer & Company Secretary, Trident Medical Services Atomic Weapons Establishment, Aldermaston, Berkshire RG7 4PR Send response to journal: Re: Medical response to radiation incidents and radionuclear theats	I would like to contribute one practical point: In any radiation incident doctors must work closely with physicists - health physicists in industry and medical physicists in hospitals. Physicists will identify and quantify the hazards, advise on protective equipment for medical staff and provide an estimate of radiation dose. It is impossible to manage a radiation incident without them. Any doctor who may have to deal with a radiation incident should get to know in advance the physicist who will be helping him/her and build up a relationship of trust. Competing interests: I run courses in medical aspects of radiation emergencies
Reply to Dr Nicholas J. Lewis 29 March 2004
Istvàn Turai, Medical Officer, WHO 20, Ave Appia, CH-1211 Geneva 27, Katalin Veress, Semmelweis University, Budapest, Hungary Send response to journal: Re: Reply to Dr Nicholas J. Lewis	Thank you Dr Lewis for your comment to our paper [1] emphasizing a very important practical point. We fully agree with your note about the role of health physicists at any workplace applying sources of ionizing radiation, and in particular at workplaces using high activity sources for industrial purposes and in medicine. That is why we have completed our paper with a paragraph advising general practitioners to "have the necessary telephone numbers readily available".…. and also that those numbers and their links to the "radiation protection service"… "should be updated regularly" [1]. As for the estimate of the radiation dose, in addition to your opinion, we`d like to lay stress also on the valuable contribution of biodosimetrists primarily using various cytogenetic technics for accidental dose assessment [2]. [1] Turai I., Veress K., Günalp B. and Souchkevitch G.: Medical response to radiation incidents and radionuclear threats. BMJ, 2004, 328: 568-572 [2] International Atomic Energy Agency: Cytogenetic Analysis for Radiation Dose Assessment. A Manual. Technical Report Series No. 405, IAEA, Vienna, 2001 Competing interests: None declared