key elements of preparing emergency -...

NCRP COMMENTARY No. 19

KEY ELEMENTS OF PREPARING EMERGENCY RESPONDERS FOR NUCLEAR AND RADIOLOGICAL TERRORISM

December 31, 2005

National Council on Radiation Protection and Measurements7910 Woodmont Avenue / Bethesda, Maryland 20814-3095

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LEGAL NOTICE This Commentary was prepared by the National Council on Radiation Protection and Measurements (NCRP).

The Council strives to provide accurate, complete and useful information in its documents. However, neitherNCRP, the members of NCRP, other persons contributing to or assisting in the preparation of this Commentary,nor any person acting on the behalf of any of these parties: (a) makes any warranty or representation, express orimplied, with respect to the accuracy, completeness or usefulness of the information contained in this Commen-tary, or that the use of any information, method or process disclosed in this Commentary may not infringe on pri-vately owned rights; or (b) assumes any liability with respect to the use of, or for damages resulting from the useof any information, method or process disclosed in this Commentary, under the Civil Rights Act of 1964, Section701 et seq. as amended 42 U.S.C. Section 2000e et seq. (Title VII) or any other statutory or common law theory gov-erning liability.

Library of Congress Cataloging-in-Publication Data

Key elements of preparing emergency responders for nuclear and radiological terrorism : December 31, 2005. p. ; cm. — (NCRP commentary ; no. 19)Includes bibliographical references.ISBN-13: 978-0-929600-88-8ISBN-10: 0-929600-88-61. Emergency management—United States—Handbooks, manuals, etc. 2. Nuclear terrorism—Safety

measures—Handbooks, manuals, etc. 3. Radiation—Safety measures—Handbooks, manuals, etc. I. National Council on Radiation Protection and Measurements. II. Series.

HV551.3.K475 2006363.325'57--dc22

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Copyright © National Council on RadiationProtection and Measurements 2005

All rights reserved. This publication is protected by copyright. No part of this publication may be reproducedin any form or by any means, including photocopying, or utilized by any information storage and retrieval systemwithout written permission from the copyright owner, except for brief quotation in critical articles or reviews.

[For detailed information on the availabilityof this and other NCRP commentaries see page 67.]


Preface

This Commentary has been prepared at the request of the US Department of HomelandSecurity (DHS). The recommendations in the Commentary are intended for officials of DHSand state and local authorities who prepare emergency responders for terrorist incidents thatinvolve radiation or radioactive materials. These incidents could result from use by terroristsof a radiation exposure device, a radiological dispersal device, or an improvised (or otherwiseobtained) nuclear device.

In 1980 the National Council on Radiation Protection and Measurements (NCRP) pub-lished Report No. 65 entitled “Management of Persons Accidentally Contaminated with Radi-onuclides,” and in 2001 published Report No. 138 entitled “Management of Terrorist EventsInvolving Radioactive Material.” These previous NCRP reports remain basic references onthe overall preparation for and management of a potential or actual terrorist nuclear or radio-logical incident.

This Commentary is limited to the key elements of preparing emergency responders fornuclear and radiological terrorism and focuses on:

• equipment requirements for emergency responders, including radiation detection andpersonal protection equipment for different types and levels of radiation;

• radiation decontamination advice and equipment, and medical supplies needed at thelocal level; and

• the content and frequency of training and exercises for emergency responders atthe federal, state and local levels (i.e., with regard to radiation protection aspects).

The recommendations in this Commentary are designed to provide DHS and state andlocal authorities advice that will assist emergency responders in the conduct of their criticalwork in a radiation environment resulting from such a terrorism incident. This adviceincludes:

• use of delineated radiation control zones;• use of a decision dose (cumulative absorbed dose to the responder) for life-saving and

other critical activities;• use of standard protective gear (i.e., bunker gear and supplied air) with regard to radi-

ation protection;• use of alarming personal radiation dosimeters;• the influence of time, distance and shielding on radiation levels, and the value of

appropriate radiation-detection instruments;• the health effects and risks associated with various radiation dose levels; and• the importance of individual radiation dose records and management of radiation

exposures for emergency responders involved in life-saving and other critical actions.

Serving on the NCRP Scientific Committee SC 2-1 that prepared this Commentary were:

John W. Poston, Sr., ChairmanTexas A&M UniversityCollege Station, Texas

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iv / PREFACE

Members

Steven M. BeckerThe University of Alabama at Birmingham

Birmingham, Alabama

Jonathan M. LinksJohns Hopkins University Bloomberg School of Public Health

Baltimore, Maryland

Brooke BuddemeierUS Department of Homeland Security

Washington, D.C.

Philip L. LiottaNaval Dosimetry CenterBethesda, Maryland

Jerrold T. BushbergUniversity of California, DavisSacramento, California

Fred A. Mettler, Jr.University of New MexicoAlbuquerque, New Mexico

John J. Cardarelli, IIUS Environmental ProtectionAgency

Cincinnati, Ohio

Terry C. PellmarArmed Forces Radiobiology Research Institute

Bethesda, Maryland

W. Craig ConklinUS Department of Homeland Security

Washington, D.C.

Leticia S. PibidaNational Institute of Standards and Technology

Gaithersburg, Maryland

Brian DoddBD ConsultingLas Vegas, Nevada

Michael J. PuzziferriFire Department City of New YorkBronx, New York

John R. FrazierAuxier & Associates, Inc.Knoxville, Tennessee

Carson A. RilandBechtel NevadaLas Vegas, Nevada

Fun H. Fong, Jr.Centers for Disease Control and Prevention

Atlanta, Georgia

Joseph P. RingHarvard UniversityBoston, Massachusetts

Ronald E. GoansMJW CorporationClinton, Tennessee

Thomas M. SeedCatholic University of AmericaWashington, D.C.

Ian S. HamiltonBaylor College of MedicineHouston, Texas

James M. SmithCenters for Disease Control and Prevention

Atlanta, Georgia

Richard T. KouzesPacific Northwest National LaboratoryRichland, Washington

Robert C. WhitcombCenters for Disease Control and Prevention

Atlanta, Georgia


PREFACE / v

NCRP Secretariat

Marvin Rosenstein, Staff ConsultantMorton W. Miller, Staff ConsultantCindy L. O’Brien, Managing Editor

David A. Schauer, Executive Director

The Council wishes to express its appreciation to the Committee members for the time andeffort devoted to the preparation of this Commentary, and to the US Department of HomelandSecurity for the financial support provided for its preparation.

Thomas S. TenfordePresident


Contents

Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

1. Main Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Emergency Responders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.3 Radiological and Nuclear Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.4 Radiation Protection Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.5 Equipment Requirements for Radiation Detection and Personal Protection,

and Pre-Existing Radiation Source Information. . . . . . . . . . . . . . . . . . . . . . . . . . . 41.5.1 On-Scene Activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.5.2 On- and Off-Scene Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.6 Decontamination Equipment and Medical Supplies. . . . . . . . . . . . . . . . . . . . . . . . 61.6.1 On-Scene Activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.6.2 On- and Off-Scene Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.6.3 Off-Scene Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.7 Training and Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2. Emergency Responders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

3. Radiological and Nuclear Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.1 Radiation Exposure Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.2 Radiological Dispersal Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.3 Improvised (or Otherwise Acquired) Nuclear Devices . . . . . . . . . . . . . . . . . . . . . 15

4. Radiation Protection Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174.1 Radiation Control Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184.2 Control of Radiation Dose in the Control Zones . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5. Equipment Requirements for Radiation Detection and Personal Protection, and Pre-Existing Radiation Source Information . . . . . . . . . . . . . . 225.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225.2 Categories of Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

5.2.1 Alarming Personal Radiation Dosimeters. . . . . . . . . . . . . . . . . . . . . . . . . 235.2.2 Passive Dosimeters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245.2.3 Survey Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245.2.4 Radionuclide Identifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

5.3 Equipment Commentary and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . 255.3.1 Post-Event Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255.3.2 Radiation-Monitoring Instruments for the First Emergency

Responders to a Scene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255.3.3 Screening for Contamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275.3.4 Availability of Pre-Existing Radiation Source Information . . . . . . . . . . . 295.3.5 Standard Personal Protection Equipment . . . . . . . . . . . . . . . . . . . . . . . . 305.3.6 Communication of Radiation Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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viii / CONTENTS

6. Decontamination Equipment and Medical Supplies . . . . . . . . . . . . . . . . . . . . . . 326.1 Understanding Contamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326.2 Hospital and Pre-Hospital Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

6.2.1 Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346.2.2 Care for Victims of Nuclear or Radiological Incidents . . . . . . . . . . . . . . . 346.2.3 Medical Staff Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

6.3 Routing Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356.4 Standard Medical Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366.5 Necessary Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366.6 Symptoms of Acute Radiation Injury and Estimating Absorbed Dose . . . . . . . . 376.7 Contamination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

6.7.1 Detection of Internal Contamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386.7.2 Use of Contaminated Critical Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . 386.7.3 Disposal of Decontamination Fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

7. Training and Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407.1 Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407.2 Applicability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407.3 Challenges to Proficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417.4 Training, Exercises and Lessons Learned. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417.5 Training Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417.6 Exercise Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437.7 Initial Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437.8 Training and Exercise Frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447.9 Training and Exercise Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457.10 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

7.10.1 National Policy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457.10.2 Development of Nuclear and Radiological Training Programs . . . . . . . . 46

7.10.2.1 Effective Integration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467.10.2.2 Accreditation and Continuing Education . . . . . . . . . . . . . . . . . 467.10.2.3 Modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477.10.2.4 “Hands-On” Demonstrations and Practical Exercises . . . . . . . 477.10.2.5 Instructional Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . 477.10.2.6 “Just-in-Time” Refresher Training Guides and Materials . . . . 477.10.2.7 Instructors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477.10.2.8 Reinforcement of Local Policy and Procedures . . . . . . . . . . . . . 487.10.2.9 Perpetuation Within the Recipients’ Organization . . . . . . . . . 49

Appendix A. Essential Training Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50A.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

A.1.1 Hazards Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50A.1.2 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50A.1.3 Key Facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51A.1.4 Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

A.2 First Responders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51A.2.1 Awareness Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51A.2.2 Operations Level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52A.2.3 Technician Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53A.2.4 Command Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53


CONTENTS / ix

A.3 First Receivers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54A.3.1 Awareness Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54A.3.2 Operations Level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54A.3.3 Technician Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

A.4 Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55A.4.1 Public Information Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55A.4.2 Public Health Department Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

The NCRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

NCRP Commentaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67


1. Main Points

1.1 Introduction

This Commentary provides specific recommendations regarding emergency response tonuclear and radiological incidents. The recommendations apply only to an emergency andonly until the designated authorities declare that the emergency is over. At that time, theestablished radiation protection procedures for both occupational and public exposure wouldnormally be reinstated, as well as any special arrangements for long-term control due to acontinuing elevated radiation environment.

This Commentary provides a technical basis for the support of preparedness activitiessuch as the development of emergency responder protocols, equipment procurement recom-mendations, and the frequency and content of training and exercises; activities that arecustomized by each organization that would need to apply them. Local implementation of thisCommentary should also:

• be consistent with the existing format and content of standard operating procedures;• identify local potential hazard sites and vulnerabilities;• be compatible with the equipment used by the end user;• take into account local customs and language; and• identify local nuclear and radiological incident response resources.

A key state and local resource for the implementation of this Commentary is the leadagency for the radiation control program in the area. The Conference of Radiation ControlProgram Directors, Inc. (CRCPD)1 can provide further information on local radiation con-trol programs.

Section 1 presents the main points that are further discussed in the Commentary in Sec-tions 2 through 7. Additional discussion on each point is given in the sections listed at the endof each bullet of Sections 1.2 through 1.7. Section 2 provides background on emergencyresponders. Section 3 discusses nuclear and radiological devices. Sections 4 through 7 providespecific recommendations in four categories grouped according to the National Council onRadiation Protection and Measurements’ (NCRP) statement of work. The four categories are:

• radiation protection guidelines for: (1) radiation control zones, and (2) total absorbeddoses to emergency responders undertaking life-saving and other critical actions (Sec-tion 4);

• equipment requirements (for radiation detection and personal protection) (Section 5);• radiation decontamination advice and equipment, and medical supplies (needed at the

local level) (Section 6); and• training and exercises (the content and frequency relating to the radiation aspects of

nuclear or radiological incidents) (Section 7).

1CRCPD is a 501(c)(3) nonprofit nongovernmental professional organization dedicated to radiation protection(CRCPD, 2005).

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2 / 1. MAIN POINTS

The two important goals of radiation protection for responders in such an emergency are:(1) to prevent acute (i.e., immediate) injuries and deaths due to short-term high-level radia-tion exposure (i.e., exposures occurring over a few hours to a few days) (Table 4.1), and (2) tolimit long-term stochastic effects (i.e., increases in cancer probability) associated with lowerlevels of radiation exposure, by keeping radiation exposure as low as reasonably achievable(i.e., the ALARA principle)2 (NCRP, 1993). In both cases, taking advantage of the basic tenetsof radiation protection (i.e., increasing the distance from the source, limiting time of exposure,and utilizing intervening shielding) is much more effective than subsequent medical treat-ment and countermeasures.

This Commentary takes the approach that nuclear and radiological terrorism representsan exceptional event. In such an emergency, it may be neither practical nor appropriate forradiation protection considerations to be governed automatically by the guidelines for occu-pational exposure used for routine operations. While the fundamental concept of the ALARAprinciple still applies, it may not be realistic to apply other traditional radiation protectionpractices for the limitation of radiation dose. The traditional practices are based on anassumption of low-level exposure over long periods, and govern situations that are more con-trollable than those associated with responding to a nuclear or radiological terrorism incident.

The numerical guidelines provided in this Commentary are intended to help planners andresponse organizations identify when further evaluation of the radiological situation is war-ranted. The numerical guidelines should be considered as decision points for evaluating therisks of emergency responder activities against the benefits that those activities produce,under potentially hazardous radiation conditions.

1.2 Emergency Responders

1.3 Radiological and Nuclear Devices

The typical malevolent use of radioactive material can be divided into three distinct types:a radiation exposure device (RED), a radiological dispersal device (RDD), and an improvised(or otherwise acquired) nuclear device (IND).

2The complete statement of the ALARA principle is: A principle of radiation protection philosophy thatrequires that exposures to ionizing radiation be kept as low as reasonably achievable, economic and social factorsbeing taken into account. The protection from radiation exposure is ALARA when the expenditure of furtherresources would be unwarranted in relation to the reduction in exposure that would be achieved.

In this Commentary, the term emergency responder refers to those individuals who in theearly stages of an incident are responsible for the protection and preservation of life,property, evidence and the environment (Section 2).


1.4 RADIATION PROTECTION GUIDELINES / 3

1.4 Radiation Protection Guidelines

The radiation protection guidelines in this Commentary refer to: (1) external exposurefrom photons; and (2) surface contamination from alpha, beta and gamma radiation. A dis-cussion of the selected guidelines is found in Section 4.3,4

An RED consists of radioactive material, either as a sealed source or as material withinsome type of container, that directly exposes people to radiation (Section 3.1).

An RDD uses conventional explosives or some other mechanism to spread radioactivecontamination (Section 3.2).

An IND incorporates nuclear materials designed to produce a nuclear explosion (Sec-tion 3.3).

3For photon energies <300 keV, the actual air-kerma rate is 0.0869 mGy h–1 (for 10 mR h–1) and 0.0869 Gy h–1

(for 10 R h–1). The numerical value (0.0869) is slightly different for higher energies (e.g., 0.0879 for 60Co gammarays).

4In practice, conversions for contamination levels for the instruments used by the emergency response organi-zations should be predefined so that field decisions can be based directly on the instrument reading, which is usu-ally in counts per minute (Section 5.3.3). The contamination levels assume an infinite plane of contamination.

Establish an outer perimeter if any of the following exposure rate or surface contamina-tion levels are exceeded:

• 10 mR h–1 exposure rate (~0.1 mGy h–1 air-kerma rate);3• 60,000 dpm cm–2 (1,000 Bq cm–2) for beta and gamma surface contamination;4 and• 6,000 dpm cm–2 (100 Bq cm–2) for alpha surface contamination.

Within the outer perimeter, the appropriate actions are to evacuate members of the public,isolate the area, and ensure that all emergency workers inside the area minimize theirtime spent in the area and follow appropriate personal protection guidelines (Section 4.1).

Establish an inner perimeter at 10 R h–1 exposure rate (~0.1 Gy h–1 air-kerma rate).3 Expo-sure and radioactivity levels within the inner perimeter have the potential to produceacute radiation injury and thus actions taken within this area should be restricted totime-sensitive, mission-critical activities such as life-saving (Section 4.1).


4 / 1. MAIN POINTS

5,6,7,8

1.5 Equipment Requirements for Radiation Detection and Personal Protection, and Pre-Existing Radiation Source Information

1.5.1 On-Scene Activities

The absorbed dose received by an individual emergency responder working in the radia-tion control zones must be controlled. The cumulative absorbed dose that triggers a deci-sion on whether to withdraw an emergency responder from within or near (but outside)the inner perimeter is 50 rad (0.5 Gy).5,6,7 In this Commentary, the 50 rad (0.5 Gy) cumu-lative absorbed dose is called the decision dose (Section 4.2). The cumulative absorbeddose received by an emergency responder while working within or near the inner perim-eter must be recorded8 (Sections 5.2.1. and 5.3.2).

5This recommendation (NCRP, 2001) applies only to the early phase of the emergency response when life-sav-ing or other critical actions may be underway within or near (but outside) the inner perimeter. If the cumulativeabsorbed dose from activities within the inner and outer perimeters reaches 50 rad (0.5 Gy), a similar decisionshould be made on whether to remove a responder from within the outer perimeter (or to a low radiation exposurelocation within the outer perimeter).

6This cumulative absorbed dose guideline also applies in those rare circumstances when medical staff mem-bers are attending a victim in a life-saving situation (e.g., the surgical removal of embedded radioactive shrapnelwith a very high level of radioactivity).

7The absorbed dose and the value obtained with the device used to monitor the absorbed dose should betreated as though it were a whole-body absorbed dose.

8The cumulative absorbed dose or exposure received by an emergency responder while working outside butnear the inner perimeter should be estimated, either from a personal radiation dosimeter worn by the responderor from information on exposure rates and stay times at the locations near the inner perimeter at which theresponder worked.

Equipment requirements for responding to a nuclear or radiological incident (referred toas post-event in this Commentary) are very different than the requirements for equip-ment used to detect illicit radiation sources (referred to as pre-event in this Commen-tary). The effective range of radiation doses that can be measured with pre-eventequipment is too limited to support most emergency operations (Section 5.3.1).

The first emergency vehicles [e.g., police, fire and emergency medical services (EMS)]responding to a suspicious incident should be equipped with radiation-monitoring instru-ments to alert personnel to the presence of radiation. Also, it is recommended that suchinstruments be set to alert the first emergency responders to a scene when the exposurerate reaches 10 mR h–1 (~0.1 mGy h–1 air-kerma rate), corresponding to the recommendedvalue for the outer perimeter (Section 5.3.2).


1.5 EQUIPMENT REQUIREMENTS FOR RADIATION DETECTION AND PERSONAL PROTECTION / 5

1.5.2 On- and Off-Scene Activities

The emergency responders that cross the outer perimeter at the scene of what is deter-mined to be a nuclear or radiological incident should be equipped with alarming personalradiation dosimeters that provide unambiguous alarms, based on predefined levels, tofacilitate decision making. It is recommended that the dosimeter provide alarms whenthe exposure rate reaches 10 R h–1 (~0.1 Gy h–1 air-kerma rate), corresponding to the rec-ommended value for the inner perimeter, and when the cumulative absorbed dose reachesthe decision dose of 50 rad (0.5 Gy). An alarming personal radiation dosimeter for eachindividual that can be used in such radiation environments is preferred over a singledetection instrument for an entire response team (Section 5.3.2).

The first emergency responders to a scene should have a simple instrument to identifythe presence of contamination at the scene and on individuals. The selectivity, sensitivityand accuracy of the instrument are not as important as the ability of the instrument toclearly detect the outer perimeter contamination levels of 60,000 dpm cm–2 (1,000 Bq cm–2)beta and gamma surface contamination, and 6,000 dpm cm–2 (100 Bq cm–2) alpha surfacecontamination (Section 5.3.3).

For response to incidents at established facilities, pre-existing site-specific radiationsource information should be available to emergency responders (Section 5.3.4).

At the scene of an incident, standard protective clothing (i.e., bunker gear) and respira-tory protection devices are sufficient to protect emergency responders against personalcontamination by radioactive materials when conducting life-saving and other criticalmissions (Section 5.3.5).

During the initial assessment of an incident, when its magnitude and nature are assessed(referred to as the size-up period), radiation levels should be communicated by the assess-ment team to the incident commander, who must evaluate the hazard to life for the vic-tims and the emergency responders (Section 5.3.6).

Additional equipment and supplies are required to screen large numbers of individualsfor contamination at the scene, and to screen for possible initial decontamination atemergency facilities (i.e., at designated reception centers and at hospital facilities) (Sec-tion 5.3.3).


6 / 1. MAIN POINTS

1.6 Decontamination Equipment and Medical Supplies99

1.6.1 On-Scene Activities

1.6.2 On- and Off-Scene Activities10

9These recommendations apply to any facility designated in pre-event planning to perform the functions ofdecontamination for radioactivity or medical evaluation of victims.

A strategy should be developed for each radiation control zone at the incident scene tominimize the time to treatment for victims. EMS personnel should attempt to removevictims from the incident scene as promptly as possible while providing for their ownsafety (Section 6.3).

Initial personal monitoring and decontamination efforts at the scene should primarilyfocus on preventing acute radiation effects to affected individuals. Cross contaminationissues are a secondary concern, especially when the contaminated incident site and num-ber of evacuees is large. Individuals with spot contamination greater than 2.2 × 106 dpm(37,000 Bq) should be a priority for decontamination (Section 5.3.3).

Nausea and vomiting are the earliest clinical signs of acute radiation syndrome (ARS).Nausea and vomiting are symptoms that occur as whole-body absorbed doses becomehigh [i.e., >100 rad (>1 Gy)]. If these symptoms occur during the conduct of activitieswithin the inner perimeter, the affected individual(s) should be removed from the innerperimeter (Section 4.2, Table 4.1, and Section 6.6). However, it must be recognized thatsuch symptoms may be caused by other agents (e.g., a neurological agent). Thus, emer-gency responders must be aware there is a potential that they could be dealing with morethan one agent in such an incident.

Unlike many chemical and biological agents, radioactive material contamination rarelyrepresents an immediate danger to the health of the victim or the responder.10 Thisreduces the immediacy of the need for decontamination and allows the emergencyresponse community greater flexibility in selecting decontamination options (Sec-tion 6.1).

10Two notable exceptions are: (1) victims at the site of, or immediately downwind of a nuclear detonation(which may be for miles), as these are areas that may have radioactive material contamination levels highenough to be of immediate danger to the life and health of emergency responders, and (2) the very rare case ofradioactive source-material shrapnel embedded in a patient. In such rare cases, the radiation dose control toolsand guidelines in this Commentary are still applicable.

9


1.6 DECONTAMINATION EQUIPMENT AND MEDICAL SUPPLIES9 / 7

1.6.3 Off-Scene Activities

Federal, state and local emergency responders should develop plans, training and exer-cises to test and coordinate their capability to receive, stage and dispense StrategicNational Stockpile (SNS) assets (Section 6.5).

It is not a priority to contain all the fluids generated during decontamination. The inci-dent commander should decide to what degree fluids resulting from decontaminationshould be contained or released based on the severity of the incident, the immediacyof the decontamination need, and the resources available in the emergency phase (Sec-tion 6.7.3).

EMS and hospitals should have detailed plans for patient care during a nuclear or radio-logical incident, prepared in advance. This planning should include determination ofpatient routing (i.e., ultimate destination of casualties), facility requirements for thetreatment of emergent and trauma patients and assistance for psychological casualtiesand individuals who come to healthcare facilities with concerns about radiation contam-ination (Section 6.2.1).

Each hospital should have a planned course of action for the care of victims exposed toradiation or contaminated with radioactive material. Ideally, the plan should be includedwithin the general hospital emergency plan (Section 6.2.2).

Unless the hospital itself is the target, the danger of radiation exposure to emergencyhospital personnel is minimal because they are outside of the radiation control zones.Their focus should remain on standard medical care (Section 6.4).

Universal precautions (i.e., standard hospital personal protection procedures) in theemergency room are generally sufficient for treatment of victims of nuclear and radiolog-ical incidents (Section 6.2.3).

In the hospital setting, multi-parameter triage [i.e., time to vomiting, lymphocyte kinet-ics, and other biodosimetry indicators (see Glossary)] offers the best early assessment ofthe victim’s absorbed dose (Section 6.6).


8 / 1. MAIN POINTS

1.7 Training and Exercises

Nasal swabs can be used to indicate the likelihood that radioactive material has beeninhaled, if internal contamination is suspected. (Section 6.7.1)

Plans should be in place for critical medical facilities and critical care equipment to con-tinue functioning with low levels of radioactive contamination (Section 6.7.2).

The overall nuclear and radiological training objectives for emergency responders are:(1) to enhance their ability to take appropriate measures to protect themselves and thepublic, and (2) to increase their confidence about effectively managing an emergencyinvolving radiation or radioactive materials (Section 7.5).

All emergency responders should undergo initial training at a level corresponding to theduties and functions that the responder would be expected to perform during a nuclearor radiological incident. Emergency responders who may take part in life-saving activi-ties should be trained at the operations level (Section 7.7, Table 7.1, and Appendix A.2.2).

Key messages of nuclear and radiological preparedness training should include:

• rescue and medical emergencies take precedence over radiological concerns (seealso Footnote 10 on page 6);

• nuclear and radiological incidents can be safely managed using the emergencyresponders’ equipment and protocols;

• being contaminated is rarely life-threatening; and • being exposed to radiation does not make an individual radioactive (Section 7.5).

Emergency responders should undergo annual refresher training to maintain proficiency.The refresher training does not need to be as extensive as the initial training (Sec-tion 7.8).

Training programs should be developed and organized to effectively integrate into theoverall training requirements of the organization, and should be reinforced throughprofessional accreditation or continuing education credits, whenever possible (Sec-tion 7.10.2.1).


1.7 TRAINING AND EXERCISES / 9

Drills or exercises should be conducted at least annually. However, full-field exercises areonly necessary every 3 y. During the exercise cycle, mechanisms for accessing and distrib-uting SNS assets should be exercised periodically (Section 7.8).

Exercise schedules should regularly involve all types of emergency responders to main-tain the proficiency of all components of the emergency-response infrastructure, includ-ing first responders, first receivers, hospitals, communications, mental health, and publichealth (Sections 2, 7.2, and 7.8).


2. Emergency Responders

The term emergency responder includes federal, state and local emergency, public safety,law enforcement, emergency response, emergency medical (including hospital emergencyfacilities), and related personnel, agencies and authorities. This includes emergency manage-ment, public health, clinical care, public works, and other skilled support personnel (such asequipment operators) who provide immediate support services during response and recoveryoperations.11 Some key disciplines and a description of their personnel are:12

• Law enforcement: Individuals who, on a full-time, part-time, or voluntary basis, workfor agencies at the local, municipal and state levels with responsibility as sworn lawenforcement officers.

• Emergency medical services (EMS): Individuals who, on a full-time, part-time, or vol-untary basis, serve as emergency medical technicians (basic, intermediate and para-medic) on ground-based and aero medical services to provide pre-hospital care.

• Fire services: Individuals who, on a full-time, part-time, or voluntary basis provide lifesafety services including fire suppression, rescue, arson investigation, public educa-tion, and prevention.

• Hazardous materials: Individuals who, on a full-time, part-time, or voluntary basis,identify, characterize, assess the risk of, and mitigate or control the release of a hazard-ous substance or potentially hazardous substance. For nuclear and radiological inci-dents, this could include radiation safety specialists.

• Public works: Organizations and individuals that make up the public and privateinfrastructure for the construction and management of essential services at the local,municipal, state and federal levels.

• Governmental administrative: Elected and appointed officials responsible for publicadministration of community health and welfare during a terrorism incident.

• Public safety communications: Individuals who, on a full-time, part-time or voluntarybasis, serve (through technology) as a conduit, and link individuals reporting anincident to response personnel and emergency managers. The purpose of the communi-cations is to identify an incident occurrence and help to support the resolution oflife safety, criminal, environmental, and facility problems associated with a terrorismincident.

In this Commentary, the term emergency responder refers to those individuals who in theearly stages of an incident are responsible for the protection and preservation of life,property, evidence and the environment.

11Definition developed as a combination of the Homeland Security Act of 2002 (HSA, 2002) and the HomelandSecurity Presidential Directive #8, National Preparedness (White House, 2003).

12Defined by the Office for Domestic Preparedness State Homeland Security Assessment and Strategy Pro-gram (DHS, 2003).


2. EMERGENCY RESPONDERS / 11

• Health Care: Clinical, forensic and administrative personnel in hospitals, physicians’offices, clinics, and other facilities responsible for providing medical care. The medicalcare includes surveillance (passive and active), diagnosis, laboratory evaluation, treat-ment, and mental health support.13

• Public Health: Personnel whose responsibility includes: preventing epidemics and thespread of disease, protecting against environmental hazards, preventing injuries, pro-moting and encouraging health behaviors, responding to disasters and assistingcommunities in recovery, assuring the quality and accessibility of health services, epi-demiology investigations, evidence collection, and fatality management for humansand animals.

13Healthcare workers are at minimal risk for occupational exposures to radioactive materials when a hospitalreceives contaminated patients, particularly during mass-casualty incidents. These hospital employees generallywork at a site remote from the location where the release occurred. This means that their exposures are limitedto the substances transported to the hospital on a victim’s skin, hair, clothing or personal effects. The location andlimited source of contaminant distinguishes them from other emergency responders who typically respond to theincident (Horton et al., 2003; OSHA, 2005a).


3. Radiological and Nuclear Devices

The malevolent use of radioactive material can be divided into three distinct types: a radi-ation exposure device (RED), a radiological dispersal device (RDD), and an improvisednuclear device (IND). Most radioactive material can be used in one or more of these threetypes of devices. A useful background reference on this subject is NCRP Report No. 138(NCRP, 2001) and IAEA (2004) provides information on radionuclides that could be used inREDs and RDDs.

3.1 Radiation Exposure Devices

The radioactive material in an RED could be in any form, including sealed sources used formedical and industrial applications, and little preparation is required other than removal ofthe shielding. General characteristics of an RED incident include:

• external exposure only;• often delayed recognition of incident;• unlikely to cause combined injuries (see Glossary);• no radioactive material contamination;• small impacted population;• potential for more severe impact on individuals exposed;• easier to locate;• easier to mitigate; and• small impacted area.

An RED may be used by terrorists to cause harm by exposing people to ionizing radiation,most likely gamma radiation, emitted by the radioactive material. For that to occur to a sig-nificant degree, the exposed individuals would have to be fairly close to the source of radiation.The lower the level of radioactivity in the source, the closer individuals would have to be forany significant effects to occur. For example, if the radioactive material typically found in anindustrial radiography device [100 Ci (3.7 × 1012 Bq) (2.2 × 1014 dpm) of 192Ir] were left withoutshielding, an individual 1 m from the source would have to remain at that distance for about5 h to get a dose that would probably prove lethal. Death in this case would occur withinabout two weeks (assuming no clinical support was given). If the distance were doubled, thetime necessary to receive the same dose of radiation will increase four times, to 20 h, and so on.

In general, short-term health effects (i.e., acute death or injury) are not likely unless thereare individuals that received high doses [>100 rad (>1 Gy)] due to their close proximity andextended periods near the source. Often, the short-term health effects can be mitigated withappropriate medical attention.

An RED consists of radioactive material, either as a sealed source or as material withinsome type of container, that directly exposes people to radiation.


3.2 RADIOLOGICAL DISPERSAL DEVICES / 13

Potential long-term health impacts of an RED include an increased risk of developing can-cer for those individuals who were exposed to significant doses of radiation (see Section 4.2 andTable 4.1 for the relationship between the radiation dose and the increased risk for cancer).

In addition, the psychological effects of an RED could be substantial. Fears related tohealth, concerns about possible future attacks, and stigmatization of people and productsfrom the affected area could persist well after the incident is over and the location is declaredsafe again. Depending upon the nature of the incident, restoring people’s sense of safety couldbe a significant challenge (Becker, 2001; 2004; 2005).

Other than an announcement by the terrorist organization that deployed an RED, thereare two basic mechanisms for discovery of such a device.

• medical discovery through identification of ARS or acute radiation skin burns, espe-cially when there are multiple presentations with an epidemiological evaluation thatidentifies a common nexus; and

• direct detection of an RED. [Because of their high dose rates, REDs are detectable fromgreat distances (hundreds of meters) using many of the radiation measurement toolscommonly employed by emergency responders.]

Evaluation and control of the scene are the most important actions that can be taken bythe first emergency responders at the scene until other emergency responders and radiationsafety specialists can safely secure the source. For emergency responders who have detectioncapability, a relatively safe14 outer perimeter can be established at 10 mR h–1 (~0.1 mGy h–1

air-kerma rate) (NCRP, 2001) (see also Section 4.1).Decontamination would not usually be required for REDs, since they are self-contained

external exposure sources and not likely to be breached in a manner that would cause dis-persal of the radioactive material. If an RED were purposely breached, it would by definitionbe an RDD.

It is likely that there will be considerable confusion in the public between the terms “radi-ation exposure” and “radioactive contamination.” Clear, frequent messages explaining thedifference and assuring the public that there is no potential for contamination from an REDis important.

3.2 Radiological Dispersal Devices

The radioactive material in an RDD could be in the form of a fine powder, a liquid mist, ora gas. The material could be spread by hand, such as by simply emptying a container over thedesired area, by entering it into a ventilation system, or by incorporating the radioactivematerial into a conventional explosive device. Usually an explosive device will have the poten-tial to spread the material initially over a larger area than manual dispersal. However,

14The value of 10 mR h–1 (~0.1 mGy h–1 air-kerma rate) for the outer perimeter is expected to be safe initiallyfor both emergency responders and members of the general public. However, the underlying assumption is thatthe incident commander would take steps to move members of the general public even further away from thescene of the RED as quickly as possible.

An RDD uses conventional explosives or some other mechanism to spread radioactivecontamination.


14 / 3. RADIOLOGICAL AND NUCLEAR DEVICES

delayed discovery of covert contamination by an RDD could result in a significant distributionof the radioactive material beyond the initial site of contamination. General characteristics ofan RDD incident include:

• can be explosive (potential rapid recognition) (so called “dirty bomb”);• can be nonexplosive (delayed recognition) (e.g., sprayer);• internal and external dose potential;• explosive would include shrapnel, which may be radioactive;• combined injuries are possible (see Glossary);• need for medical triage;• contamination will be present, but the extent of contamination depends on the type of

dispersal and radioactive material used;• widespread social and psychological effects are possible;• population impacted would be greater than for an RED, but depends on the type of dis-

persal and radioactive material used;• for an explosive device, fatalities and effects from the blast may exceed radiological

fatalities and effects (depends upon material);• mitigation depends on dispersal methods and radioactive material used; and• extent of impact depends on the location, type of dispersal, and radioactive material

used.

Construction of an RDD with a commonly used radioactive source is not difficult. It can bemade using lower-radioactivity sources such as those in nuclear medicine clinics, or by usinghigher-radioactivity sources such as those used in industrial radiography or in radiationoncology clinics.

The consequences of an incident with an RDD may include: the long-term loss of use of thesite, facility or businesses; disruption of critical infrastructures and key resources; and wide-spread public alarm or distress. An RDD attack could also be directed at contaminating foodor water supplies with radioactive materials. The aims of this type of attack may be to: exposethe public who consume the contaminated food or drink the contaminated water, stop the pro-vision of food or water supplies to the public, and cause widespread distress and public alarm.The radiological consequences may include: contamination of water treatment plants, servicereservoirs, header tanks and water supply systems; contamination of food products, wholesalefood markets, supermarkets or food processing facilities; and the loss or disruption ofthe water or food supply chain. The occurrence of immediate fatalities or casualties sufferingfrom the effects of radiation exposure via the ingestion pathway is very unlikely sinceextremely large amounts of radioactive material would be required to achieve sufficientlyhigh concentrations and, even if this occurs, it is very unlikely that it would affect a largenumber of people.

The dispersal of the source using explosives causes the concentration of radioactive mate-rial to diminish in proportion to the extent of the spread. Therefore, increasing the number ofaffected people by dispersing the material over a wide area will also diminish its healthimpacts. However, even with minimal health effects, the impact of the spread of contamina-tion, especially the psychological impact as well as the effects on the local economy, could beconsiderable.

The area affected depends on the device used and the location and method of dispersal ofthe radioactive material. It could vary from a few square meters to several city blocks, or theinterior of an entire building.


3.3 IMPROVISED (OR OTHERWISE ACQUIRED) NUCLEAR DEVICES / 15

3.3 Improvised (or Otherwise Acquired) Nuclear Devices

An IND may be fabricated in a completely improvised manner, may be an improvised mod-ification to a nuclear weapon, or may be acquired in some other way. General characteristicsof an IND incident include:

• need for medical triage;• likelihood of significant short- and long-term radiation health effects;• catastrophic combined injuries (see Glossary);• destruction of local response infrastructure;• multiple hazards;• internal and external dose potential;• rapid recognition of incident;• extensive contamination;• extensive population impacted; and• widespread and profound psychosocial impacts.

The use of an IND by terrorists is generally thought to have a very low probability of occur-rence because of the difficulty of obtaining the material and constructing such a device. How-ever, such use would result in major adverse consequences to public health and safety, sinceit would have the impact of a low-yield nuclear bomb. The effects in the immediate area of thenuclear explosion will be catastrophic and will essentially destroy the existing infrastructurefor response in that area. Emergency response will be from capabilities outside the immediatearea.

Blast effects from an IND are caused by either a shock wave that moves outward throughair, earth, water or solid objects in all directions from the detonation or from the over pressurecaused by a high-pressure air wave that moves outward from the fireball. Typical blast effectsinclude blown out windows and doors, overturned vehicles, collapsed buildings, ruptured gasand water mains, and collapsed tunnels. Typical injuries to people include contusions fromflying glass and debris, crush injuries, and broken bones.

Thermal effects are caused by the emission of ultraviolet, infrared, and visible electromag-netic radiation during the detonation. Typical thermal effects include temporary blindness,skin burns, and fires.

Acute radiation effects are caused by x rays, gamma rays, and neutrons emitted during thedetonation and manifest themselves in numerous symptoms depending on the amount ofradiation absorbed by the individual. Typical effects following high radiation doses [i.e.,>100 rad (>1 Gy)] include mild to severe nausea, vomiting, fatigue, weakness, dizziness, dis-orientation, fluid imbalance, severe suppression of the immune system with increased risk ofinfection, and even death.

Potential long-term effects from radioactive fallout include the contamination of people,facilities, food, water, and the environment. Those people exposed to radiation and who sur-vive have an increased risk of developing cancer in the future (see Section 4.2 and Table 4.1).The extent and magnitude of these long-term effects depend on several factors, including theyield of the device, proximity to the detonation, radiation dose received and the pre-existinghealth status of exposed individuals.

An IND incorporates nuclear materials designed to produce a nuclear explosion.


16 / 3. RADIOLOGICAL AND NUCLEAR DEVICES

The actions of emergency responders need to be weighed against their risk from taking theaction. The results of taking an action may not warrant the expected radiation exposure.

Immediate response efforts include removing survivors from the affected areas, providingmedical assistance to irradiated and contaminated individuals with injuries, preventing thespread of fires, and repairing damaged critical infrastructure. Evacuation and sheltering ofpeople represent the basic types of protective actions that can be used to reduce radiationexposure. These two actions implement the principles of time, distance and shielding used byradiation safety specialists (health physicists) for reducing exposure. Decontamination ofindividuals and objects may be accomplished with warm water and mild soap, or a multitudeof other options.

A nuclear incident will also produce widespread and profound social, psychological andbehavioral impacts at all levels of society: individuals, families, communities and the nationas a whole (Becker, 2001; 2004; NCRP, 2001; Tonnessen and Weisaeth, 2004). Emergencyresponders, too, are likely to be greatly affected. The types of situations emergency responderscould encounter after an IND incident (i.e., dead and injured people, grotesque injuries, lossof colleagues, prolonged separation from family, lack of sleep, and uncertainty) could put themat significantly elevated risk for psychological distress. Effective communication, training andinformation, and appropriate mental health support and interventions before, during andafter an incident, are vital parts of any effort to protect emergency responders from theextraordinary stresses associated with an IND (Becker, 2004; 2005; Hall et al., 2004).


4. Radiation Protection Guidelines

This Commentary takes the approach that nuclear and radiological terrorism representsan exceptional event. In such an emergency, it may be neither practical nor appropriate forradiation protection considerations to automatically be governed by guidelines applied inmore routine scenarios. While the fundamental concept of keeping all radiation exposuresALARA (NCRP, 1993) should still apply, it may not be realistic to apply other traditional radi-ation protection guidelines for limitation of radiation dose. The traditional guidelines arebased on an assumption of low-level exposure over long periods, and govern activities and sit-uations that are more controllable and are not as critical as those associated with respondingto a nuclear or radiological terrorism incident.

The approach to radiation protection described here is based on two considerations: (1) theidentification of radiation control zones, and (2) the control of the absorbed dose to individualemergency responders. The radiation control zones (Section 4.1) segment the site into areasof differing levels of radiation risk by using observed exposure rates. The absorbed dose to anindividual emergency responder governs decisions regarding duration (stay time) for variousemergency response activities.

The primary radiation quantities and units used in Sections 4.1 and 4.2 in this Com-mentary are those in common use in emergency response, and are listed below (also see theGlossary):

• exposure rate in roentgens per hour (R h–1) or milliroentgens per hour (mR h–1);• absorbed dose in rads (rad) or millirads (mrad);• absorbed dose rate in rad h–1 or mrad h–1;• radioactivity15 in disintegrations per minute (dpm); and• radioactivity per unit area in dpm cm–2.

Here, milli (m) is a prefix that means 10–3 (1 one-thousandth). NCRP has adopted the International System (SI) of radiation quantities and units for its

reports (NCRP, 1985). Therefore, the corresponding SI quantity and unit usually will bedisplayed either in parentheses after the common quantity and unit or in an accompanyingfootnote.

In practical terms, the following relationships can be utilized for measurements (made ata point in air or tissue) in the conduct of emergency response operations as a first approxima-tion when x and gamma radiations are involved:

• Common system: 1 R (exposure in air) = ~1 rad (air kerma or absorbed dose in air) =~1 rad (absorbed dose in tissue) = ~1 rem (dose equivalent in tissue) (see Glossary).

• SI system: 1 Gy (air kerma or absorbed dose in air) = ~1 Gy (absorbed dose in tissue) =~1 Sv (dose equivalent in tissue) (see Glossary).

15Radioactivity can also be expressed in curies (Ci), where 1 Ci = 3.7 × 1010 disintegrations per second (dps)= 2.22 × 1012 dpm; and in becquerels (Bq) (in the SI system) where 1 Bq = 1 dps (see Glossary). 1 dpm = 60 dps= 60 Bq.


18 / 4. RADIATION PROTECTION GUIDELINES

The radiation protection guidelines in this Commentary are recommended with the knowl-edge that emergency responders will have minimal information in the immediate phase of theemergency. More specific guidance will need the support of experts, qualified in radiationmeasurements and their interpretation, who may not be available until the latter stages ofthe emergency. It is recommended that the appropriate emergency response organization(s)have individuals on-call who can provide technical support for radiological emergencies. TheHealth Physics Society16 and CRCPD17 can provide additional guidance on how to find radi-ation safety experts and resources.

4.1 Radiation Control Zones

Incidents involving radiation or radioactive material usually will require emergencyresponders to be aware of the potential for health effects associated with various levels of radi-ation exposure. High radiation absorbed doses [i.e., >100 rad (>1 Gy)] can be potentiallylife-threatening. In a previous report (NCRP, 2001), a process based on radiation control zoneswas recommended as guidance for planning emergency response to nuclear and radiologicalincidents. This Commentary further relates the radiation control zones (using the terms innerperimeter and outer perimeter) to the actions listed below.

18,19,20

16The Health Physics Society is a nonprofit scientific professional organization whose mission is to promote thepractice of radiation safety.

17CRCPD is a 501(c)(3) nonprofit nongovernmental professional organization dedicated to radiation protection(CRCPD, 2005).

Establish an outer perimeter if any of the following exposure rate or surface contamina-tion levels18 are exceeded:

• 10 mR h–1 exposure rate (~0.1 mGy h–1 air-kerma rate);19

• 60,000 dpm cm–2 [1,000 becquerels per square centimeter (1,000 Bq cm–2)] for betaand gamma surface contamination;20 or

• 6,000 dpm cm–2 (100 Bq cm–2) for alpha surface contamination.

Within the outer perimeter, the appropriate actions are to evacuate members of the public,isolate the area and ensure that all emergency workers inside the area minimize theirtime spent in the area and follow appropriate personal protection guidelines.

18The values for the surface contamination levels have been adopted from IAEA (2003).19For photon energies <300 keV, the actual air-kerma rate is 0.0869 mGy h–1 (for 10 mR h–1) and 0.0869 Gy h–1

(for 10 R h–1). The numerical value (0.0869) is slightly different for higher energies (e.g., 0.0879 for 60Co gammarays).

20In practice, conversions for contamination levels for the instruments used by the emergency response organi-zations should be predefined so that field decisions can be based directly on the instrument reading, which is usu-ally in counts per minute (Section 5.3.3). The contamination levels assume an infinite plane of contamination.

Establish an inner perimeter at 10 R h–1 exposure rate (~0.1 Gy h–1 air-kerma rate).19

Exposure and radioactivity levels within the inner perimeter have the potential to pro-duce acute radiation injury and thus actions taken within this area should be restrictedto time-sensitive, mission-critical activities such as life-saving.


4.2 CONTROL OF RADIATION DOSE IN THE CONTROL ZONES / 19

The area outside the outer perimeter is where the command post and other support func-tions are located. To implement the ALARA principle, the selection of locations for decontam-ination as well as for staging equipment and support personnel should be made carefully, andif possible, these functions should be established in areas without elevated exposure rates,but control of the incident is the primary consideration.

The radiation protection guideline for external exposure at the outer and inner perimetersrefers to photons only. Neutrons are not expected to be present or will be a minimal contrib-utor at the time emergency responders are present.21 The radiation protection guideline forsurface contamination refers to alpha and beta particles and gamma rays from radioactiveground contamination, and should be used to establish the outer perimeter even if the expo-sure rate is less than 10 mR h–1 (~0.1 mGy h–1 air-kerma rate).

An alarming personal radiation dosimeter (Section 5.2.1) should be used by each emer-gency responder that conducts activities within the inner perimeter.

4.2 Control of Radiation Dose in the Control Zones

22,23,24,25

In addition to establishing the inner and outer perimeters for the incident, the absorbeddose to an individual responder working in the radiation zones must be controlled, and thecontrol level should be used as a basis for determining actions such as withdrawingthe responder from within or near the inner perimeter, or, if necessary, outside the outerperimeter (or to a low radiation exposure location within the outer perimeter). This Commen-tary takes the approach of a decision dose (i.e., an individual cumulative absorbed dose that

21Significant neutron dose is expected only during the blast from an IND or an ongoing criticality incident. Theblast will be over before responders arrive and a continuing criticality incident would be almost impossible for aterrorist to achieve. Therefore, instruments designed for use by emergency responders do not need to be sensitiveto neutrons.

The absorbed dose received by an individual emergency responder working in the radia-tion control zones must be controlled. The cumulative absorbed dose that triggers a deci-sion on whether to withdraw an emergency responder from within or near (but outside)the inner perimeter is 50 rad (0.5 Gy).22,23,24 In this Commentary, the 50 rad (0.5 Gy) cumu-lative absorbed dose is called the decision dose. The cumulative absorbed dose receivedby an emergency responder while working within or near the inner perimeter must berecorded.25

22This recommendation (NCRP, 2001) applies only to the early phase of the emergency response when life-saving or other critical actions may be underway within or near (but outside) the inner perimeter. If the cumula-tive absorbed dose from activities within the inner and outer perimeters reaches 50 rad (0.5 Gy), a similar deci-sion should be made on whether to remove a responder from within the outer perimeter (or to a low radiationexposure location within the outer perimeter).

23This cumulative absorbed dose guideline also applies in those rare circumstances when medical staff mem-bers are attending a victim in a life-saving situation (e.g., the surgical removal of embedded radioactive shrapnelwith a very high level of radioactivity).

24The absorbed dose and the value obtained with the device used to monitor the absorbed dose should betreated as though it were a whole-body absorbed dose.

25The cumulative absorbed dose or exposure received by an emergency responder while working outside butnear the inner perimeter should be estimated, either from a personal radiation dosimeter worn by the responderor from information on exposure rates and stay times at the locations near the inner perimeter at which theresponder worked.


20 / 4. RADIATION PROTECTION GUIDELINES

triggers consideration of withdrawing an emergency responder from within the relevantperimeter). In practice, there are two types of scenarios: (1) where the absorbed dose rateis adequately known and (2) where the absorbed dose rate is not adequately known. Inthe former case, an estimate of the time the responder can remain within or near the innerperimeter (the stay time) can be made ahead of time (i.e., the decision dose determines the staytime of the responder). In the latter case, the alarming personal radiation dosimeter wornby the responder should provide for an alarm that indicates the decision dose has beenreached, at which time the responder should withdraw from within the relevant perimeterand seek further guidance from the incident commander, unless a different protocol has beenestablished.

The radiation protection guideline for the cumulative absorbed dose from external expo-sure refers to photons only. Neutrons are not expected to be present or will be a minimalcontributor at the time emergency responders are present. Alpha and beta particles will notpenetrate the protective bunker gear of responders, and the inhalation of radioactive materialcan be controlled by the responders’ respiratory protection.

The choice of the decision dose in this Commentary is based on the absorbed dose at whichacute effects occur (see Table 4.1 and the Glossary), and previous guidelines provided byNCRP (1993).26,27 As a population average, the threshold for most acute effects is ~100 rad(~1 Gy), following short-term whole-body radiation exposure. To minimize the risk of an acuteeffect this Commentary uses as a safety margin a factor of two, which sets the decision doseat 50 rad (0.5 Gy). The decision dose is the short-term cumulative absorbed dose that triggersthe need for a decision on whether to remove an emergency responder from within the rele-vant perimeter. Ultimately, the incident commander determines what action, if any, is neces-sary to protect both the responder and the public from harm when a given responder reachesthe decision dose.

Table 4.1 presents the two very different types of health risks that may result from theshort-term, high-level whole-body radiation exposure: (1) acute deaths from injury to organsand tissues (e.g., bone marrow) and (2) increased risk for solid cancers and leukemia thattypically occur 10 to 40 y after exposure for solid cancers and less than 5 y after exposure forleukemia.

The data in Table 4.1 indicate that the percent of acute deaths is very low or unlikely atabsorbed doses of less than 150 rad (1.5 Gy) or three times higher than the 50 rad (0.5 Gy)decision dose. Thus, the 50 rad (0.5 Gy) decision dose allows for possible uncertainties in indi-vidual susceptibility, radiation dose measurement, and contingencies of a specific situation.However, there is a very steep rise in acute deaths as absorbed doses exceed several hundredrad (several gray). Table 4.1 also shows that nausea and vomiting are symptoms that occuras absorbed doses become high. If these symptoms occur during conduct of activities withinthe inner perimeter, the affected individual(s) should be removed from the inner perimeter(Section 6.6). Physical injuries such as burns and wounds will significantly increase the risksfor the acute effects of these radiation exposures (Mettler and Upton, 1995). Death can result

26NCRP (1993) states that for life-saving or equivalent purposes, emergency workers may approach or exceed50 rem (0.5 Sv) equivalent dose [50 rad (0.5 Gy) absorbed dose for x and gamma radiation] to a large portion ofthe body and 500 rem (5 Sv) [500 rad (5 Gy) for x and gamma radiation] to the skin (see Glossary for rem andsievert). Emergency exposures are considered to occur once-in-a-lifetime. The 50 rad (0.5 Gy) value is well belowthe threshold for ARS. A short-term radiation dose of 500 rad (5 Gy) to the skin is not expected to result in anypermanent skin damage. The decisive control for emergency responders working within or near the inner perime-ter with personal protection equipment (PPE) is the 50 rad (0.5 Gy) whole-body value, since it will be reachedbefore the 500 rad (5 Gy) value for the skin.

27For x and gamma radiations, the radiation weighting factor for converting absorbed dose to equivalent doseis assigned a value of unity (see Glossary).


4.2 CONTROL OF RADIATION DOSE IN THE CONTROL ZONES / 21

from such combined injuries, even when the injury or the radiation exposure alone would notbe lethal. The data in Table 4.1 also indicate that the estimated excess cancer risks atabsorbed doses of less than 100 rad (1 Gy) [i.e., two times the decision dose of 50 rad (0.5 Gy)]are less than the normal risk of cancer without radiation exposure. As absorbed doses exceedseveral hundred rad (several gray), the excess cancer risk, in those individuals that surviveARS, approaches or exceeds the normal lifetime cancer risk.

TABLE 4.1—Approximate acute death, acute symptoms, and lifetime fatal cancer risk estimates as a function of whole-body absorbed doses (for adults), for use in decision making after short-terma

radiation exposure (adapted from AFRRI, 2003; Goans and Wasalenko, 2005; IAEA, 1998; ICRP, 1991; Mettler and Upton, 1995).

Short-Term Whole-Body

Dose[rad (Gy)]

Acute Deathb from Radiation

Without Medical

Treatment(%)

Acute Death from Radiation with Medical Treatment

(%)

Acute Symptoms

(nausea and vomiting

within 4 h)(%)

Lifetime Risk of Fatal Cancer

Without Radiation Exposure

(%)

Excess Lifetime Risk of Fatal

Cancer Due to Short-Term Radiation Exposurec

(%)

1 (0.01) 0 0 0 24 0.08

10 (0.1) 0 0 0 24 0.8

50 (0.5) 0 0 0 24 4

100 (1) <5 0 5 – 30 24 8

150 (1.5) <5 <5 40 24 12

200 (2) 5 <5 60 24 16

300 (3) 30 – 50 15 – 30 75 24 24d

600 (6) 95 – 100 50 100 24 >40d

1,000 (10) 100 >90 100 24 >50d

aShort-term refers to the radiation exposure during the initial response to the incident. The acute effects listed are likely to be reduced by about one-half if radiation exposure occurs over weeks.

bAcute deaths are likely to occur from 30 to 180 d after exposure and few if any after that time. Estimates are for healthy adults. Individuals with other injuries, and children, will be at greater risk.

cMost cancers are not likely to occur until several decades after exposure; although leukemia has a shorter latency period (<5 y).

dApplies to those individuals that survive ARS.


5. Equipment Requirements for Radiation Detection and Personal Protection, and Pre-Existing Radiation Source Information

5.1 Overview

Emergency responders need tools that allow them to perform their duties effectively whilekeeping themselves safe. With the increased emphasis on homeland security, many govern-ment agencies and emergency responders are considering purchase of appropriate radiationdetection and identification equipment. Section 5 is a discussion of the characteristics andtypes of equipment that would be most useful in response to a nuclear or radiological terror-ism incident.

Humans cannot directly detect radiation using our senses such as hearing, touching,seeing or tasting. Since specialized equipment is required to detect radiation or radioactivematerial, an unknown source or dispersal may not be identified for some period of time. Localemergency responders should be trained to detect the possibility of external radiation (partic-ularly the presence of gamma radiation) or surface contamination (which can include alpha,beta and gamma radiation from radioactive materials) at suspicious explosions or fires. Ide-ally, emergency responders should have equipment that alerts them to the nuclear or radio-logical nature of an incident without having to perform any special action.

Some training is necessary to operate and interpret properly the results of these instru-ments, especially the contamination monitors that must be used in a specific manner to beeffective. Deployment of inexpensive radiation-monitoring equipment to emergency respond-ers can help quickly determine if radiation or radioactive material is involved in an incident.A positive indication of the presence of radiation or radioactive material can indicate the needfor follow-on characterization efforts and the implementation of dose-control efforts such asestablishing inner and outer perimeters. Also, an alarming personal radiation dosimeter canbe used to monitor the radiation exposure of emergency responders while performing time-sensitive, mission-critical activities.

Once the nuclear or radiological nature of an incident has been identified, then speciallytrained local, state or federal radiation specialists can be called upon to provide more specificinformation about the nature of the radiation source or the nature and extent of the radioac-tive contamination.

To be an effective warning device for use by an emergency responder working in the radi-ation control zones, the personal radiation dosimeter should have the following properties:

• alarms to notify the wearer of a hazardous radiation situation. This is best done by analarm that is activated when the predefined decision dose for cumulative absorbeddose [i.e., 50 rad (0.5 Gy)] is reached. In addition, one could also set an alarm that isactivated when a predefined high exposure rate is reached [e.g., 10 R h–1 (~0.1 Gy h–1

air-kerma rate)];


5.2 CATEGORIES OF INSTRUMENTS / 23

• alerts the user to the presence of higher than normal levels of radiation even inan emergency environment (e.g., fire, smoke, noise) without user interaction, whileminimizing the number of false positive alerts from naturally-occurring radioactivematerial. This is best done by setting the alert for a relatively high exposure rate (i.e.,compared to normal background) of 10 mR h–1 (~0.1 mGy h–1 air-kerma rate);

• works continuously without user intervention to operate;• displays exposure rate and records cumulative absorbed dose (useful for dose control

and planning);• simple and intuitive, requiring little training to operate;• small in size, and easily and securely worn (not carried); • inexpensive to purchase and maintain; and• rugged enough for field use.

5.2 Categories of Instruments

For the purposes of this Commentary, instruments can be divided into four categories:(1) alarming personal radiation dosimeters (i.e., an active device) for use by emergencyresponders working in the radiation control zones to actively monitor the levels of radiation,and to notify them (by alarm) of hazardous radiation conditions; (2) passive dosimeters tomonitor radiation exposure or dose; (3) survey instruments to detect the presence of an exter-nal radiation field and surface contamination; and (4) radionuclide identifiers to determinethe type of radioactive material. A brief explanation of each of these instruments is providedbelow.

5.2.1 Alarming Personal Radiation Dosimeters

Ideally, an alarming personal radiation dosimeter would identify radiation exposure ratesin the range of 1 mR h–1 (~0.01 mGy h–1 air-kerma rate)28 to 500 R h–1 (~5 Gy h–1 air-kermarate), and could integrate exposure up to 500 R (~5 Gy air kerma) with a visual status indi-cator (not necessarily a numerical readout). Whenever possible, such a dosimeter should beassigned to each emergency responder that may work in the radiation control zones.

The alarming personal radiation dosimeter should be constantly available and should besufficiently rugged to withstand the rigors of the field such as responding to fires. As a result,these dosimeters should be small, lightweight and easily integrated into a responder’s normalequipment load. Such a dosimeter would need a larger display and readily visible indicatorlights (or audible alarms) that are tied to exposure rate and decision dose. An alert should beset at 10 mR h–1 (~0.1 mGy h–1 air-kerma rate) (e.g., a yellow light) to minimize the numberof false alerts due to natural and permissible sources of radioactivity. The hazard alarm (e.g.,a red light) should be set at 10 R h–1 exposure rate (~0.1 Gy h–1 air-kerma rate) and a decisiondose alarm at a 50 rad (0.5 Gy) cumulative absorbed dose. The alert and alarm levels wouldbe set by the local authority to ensure compliance with local guidelines, thereby reducing theneed for the wearer to read and interpret a value in the field.

The alarming personal radiation dosimeter should not be adversely impacted by variationsin environmental conditions such as temperature, humidity, dust, rain, changes in atmo-spheric pressure, vapors and trace chemical quantities, frequently going from indoors to out-doors, impact, vibration, and electromagnetic fields.

28This value is one-tenth of the value [i.e., 10 mR h–1 (~0.1 mGy h–1 air-kerma rate) for the outer perimeter].


24 / 5. EQUIPMENT REQUIREMENTS FOR RADIATION DETECTION AND PERSONAL PROTECTION

5.2.2 Passive Dosimeters

Devices to assess an individual’s total radiation dose have been available for many yearsand extensive performance and operational experience has been acquired. These passivedosimeters reliably measure the wearer’s total radiation dose but do not generally display thedose level. Therefore, the incident commander cannot instantly monitor doses to ensure com-pliance with dose guidelines. Many current dosimeters, such as film, thermoluminescentdosimeters, and optically-stimulated luminescent dosimeters, are integrating, passive devicesthat require a processing system to determine the wearer’s dose. While these dosimeters haveproven to be accurate and reliable, they would not be acceptable to manage radiation doses atthe scene because the results cannot be determined until well after the dose was received.These dosimeters would be valuable to measure an individual’s total radiation dose after theincident.

5.2.3 Survey Instruments

Radiation survey instruments to detect the presence of an external radiation field andsurface contamination have been available for many decades and are generally available tomeet the needs of the response community. Larger metropolitan centers, academic and med-ical centers, biomedical research facilities, and nuclear medicine departments are likely tohave radiation monitors that could supplement those of the emergency responder and a hos-pital’s emergency department (ED) survey instrument inventory. A thin-window Geiger-Mueller (GM) (either “pancake,” or end-window) hand-held survey meter would be acceptableto monitor for either area or personal contamination.

Radiation survey instruments are well suited to scanning for contamination and shouldhave detection capabilities of at least 6,000 dpm cm–2 (100 Bq cm–2) for beta or gamma surfacecontamination and 600 dpm cm–2 (10 Bq cm–2) for alpha surface contamination. These valuesare one-tenth of the respective values for surface contamination at the outer perimeter [i.e.,60,000 dpm cm–2 (1,000 Bq cm–2) for beta or gamma; 6,000 dpm cm–2 (100 Bq cm–2) for alpha](Section 4.1). The maximum activity likely to be encountered in a terrorist incident is difficultto specify but the upper range of detection for instruments used for contamination monitoringshould be between a factor of 100 and 1,000 above the minimum capabilities given above.

5.2.4 Radionuclide Identifiers

While much of the initial response to a nuclear or radiological incident can be managedwithout knowing the specific radioactive material(s) present, identification of the radioactivematerials will allow better management of contaminated individuals and protective measuresfor the emergency responders. Commercially available radioactive-material identifiers (gen-erally referred to as radionuclide identifiers) have been available for many years to identifygamma-ray emitting radioactive materials. Usually these instruments required considerablymore knowledge and skill to operate than a survey meter. Improved units are now availablethat are small, relatively light weight, and provide information in a manner that can be inter-preted initially by individuals trained at the technician level (Section 7.7 and AppendixA.2.3).

Emergency response plans should include consideration of access to a radionuclide identi-fier. However, the initial and ongoing operating costs of an identifier may not warrantpurchase specifically for this application. It is likely that state radiation control organiza-tions will have such equipment available on-site soon after the initiation of the incident. In


5.3 EQUIPMENT COMMENTARY AND RECOMMENDATIONS / 25

addition, nuclear medicine laboratories, university radiation safety programs, research labo-ratories, radioactive materials licensees, and hazardous materials teams would be able to pro-vide a service to identify the involved radionuclide(s). It may also be possible to use nuclearmedicine gamma cameras to identify the radionuclide(s).

5.3 Equipment Commentary and Recommendations

5.3.1 Post-Event Equipment

In pre-event monitoring, instruments monitor low levels of radiation and report signifi-cant deviations from natural radiation background levels. In comparison, post-event instru-ments measure potentially high exposure or dose rates and integrate personal radiationexposure or dose over a wide dynamic range. Both pre- and post-event instruments need to belightweight and able to withstand the rigors of field use in a harsh environment. Thepost-event instruments must operate over a wide temperature range and withstand rapidtemperature changes while surviving the demanding mechanical requirements of use inemergency response. They should not have any electromagnetic interference with otherdevices worn by emergency responders. The requirement to monitor small changes in radia-tion levels may preclude use of pre-event instruments from monitoring the much higherradiation exposure and dose rates expected in the post-event environment. Post-event instru-ments need to measure total radiation exposures and doses that could extend to hundreds ofrad (several gray) or rapidly measure high levels of radioactive contamination.

5.3.2 Radiation-Monitoring Instruments for the First Emergency Responders to a Scene

This Commentary recognizes the need for two different radiation-monitoring instrumentsfor the first emergency responders to a scene: a survey instrument to determine whether theincident has a nuclear or radiological component, and alarming personal radiation dosimetersto monitor exposure rates and cumulative doses for each responder crossing the outer perim-eter [10 mR h–1 (~0.1 mGy h–1 air-kerma rate)] of a nuclear or radiological incident.

Equipment requirements for responding to a nuclear or radiological incident (referred toas post-event in this Commentary) are very different than the requirements for equip-ment used to detect illicit radiation sources (referred to as pre-event in this Commen-tary). The effective range of radiation doses that can be measured with pre-eventequipment is too limited to support most emergency operations.

The first emergency vehicles (e.g., police, fire and EMS) responding to a suspicious inci-dent should be equipped with radiation-monitoring instruments to alert personnel to thepresence of radiation. Also, it is recommended that such instruments be set to alert thefirst emergency responders to a scene when the exposure rate reaches 10 mR h–1

(~0.1 mGy h–1 air-kerma rate), corresponding to the recommended value for the outerperimeter.



Such an instrument should be mounted in the least unobstructed placement (i.e., the topof a vehicle dashboard). The instrument could be mounted permanently or could be removablesuch that the emergency responders could use it at the scene once the nuclear or radiologicalnature of the incident was verified. The latter instance would also be useful if, in the interestof economy, the instrument were to double as the surface contamination monitor necessary todetect the nuclear or radiological nature of the incident. That is, if the vehicle or team wereto be equipped with only one survey instrument, it should be a pancake GM probe-based, por-table detector system. The alarming personal radiation dosimeters recommended below couldbe used for this purpose as well. It is recommended that emergency response personnel beequipped with instruments dedicated to select purposes, if possible.

The necessary detection sensitivity for such an instrument could be achieved with abroader range of potentially less expensive instrument types than has been suggested forother purposes in this Commentary, and may already be available to some response teams. Inaddition, the useful range requirements for such an instrument would be less demandingthan for other instruments discussed in this Commentary because of the essentially “go” or“no go” character of its purpose. Examples include sodium iodide scintillator-based probes,and pressurized and nonpressurized ion chambers. It is recommended that such an instru-ment be set to alert the first emergency responders to a scene when the exposure rate reaches10 mR h–1 (~0.1 mGy h–1 air-kerma rate). The alert level may be set according to the prescrip-tion of local authorities, but should be sufficiently high to prevent false positive indicationsassociated with naturally-occurring sources of radiation. It is not necessary for this instru-ment to have additional alarms at 10 R h–1 (~0.1 Gy h–1 air-kerma rate) (the inner perimeter)or at the decision dose (50 rad) if responders (or a subgrouping thereof) will have the alarmingpersonal radiation dosimeters recommended below.

The alarming personal radiation dosimeter for the emergency responders that cross theouter perimeter at the scene of a nuclear or radiological incident are used to warn individualswithout extensive radiation protection training of the possibility of elevated radiation levelsthat may require some action. These warnings should be set at predefined levels and shouldindicate in a way that makes the level of hazard clear to the responder. For example, thedosimeter could be designed with audible indicators or visual indicators (such as a green/yellow/red light or a large numeric display) so an emergency responder clad in bunker gearcould readily interpret the indications.

As an example, the dosimeter could produce an alarm, such as a steady red indicator (andperhaps also an audible indication or vibrations), that the responder has reached a cumula-tive absorbed dose of 50 rad (0.5 Gy). When the exposure rate is 10 R h–1 (~0.1 Gy h–1

air-kerma rate) or more the red light could blink, and a steady yellow light could be displayedwhen the exposure rate is at or above 10 mR h–1 (~0.1 mGy h–1 air-kerma rate) but below

The emergency responders that cross the outer perimeter at the scene of what is deter-mined to be a nuclear or radiological incident should be equipped with alarming personalradiation dosimeters that provide unambiguous alarms, based on predefined levels, tofacilitate decision making. It is recommended that the dosimeter provide alarms whenthe exposure rate reaches 10 R h–1 (~0.1 Gy h–1 air-kerma rate), corresponding to the rec-ommended value for the inner perimeter, and when the cumulative absorbed dose reachesthe decision dose of 50 rad (0.5 Gy). An alarming personal radiation dosimeter for eachindividual that can be used in such radiation environments is preferred over a singledetection instrument for an entire response team.



10 R h–1 (~0.1 Gy h–1 air-kerma rate). The dosimeter could display a steady green light whenthe exposure rate is below 10 mR h–1 (~0.1 mGy h–1 air-kerma rate). Such a combination ofindicators would inform the responder of the radiation levels and provide enough informationto assist the incident commander (in verbal contact with the responder, or by virtue of prede-termined stay times) in managing life-saving and other vital tasks, particularly within theinner perimeter.

The dosimeter should be capable of tracking the responder’s cumulative absorbed dose andthe exposure rate in the emergency environment. An alarming personal radiation dosimeter,for each individual, that can be used in such radiation environments is preferred over a singledetection instrument for an entire response team. However, because it is likely that a givendosimeter may be shared among multiple responders, the absorbed-dose integration featureshould be able to be reset at the scene by trained and authorized staff. Every member of theresponse team during the early phase of an incident that is determined to have a nuclear orradiological component should at least be equipped with a passive dosimeter (e.g., opti-cally-stimulated luminescent dosimeter, thermoluminescent dosimeter) for later follow-upassessment. Also, records of an individual responder’s cumulative absorbed dose obtainedduring activities within and near the inner perimeter should be maintained and tracked dur-ing emergency operations.

The above discussion is consistent with similar recommendations concerning radiationdetection in NCRP Report No. 138 (NCRP, 2001).

5.3.3 Screening for Contamination

In practice, instruments for this initial assessment should be rugged and simple to use.The instrument should clearly alarm when the relevant contamination level for the outerperimeter is reached. For survey instruments that cannot discriminate between alpha andbeta radiation (i.e., have poor selectivity) (such as a thin-window GM), the alarm should beset to the lower value [i.e., the 6,000 dpm cm–2 (100 Bq cm–2) value for alpha surface contam-ination].

Contamination-monitoring instruments must be maintained and operated in a specificmanner to be useful. A number of parameters determine the proper performance of theinstrument, including certain physical properties (e.g., window thickness), the calibration(e.g., probe high-voltage setting, distance between the calibration source and the probe win-dow), and human factors such as the speed with which the detector probe is scanned over apotentially contaminated surface. Other properties discussed previously (e.g., speed ofresponse, audible indication) are important for contamination monitors as well.

Some training is necessary to properly operate and interpret the results of contamination-monitoring instruments, especially given that such instruments will normally provide a read-out in counts per minute (cpm). The readout in cpm must be converted to dpm cm–2 to be com-parable with the recommended contamination levels for the outer perimeter. The counting

The first emergency responders to a scene should have a simple instrument to identifythe presence of contamination at the scene and on individuals. The selectivity, sensitivityand accuracy of the instrument are not as important as the ability of the instrument toclearly detect the outer perimeter contamination levels of 60,000 dpm cm–2 (1,000 Bq cm–2)beta and gamma surface contamination, and 6,000 dpm cm–2 (100 Bq cm–2) alpha surfacecontamination.



efficiency for the instrument is determined during calibration of the instrument, and takesinto account many of the factors mentioned above, such that the operator need only know aminimum of information to interpret the cpm results.

Proper use of the instrument assumes that the cpm derived during a surface scan wasobtained with the appropriate geometry (i.e., window facing the potentially contaminated sur-face and at the same aspect and distance from the probe as was the source used to derive thecounting efficiency). In addition, many instruments use energy-dependent detectors (e.g., GMpancake probes) and may require the use of several counting efficiency values given the broadrange of beta-particle and gamma-ray energies encompassed by the variety of radionuclidesthat may be used during a terrorist incident involving radioactive material.

To avoid these complications and the confusion that may ensue, a simple approach shouldbe used in converting instrument readings in cpm to dpm cm–2, taking into account both thearea and efficiency of the probe. For example, using a 15 cm2 probe (which is a smaller areathan the contaminated surface area being monitored) with a 20 % efficiency (i.e., 1 cpm =5 dpm) would require dividing the number of cpm by three to get the number of dpm cm–2 [i.e.,(cpm / 15 cm2) × (5 dpm / cpm) = cpm / 3]. Similar conversions would be derived (in advance)for other detectors with different probe areas and efficiencies. Follow-on radiation measure-ments by radiation protection experts using more selective, sensitive and accurate instru-ments will refine the location(s) of the outer perimeter, and provide better evaluation of theradiation hazard for determination of the appropriate personal protection equipment (PPE).

To avoid acute radiation-induced skin injury, screening efforts should strive to locate spotcontamination on the skin that exceeds 2.2 × 106 dpm (37,000 Bq) (FEMA, 2002a). The pre-sumed spot size is 0.2 cm2. Individuals that exceed this level represent a priority for decon-tamination efforts. Studies have indicated that screening individuals for this level can beaccomplished in ~15 s per individual using a thin window “pancake” style GM, ~2.5 min perindividual using an end-window instrument [such as the CD V-718 civil defense meter(Nuclear Research Corporation, Philadelphia, Pennsylvania)], or ~4 min per individual usinga “hotdog” style GM probe [such as used with the CD V-700 civil defense meter (Victoreen,Inc., Cleveland, Ohio; Lionel Electronic Laboratories, Brooklyn, New York)] (FEMA, 2002a).

In the case of spot contamination, the use of a 15 cm2 probe (which is a much larger areathan the assumed spot size of 0.2 cm2) with a 20 % efficiency would require only multiplyingthe number of cpm by five to get the number of dpm.

During the initial response to a nuclear or radiological incident, a radiation control zone,such as an outer perimeter, will be established for the impacted area. Emergency responders

Initial personal monitoring and decontamination efforts at the scene should primarilyfocus on preventing acute radiation effects to affected individuals. Cross contaminationissues are a secondary concern, especially when the contaminated incident site and num-ber of evacuees is large. Individuals with spot contamination greater than 2.2 × 106 dpm(37,000 Bq) should be a priority for decontamination.

Additional equipment and supplies are required to screen large numbers of individu-als for contamination at the scene, and to screen for possible initial decontamination atemergency facilities (i.e., at designated reception centers and at hospital facilities).



will enter and leave this control zone as casualties are extricated and noncasualties areremoved from the impacted area. Presumably, a large number of individuals will be exitingthis control zone, putting demands on contamination control. It will be necessary to rapidlyscreen at the outer perimeter to distinguish those individuals significantly contaminated bythe incident from those who were not. Decontamination, when necessary, will occur within ornear the outer perimeter for both emergency responders and the public.

Decontamination will require the availability of a few select, but essential supplies,namely, an ample source of water and soap for body washing and showering, clean clothing ordrapes, blankets, and bags and waste containers to collect contaminated clothing.

EMS personnel should be trained to give guidance to individuals that are minimallycontaminated regarding the relatively low risk of radiation effects from such contamination(Section 6.1). For consistency, the guidance should be prepared in advance, in order to provideaffected individuals with accurate information.

An instrument placed at the entrance to the hospital ED can detect above normal radiationlevels and monitor for contaminated individuals entering the ED. However, some detectors,such as GM detectors or plastic scintillators, will also alarm when a nuclear medicine patientpasses through the ED entrance. Instruments are available that can selectively ignorelow-energy radiation from nuclear medicine patients. Each ED should evaluate the advan-tages and disadvantages of an entrance monitor. If an ED decides to use an entrance monitorit would need to have an alarm level high enough to minimize the number of false alarms dueto variations in background [e.g., a level, such as 10 mR h–1 (~0.1 mGy h–1 air-kerma rate) thatis well above the normal background exposure rate].

A radiation portal monitor or pedestrian portal monitor could be used at the ED entranceto monitor for the unexpected presence of radiation. A portal monitor could also be used toscreen patients during a nuclear or radiological incident. These portal monitors may alsoinclude a spectroscopic option to identify the radioactive material. With the greater capabili-ties of a portal monitor come a substantially higher initial investment and larger ongoingoperating costs as well as increased training and maintenance costs.

If there were a nuclear or radiological incident, it is likely that health care facilities wouldneed a large number of radiation survey instruments to adequately manage patient screeningand general contamination monitoring. A walk-through radiation portal monitor will increasethe patient screening rates. While these portal monitors will increase the monitoring rate, theinitial cost29 may preclude placing them at every ED. Emergency management agencies orlocal and state radiation control programs may want to consider purchasing one that could bedelivered to a temporary screening facility such as an auditorium, stadium or designated ED.

5.3.4 Availability of Pre-Existing Radiation Source Information

Established sites such as a hospital, research reactor, or other research facility, shippingwarehouse and loading platform, post office or other types of structures containing or poten-tially housing radioactive material permanently (e.g., a nuclear medicine department or radi-

29The initial purchase price for a radiation portal monitor is ~$5,000, with installation costs additional, whilethe cost of a GM detector is ~$1,000 with installation costs additional.

For response to incidents at established facilities, pre-existing site-specific radiationsource information should be available to emergency responders.



ation oncology clinic) or temporarily (e.g., a loading dock with radioactive materials fortransport) should be included in a location database. An example of such a database is theFire Department of New York City’s Critical Information Dispatch System.

The system should alert emergency responders of unusual hazards and hazardous mate-rials (in this case radioactive material) known to be present or possibly present at the locationof the emergency when the street address or name that is the subject of the response was pre-viously entered into the dispatch system. This information, when coupled to an address, isautomatically transmitted to the responders as they leave quarters or are assigned throughradio or mobile data terminals when out of quarters and alerted to respond. The informationshould be designed to have an impact on operational strategy. For example, it can affect thetype, number and direction of units responding when considered with the reported conditions(such as a bomb blast at a hospital storage room), as well as alert the emergency respondersto ensure that radiation detection instruments are operating when approaching the scene.

On arrival at the scene of the reported emergency, the responders verify or ascertain thelocation. The emergency responders can consider the potential impact that radioactive mate-rial would have on operations and safety if deteriorating conditions were to cause the radio-active material to become part of the problem (if radioactive materials were not the originalcause of the response). The sooner the emergency responders can define the hazards at thescene, the quicker this information can be incorporated into the initial incident evaluation todetermine tactics and increase safety for the operating members.

5.3.5 Standard Personal Protection Equipment

Bunker gear and respiratory protection equipment currently used by emergency respond-ers are designed to protect from hazards similar to radioactive material contaminants. Stan-dard bunker gear is sufficient for almost any nuclear or radiological incident as long as properradiation instrumentation is available to control the exposure time to penetrating radiation.Use of bunker gear will sufficiently prevent personal contamination from radioactive mate-rial, and the respiratory protection equipment used to prevent smoke inhalation and exposureto other hazardous materials will also protect from inhalation of radioactive materials.

It is important to remember that bunker gear and respiratory protection equipment willonly protect an individual from internal and external radioactive material contamination. Itwill not protect an individual from external radiation exposure.

There may be situations in which the first emergency responder to the scene is notequipped with bunker gear and respiratory protection equipment. In these situations, normalclothing (e.g., a uniform) will provide some protection from contamination but prolonged wear-ing of such clothing (once contaminated) should be avoided. In addition, it may be necessaryto use ad hoc methods of respiratory protection. For example, covering the mouth and nosewith a handkerchief, a bandana, or another article of clothing will reduce the possibility ofinhaling airborne radioactive materials. As with the protective clothing, this approach is a“stop gap measure” and is not recommended for long-term use in an emergency.

At the scene of an incident, standard protective clothing (i.e., bunker gear) and respira-tory protection devices are sufficient to protect emergency responders against personalcontamination by radioactive materials when conducting life-saving and other criticalmissions.



5.3.6 Communication of Radiation Levels

The first unit to arrive at the scene of operations must give a brief assessment of conditionsencountered, including a general description of the building and location and verification ofthe address and name in their preliminary report to the dispatcher. The message shouldinclude information on elevated radiation levels and the presence of radioactive material.

A quick preliminary message of this type would immediately generate a hazardous mate-rials group response and alert the subsequent arriving units. These units would then knowto be properly suited in PPE with respiratory protection mask donned when they arrive at thescene. They would also set up any required perimeters based on instrument readings. In addi-tion, this message would prompt the incident commander to have the dispatcher officiallynote the time of arrival, and to begin radiation dose assessments once exposure rates and thepotential for cumulative absorbed doses are determined so that members of the operatingunits can be rotated as necessary.

During the initial assessment of an incident, when its magnitude and nature are assessed(referred to as the size-up period), radiation levels should be communicated by the assess-ment team to the incident commander, who must evaluate the hazard to life for thevictims and the emergency responders.


6. Decontamination Equipment and Medical Supplies30

6.1 Understanding Contamination31

Contamination occurs when radioactive material is deposited on skin, hair, clothing, or anyplace where it is not desired. It is important to remember that radiation does not spread orget “on” or “in” people; rather it is the radioactive material that can spread. An individual con-taminated with radioactive material may be irradiated until the material is removed. Someradiation emitted by the material (alpha particle and low-energy beta radiation) cannot pen-etrate the dead layer of skin on the body and does not pose a significant hazard to the indi-vidual. However, even this material should be removed as soon as possible to limit the spreadof the material and the potential for an intake of the contamination. There are three situa-tions that must be understood with regard to contamination:

• an individual is externally contaminated if radioactive material is on skin, hair orclothing;

• an individual is internally contaminated if radioactive material is inhaled, swallowedor absorbed through the skin or in wounds; and

• the environment is contaminated if uncontrolled radioactive material is spreadthroughout an area where it is not desired.

Often, decontamination can be accomplished individually using soap and water and simpletechniques such as removal of contaminated clothing. Usually, it is not necessary to use exten-sive facilities for decontamination unless there are a large number of contaminated victimsand immediate medical care is not the primary consideration. In this case, essential processesand needed supplies should be available much the same as in the hospital environment. In

30These recommendations apply to any facility designated in pre-event planning to perform the functions ofdecontamination for radioactivity or medical evaluation of victims.

Unlike many chemical and biological agents, radioactive material contamination rarelyrepresents an immediate danger to the health of the victim or the responder.31 Thisreduces the immediacy of the need for decontamination and allows the emergencyresponse community greater flexibility in selecting decontamination options.


30


6.1 UNDERSTANDING CONTAMINATION / 33

this regard, the staging and decontamination area should have adequate triage supplies, acopious water supply, methods for containment (if possible), and consideration of clothingexchange and individual privacy. In areas of cold climates, provisions should be made to pro-tect victims from hypothermia.

In general, removal of contaminated clothing will remove 80 to 90 % of external contami-nation (Goans, 2004). If the patient needs emergent medical or surgical treatment, othercontamination-control measures may be necessary so that immediate medical care can be pro-vided. For example, the contaminated patient could be wrapped in a sheet prior to transport,which would reduce contamination of the transport vehicle.

Decontamination strategies can include self-decontamination recommendations if thenumber of evacuees is larger than can be safely and efficiently decontaminated. For example,the health effects due to hypothermia from outdoor “fire hose” decontamination techniques incold climates may be more hazardous than the contamination. Self-decontamination recom-mendations should include:

• use of ad hoc respiratory protection to reduce inhalation of resuspended particles(including examples of such protection);

• removal and bagging of the outer layer of clothing before entering a residence;• showering with warm (not hot) water;• use of soap and shampoo (but not hair conditioner); and• thoroughly washing the skin but not so aggressively as to abrade the skin.

Vehicles used to transport evacuees should be monitored before reuse. Reuse of vehiclesthat have low levels of contamination should be permitted. Levels at which reuse will ceaseand decontamination initiated should be specified in the local emergency plan. These levelsshould be established in consultation with local and state radiation control programs. How-ever, use of contamination levels equal to those for the outer perimeter should provide minimalrisk while allowing continued response to the emergency.

Monitoring should be conducted to evaluate the success of decontamination efforts. Thisshould be conducted away from the incident site and does not have to be conducted immedi-ately. Satellite reception centers can be used for the more detailed monitoring necessary toevaluate the effectiveness of decontamination efforts (both at the scene and for those whoself-decontaminate) and to determine if additional decontamination is warranted.

Decontamination procedures should strive to reduce contamination on any one spot to lev-els below 2.2 × 105 dpm (3,700 Bq), and to reduce surface body contamination to levels below10,000 dpm cm–2 (~170 Bq cm–2). The decontamination objectives are to: (1) reduce residualfixed contamination on any one spot to avoid acute skin effects, and (2) reduce residual fixedsurface body contamination to minimize potential stochastic effects (i.e., an increase in cancerprobability). These levels are equal to the monitoring objectives in Background Informationon FEMA-REP-22: Contamination Monitoring Guidance for Portable Instruments Used forRadiological Emergency Response to Nuclear Power Plant Accidents (FEMA, 2002a) for fixedcontamination and 10 times below the initial population contamination screening values rec-ommended by FEMA (2002a) for loose contamination. Decontamination attempts shouldcease if skin abrasion occurs or when two successive attempts do not noticeably reduce thecontamination level. Harsh cleansers and aggressive scrubbing of exposed skin should beavoided.

A more detailed discussion of contamination screening and decontamination objectives isprovided by FEMA (2002a).


34 / 6. DECONTAMINATION EQUIPMENT AND MEDICAL SUPPLIES

6.2 Hospital and Pre-Hospital Planning

6.2.1 Planning

EMS staging areas need to be considered in response planning for scenarios with masscasualties, so that personnel can perform, as early and efficiently as possible, initial triage,administration of critical care, and decontamination procedures (as necessary).

Generally, statutory requirements mandate hospitals, EMS, local elected officials, repre-sentatives of the public, local law enforcement, and local government agencies to work coop-eratively in designing and implementing local and regional EMS and trauma care plansand systems. This cooperation is generally through Department of Health regional EMS andtrauma care plans (Krajewski et al., 2005).

These requirements should include a plan for addressing inter-regional patient careresponses, transport and transfer of patients to facilities outside the region and the EMS andtrauma system response to mass-casualty incidents at all levels. Generally, this degree ofcooperation is currently in place in many jurisdictions and also among states.

Regional EMS and trauma care councils currently perform the following activities:

• assess and analyze regional EMS and trauma care needs; • identify and implement specific activities necessary to meet statewide standards and

patient care outcomes; • establish the number and levels of facilities to be designated as trauma facilities; • identify the need for and recommend the distribution and level of care of pre-hospital

services, to assure adequate availability and avoid inefficient duplication of services; and• advise the Department of Health on all matters relating to EMS and trauma care

delivery within the region.

Hospitals and EMS should collaborate in planning for initial casualty management andcare during nuclear or radiological incidents, for EMS determination of casualty destination,and facility requirements regarding the treatment of both emergent and trauma patients.Existing tools include various state trauma triage tools, approved regional patient care pro-tocols, and county operating procedures. It is crucial that jurisdictions develop a mutual aidplan for nuclear or radiological incidents and plan for deploying EMS units in jurisdictionsthey do not normally cover.

6.2.2 Care for Victims of Nuclear or Radiological Incidents

EMS and hospitals should have detailed plans for patient care during a nuclear or radio-logical incident, prepared in advance. This planning should include determination ofpatient routing (i.e., ultimate destination of casualties), facility requirements for the treat-ment of emergent and trauma patients, and assistance for psychological casualties andindividuals who come to healthcare facilities with concerns about radiation contamination.

Each hospital should have a planned course of action for the care of victims exposed toradiation or contaminated with radioactive material. Ideally, the plan should be includedwithin the general hospital emergency plan.


6.3 ROUTING STRATEGY / 35

Essentially all hospitals with basic medical and surgical capability should be able to pro-vide initial care for victims of a nuclear or radiological incident. When responding to a nuclearor radiological incident, the number of victims, each patient’s medical status and type ofinjury, the radiological status (exposed externally versus internal contamination), and theidentity of sources and internal contamination (if known) should be noted. If any doubt aboutcontamination exists, it is prudent to assume the victim is contaminated until proven other-wise.

Each member of the hospital emergency team should be familiar with the hospital's writ-ten plan and be required to participate in scheduled drills. More frequent drills (e.g., semi-annually) should be considered by subgroups to practice decontamination, triage or radiationmonitoring. Special training may also be necessary to accommodate staff turnover. The train-ing should include nonhospital emergency management and paramedic personnel, since theyplay an important role in assisting the hospital ED staff through notification proceduresbefore arrival, proper transport of radiation accident victims, and emergency medical careduring transport.

6.2.3 Medical Staff Precautions

The purpose of protective clothing in the ED is to keep bare skin and personal clothing freeof contamination. Members of the hospital emergency response teams should dress in surgicalclothing (scrub suit, gown, mask, cap, eye protection, and gloves). Waterproof shoe coversalso should be used. All open seams and cuffs should be taped using masking or adhesive tapeand two pairs of surgical gloves are recommended. The first pair of gloves should be tapedat the arm cuff. The second pair of gloves should be easily removable and replaced if theybecome contaminated. A self-reading radiation dosimeter also should be assigned to eachmedical team member and attached to the outside of the surgical gown at the neck whereit can be easily removed and read. If available, a film badge or other type of passive dosimetercan be worn under the surgical gown.

To protect the embryo or fetus of a pregnant individual in an occupational situation, NCRPrecommends a monthly equivalent dose limit of 50 mrem (0.5 mSv) to the embryo or fetus[excluding medical (i.e., from health care for the pregnant individual) and natural backgroundradiation] once the pregnancy is known (NCRP, 1993). This dose limit is applicable for mem-bers of the hospital emergency response teams providing medical services in the ED during anuclear or radiological incident.

6.3 Routing Strategy

Universal precautions (i.e., standard hospital personal protection procedures) in theemergency room are generally sufficient for treatment of victims of nuclear or radiologi-cal incidents.

A strategy should be developed for each radiation control zone at the incident scene tominimize the time to treatment for victims. EMS personnel should attempt to removevictims from the incident scene as promptly as possible while providing for their ownsafety.



All casualties within designated radiation control zones, especially those from within theinner perimeter, need to be extricated as rapidly and efficiently as possible. Some of thesecasualties may require prompt treatment of medical and surgical conditions and an initialevaluation of their radiation exposure. Since radiation-related illness requires hours to daysto become clinically evident, emergency responders should triage victims of a nuclear or radio-logical incident using traditional medical and trauma criteria. Patients should be medicallystabilized and then assessed for radiation injury based on clinical symptoms, dose, radionu-clide, and whether there is internal contamination. Resource limitations may necessitatesome differences in care in the event of mass casualties.

The first hour after a traumatic event is widely recognized by trauma surgeons to be anhour of opportunity in which the lives of severely injured people may be saved if they are rap-idly triaged to definitive treatment by emergency responders. Radiological concerns must notpreclude life-saving efforts. Patients in shock or near shock can die if not treated within thatfirst hour. In a nuclear or radiological incident, the presence of radioactive material must notinterfere with rapid triage and removal of trauma victims from the incident scene. EMS per-sonnel should attempt to remove victims from the incident scene as promptly as possiblewhile providing for their own safety.

6.4 Standard Medical Care

When EMS arrives at the site, the standard procedure is to assess the situation and anyinjuries, triage (with medical and surgical concerns being primary), and transport casualtiesas indicated to definitive medical care. The same standard procedure should apply to nuclearand radiological incidents.

Some patients involved in a nuclear or radiological incident may be externally contami-nated. Removing contaminated clothing of patients and emergency responders will eliminate80 to 90 % of external contamination, and soap and water should be the first approach toremoving remaining radioactive material. Irrigation of contaminated wounds is readily per-formed using a saline jet under mild pressure.

Exposure rates from contaminated wounds rarely exceed a few mR h–1 (approximately a fewhundredths of mGy h–1 air-kerma rate) and emergency responders should be reassured thattheir exposures in this situation will very likely be insignificant or minimal (Goans, 2004).

When casualties are suspected to have received short-term high-level, whole-body doses ofpenetrating radiation (e.g., photons, neutrons), all skin wounds (open, serious abrasions,burns) need to be attended to as quickly as possible with topical anti-infectives and properdressings. Wounds should be closed as soon as possible and necessary surgical proceduresshould be performed within 36 to 48 h, as radiation can markedly compromise wound healingwithin hours of exposure.

6.5 Necessary Supplies

Unless the hospital itself is the target, the danger of radiation exposure to emergencyhospital personnel is minimal because they are outside of the radiation control zones.Their focus should remain on standard medical care.

Federal, state and local emergency responders should develop plans, training and exer-cises to test and coordinate their capability to receive, stage and dispense SNS assets.


6.6 SYMPTOMS OF ACUTE RADIATION INJURY AND ESTIMATING ABSORBED DOSE / 37

SNS is a national repository of antibiotics, chemical antidotes, antitoxins, life-supportmedications, intravenous administration equipment, airway maintenance supplies, andmedical/surgical items. The SNS Program has countermeasures available for a nuclear orradiological incident that include: (1) a limited supply of chelating agents, Prussian Blue andpotassium iodide; and (2) pain medications, anti-nausea medications, hematopoietic growthfactors, and burn creams. Additionally, the SNS Program has fluid replacement products,gauze dressings, and laceration repair supplies for burn and blast victims. SNS is designed tosupplement and re-supply state and local public health agencies in the event of a nationalemergency anywhere, and at anytime, within the United States or its territories. To receiveSNS assets, the affected state’s governor’s office will directly request the deployment of theSNS assets from the Centers for Disease Control and Prevention or the US Department ofHealth and Human Services. The SNS Program is committed to deliver the relevant assetsdelivered anywhere in the United States or its territories within 12 h of a federal decision todeploy.

6.6 Symptoms of Acute Radiation Injury and Estimating Absorbed Dose

Nausea, vomiting and diarrhea during or shortly after exposure can signal high absorbeddoses of radiation. The minimum short-term whole-body absorbed dose for these symptoms is~100 to 150 rad (~1 to 1.5 Gy). Generally these symptoms occur more rapidly and moreintensely the higher the absorbed dose. If these symptoms appear in less than an hour, theabsorbed dose is very high. If this occurs, the individual should leave the radiation controlzones immediately and promptly seek medical evaluation. While these symptoms could becaused by other health conditions, if they occur within the inner perimeter, they should be pre-sumed to be radiation-exposure related until medical evaluation is made. If the symptomsoccur outside the inner perimeter, and the individual has not conducted previous activitieswithin or near the inner perimeter, the symptoms are more likely due to other agents or envi-ronmental conditions.

The time- and dose-dependent depletion of peripheral blood lymphocytes after humanwhole-body exposure provides an early approximation of absorbed dose. Portable blood cellcounts allow on-site serial lymphocyte counts for determination of lymphocyte depletionkinetics. For example, a normal lymphocyte count in healthy individuals ranges between1,500 and 3,500 mm–3 (Wallach, 1998). Because radiation-induced lymphocyte depletion istransient, this assay can be used only during the first few days after exposure.

Nausea and vomiting are the earliest clinical signs of ARS. Nausea and vomiting aresymptoms that occur as whole-body absorbed doses become high [i.e., >100 rad (>1 Gy)].If these symptoms occur during the conduct of activities within the inner perimeter, theaffected individual(s) should be removed from the inner perimeter. However, it must berecognized that such symptoms may be caused by other agents (e.g., a neurological agent).Thus, emergency responders must be aware there is a potential that they could be dealingwith more than one agent in such an incident.

In the hospital setting, multi-parameter triage [i.e., time to vomiting, lymphocyte kinet-ics, and other biodosimetry indicators (see Glossary)] offers the best early assessment ofthe victim’s absorbed dose.



A software tool has been developed to integrate lymphocyte counts, onset of vomiting, andother clinical data to estimate absorbed dose. This program (the Biodosimetry AssessmentTool) is available online (AFRRI, 2005).

It is almost always true that minimal radiation exposure data are available when medicaltreatment decisions must be made in the ED. No treatment for radiation exposure is neces-sary during transport to the hospital. However, routine life-saving intravenous fluids andcardiac and other medicine consistent with current Advanced Trauma Life Support orAdvanced Cardiac Life Support protocols will occasionally be necessary for treatment of otherinjuries.

6.7 Contamination

6.7.1 Detection of Internal Contamination

Positive results from nasal swabs indicate a potential intake of radioactive material byinhalation and may dictate additional bioassay measurements. However, negative resultsfrom nasal swabs can be misleading and should not be assumed to be a confirmation of nointake. Current models indicate that inhaled material will be clear from the anterior nasalpassages with a half-time of 17 h (ICRP, 1994). Thus, nasal swabs need not be taken immedi-ately and can be taken by first receivers (Section 7.2) once the patient has been stabilized andtransported to the ED. The emergency plan for the ED should include a protocol for obtainingand evaluating these samples.

6.7.2 Use of Contaminated Critical Facilities

To avoid shutting down critical medical facilities or taking critical care equipment out ofservice because of low levels of radioactive contamination, emergency plans should includeprocedures for functioning even with low levels of contamination in the medical facility inorder for the facility to continue to save lives of the victims. Levels at which continued use ofthe facility will cease and decontamination initiated should be specified in the local emer-gency plan. These levels should be established in consultation with local and state radiationcontrol programs.

Medical facilities and emergency transport assets (e.g., fire trucks, ambulances, life-flighthelicopters) should be decontaminated to the extent possible. For some items (e.g., portablerespirators, electrocardiogram leads), replacement may be more cost effective and practicalthan decontamination. Decisions on decontamination should be consistent with the ALARAprinciple (Section 1.1).

Areas of fixed contamination (radioactive material that cannot be easily removed from sur-faces) may exist in patient care areas and should be labeled. Engineering controls (e.g., barri-ers, lead sheeting) should be used to reduce exposure rates to staff and uncontaminated

Nasal swabs can be used to indicate the likelihood that radioactive material has beeninhaled, if internal contamination is suspected.

Plans should be in place for critical medical facilities and critical care equipment to con-tinue functioning with low levels of radioactive contamination.


6.7 CONTAMINATION / 39

patients to less than 2 mR h–1 (~0.02 mGy h–1 air-kerma rate) while decontamination effortsare underway. The 2 mR h–1 exposure rate (~0.02 mGy h–1 air-kerma rate) (when due predom-inantly to photons) is consistent with recommendations made for limiting the dose equivalentrate to 2 mrem h–1 (0.02 mSv h–1) in unrestricted (i.e., public) spaces (NRC, 2004).

The goal should be to keep the cumulative effective dose (see Glossary) from fixed contam-ination to staff and uncontaminated patients to less than 100 mrem (1 mSv) for the yearfollowing the incident, while allowing these critical facilities to remain operational. Achievingthis goal would be comparable to protecting staff and uncontaminated patients to the samelevel as that for members of the public [i.e., 100 mrem y–1 (1 mSv y–1) effective dose (NCRP,1993)]. If that goal cannot be reasonably met, the limit on cumulative effective dose to staffand uncontaminated patients can be increased to 500 mrem (5 mSv) for the year following theincident to allow for proper medical care.

6.7.3 Disposal of Decontamination Fluids

While it is desirable to obtain samples during the decontamination effort that can be usedto determine the radionuclides present, it is not a priority to attempt to contain all the fluidsgenerated during decontamination.

EPA32 has advised that it will not pursue enforcement actions against state and localresponders for the environmental consequences of necessary and appropriate emergencyresponse actions. Further, EPA states that during a hazardous materials incident (includinga terrorist incident involving a chemical or biological agent), emergency responders shouldundertake any necessary emergency actions to save lives and protect the public and them-selves. This advice stems from the Comprehensive Environmental Response, Compensationand Liability Act (CERCLA, 1980). State and local authorities should contact EPA to assurethat this advice is applicable to nuclear and radiological terrorist incidents.

It is not a priority to contain all the fluids generated during decontamination. The inci-dent commander should decide to what degree fluids resulting from decontaminationshould be contained or released based on the severity of the incident, the immediacy ofthe decontamination need, and the resources available in the emergency phase.

32Makris, J. (1999). Personal communication (Office of Solid Waste and Emergency Response, US Environmen-tal Protection Agency, Washington)


7. Training and Exercises

7.1 Objective

There is an abundance of material and advice already available regarding training fornuclear and radiological incident response (FEMA, 2005; NCRP, 2001). The purpose of thisSection is not to replicate the information, but to summarize key aspects including:

• identification of the essential knowledge, skills and abilities needed for each group thatmust be included in any training;

• identification of training and exercise resources and methods; and• recommendations for response organizations, federal agencies that facilitate training,

and training program developers.

7.2 Applicability

This Section will expand on the initial recommendations made by NCRP Report No. 138,Management of Terrorist Events Involving Radioactive Material (NCRP, 2001), which did notspecifically define emergency responders or the content and requirements of training for thatgroup. Individuals involved with emergency response include: fire fighters, EMS, law enforce-ment, health care, public health, and emergency management personnel. This includes publicand private sector organizations and companies.33

This Section addresses the training of two groups whose actions in the early stages of anincident are critical for the protection and preservation of life, property, evidence and theenvironment. The first group is best defined by the Occupational Safety and Health Admin-istration’s (OSHA) 29 CFR Part 1910.120(q) (OSHA, 2005b), which applies to all individualsand agencies that are expected to respond to an emergency involving hazardous materials;that is, career or volunteer fire, EMS or law enforcement personnel. OSHA (2005b) and theUS Environmental Protection Agency’s 40 CFR Part 311 (EPA, 2004) require that emergencyresponse employees be completely trained before they perform in emergencies. At a mini-mum, such training should include the elements of each organization’s emergency responseplan, standard operating procedures, and procedures for notification and handling of emer-gency nuclear and radiological incidents. These individuals are called first responders.

The second group is healthcare workers at risk for exposure to radioactive materials whena hospital receives contaminated patients, particularly during mass-casualty incidents.These hospital employees generally work at a site remote from the location where the incidentoccurred. This means that their exposures are limited to the substances transported to thehospital on victims’ skin, hair, clothing or personal effects. The location and limited source ofcontamination distinguishes these individuals from the first responders noted above, whotypically respond to the incident (Horton et al., 2003; OSHA, 2005a). These healthcare work-ers are called first receivers.

33ANSI's Homeland Security Standards Panel draft work on Standardization for Training Programs for FirstResponse to WMD Events.


7.3 CHALLENGES TO PROFICIENCY / 41

There are many other individuals who play important roles in response to nuclear andradiological terrorism, including public works, emergency managers, and even citizens.Training and education needs for these individuals can be derived from the requirements ofthe two groups identified above depending on the role the individual may perform during anemergency. Additional information on groups involved in emergency response can be found inSection 2.

7.3 Challenges to Proficiency

The majority of first responders in the United States are volunteers or part-time employ-ees and have significant time constraints and limited flexibility to attend training. Evenfull-time response employees have difficulty maintaining proficiency in the skills needed torespond to commonly occurring emergencies (e.g., fires, hazardous material spills, traffic acci-dents) without the additional requirements of preparing for response to an incident involvingradiation or radioactive material. This makes determining what constitutes a minimum levelof proficiency and ensuring minimum requirements are met of critical importance.

The National Fire Protection Association (NFPA, 2002a) and OSHA (2005b) have definedcore competencies for awareness, operations, technician and incident commander levels foremergency response employees. Although there are basic competencies, no single genericcourse can meet the diverse needs of the police, fire, EMS, public works, transportation, san-itation employees, and others.

The same level of legal requirements does not exist for first receivers, although guidancein grant programs (Section 7.9) provides some incentive for conformity. Appendix A.3 identi-fies a similar set of competency levels for first receivers comparable to the first responder com-petency levels.

7.4 Training, Exercises and Lessons Learned

Maintaining competency requires an integrated training, exercise and lessons learned pro-gram. In addition to the practical exercises that are part of any training program, organiza-tional exercises that reinforce the training, standard operating procedures, and operationalguidelines are essential to keep organizational capabilities up to date. Improvements toresponse protocols and training programs depend on the ability to effectively capture lessonslearned from exercises and actual responses.

Financial and technical assistance on training and exercises can be found in the USDepartment of Homeland Security’s (DHS) Homeland Security Exercise and Evaluation Pro-gram (HSEEP) (DHS, 2005a), developed to enhance and assess terrorism prevention,response and recovery capabilities at the federal, state and local levels. HSEEP is a threat-and performance-based exercise program that provides doctrine and policy for planning, con-ducting and evaluating exercises.

7.5 Training Content

Most first responders and first receivers who have received no or minimal training on radi-ation will tend to overestimate its effects. Radiation is often equated to the hazards of chem-ical warfare agents that can kill or injure in small amounts. Unfortunately, this often leads toinappropriate responses to a nuclear or radiological incident, such as the delay of victim res-cue and transport, or vigorous, and often unnecessary, decontamination practices.


42 / 7. TRAINING AND EXERCISES

To meet these objectives, awareness level training should be customized and provided tothe broadest possible audience. General awareness level competencies are described belowand will provide the foundation required to understand several key messages about emer-gency response to a nuclear or radiological incident.

34

NFPA (2002a; 2002b; 2002c) and OSHA (2005b) define the general content and objectivesof all the first responder competency levels. For example, the first responder awareness com-petency level requires:

• an understanding of what hazardous materials are and the associated risks; • an understanding of potential outcomes when hazardous materials are present; • the ability to recognize the presence of hazardous materials; • an understanding of first responders’ roles and use of the North American Emergency

Response Guidebook (DOT, 2005); and• the ability to recognize the need for additional resources and knowledge of the proce-

dures to make the appropriate notifications.

When these generic principles are applied to nuclear and radiological incidents, they canbe written as:

• an understanding of what radiation and radioactive materials are, and the risks asso-ciated with them in an incident;

• an understanding of the potential outcomes associated with an emergency that arecreated when radiation or radioactive materials are present;

• the ability to recognize the presence of radioactive materials in an emergency;• the ability to identify the types of radioactive materials present, if possible;

The overall nuclear and radiological training objectives for emergency responders are:(1) to enhance their ability to take appropriate measures to protect themselves and thepublic, and (2) to increase their confidence about effectively managing an emergencyinvolving radiation or radioactive materials.

Key messages of nuclear and radiological preparedness training should include:

• rescue and medical emergencies take precedence over radiological concerns;34

• nuclear and radiological incidents can be safely managed using emergencyresponders’ equipment and protocols;

• being contaminated is rarely life-threatening; and • being exposed to radiation does not make an individual radioactive.



7.6 EXERCISE TYPES / 43

• an understanding of the role of first responders (at the awareness level) in the emer-gency response plan (including site security and control) and use of the North Ameri-can Emergency Response Guidebook; and

• the ability to realize the need for additional resources, and to make appropriate notifi-cations to the incident communication center.

Further objectives, procedures and key facts on the nuclear- and radiological-specificelements of the various competency levels for first responders and first receivers can be foundin Appendix A.

7.6 Exercise Types

As identified in the HSEEP documents (DHS, 2005a) and NCRP (2001), there are a varietyof exercises that can be used to better prepare an organization for emergencies. The threemain types of exercises are: table-top, command-post (or functional), and full-field (or full-scale).

Table-top exercises involve senior staff, elected or appointed officials, or other key person-nel in an informal setting, discussing simulated situations. This type of exercise is intendedto stimulate discussion of various issues regarding a hypothetical situation. It can be used toassess plans, policies and procedures or to assess types of systems needed to guide the pre-vention of, response to, and recovery from a defined incident.

Command-post (or functional) exercises are designed to test and evaluate individual capa-bilities, multiple functions or activities within a function, or interdependent groups of func-tions. They are generally focused on exercising the plans, policies, procedures and staffs of thedirection and control nodes (i.e., the command structure). Generally, incidents are projectedthrough an exercise scenario with incident updates that drive activity at the managementlevel. Movement of personnel and equipment is simulated.

Full-field (or full-scale) exercises are multi-agency, multi-jurisdictional exercises that testmany facets of emergency response and recovery. They include many emergency respondersoperating under the command structure. The incidents are projected through a scripted exer-cise scenario with built-in flexibility to allow updates to drive activity. They are conducted ina real-time, stressful environment that closely mirrors a real incident. Emergency respondersand resources are mobilized and deployed to the scene where they conduct their actions as ifa real incident had occurred.

The type of exercise that best meets an organization’s requirements is identified throughanalysis of the stated exercise purpose, proposed objectives, experience, operations, and rec-ommended levels of participation. Exercises should focus on a few key objectives.

7.7 Initial Training

All emergency responders should undergo initial training at a level corresponding to theduties and functions that the responder would be expected to perform during a nuclearor radiological incident. Emergency responders who may take part in life-saving activi-ties should be trained at the operations level (Appendix A.2.2).



Training should be based on the duties and functions to be performed by each emergencyresponder in an emergency response organization. The knowledge, skills and abilitiesrequired for all new emergency responders should be conveyed to them through trainingbefore they are permitted to take part in actual emergency operations at the site of an inci-dent. Table 7.1 summarizes the duration, type and frequency of training for first respondersrecommended for each level by OSHA (2005b) and NFPA (2002a). Note that this is the mini-mum time for “all-hazards” hazardous-materials training needs, and chemical, biological,radiological, nuclear and explosives (CBRNE) training needs; approximately one-fourth of thetime should be spent on the nuclear and radiological components.

7.8 Training and Exercise Frequency

Exercises can help encourage training and aid in retention of training material. Exercises,like training, should take an all-hazards approach.

Emergency responders should undergo annual refresher training to maintain proficiency.The refresher training does not need to be as extensive as the initial training.

Drills or exercises should be conducted at least annually. However, full-field exercises areonly necessary every 3 y. During the exercise cycle, mechanisms for accessing and distrib-uting SNS assets should be exercised periodically.

Exercise schedules should regularly involve all types of emergency responders to main-tain the proficiency of all components of the emergency-response infrastructure, includ-ing first responders, first receivers, hospitals, communications, mental health, and publichealth.

TABLE 7.1—Type and duration of training for each first responder competency level.

Level Training Prerequisite and Minimum Requirementsa Type

Awareness No legal minimums identified, 4 to 16 h common practice

Classroom

Operations Awareness + 8 h required, 8 to 40 h common practice

Classroom, practical,exercises

Technician Awareness + 24 h required, 40 to 240 h common practice

Classroom, practical,exercises

Command 24 h at operations level + incident commander training

Classroom, exercises

aTimes listed are for “all-hazards” hazardous-materials and CBRNE training. Approximately one-fourth of the time should be spent on training for nuclear and radiological incidents.


7.9 TRAINING AND EXERCISE RESOURCES / 45

7.9 Training and Exercise Resources

The Department of Homeland Security (DHS) offers a Compendium of Federal TerrorismTraining online.35 This compendium is intended to serve as a broad review of the federaland some private sector terrorism training that is offered to assist communities in preparingfor terrorist attacks. Information on over 140 federal training courses includes the sponsor,description, objectives, areas of competencies, target audience, type of instruction (e.g.,classroom, computer), and other relevant information (locations, availability and points ofcontact).

DHS offers specialized and advanced training through government sponsored trainingcenters and providers. States may also use grant funds to support CBRNE training activitieswithin existing training academies, universities, junior colleges, or attendance at approvedCBRNE classes. Although local training program development is encouraged to cultivatelocal capabilities and expertise, DHS evaluation and approval for locally developed trainingfor grant support can take some time. DHS uses training preparedness officers to assist statesin understanding and prioritizing their training resources. Their role includes helpingdevelop and identify appropriate training resources and identifying funding and availableassistance resources.36

A separate, similar DHS program exists for exercises. In accordance with the HSEEP man-ual (DHS, 2005a), an exercise manager is assigned to work with each state and its jurisdic-tions to help develop and find resources to support an integrated exercise program.

In addition, to access the programs noted above, first receivers have grant programs fortraining and exercises through the US Department of Health and Human Services. Such pro-grams include direct grants to academic institutions (e.g., the Centers for Disease Control andPrevention-funded Centers for Health Preparedness) and Health Resources and ServicesAdministration training and exercise grant programs administered by state and local healthdepartments.

7.10 Recommendations

Optimally, most first responders and first receivers should have competency in the nuclearand radiological aspects of operations-level training. First responders at the operational levelare those individuals who respond to releases or potential releases of hazardous materials aspart of the initial response to the incident for the purpose of protecting nearby individuals,the environment, or property from the effects of the release. They should be trained to respondin a defensive fashion to control the release from a safe distance and keep it from spreading(NFPA, 2002a).

7.10.1 National Policy Issues

Conducting the training necessary to prepare the nation for nuclear and radiological ter-rorism is a much larger task than any one federal agency can perform, however one organi-zation should be given the task, the resources, and the authority to lead the training efforts.

35The full compendium, including the appendices, contains more than 400 pages. An updated electronic copy ofavailable courses is accessible via the DHS website (FEMA, 2005).

36For information on the full range of DHS sponsored training or to obtain a copy of the Office for DomesticPreparedness (ODP) Weapons of Mass Destruction Training Programs course catalog, contact the CentralizedScheduling Information Desk at (800) 368–6498 or visit the DHS/ODP website (DHS, 2005b).



State and local authorities also have a role in this training. Based on the findings by the Fed-eral Emergency Management Agency (FEMA, 2002b), this Commentary makes the followingrecommendations to improve terrorism preparedness training:

• designate one entity to lead federal terrorism training efforts;• adopt a competency-based approach including a master list of competencies for appro-

priate response groups;• create an interagency training management system;• utilize existing instructional delivery systems;• use multiple instructional delivery methods (e.g., classroom, distance learning, mobile

training teams, and exercises);• address interoperability training among police, fire, public works, and other emergency

management functions;• enhance and plan for sustainment of training (e.g., refresher training); and• study training needs of small and rural communities.

7.10.2 Development of Nuclear and Radiological Training Programs

The recommendations below represent several key concepts that will facilitate effectivelocal, state or national training programs. Several good examples of training programs can befound that use many of these concepts. An excellent example of a healthcare preparednessprogram can be found in California’s Emergency Medical Services Authority training,CBRNE: Emergency Preparedness for Medical Care Providers (CEMSA, 2005). Although itprimarily addresses radiological transportation emergencies and not terrorism concerns,another good example of a radiological preparedness program can be found in the US Depart-ment of Energy’s Transportation Emergency Preparedness Program (DOE, 2005).

7.10.2.1 Effective Integration. There are two main organizations that provide curriculumguidelines for hazardous materials incident response. OSHA (2005b) identifies minimumtraining requirements and NFPA, in its 472 and 473 standards (NFPA, 2002a; 2002b), iden-tifies additional training recommendations (FEMA, 2003). Nuclear and radiological trainingdeveloped for hazardous materials responders should be consistent with the competencylevels (i.e., awareness, operations and technician) and training objective minimums andrecommendations defined in these documents.

Healthcare workers (first receivers) represent another group that has specialized trainingneeds. Although state healthcare worker training requirements vary, the Joint Commissionon Accreditation of Healthcare Organizations requires emergency management drills twice ayear in Standard EC.4.20 (JCAHO, 2005).

7.10.2.2 Accreditation and Continuing Education. Although certification may not always berequired, all training programs should aggressively seek accreditation for continuing medicaleducation units from the appropriate professional society. This process will (1) ensure that thetraining program meets the needs of the profession and (2) help professional societies under-stand the importance of radiological terrorism training for topical inclusion in board certifi-cations and continuing educational units.

Training programs should be developed and organized to effectively integrate into theoverall training requirements of the organization, and should be reinforced through pro-fessional accreditation or continuing education credits, whenever possible.


7.10 RECOMMENDATIONS / 47

7.10.2.3 Modules. Training topics should be separated into modules lasting less than 45 minin duration. This allows response organizations flexibility to provide the training in a mannerthat meets their training demands and facilitates interchangeable content. Pre-tests shouldbe used to allow trainees familiar with the material to engage the training program at theappropriate level for their previous training and experience. Table 7.2 provides an example ofa modular training program for nuclear and radiological incidents.

7.10.2.4 “Hands-On” Demonstrations and Practical Exercises. Training programs shouldintegrate a significant number of “hands-on” demonstrations and practical exercises into thetraining curriculum. Even at the awareness level, simple demonstrations of the principles ofradiation using trainees’ own equipment or an interactive exercise can significantly increasetrainee confidence and knowledge retention.

7.10.2.5 Instructional Delivery Systems. A variety of instructional delivery systems should beused to enhance educational options, including:

• classroom instruction• computer-based training materials• web-based training materials• self-study materials• videos• practical exercises

As with modular training, multiple instructional delivery systems will promote inter-changeable and customized training programs that meet the needs of the user community.

7.10.2.6 “Just-in-Time” Refresher Training Guides and Materials. During a major emergencywhere additional resources may be utilized from outlying areas, there will often be time toprovide “just-in-time” refresher training to the these emergency responders. This materialshould be included in the initial training and helps remind trainees of key subject competen-cies. The training should be short, perhaps a few pages or a 20 min video or instruction, andshould be immediately accessible in times of crisis.

7.10.2.7 Instructors. Training should be provided by an instructor with nuclear and radiolog-ical incident response expertise. The most credible instructor is one who is in the trainees’field and has actually performed work with high levels of radiation or contamination. Becauseof this nation’s excellent safety record with radioactive materials, there are very few emer-gency responders who have actually responded to nuclear or radiological emergencies. How-ever, there are health physicists and radiation protection specialists throughout the nationwho regularly work in a radiation environment and respond to “on-site” radiological emergen-cies. Access to these professionals, many of whom are in the trainees’ area, can be foundthrough their professional societies or accrediting organizations such as the Health PhysicsSociety, the American Board of Health Physics, the American Association of Physicists inMedicine, the American Board of Medical Physics, the American College of Radiology, or theNational Registry of Radiation Protection Technologists. It should also be noted that individ-uals certified by the American Board of Health Physics and the National Registry of Radia-tion Protection Technologists meet the technical competencies of the NFPA and OSHATechnician Employee – Radiological (NFPA, 2002a; OSHA, 2005b).



7.10.2.8 Reinforcement of Local Policy and Procedures. When training programs are appliedto a locality, preparatory actions should include reviewing local nuclear and radiologicalresponse protocols, procedures and resources. This is very important for three reasons:

• reinforcement of the policies and protocols used in the trainees’ organization• ensuring that generic protocols offered in the training do not contradict local or state

protocols for responding to a nuclear or radiological incident; and• ensuring that the trainee understands what local and state resources are available, and

how nuclear and radiological incidents are managed within the trainees’ organization.

TABLE 7.2—Example of a modular training program for nuclear and radiological incidents.

Hazardous Materials(example of 45 min modules)

Competency Level

Radiological basics Awareness

Biological effects of ionizing radiation Awareness

Hazard recognition Awareness

Initial response actions Awareness

Radioactive material shipping packages Awareness

Radiological terrorism Awareness

Nuclear weapons effects and response overview Awareness

Radiological equipment and guidelines overview Awareness

Contaminated patient handling Operations / EMS

Scene and incident control Operations

Radiological terminology and units Operations / technician

Assessment of shipping package integrity Technician

Tactics and strategy Technician

Information resources and federal responders Technician

Radiation measurement instruments and devices Technician

Decontamination Technician

Pre-hospital practices EMS

Psychosocial impacts Operations / technician / command

Incident commander – response phase Command

Incident commander – recovery phase Command


7.10 RECOMMENDATIONS / 49

For nuclear and radiological incidents, this information is usually available through thestate radiation control office.37

7.10.2.9 Perpetuation Within the Recipients’ Organization. Many organizations can perpetu-ate nuclear and radiological training within their organizations using their own in-houseinstructors, technician level emergency responders, or local expertise. Given the large num-ber of emergency responders that need training (and retraining), this should be encouragedand facilitated through:

• initial “train-the-trainer” sessions• blended training delivery38

• “just-in-time” training guides• detailed “instructor guides”• predeveloped practical exercises, exams and presentations

37A listing of local contacts can be found on the CRCPD website (CRCPD, 2005).38Blended training refers to using a variety of delivery methods to train emergency responders (e.g., tradi-

tional classroom instruction and exercises; as well as web-based, computer-based, and video teletraining meth-ods). More information on the blended learning approach can be found on the DHS website (DHS, 2005c).


Appendix A

Essential Training Competencies

A.1 Overview

The required knowledge, skills and abilities of emergency responders can be summarizedunder four headings: (1) hazards awareness, (2) objectives, (3) key facts, and (4) procedures.

A.1.1 Hazards Awareness

An objective awareness of the hazards associated with each particular type of emergencyis essential so that personnel involved: (1) do not make the existing situation worse; (2) do notbecome part of the problem; and (3) can understand, evaluate and control their own personalrisk. In particular, a proper perspective is important where radiation or radioactive materialis involved to ensure that emergency responders appropriately balance the real risks, and donot become overly concerned about insignificant radiation or contamination levels.

Appendix 7 in IAEA’s Method for Developing Arrangements for Response to a Nuclear orRadiological Emergency (IAEA, 2003) contains guidance for 19 different nuclear or radiolog-ical emergencies, including intentional incidents. For each type of incident the potential haz-ards and emergency response procedures for the main groups of personnel involved are given.

A.1.2 Objectives

Individuals responding to an emergency should understand the overall objectives of theresponse as well as their own specific objectives. A proper understanding of objectives willenable emergency responders to appropriately prioritize resources, including focusing theirown particular efforts.

The following is a list of overall goals for nuclear and radiological incident response and isadapted from IAEA (2002):

• regain control of the situation;• prevent or mitigate the consequences at the scene;• prevent the occurrence of acute health effects in workers and the public;• render first aid and manage the treatment of radiation injuries;• keep radiation exposures ALARA, and therefore limit the additional risk of cancer to

the population;• prevent, to the extent practicable, the occurrence of nonradiation hazards for the

affected individuals or populations;• protect, to the extent practicable, property, evidence and the environment; and• prepare, to the extent practicable, for the resumption of normal social and economic

activity.


A.2 FIRST RESPONDERS / 51

A.1.3 Key Facts

In each of the various disciplines involved in a nuclear or radiological incident responsethere are a few key pieces of information that should form the foundation of each individual’sknowledge base. These are the basic principles that, if all else is forgotten, will enable the indi-vidual to perform his or her duties essentially correctly. As an example from Mettler and Upton(1995), a key fact is that “All patients should be medically stabilized from their traumatic inju-ries before radiation injuries are considered” (see Section 7.5 for a list of key messages).

A.1.4 Procedures

The bulk and the core of any nuclear and radiological incident response training, apartfrom the awareness level, will involve learning the procedures for that particular disciplineor function. Ideally, procedures should be logical, sequential and fit within the normal workcontext. They can be taught initially in class, but must be routinely practiced and exercisedin order for them to become familiar.

A.2 First Responders

A.2.1 Awareness Level

First responders trained at the awareness level are individuals who are likely to witnessor discover a nuclear or radiological incident and may initiate an emergency responsesequence by notifying the proper authorities. They would take no further action beyond noti-fying the authorities and employing basic radiation protection principles to avoid unneces-sary radiation exposure. First responders at the awareness level should have sufficienttraining or sufficient experience to objectively demonstrate competency in:

• understanding what radiation and radioactive materials are, and the risks associatedwith them in an incident;

• understanding the potential outcomes associated with an emergency created whenradiation or radioactive materials are present;

• recognizing the presence of radioactive materials in an emergency;• taking actions to minimize their radiation exposure;• identifying the radioactive materials, if possible;• understanding the role of the first responder (at the awareness level) in the emergency

response plan, including site security and control and the US Department of Transpor-tation's Emergency Response Guidebook (DOT, 2005); and

• realizing the need for additional resources, and to make appropriate notifications tothe incident communication center.

The key points to be emphasized with regard to the awareness level are:

• recognition of the nuclear or radiological nature of an incident, and initiation and supportof a response by operations or technician level personnel is part of their responsibility;

• rescue and medical emergencies take precedence over radiological concerns;39



52 / APPENDIX A

• nuclear or radiological emergencies can be safely managed using responders’ equip-ment and basic radiation protection principles;

• being contaminated is rarely life-threatening; and• being exposed to radiation does not make an individual radioactive.

If possible, it is recommended that trainees have an overview of:

• radiation equipment used by the trainees’ organization; and• policies and guidelines on radiation control zones and the decision dose that apply to

the trainee’s organization.

First responders trained at the awareness level will typically include most law enforce-ment or security personnel.

A.2.2 Operations Level

First responders trained at the operations level are individuals who respond to nuclear orradiological incidents, including releases or potential releases of radioactive materials, as partof the initial response to the scene for the purpose of protecting nearby individuals, property,or the environment from the effects of the incident. They are trained to respond in a defensivefashion without actually trying to stop any release. Their function is to contain the releasefrom a safe distance, keep it from spreading and to minimize exposures, by keeping or movingpeople away.

First responders at the operations level should have received at least 8 h of training or havesufficient experience to objectively demonstrate (in addition to the competencies listed for theawareness level) competency in:

• knowing the basic radiation hazards and risk assessment techniques;• selecting and using proper PPE and radiation-monitoring instrumentation;• performing first aid and life-saving operations;• understanding basic radiation and radioactive materials terms;• performing basic control, containment and confinement operations within the capabili-

ties of the resources and PPE available with their unit;• being aware of additional factors that may need to be considered at intentional nuclear

or radiological incidents, such as secondary devices, multi-agent incidents, security,and crime scene issues;

• implementing basic decontamination procedures;• understanding the relevant standard operating procedures;• understanding the medical prophylaxis and countermeasures that exist for radiation

exposure; and• being aware of the psychosocial impacts of nuclear and radiological incidents, including

their potential effects on the general public and on emergency responders.

The main goals of an operation-level response are to: evaluate the hazards, save lives,control the situation and area, and secure additional help. Most fire fighters and emergencymedical response personnel (including pre-hospital healthcare workers) should be trained tothe operations level.


A.2 FIRST RESPONDERS / 53

A.2.3 Technician Level

Hazardous materials technicians are individuals who respond to releases or potentialreleases for the purpose of stopping the release. They assume a more aggressive role than afirst responder at the operations level in that they will approach the point of release to plug,patch or otherwise stop the release of a hazardous substance. With regard to incidents involv-ing radioactive materials, an individual at the technician level should be able to characterize(quantify and identify) any radiation or contamination present using available instrumenta-tion as well as direct or advise on initial protective actions.

Nuclear and radiological incident response technicians should have received at least 24 hof training equal to the first responder operations level and, in addition, demonstrate compe-tency in:

• implementing the emergency response plan;• knowing the classification, identification and verification of known and unknown radi-

ation and radioactive materials by using field survey instruments and equipment;• functioning within an assigned role in the Incident Command System;• selecting and using proper specialized PPE provided to the hazardous materials

technician;• understanding radiation hazards and risk assessment techniques;• performing advance control, containment and confinement operations within the capa-

bilities of the resources and PPE available with the unit;• understanding and implementing decontamination procedures.;• understanding termination procedures to end the emergency phase of an incident;• understanding basic radiation and radioactive materials terminology and behavior;• identifying ARS symptoms and performing basic triage; and• being aware of the psychosocial impacts of nuclear and radiological incidents, including

their potential effects on the general public and on responders.

The key points for the technician level are to: characterize the nuclear or radiological haz-ard and provide further advice to the incident commander based on this assessment. Somefire fighters and all members of hazardous-material response and EMS teams should betrained to the technician level.

A.2.4 Command Level

Incident commanders, who will assume control of the incident, should receive at least 24 hof training equal to the first responder operations level and, in addition, have competency in:

• knowing and implementing the incident command system;• knowing and understanding the hazards and risks associated with employees working

in protective clothing;• implementing the local emergency response plan;• knowing the state emergency response plan and the Federal Radiological Emergency

Response Plan;• knowing and understanding the importance of decontamination procedures; and• being aware of the psychosocial impacts of nuclear and radiological incidents, and

understanding their potential implications for response operations.

The key points for the incident command level are to: manage a scene and be aware of addi-tional resources that are available and how to contact and activate them.


54 / APPENDIX A

A.3 First Receivers

Healthcare workers at a hospital receiving irradiated or contaminated victims for treat-ment may be termed first receivers (OSHA, 2005a). This group is a sub-set of emergencyresponders. However, first receivers are usually remote from the location where the incidentoccurred. Thus the exposure of first receivers is limited to the radioactive material arrivingat the hospital as a contaminant on victims and their clothing or personal effects. First receiv-ers typically include personnel in the following roles: clinicians (physicians, nurses, nursepractitioners, physician assistants, and others) and other hospital staff who have a role inreceiving and treating contaminated victims (e.g., triage, decontamination, medical treat-ment, and security) and those whose roles support these functions (e.g., set up and patienttracking).

A.3.1 Awareness Level

This level is appropriate for hospital personnel, such as administrators, maintenance oroffice staff members that are not directly involved in the triage, decontamination or medicaltreatment of irradiated or contaminated patients. First receivers at the awareness levelshould have sufficient training or sufficient experience to demonstrate competency in:

• being aware of the distinction between an irradiated and a contaminated patient, aswell as the difference between being internally and externally contaminated;

• being aware that the radiation hazard to attending personnel from an irradiatedpatient is zero, and that from most contaminated patients it is minimal;

• being aware of the necessity for access control to areas where potentially contaminatedpatients are being received and treated; and

• being sensitive to the particular needs of victims of nuclear and radiological incidents.

A.3.2 Operations Level

Personnel involved with receipt, triage, initial medical treatment, and decontamination ofpatients should be trained at the operations level, which includes (in addition to the aware-ness level competencies) competency in:

• knowing medical triage, and particularly the necessity of assessing traumatic injuryand medical conditions prior to consideration of radiation exposure or contamination;

• knowing contamination control methods, and that removing clothing removes mostexternal contamination;

• recognizing that mass casualties may overwhelm health care resources and adaptabletriage methods will be indicated, including the use of the onset of time to vomiting as akey indicator of the radiation dose and prognosis;

• being aware of the psychosocial impacts of nuclear and radiological incidents, includingtheir potential effects on the general public and on responders;

• knowing methods for decontamination of radioactive materials from skin and wounds;• taking a medical history and conducting a physical examination;• knowing the prodromal signs and symptoms of ARS and the importance of noting their

time of onset, duration and severity;• being aware of the usefulness of nasal swabs for evaluating the presence of internal

contamination via inhalation;• being aware of the availability of cytogenetic biodosimetry;


A.4 OTHERS / 55

• knowing the need for an initial complete blood count and a repeat count every 4 to 6 hto evaluate lymphocyte depletion kinetics;

• being aware of a possible need for treatment for internal contamination; and• knowing the potential medical complications and management of casualties with com-

bined injuries (e.g., radiation and thermal burns, radiation and wounds).

A.3.3 Technician Level

These are mainly the physicians and other medical staff who are responsible for thelonger-term medical treatment of individuals who are significantly irradiated or internallycontaminated. These individuals should have competency in:

• knowing the levels of radiation dose associated with the onset of dermal (skin) mani-festations;

• knowing the levels of radiation dose associated with ARS;• obtaining cytogenetic biodosimetry;• knowing the therapeutic and palliative treatments for irradiated patients;• knowing current methods for the treatment for internal contamination;• understanding the psychological impacts of nuclear and radiological incidents, and of

resources and approaches for assisting patients and their families; and• managing casualties with combined injuries.

A.4 Others

A.4.1 Public Information Officers

This Section assumes that public information officers have already been trained in how todo their job. Therefore, only the additional training necessary to deal with nuclear and radio-logical incidents is addressed. These individuals should have competency in:

• being aware of the likely intense media and public interest in nuclear and radiologicalincidents;

• being aware of the common misunderstandings and perceptions with regard to thehazards and health impacts of radiation and radioactive materials;

• understanding the basic terminology associated with radiation and radioactive materi-als, their uses and health impacts as well as associated standard protective actions;

• understanding the balance between information dissemination and confidentialityassociated with intentional nuclear and radiological incidents;

• being aware of the importance of conveying useful, factual information rather thanspeculation; and

• knowing the content of Section 7 and Appendix E in NCRP Report No. 138 (NCRP,2001).

A.4.2 Public Health Department Staff

The Columbia University School of Nursing has published a guide (CUSN, 2001) of compe-tencies needed by the public health workforce to prepare for and respond to acts of terrorism.This guide identified nine core competencies; these core competencies were subsequentlyadopted by the Centers for Disease Control and Prevention, and have formed the basis foron-going training of public health workers. These individuals should have competency in:


56 / APPENDIX A

1. describing the public heath role in emergency response in a range of emergencies thatmight arise;

2. describing the chain of command in emergency response;3. identifying and locating the agency emergency response plan (or the pertinent portion

of the plan);4. describing public health workers’ functional role(s) in emergency response and demon-

strating those role(s) in regular drills;5. demonstrating correct use of all equipment used for emergency communications (e.g.,

phone, telefax, radio);6. describing communication role(s) in emergency response: (a) within the agency using

established communication systems, (b) with the media, (c) with the general public,and (d) with personal family and neighbors;

7. identifying limits to one’s own knowledge, skill and authority, and identifying keysystem resources for referring matters that exceed these limits;

8. recognizing unusual events that might indicate an emergency and describing appropri-ate action; and

9. applying creative problem solving and flexible thinking to unusual challenges withinpublic health workers’ functional responsibilities and evaluating effectiveness of allactions taken.

These competencies imply the need for training in a variety of areas, including:40

• the “all-hazards” model [1];• the concepts of prevention, preparedness, response and recovery [1,8,9];• the roles of public health, public safety, and public works [1];• the National Incident Management System and incident command [2,4,5];• the development and accreditation of an emergency response plan [3];• weapons of mass destruction (sources, agents, environmental distribution, exposure,

health effects) [4];• surveillance, population monitoring, and environmental monitoring [4,8];• psychosocial, mental health, and risk communication issues [6];• medical countermeasures [4];• mass-casualty handling (including dead bodies) [4];• forensic epidemiology [1,4,8]; and• evaluation [7].

When applied to nuclear and radiological terrorism, training of the public health workforceshould specifically include the following subjects:

• sources of radioactive materials and nuclear weapons;• radiation terrorism scenarios (e.g., RDDs, an attack on an established nuclear facility,

INDs, an attack on radioactive material in transit);• characteristics of and distinctions between REDs, RDDs and INDs;• decontamination procedures for external contamination;• processes used to reduce internal contamination (NCRP, 1980);• methods of assisting with mass-casualty handling and surge capacity, with a focus on

decontamination and treatment of radiation syndromes;

40The numbers in brackets indicate the relevant competencies.


A.4 OTHERS / 57

• specific radiological factors in forensic epidemiology;• risk perception and vulnerability to mental health impacts of radiation terrorism;• identification of population subgroups at high risk (for either physical or mental health

adverse effects);• specific risk communication messaging to the public (pre-event, crisis-phase, and

consequence-phase);• use of radiopharmaceuticals in medicine, and use of sealed radioactive sources in tele-

therapy and brachytherapy;• short-term population monitoring (for both physical and mental health effects); and• post-event long-term population monitoring (for both physical and mental health

effects).


Glossary

absorbed dose: The energy imparted by ionizing radiation to matter per unit mass at the point ofinterest. In SI, the unit is joule per kilogram (J kg–1), given the special name gray (Gy) (see radand cumulative absorbed dose).

accuracy: The degree of agreement between the observed value and the conventionally true value ofthe quantity being measured.

acute radiation syndrome (ARS): A broad term used to describe a range of acute signs and symp-toms that reflect severe damage to specific organ systems that can lead to death within hours orseveral weeks.

air kerma (kerma in air): Kerma (kinetic energy released per unit mass) is the sum of the initialkinetic energies of all the charged particles liberated by uncharged particles per unit mass of aspecified material. The SI unit of kerma is joule per kilogram (J kg–1), with the special name gray(Gy). Kerma can be quoted for any specified material at a point in free space or in an absorbingmedium (in this case air).

alarm: An audible, visual or other signal activated when an instrument reading or response exceedsa preset value or falls outside a preset range.

alpha particles: (see radiation types).antitoxin: An antibody formed in response to antigenic poisonous substances of biologic origin. as low as reasonably achievable (ALARA): A principle of radiation protection philosophy that

requires that exposures to ionizing radiation should be kept as low as reasonably achievable, eco-nomic and social factors being taken into account. The protection from radiation exposure isALARA when the expenditure of further resources would be unwarranted in relation to the reduc-tion in exposure that would be achieved.

becquerel: (see radiation units and names).beta particles: (see radiation types).biodosimetry: Use of a biological response as an indicator of a dose of an effective agent (e.g., the

extent of decline in peripheral blood lymphocytes of humans exposed to ionizing radiation can beused as an indicator of the absorbed dose to the whole body from that exposure).

bunker gear: A firefighter’s protective clothing. Bunker gear usually consists of boots, pants, coat,gloves, hood and helmet. Also called personal protection equipment and includes a self-containedbreathing apparatus.

calibration: The act of standardizing an instrument to a known source, or a laboratory procedure toa known result.

combined injury: Radiation injury exacerbated by other types of bodily injury (e.g., skin burns, openwounds).

complete blood count: A calculation of the number of red and white blood cells in a cubic millimeterof blood, by means of counting the cells in an accurate volume of diluted blood.

cumulative absorbed dose: In this Commentary, a real-time integration of absorbed dose to thewhole body from photons.

curie: (see radiation units and names).decision dose: In this Commentary, a cumulative absorbed dose to the whole body (from photons) of

50 rad (0.5 Gy) to a specific emergency responder. At that whole-body absorbed dose, the decisionat the command level is whether the emergency responder should be withdrawn from the radiationcontrol zones.

decontamination: The removal of radioactive contaminants from surfaces (e.g., skin) by cleaningand washing.

dermal: A term meaning of or relating to the skin.


GLOSSARY / 59

detector: A device or component designed to produce a quantifiable response to ionizing radiation,normally measured electronically.

dose: In this Commentary, used as a generic term when not referring to a specific quantity, such asabsorbed dose.

dose equivalent: The absorbed dose at a point in tissue, modified by the quality factor at that point.The quality factor takes into account the relative effectiveness of a type of ionizing radiation ininducing stochastic health effects (the quality factor for photons is assigned a value of unity). TheSI unit for dose equivalent is the joule per kilogram (J kg–1) with the special name sievert (Sv) (seealso rem).

effective dose: The sum over specified tissues of the products of the equivalent dose in a tissue ororgan and the tissue weighting factor for that tissue or organ. The tissue weighting factor repre-sents the fraction of the total radiation detriment to the whole body attributed to that tissue whenthe whole body is irradiated uniformly. The SI unit for effective dose is the joule per kilogram(J kg–1), with the special name sievert (Sv) (see also equivalent dose).

electromagnetic: An adjective that describes the broad range of radiations that include: radiowaves; microwaves; infrared, visible and ultraviolet radiation; x and gamma rays (i.e., the electro-magnetic spectrum).

energy-dependent detector: An instrument that has a response that varies as a function of radia-tion energy.

equivalent dose: A quantity used for radiation protection purposes that takes into account thedifferent probabilities of stochastic effects that occur with the same absorbed dose delivered byradiations with different radiation weighting factors. It is defined as the product of the meanabsorbed dose in an organ or tissue modified by the radiation weighting factor. The SI unit ofequivalent dose is the joule per kilogram (J kg–1), with the special name sievert (Sv) (see also radi-ation weighting factor and stochastic effects).

exposure: In this Commentary, exposure is used often in its general sense, meaning to be irradiated.When used as a defined radiation quantity, exposure is a measure of the ionization produced in airby x or gamma radiation. The SI unit of exposure is coulomb per kilogram (C kg–1). The special unitfor exposure is roentgen (R), where 1 R = 2.58 × 10–4 C kg–1. Air kerma is often used in place ofexposure. An exposure of 1 R corresponds to an air kerma of 8.76 mGy (see also roentgen, gray,air kerma).

exposure rate: The exposure per unit time [e.g., 1 roentgen per hour (1 R h–1) (~0.01 Gy h–1

air-kerma rate)].false positive: In the context of this Commentary, an alert not caused by the radiation source of

interest (i.e., an RED, RDD or IND); an indication of a positive meter reading where no radiationsource of interest exists.

gamma rays: (see radiation types).gray (Gy): (see radiation units and names).indication: A displayed signal from an instrument to the user conveying information such as scale or

decade, status, malfunction or other critical information.instrument: A complete system consisting of one or more assemblies to quantify one or more charac-

teristics of ionizing radiation or radioactive material.lymphocyte kinetics: An assessment of the number of lymphocytes per unit volume of blood at peri-

odic intervals to determine if their numbers are maintaining, increasing or decreasing with time.With substantial whole-body exposures to ionizing radiation, the number of lymphocytes in thecirculating blood decreases shortly after exposure; the degree of decrease is dose dependent.

lymphocytes: One type of white blood cell formed in lymphatic tissue throughout the body. The func-tion of lymphocytes is to mitigate invasion by microbes (e.g., bacteria).

monitoring: Means provided to indicate continuously or intermittently the state or condition ofa system or assembly (e.g., the real-time measurement of the level of radioactivity or radiationexposure).

neutrons: (see radiation types).palliative: Reducing the severity of, or denoting the alleviation of symptoms, without curing the

underlying disease.


60 / GLOSSARY

personal radiation dosimeter: A device worn by an individual to determine the radiation dosereceived by the individual.

personal protection equipment: (see bunker gear).prodromal: Relating to prodrome (an early or premonitory symptom of a disease).radiation control zones: In this Commentary, radiation control zones refer to two perimeters, cate-

gorized by radiation-exposure rate [i.e., the inner perimeter (10 R h–1) (~0.1 Gy h–1 air-kerma rate)and the outer perimeter (10 mR h–1) (~0.1 mGy h–1 air-kerma rate)].

radiation types (ionizing):alpha particles: Energetic nuclei of helium atoms, consisting of two protons and two neutrons

emitted spontaneously from nuclei in the decay of some radionuclides (e.g., 226Ra). Alpha parti-cles have very low penetrating power (e.g., typically stopped by a few centimeters of air, or theouter dead layer of skin). Alpha particles are generally not a health problem unless the sourceis taken into the body via inhalation, ingestion or absorption, or through wounds.

beta particles: Energetic electrons or positrons (i.e., positively charged electrons) emitted sponta-neously from nuclei in the decay of some radionuclides (e.g., 90Sr). Beta particles are not highlypenetrating (e.g., the lower-energy beta particles are typically stopped by a few millimeters oftissue; the higher-energy beta particles can be stopped by a few centimeters of tissue).

gamma rays: High-energy electromagnetic radiation (photons) emitted in nuclear transitions(e.g., radioactive decay of 137Cs) with energies particular to the transition. Gamma rays havemoderate-to-high penetrating power, are often able to penetrate deep into the body, and requirethick shielding, such as up to a meter of concrete.

neutrons: Uncharged particles found in the nucleus of every atom except 1H. Energetic neutronsare produced in spontaneous fission of nuclei (e.g., 252Cf), fission induced by absorption of neu-trons by nuclei (e.g., 239Pu), and by absorption of other particles by nuclei (e.g., absorption ofalpha particles by 9Be). Neutrons have no electric charge, are usually highly penetrating, havean enhanced ability to cause biological damage, and require thick shielding.

photons: Quanta of electromagnetic radiation, having no charge or mass (see gamma rays andx rays).

x rays: Electromagnetic radiation (photons) emitted in transitions of atomic orbital electrons afterionization or excitation of atoms (yielding characteristic x rays), or in the deceleration of ener-getic charged particles (e.g., beta particles) in passing through matter (bremsstrahlung). X raysare typically of lower energy than gamma rays, but some orbital electron transitions are ofhigher energy than some nuclear transitions, so there can be an overlap between the low-energygamma rays and high-energy x rays. X rays have moderate-to-high penetrating power, are ableto penetrate deep into the body, and may require shielding of up to a few tens of centimeters ofconcrete.

radiation units and names:becquerel (Bq): The SI special name for the unit [disintegration per second (s–1)] of radioactivity.

1 Bq = 1 disintegration per second (see radioactivity and curie).curie (Ci): The previous special unit for radioactivity. 1 curie = 3.7 × 1010 disintegrations per sec-

ond = 3.7 × 1010 Bq (see radioactivity and becquerel).gray (Gy): The SI special name for the unit (J kg–1) of absorbed dose. 1 Gy = 1 J kg–1 (see

absorbed dose and rad).rad: The previous special unit for absorbed dose. 1 rad = 0.01 J kg–1; 100 rad = 1 Gy (see absorbed

dose and gray).rem (roentgen equivalent man): The previous special unit for dose equivalent. 1 rem =

0.01 J kg–1; 100 rem = 1 Sv (see dose equivalent, equivalent dose, effective dose, andsievert).

roentgen (R): The previous special unit for exposure. 1 R = 2.58 × 10–4 coulombs per kilogram(C kg–1) (see exposure).

sievert (Sv): The SI special name for the unit (J kg–1) of dose equivalent, equivalent dose, andeffective dose. 1 Sv = 1 J kg–1 (see dose equivalent, equivalent dose, effective dose,and rem).


GLOSSARY / 61

radiation weighting factor: The factor by which the mean absorbed dose in a tissue or organ ismodified to account for the type and energy of radiation in determining the probability of stochas-tic effects (see also stochastic effects).

radioactivity: The property of some atomic nuclei of spontaneously emitting gamma rays orsubatomic particles (e.g., alpha and beta particles).

radioactive material: Material that has a component with the property of radioactivity (see radio-activity).

radiological: A general term pertaining to radiation and radioactive materials.radionuclide: A radioactive element, man-made or from natural sources, with a specific atomic

weight.range (of an instrument): All values lying between the detection limits of the instrument. The

lower detection limit is the minimum statistically quantifiable instrument response or reading.The upper detection limit is the maximum level at which the instrument meets the required accu-racy.

readout: The portion of an instrument that provides a visual display of the response of the instru-ment (e.g., the displayed value with units).

rem: (see radiation units and names). roentgen (R): (see radiation units and names).selectivity: In this Commentary, the ability of an instrument to distinguish between types of radia-

tion (e.g., between alpha, beta and gamma radiation). sensitivity: The ability of an instrument to identify the quantities of interest.sievert (Sv): (see radiation units and names).stochastic effects: Health effects, the probability of which, rather than their severity, is assumed to

be a function of radiation dose without a threshold.syndrome: The aggregate of signs and symptoms associated with any morbid process, and constitut-

ing together the picture of the disease.terrorism: The unlawful use of force against individuals or property to intimidate a government, the

civilian population, or any segment thereof, in the furtherance of political objectives.therapeutic: Concerning the practical treatment for remediation of diseases or disorders.threshold: The point at which a stimulus first produces an effect (response).time to vomiting: A symptom of the acute radiation syndrome; the time lapse from radiation expo-

sure to when vomiting initially occurs.triage: Medical screening of patients prior to treatment to determine their relative priority for treat-

ment, with separation into one of three groups: (1) those who cannot be expected to survive evenwith treatment; (2) those who will recover without treatment; and (3) the highest priority, thosewho will or may survive with treatment.

x rays: (see radiation types).


62

Acronyms and Abbreviations

ALARA as low as reasonably achievableARS acute radiation syndromeCBRNE chemical, biological, radiological, nuclear and explosives CW chemical warfare agentDNE domestic nuclear explosionDTPA diethyltriaminepentaacetic acidED emergency departmentEMS emergency medical servicesGM Geiger-Mueller (radiation detector)HSEEP Homeland Security Exercise and Evaluation ProgramIED improvised explosive deviceIND improvised (or otherwise acquired) nuclear devicePPE personal protection equipmentRDD radiological dispersal deviceRED radiation exposure deviceSI Systeme Internationale (International System) of Radiation Quantities

and UnitsSNS Strategic National Stockpile


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66

The NCRP

The National Council on Radiation Protection and Measurements is a nonprofit corporation char-tered by Congress in 1964 to:

1. Collect, analyze, develop and disseminate in the public interest information and recommenda-tions about (a) protection against radiation and (b) radiation measurements, quantities andunits, particularly those concerned with radiation protection.

2. Provide a means by which organizations concerned with the scientific and related aspects ofradiation protection and of radiation quantities, units and measurements may cooperate foreffective utilization of their combined resources, and to stimulate the work of such organizations.

3. Develop basic concepts about radiation quantities, units and measurements, about the applica-tion of these concepts, and about radiation protection.

4. Cooperate with the International Commission on Radiological Protection, the InternationalCommission on Radiation Units and Measurements, and other national and international orga-nizations, governmental and private, concerned with radiation quantities, units and measure-ments and with radiation protection.

The Council is the successor to the unincorporated association of scientists known as the NationalCommittee on Radiation Protection and Measurements and was formed to carry on the work begun bythe Committee in 1929.

The participants in the Council’s work are the Council members and members of scientific andadministrative committees. Council members are selected solely on the basis of their scientific exper-tise and serve as individuals, not as representatives of any particular organization. The scientific com-mittees, composed of experts having detailed knowledge and competence in the particular area of thecommittee's interest, draft proposed recommendations. These are then submitted to the full member-ship of the Council for careful review and approval before being published.


67

NCRP Commentaries

NCRP commentaries are documents that provide preliminary evaluations, critiques, review, resultsof exploratory studies, or extensions of previously published NCRP reports on an accelerated schedulewhen time for the normal Council review process is not available. They are approved for publication bythe Board of Directors of the Council. Included in the series are:

No. Title

1 Krypton-85 in the Atmosphere—With Specific Reference to the Public Health Significance of theProposed Controlled Release at Three Mile Island (1980)

3 Screening Techniques for Determining Compliance with Environmental Standards—Releasesof Radionuclides to the Atmosphere (1986), (rev. 1989)

4 Guidelines for the Release of Waste Water from Nuclear Facilities with Special Reference to thePublic Health Significance of the Proposed Release of Treated Waste Waters at Three MileIsland (1987)

5 Review of the Publication, Living Without Landfills (1989) 6 Radon Exposure of the U.S. Population—Status of the Problem (1991) 7 Misadministration of Radioactive Material in Medicine—Scientific Background (1991) 8 Uncertainty in NCRP Screening Models Relating to Atmospheric Transport, Deposition and

Uptake by Humans (1993) 9 Considerations Regarding the Unintended Radiation Exposure of the Embryo, Fetus or Nursing

Child (1994)10 Advising the Public about Radiation Emergencies: A Document for Public Comment (1994)11 Dose Limits for Individuals Who Receive Exposure from Radionuclide Therapy Patients (1995)12 Radiation Exposure and High-Altitude Flight (1995)13 An Introduction to Efficacy in Diagnostic Radiology and Nuclear Medicine (Justification of

Medical Radiation Exposure) (1995)14 A Guide for Uncertainty Analysis in Dose and Risk Assessments Related to Environmental

Contamination (1996)15 Evaluating the Reliability of Biokinetic and Dosimetric Models and Parameters Used to Assess

Individual Doses for Risk Assessment Purposes (1998)16 Screening of Humans for Security Purposes Using Ionizing Radiation Scanning Systems (2003)17 Pulsed Fast Neutron Analysis System Used in Security Surveillance (2003)18 Biological Effects of Modulated Radiofrequency Fields (2003)19 Key Elements of Preparing Emergency Responders for Nuclear and Radiological Terrorism

(2005)

NCRP publications can be obtained online in both hard- and soft-copy (downloadable PDF) formatsat http://NCRPpublications.org. Professional societies can arrange for discounts for their members bycontacting NCRP. Additional information on NCRP publications may be obtained from the NCRP web-site (http://NCRPonline.org) or by telephone (800-229-2652, ext. 25) and fax (301-907-8768). The mail-ing address is:

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Abstracts of NCRP reports published since 1980, abstracts of all NCRP commentaries, and the textof all NCRP statements are available on the NCRP website.


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