Health Physics Considerations inMedical Radiation EmergenciesKen Miller and Mike Erdman*Abstract: Preplanning and organizationcan facilitate the health physics response inthe event of a medical radiation emergency.Anticipating the needs will allow for ad-vanced assembly of needed information andsupplies that would be useful in effectivelyresponding to such events. Annual training ofemergency care providers and an easy to readand understand poster will be of great benefitin guiding personnel until health physics ar-rives. Major events also need consideration, inadvance, as they will place additional de-mands on health physics. Health Phys.87(Supplement 1):S19–S24; 2004

Key words: operational topic; emergencyplanning; radiation, medical; emergencies,radiological

INTRODUCTIONWhen medical radiation emer-

gencies occur, they are always ac-companied by a great deal of con-fusion (Weidner et al. 1980;DeMuth and Miller 1982). Thehealth physicist involved typi-cally ends up in a tug-of-war intrying to attend to the many re-sponsibilities and provide an-swers to those who are in a need-to-know. The confusion thatsurrounds such events can belessened with preplanning andan organized approach (Millerand Weidner 1982; Mettler 2001;NCRP 1979). A checklist of thingsto consider in preparing for re-ceipt of a contaminated accident

victim(s) can help to make thingsgo smoother. Quite often, thephysician involved in medical ra-diation emergency responsemight not be especially well-versed in health physics or theunique aspects of radiationand/or radioactive materials. Thelevel of expertise of the physicianwill direct the involvement andactivities of the health physicist.

Initial responsibilities

● Helping the physician tounderstand what is goingon. Handling medical radiationemergency cases is not an every-day occurrence. Although manyphysicians have received train-ing in how to handle such cases,when the real thing occurs, theyoften need answers to questionsso they can respond appropri-ately to not only the patient butto the concerns of the medicalstaff assisting with the patient. Itis imperative that the healthphysicist obtain as much infor-mation as possible about thestatus of the patient and the pos-sibility and extent of contamina-tion before the patient arrives(NCRP 1979, 1991). Thus, themedical radiation emergencyplan should provide for the col-lection of as much pertinent in-formation as possible when theinitial call is received, alerting

healthcare professionals of thepending arrival of a possiblycontaminated patient(s). It is ex-tremely important that the per-son receiving the initial call ob-tain, among other things, acontact name and call-backphone number.

● Providing reassurance.There is a normal tendency formedical personnel who will beinvolved in the handling ofmedical radiation emergencycases to be apprehensive aboutthe risk posed by the patient, themethods they will use to assuretheir own safety, and the correctprocedures to use in dealing ef-fectively with the patient. Thehealth physicist will have theresponsibility of responding totheir concerns, answering theirquestions, providing them guid-ance, and providing them withreassurance.

● Preventing panic. Dealingwith medical radiation emer-gency cases from the outside isoften analogous to diving intounknown waters. While medi-cal staff have few concernsabout dealing with a contami-nated individual from withinthe hospital, there is a mys-tique and uncertainty about apossible contaminated patientcoming in from the outside.The health physicist can allayfears by interpreting the pa-tient’s contamination condi-tion for the medical staff andputting this into perspective forthem. Comparison to nuclearmedicine diagnostic or thera-peutic patients (Miller et al.

*Penn State Hershey Medical Center, Hershey, PA17033.

Kenneth L. Miller, CHP, is editor of Operational Radiation Safety and past editor ofHealth Physics Journal. He is a professor of radiology at Penn State’s College ofMedicine and the Director of the Health Physics program at The Milton S. HersheyMedical Center. He has held many positions over the years in the Health PhysicsSociety. Earlier in his career Ken received the prestigious Elda E. Anderson Award,which is awarded each year to the one young member who has demonstrated excellencein research or made a significant contribution to the field. He has authored numerouspeer-reviewed articles in his career. His email address is kmiller@psu.edu.

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1979; NCRP 1996; Achey et al.2001) is an effective way ofquickly explaining the situa-tion and putting minds at ease.

● Activating the medical ra-diation emergency plan.Prior to arrival of the patient(s),the medical radiation emer-gency plan (Mettler 2001; Millerand DeMuth 1983) must be acti-vated and the medical radiationemergency room(s) must be pre-pared for receipt of the patient. Aclear and simplified poster (seeAppendix A) of the medical radi-ation emergency plan that canbe posted in the radiation emer-gency area and used to brief staffis useful.

Initial steps by the health physicist

● Activation of the medicalradiation emergency plan.Every hospital should have awell defined Medical RadiationEmergency Plan (see AppendixA) that will guide the emer-gency participants in prepara-tion of the medical radiationemergency room(s), assemblyof supplies and instrumenta-tion that might be needed inhandling the patient, proce-dures for gowning, monitoringand protecting staff, and proce-dures for dealing with contam-ination, including its evalua-tion and effective removal.

● Provide back-up healthphysics support. The medicalradiation emergency planshould identify the members ofthe radiation safety staff whowill respond immediately andassist in activating the plan. Ifthe hospital does not have ahealth physics staff, then the planshould include names and phonenumbers of consultants who canbe called in to assist the RadiationSafety Officer, if needed.

● Assure that all necessarysupplies are available. Priorto patient(s) arrival, the healthphysicist should review themedical radiation emergency

room(s) to assure that it hasbeen prepared according to themedical radiation emergencyplan, review the individualswho will participate in caringfor the patient to assure thatthey are properly gowned andwearing appropriate personnelmonitoring, and review theavailable supplies to assure thateverything that will be neededfor monitoring the patient,sample taking, and decontami-nation are available. A checklistfor each of these will aid inperforming quick inspections.

● Brief staff on their respec-tive duties. Often, the medicalradiation emergency physicianwill defer to the health physicistto brief staff on the proceduresthey will take to monitor, evalu-ate, sample, and decontaminatethe patient. The health physicistwill also need to brief staff on theproper procedures to safely han-dle contamination and assurethat the medical radiation emer-gency room does not becomeunduly contaminated or thatcontamination spreads beyondthe medical radiation emer-gency room. All health careworkers understand the conceptof using “universal precautions,”i.e., the use of protective barrierssuch as gloves, gowns, aprons,masks, or protective eyewear toreduce the risk of exposure of thehealth care worker’s skin or mu-cous membranes to potentiallycontaminating materials.

● Answer questions and putthings into perspective.Hospital staff who will partici-pate in the handling of themedical radiation emergencycase(s) are usually apprehensiveand have questions regardingthe type of contamination,level of contamination and itsimplication for potential con-tamination and/or exposure,and the proper procedures foreffectively dealing with the sit-uation. Briefings by the healthphysicist can alleviate appre-

hension and provide guidanceon effectively dealing with allaspects of the emergency situa-tion. Putting things into per-spective can best be accom-plished by comparison tothings normally encounteredin the hospital such as the radi-ation reading from a nuclearmedicine bone scan patient orthe radiation safety precautionsused with patients treated withradioiodine for thyroid cancer.

Inform/instruct other departments

The handling of medical radia-tion emergency cases might im-pact departments outside of theemergency department. Theseother potential groups (NCRP1991) need to be apprised andadvised by the health physicist asto the situation and what mightbe expected of them.

● Administration. Administra-tion needs to know what is goingon so that they can assure thateverything needed to effectivelydeal with the situation is available.They also need to be able to re-spond effectively to inquiries fromthe media or the public.

● Security. Security is typicallyasked to help control access to themedical radiation emergency areaand any other designated controlarea. An example might be thatsecurity would be asked to makecertain that the ambulance thatdelivered the patient(s) not leavethe hospital area until surveyedand decontaminated, if necessary.Security might also be asked tokeep anyone from entering a con-taminated ambulance until it hasbeen decontaminated.

● Radiology. The radiation ac-cident victim(s) might havetrauma that requires x-ray pro-cedures for appropriate evalua-tion of the patient’s medicalcondition. If so, Radiology per-sonnel will need instructionson how to achieve the re-quested procedure withoutcontaminating equipment orstaff.

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● Anesthesiology. If the radia-tion accident requires surgery,anesthesiology will need to beinvolved. If so, the anesthetistwill need assurance and guid-ance from the health physiciston how to perform their func-tion without receiving undueexposure or contamination.

● Surgery. Surgery on a radia-tion accident victim is no dif-ferent than surgery on a nu-clear medicine diagnostic ortherapeutic patient or, in somecases, a radiation oncologybrachytherapy patient. The sur-geons involved will need to bemonitored and will need toperform the surgical procedurewithout receiving excessive ex-posure or causing unnecessarycontamination.

● Public relations. Public rela-tions will need to be briefed sothat they can effectively fieldquestions from the news me-dia, know who the key playersare, and arrange for news brief-ings and prepare bulletins, ifnecessary.

● Telephone operators. Thehospital telephone operatorswill need to know what is going

on and who can take calls fromthe outside. A designated, in-formed individual to whom theoperators can refer is essential.

Handling the radiation accidentvictim(s)

Once the patient(s) arrives, thehealth physicist will have addi-tional responsibilities in regard tothe medical radiation emergencyplan:

Provide health physics guidance.The health physicist will need tobe prepared to do whatever isnecessary to assure that the med-ical radiation emergency plan iscarried out effectively (Fig. 1),that the patient is appropriatelyevaluated (Toohey 2002) and de-contaminated (Mettler 2001;Berger et al. 2003; NCRP 1979;NCRP 2001; AFFRI 1999), thatstaff are not overly exposed orcontaminated and that the facil-ity and hospital equipment arenot excessively contaminated.

Assure monitoring, sampling,evaluation, decontamination andwaste disposal

● Monitoring and surveying.This will include monitoring or

surveying of the patient for con-tamination (Fig. 2), monitoringof staff exposures and surveyingto verify they do not becomecontaminated or are appropri-ately decontaminated as neces-sary, surveying of any samples oritems (such as clothing) takenfrom the patient, and surveyingof anything brought from themedical radiation emergencyroom(s). A survey of the emer-gency department entryway toreturn the corridor to immediateroutine traffic use after contami-nated patient passage may benecessary.

● Sampling. This involves any-thing taken from the patientthat might be useful in deter-mining the contaminating ra-dionuclides, level of contami-nation, resulting doses andeffective medical care. Samplesmight include blood, urine, fe-ces, nasal secretions, nasalswabs, swipes, shrapnel, ex-cised tissue, irrigation fluids orthe patient’s clothing.

● Vacating medical radia-tion emergency room. Oncethe event is over, the patientand hospital staff will need tobe removed from the medicalradiation emergency area so sur-veying, decontamination and re-

Figure 1. Transfer of patient to a decontamination tray on a clean litter.Figure 2. Survey of patient in medicalradiation emergency room.

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turn of the area to routine usecan be accomplished. If theroom became contaminated,care will be required in removingthe patient (Fig. 3) withoutspreading contamination out-side the room. This is often ac-complished by unrolling a cleanfloor covering into the room tothe patient’s litter and transfer-ring the patient to a clean litter.Likewise, staff will need to exitthe room in a systematic man-ner to prevent spread of contam-ination. Step-off pads at thedoorway and a container for col-lection of clothing, gloves andshoe covers plus appropriate sur-veying are necessary.

● Return of radiation emer-gency room to routine use.Once the patient and hospitalstaff have been removed from theroom(s), surveying, decontamina-tion, waste disposal and return tonormal can commence.

● Critique, upgrade, refineand retrain. Each medical ra-diation emergency provides anopportunity for training, up-grading and refining of themedical radiation emergencyplan. After things have calmeddown, within a day or two, ev-eryone involved should be as-

sembled for a review and cri-tique of the handling of theevent. If there are problems,they can be corrected, if addi-tional supplies or equipmentare needed, they can be listed,if modifications of the writtenprocedures are indicated, theycan be accomplished. The cri-tique will also provide thehealth physicist and emer-gency physician with an oppor-tunity for positive feedbackand reassurance for the staff.

Large scale events

For large scale events (NCRP2001; AFFRI 1999; Donovan et al.1983; Miller 1990; Miller 1994),such as from terrorist activities orthe unlikely event of an accident ata nuclear facility, the traditionalmedical radiation emergency plan,usually designed to handle a lim-ited number of contaminated indi-viduals, would be inadequate. Ifthere are massive numbers of con-taminated individuals, then thehospital plan would be inadequateand large numbers of contami-nated individuals arriving at aemergency department wouldthreaten to contaminate the de-partment and possibly lead to itsshutdown. For such situations, al-ternative plans for rapid decon-tamination at an area remote fromthe emergency department wouldneed to be implemented. Since9/11, a great deal of thought hasgone into how to accomplish de-contamination of large numbers ofcontaminated, uninjured patients.Pop-up decontamination tentssuch as the one shown in Fig. 4have become available.

In addition, many first re-sponders and fire departmentshave developed plans to use theshowering capabilities of firetrucks (Fig. 5) to effectively andquickly decontaminate largenumbers of individuals contami-nated with radioactive, biologi-cal, or chemical contaminants.

If the hospital is in a fallout zone

In the unlikely event that a hos-pital might be in a nuclear falloutzone, consideration will need to begiven for protecting patients, staff,and visitors. In such an event, thehealth physicist will play a key rolein providing guidance and control-ling the situation.

Initiate environmentalmonitoring. Assessing a falloutor radioactive plume involves ra-diation measuring and possiblythe evaluation of appropriatesamples, including air, water,vegetation and fallout from sur-faces.

Controlling air handlingsystems. Air intake systemsshould be turned off duringplume passage.

Prepare briefs for staff. In amajor radiological emergency, ev-eryone is worried and everyonehas questions. The health physicistneeds to be attuned to these con-cerns and questions and be pre-pared to give briefings, in lay terms.The health physicist must also beprepared to provide briefings foremergency physicians and other de-cision makers, and may be asked to:

● Explain doses and other radia-tion related terminology in layterms;

● Prepare for interaction with themedia, staff and the public;

● Prepare written briefs for themedia;

● Establish contacts with outsideexperts, e.g., REAC/TS (see Ap-pendix B);

Figure 3. Removal of patient from medi-cal radiation emergency room. Figure 4. Emergency decontamination tent.

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● Open lines of communicationswith assistance groups, e.g., Nu-clear Regulatory Commission,State Bureau of Radiation Protec-tion, Health Physics Society;

● Additional considerations(Miller 1986; Weidner et al.1980) might include: (1) Settingup an on-call team (this couldinclude health physics staff, nu-clear medicine physicians, radi-ologists, medical physicists, do-simetrists, etc.); (2) Prepare listsof typical questions and appro-priate answers; (3) Prepare infor-mation bulletins; (4) Establish“hot lines” manned by individ-uals briefed in advance.

•Advise administration. Inthe event of such an occurrence,the health physicist will be calledupon by administration to helpinterpret situations and designthe best plan that will provideprotection for patients, staff, vis-itors, and the facility.

•Move inward and down-ward. In a fallout situation, con-siderable protection is provided bybuilding materials. This protectioncan be maximized by moving ev-eryone inward and downward.

•Plan for evacuation. If anevacuation is ordered, the healthphysicist will need to advise onthe safest way to accomplish theevacuation and provide monitor-ing outside the evacuation zone.

•Improvise as the needarises. In a major situation thereare many unexpected things thatcan arise that will require thehealth physicist to respond appro-priately. Some examples might be:

● A need for additional surveymeters or radiation detectors.This can be satisfied by round-ing up all such meters at a fa-cility. In addition to surveymeters maintained in healthphysics, meters are required innuclear medicine, radiation on-cology and biomedical researchlabs. If the need arises, thesecan be brought to a designatedlocation for use as appropriate.

● Establish monitoring for thepublic. This could include thy-roid uptake counting using nu-clear medicine equipment,urine bioassay using healthphysics equipment or wholebody counting using appropri-ate and available equipment.

● Prepare for the aftermath. Forthe health physicist involved, amajor radiological incidentdoes not end when the situa-tion is brought under control.Often, recovery, monitoring,corrective actions, evaluations,and epidemiologic studies willgo on for years and even de-cades after the event.

CONCLUSIONThroughout the course of a

medical radiation emergency, thehealth physicist assumes a host ofresponsibilities and must work tomaintain a sense of order andcalm among the numerous andvaried staff attending to theemergency. In helping to preventthings from being overlooked,the health physicist must com-municate frequently with theemergency department physi-cian, the charge nurse, the inci-dent commander, and otherswho play active roles in respond-ing to such emergency situations.

Acknowledgment: Adapted from presentations given in the

American Academy of Health Physics Homeland Security

Training Program, San Antonio, Texas, January 25, 2003.

REFERENCESAchey BA, Miller KL, Erdman MC, King

SH. Some experiences with treatingthyroid cancer patients. OperationalRadiation Safety, Health Phys80(Suppl.2):S62–S66; 2001.

AFFRI. Medical management of radiologicalcasualties. McLean, VA: Armed Forces Ra-diobiology Research Institute, Interna-tional Medical Publishing, Inc.; 1999.

Berger ME, Jones OW, Ricks RC, Garrett S.Decontaminating the nasal passages.Operational Radiation Safety, HealthPhys 84(Suppl.2):S80–S82; 2003.

DeMuth WE, Miller KL. Disaster planningfor mass casualties. In: Early care of theinjured patient. Philadelphia: W. B.Saunders Company; 1982: 376–384.

Donovan JW, Trautlein JJ, Miller KL, MullerHA. Disaster management during a nuclearaccident. Disaster Med 1:405–407; 1983.

Mettler FA. Hospital preparation for radi-ation accidents. In: Gusev IA, GuskovaAK, Mettler FA, eds. Medical manage-ment of radiation accidents. Boca Ra-ton, FL: CRC Press; 2001: 425–435.

Miller KL, Bott SM, Velkley DE, Cunning-ham DE. A review of the contaminationand exposure hazards associated withtherapeutic uses of radioiodine. J NuclMed Technol 7:163–166; 1979.

Miller KL, Weidner WA. Medical Centerpreparations for Three Mile Island. In:Brodsky AM, ed. Handbook of radiationmeasurement and protection, VolumeII, Section A. Boca Raton, FL: CRC Press,Inc.; 1982: 699–708.

Miller KL, DeMuth WE. Handling radia-tion emergencies: No need to fear.J Emergency Nursing 9:141–144; 1983.

Miller KL. Techniques and methods ofdisseminating information to the pub-lic about radiation and nuclear power.

Figure 5. Fire truck spray units can be used to quickly and effectively decontaminate largenumbers of contaminated individuals. Photo courtesy of Glen D. Rudner, Virginia Departmentof Emergency Management.

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In: Miller KL, Weidner WA, eds. Hand-book of management of radiation pro-tection programs. Boca Raton, FL: CRCPress, Inc.; 1986: 35–37.

Miller KL. The regional approach to man-agement of radiation accident victims.In: Vince MA, ed. Coping with radiationaccidents. Envirotox Management, Inc.,Ravenna, OH 44266; 1990: 121–130.

Miller KL. The nuclear reactor accident atThree Mile Island. Radiographics14:215–224; 1994.

National Council on Radiation Protectionand Measurements. Management ofpersons accidentally contaminatedwith radionuclides. Bethesda, MD:NCRP; Report No. 65; 1979.

National Council on Radiation Protectionand Measurements. Developing radia-tion emergency plans for academic, med-ical or industrial facilities. Bethesda, MD:NCRP; Report No. 111; 1991.

National Council on Radiation Protectionand Measurements. Sources and magni-tude of occupational and public exposuresfrom nuclear medicine procedures. Be-thesda, MD: NCRP; Report No. 124; 1996.

National Council on Radiation Protectionand Measurements. Management ofterrorist events involving radioactivematerials. Bethesda, MD: NCRP; ReportNo. 138; 2001.

Toohey RE. Role of the health physicist indose assessment. In: Ricks RC, BergerME, O’Hara FM Jr., eds. The medicalbasis for radiation-accident prepared-ness. New York: The Parthenon Pub-lishing Group, Inc.; 2002: 33–43.

Weidner WA, Miller KL, Rohrer GV, Lat-shaw RF. The impact of a nuclear crisison a radiology department. Radiology135:717–723; 1980.

APPENDIX AMedical radiation emergency poster

APPENDIX BAdditional useful information

Outside assistance.

● Radiation Emergency Assis-tance Center/Training Site(REAC/TS), (865) 576 –1005,url: www.orau.gov/reacts/;

● Medical Radiobiology AdvisoryTeam (MRAT) Armed Forces Ra-diobiology Research Institute(AFRRI), (301) 295–0530, url:www.afrri.usuhs.mil;

● Health Physics Society, (703) 790–1745, url: http:www.hps.org.

Helpful books, articles, and websites.

● Medical Management of Radia-tion Accidents; Gusev, Guskova,Mettler, 2001;

● Medical Effects of Ionizing Radia-tion; Mettler and Upton, 1995;

● The Medical Basis for Radiation-Accident Preparedness; REAC/TSConference, 2002;

● AFFRI’s Medical Management of Ra-diological Casualties, Armed ForcesRadiobiology Research Institute,International Medical Publishing,Inc., McLean, VA, 1999;

● National Council on RadiationProtection Reports Nos. 65 and138;

● “Major Radiation Exposure—What to Expect and How toRespond,” Mettler and Voelz,New England J Medicine, 2002;346: 1554–1561;

● www.acr.org — Disaster Pre-paredness for Radiology Profes-sionals;

● www.afrri.usuhs.mil — MedicalManagement of RadiologicalCasualties.

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