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Direct Case for Los Angeles Physicians for Social Responsibility.* License for Facility Should Be Denied on Basis of Health Reasons,Including Unacceptable Radioactive Releases from Facility Over Yrs.W/Certificate of Svc
	ML20006F462
Person / Time
Site:	07000025
Issue date:	02/19/1990
From:	Saxon R; PHYSICIANS FOR SOCIAL RESPONSIBILITY
To:	; Atomic Safety and Licensing Board Panel
References
	CON-#190-9916 89-594-01-ML, 89-594-1-ML, ML, NUDOCS 9002280058
	Download: ML20006F462 (62)
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' Physicians for Social Rerponsibility 19 Febru ry 1990 L

1431 ocean Avenue, suite B DOWETED Santa Monica, CA 90401 usNhc

'90 FEB 20 P2 41 BEFORE DE AKHIC SAFETY AND LICENSING BOARD mCE F SLCRETARY pgtgt1SgasiHvlCL U.S. NUCLEAR REX 7JLVIORY COMMISSION ilRANCH t

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In the Matter of

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Docket No. 70 M L ROCKWELL I!CERNATIONAL

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00RIORATION

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ASLBP No. 89-594-01-ML Rocketdyne Division

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(Special Nuclear Materials )

License No. StE-21)

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DIRECT CASE OF IDS ANGEIES HIYSICIANS FOR SOCIAL RESPONSIBILITY Introduction Los Angeles Physicians for Social Responsibility (LAPSR) was admitted to this license renewal proceeding with the following concerns:

(1) te record and ability of the applicant, Rockwell International, to comply with radiation standards to protect the public, (2) The effect of increased population density around the Santa Susana Field Laboeratory'(SSFL),

(3) Rockwell's use of unreasonably optimistic assumptions in analyzing potential accident inpacts, including the failure to consider the releases that might occur if the HEPA filters were to fail in a fire and/or a criticality incident, (4) ne cumulative impact of radioactive and hazardous chemicals waste disposal sites and contaminetion, 9002200050 900219 PDR ADOCK 07000025-PDR p

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-(5) Worker health and safety, (6) Reliability and conpleteness of information from the applicant, i

and (7) Transportation risks.

In order to conserve limited resources and avoid unnecessary repetition of material that will be contained in pleadings by other parties with similar concerne, we have decided to focus herein on areas within our particular area of expertise and concern.

We are health care professionals, and our special concern is for the health risks associated with the Rockwell nuclear facility. We are concerned, for example, that the claims made in l

the Radiological Contingency Plan about arrangements that have assertedly been made by Rockwell with nearby hospitals do not accurately reflect the state of available medical care in case of radiological accidents.

We are concerned that the health risks associated with the release of plutonium have not been honestly recognized and assessed.

We are concerned that the health physics practices at the facility are not accurate.

To the extent that our itemized concerns are being addressed by other parties, we join in their presentations.

In our specialized areas of concern-health-we submit the following in addition, based on a review by a working group of physicians established by IAPSR to examine these issues.

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I 10 The record and ability of the applicant to comply with radiation standards,t_o protect the public

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o 10 CFR 70.23 (a)(2), (3), and (4), as well as the radiation protection requirements of 10 CFR 20, including the ALARA ('as low as reasonably achievable") requirements therein, and 40 CFR 190.10 and 40 CFR 61.102, require an applicant to be able to demonstrate that it is qualified by reason of training and experience to comply with radiation standards to protect the public and that it has appropriate equipment, facilities and procedures to assure radiation exposures to the public are kept as low as reasonably achievable, and certainly below the regulatory dose limits.

We note that this is even more important now that the National Academy of Sciences' National Research Council has issued its new report on the Biological Effects of Ionizing Radiation (BEIR V), which increases official estimates of the health hazards of radiation by factors of 3.4 - 18.3 from the estimates in BEIR III, upon which current radiation protection standards are generally based.

(Health Effects of Exposure to Low Levels of Ionizing Radiation, National Academy Press, Washington, D.C.,1990; Table 4-4, p.

176, attacned as an exhibit).

We join in the discussions by the other intervenors of the unacceptable l

radioactive releases and contamination by Rockwell over the years, and of the extremely poor health physics practices that have been employed.

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EPA report of July 28, 1989, already in the hearing file, stands, we believe l

as an indictment of the monitoring practices by Rockwell.

We rely upon it 1

as an exhibit. We are particularly concerned about the practices of washing vegetation samples before monitoring them and heating both soil and vegetation samples to high temperatures before they are checked for radioactivity. These practf ces seem designed to remove and/or drive off radioactive material from samples prior to measurements so as to produce 3

l much lower readings of contamination than are factually correct, potentially severely underestimating actual radiation doses.

Our review of the EPA report and related documents indicate that Rockwell's radiation monitoring practices have been and remain so deficient that they cannot in any fashion demonstrate the safety of their activity. Indeed, the grossly improper monitoring procedures in and of themselves should disqualify Rockwell from continued authority to handle nuclear materials.

We are concerned that Rockwell has not demonstrated the attitude

.of respect for the extraordinary toxicity of the materials in question necessary to take the precautions required to protect public health and safety from their adverse health effects.

This is a problem that has been widely noted regarding Rockwell and other contractors operating facilities for DOE--what DOE Secretary Watkins has described as a " nuclear culture" which needs to be changed.

Rockwell's attitude on the part of its property that it operates for itself appears no different than the lax safety attitude expressed on the other parts of the property.

We note that Secretary Watkins has recently removed Rockwell from authority to operate che Rocky Flats plutonium facility because of its sloppy practices and lax safety attitude.

NRC should take official notice of that action by its fellow federal agency.

If Rockwell is not qualified to continue to handle and utilize plutonium in Colorado for DOE, with its generally weaker safety ctandards, then it certainly is not qualified under the stricter NRC ctandards to continue to possess and utilize plutonium in California.

Plutonium Risks Inappropriately Minitrized An example of the failure of Rockwell to have the appropriate attitude 4

regarding the risks associated with handling the nuclear materials for which 1

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it has requested license renewal is Rockwell's apparent lackadaisical attitude towards the health risks of plutonium.

We believe that Rockwell has mis-characterized the health risks associated with the requested quantities of plutonium. Rockwell has asked for possession authority for up to 400 grams of Specia5 Nuclear Material and authority to conduct high temperature experiments with up to 6 grams of plutonium.

It has attempted to give the impression that these quantities of plutonium are inconsequential from a public health and safety standpoint.

As health professionals, we know this to be quite incorrect. Plutonium is among the most toxic materials known to human beings. Astonishingly small quantities can be a serious health risk. Permissible levels are measured in 10-12 to 10~14 microcuries per milliliter of air (10-18 to 10-20 curies /ml)

(10 CFR 20 Appendix B, attached); ALARA levels are generally to be one-hundredth of these levels.1 Just one of the 400 grams of plutonium requested by the applicant represents about 7.5 curies, if reactor grade.

Just one of the 400 grams could thus, if released, contaminate something like 1019 milliliters of air to beyond the maximum permissible levels provided by the regulations. That is ten billion billion milliliters of cir, or 10,000,000,000,000,000 liters. This would contaminate, by our calculations, an area 1/6 of the area of Los Angeles to a height of 6/10th of a mile if evenly dispersed.

Even averaging over a year, one gets a monumental amount of air in which the plutonium would have to be dispersed

1. See, for example, 10 CFR 50 Appendix I, which gives quantitative guidelines for ALARA for nuclear power plants that are equivalent to a few millirem per year, or about 1% of maximum permissible levels.

We are not cware of comparable numerical guidelines for ALARA for a facility such as Rockwell's, but know of no legitimate reason why they should give off more radioactivity than that specified for huge nuclear power plants.

The general ALARA requirement of 10 CFR 20.1(c) applies to all NRC licensees.

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o before it would be below regulatory levels.

Mcving from the regulatory to the health field to provide perspective on the extreme toxicity of plutonium in the quantities requested by Rockwell, inhaled doses which involve a significant increase in the chance of getting cancer are on the order of a few micrograms, i.e. millionths of gram.

Plutonium is a powerful alpha-particle-emitter; when inhaled, for example, and lodged in the body, it irradiates a small section of tissue for a long period of time with intense radiation, producing a remarkably high probability of resulting in cancer. Thus a few grains of plutonium, if dispersed (say in a fire) could theoretically produce on the order of a million cancers. Now, of course, not each plutonium oxide particle released will end up inhaled by a person. But if even a small fraction of them do, a small fraction of a million cancers can still be a large and totally unacceptable number. And because of the long half-life of the primary plutonium isotope, plutonium-239, (24,000 years), plutonium that is not inhaled or ingested by someone at the time of'the initial accident will be in the environment for many generations, capable of causing new deaths for thousands of years.

Indeed, the plutonium lodged in someone's lung today as a result of a nuclear accident involving quantities of the sort Rockwell has requested, can kill that person, and if the body is cremated, the plutonium in their lung can be released to the environment, capable of killing someone else, and so on.

In short, plutonium in the amounts requested by Rockwell (6 grams in use, 400 in possession) are medically extremely significant quantities; release of even a small fraction of the requested amounts could have devastating (and long-lasting) public health effect.

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o-2.

The effect of increased population density around the Santa Susana l

Facility This is a matter addressed in the submission by the Susana Knolls Homeowners Association.

In order to avoid duplication, we will not repeat that material here but merely join in it and include it herein by reference.

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Rockwell's use of unreasonably optimistic assumptions e analyzino f

1 potential accident inpacts 10 CFR 70.22(i)(1) requires an honest evaluation of potential doses to the public in the event of an accident, or an emergency plan capable of L

effectively mitigating any potential harm.

In section 6 we discuss the inadequacies and misstatements in the Radiological Contingency Plan.

Here we are concerned with the inadequacies in the accident consequence calculations.

t This is a matter addressed in detail in the submissions by the Committee to Bridge the Gap and the Southern California Federation of Scientists. In order to avoid duplication, we do not repeat the material here but join in it and include it herein by reference.

We do note, in particular, however, as we did in our original petition, the failure to consider the releases that might occur if the HEPA filters were to completely fail in a fire.

It is most unreasonable for Rockwell to assume a hundred-fold reduction in emissions in a worst-case accident due to taking credit for at least some of the HEPA filters remaining operational. A fire or other accident can destroy or bypass the filters.

We note that, in fact, the HEPA filters failed at the plutonium fires at Rockwell's Rocky Flats facility, causing substantial releases.

We share the other groups' concerns, in addition, that the 10-7 release 7

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fraction fur plutonium in a fire, irrespective of the filters, is grossly optimistic.

Plutonium metal burns; there is no scientific reason for assuming that a substantial fraction of it will not be released in such a i

i fire.

t Correcting these errort produces doses about a billion times larger than those assumed by Rockwell. 2ey calculated (without providing details as to the calculation and input assumptions) maximum doses of.03 mrem to the lung and.04 mrem to bone at the site boundary, for release fractions of about 3 x 10-8 to 5 x 10-7 total wtt (3 x 10-10 to 5 x 10~9 total release fraction). (Revised Onsite Contingency Plan, p. 3-8.) Substituting more sensible assumptions for just the two grossly optimistic assumptions identified above produces dose estimates on the order of a billion times higher, producing doses of about 10,000 Rem to the organs in question, or about a thousand Rem whole body dose. Rese are monumental exposures, which are totally unacceptable.

(Just as a rough comparison, a modern two-sided chest X-ray is about.029 Rem, 30,000 times smaller than the assumed dose; whole body doses of about 400 Rem are the LD 50/30 levels, capable of killing half those exposed to those levels in thirty days from acute radiation syndrome; NRC regulations prohibit exposures to the public of.5 Rem whole body and slightly higher than that for specific organs, with EPA regulations considerably lower.) And note that this is without reviewing 1

the release fraction-ultimate dose calculation, which Rockwell failed to l.

provide in its estimates, and assuming only 1 of the 400 grams Rockwell has requested to possess is involved in the postulated fire, and neglecting the other radioactive materials that could be released in the same accident.

I Correcting for unreasonably optimistic assumptions produces consequences from an accident at Rockwell, should it receive the requested 8

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O license, that would be totally unacceptable, both from a regulatory standpoint and from a medical standpoint.

We requested license should be denied.

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The cumulative impact of radioactive and hazardous chemicals waste disposal sites and _contamiistion

% ese concerns are addressed in the filings by John Scott, Estelle Lit and Jercme Raskin, SCPS, CBG, and the Susana Knolls Homeowners Association.

We join in their submissions in this regard and will not attempt to repeat the same material here.

We do wish to make one related public health point, however.

Because of the division of regulatory responsibility for the Rockwell site--DOE, NRC, State Health Department, EPA, etc.- '.here is a risk that the cumulative risk from the site and continued activity there will not be properly assessed. For example, the proposed TRUMP-S project will involve chemically toxic materials such as cadmium, special nuclear materials such as plutonium, and other very dangerous actinides such as neptunium and americium.

Examining only the public health consequences of accidental releaces of one of the items, even though all would be released, and determining whether the project should be licensed based on only one component, not the aggregate risk, would be to fail in the responsibility to protect public health and safety. The TRUMP-S project cannot go forward without NRC license. Thus the potential environmental and health impacts of that federal decision-which is in our view a major federal decision which could substantially affect the environment--must be examined in their entirety. 10 CFR 70.22(i)(3)(xiii), for example, recognizes the aggregate l

chemical and radioactive risk and requires licensees to take measures l

appropriate to both hazards.

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j We note similarly that the aggregate risk to the public from the radioactive materials Rockwell has mismanaged at the Santa Susana Field Laboratory must, be assessed as well as any addition to that aggregate risk that would be posed by continued and/or new operations were the requested relicensing granted.

10 CFR 20 makes clear that activities cannot be permitted if they, e their aggregate, result in doses to the public in i

excess of regulatory limits. In other words, several activities, each of which individually may result in doses below regulatory limits, are still impermissible if together they result in doses in excess.

We believe that with all the other contamination at SSFL, approval of additional operations cannot be justified because of the aggregate inpact.

Additionally, we are concerned about the aggregate impact of permitting continued use of the Hot Lab for new activity while trying to decontaminate and decommission it and the rest of the site. Approval of the renewed license would, we believe, interfere with and delay cleanup, which would have an adverse public health and safety impact.

Radioactive contamination which is spreading could get farther, more people could be potentially exposed, because of the interference with and delay in environmental restoration activities. Likewise, Rockwell's plans to do decommissioning and decontamination work on three of the Hot cells in the Hot Lab at the same time while it is doing new and dangerous work with plutonium in the fourth Hot Cell produces an increased aggregate risk because of the increased risk that the Decontamination an! Decommissioning will interfere with the TRUMP-S activity going on in the same building.

Flammable solvents, heavy equipment, extensive activity involved with decontamination going on side-by-side the plutonium activity increases the risk of accident with it (e.g., fire).

All of these aggregate risks need to be fully assessed before a 10

decision to approve licensing could be made. We believe the aggregate risks necessitate denying the requested license.

h Worker health and safety 10 CFR 20 provides radiation protection requirements for both workers t

and members of the public.

We believe that Rockwell's measures to protect its employees have been as ineffective as the measures to protect the public.

We are concerned about the Workers compensation cases that have been filed against Rockwell, and a nunber of worker exposure incidents.

We believe that, should NRC contemplate granting renewal of the Rockwell nuclear license despite the wealth of reasons against doing so described in this statement and the others being provided simultaneously, a reasonable condition of such renewal would be the requirement that Rockwell make available for a serious independent epidemiological study raw data related to worker health.

We note that DOE Secretary Watkins has recently announced a new policy of openness in this regard.

We believe the license should be denied, but were it granted, it should be conditioned on such a study.

We also note that the accident analysis in the Radiological contingency Plan has a grievous omission.10 CFR 70.23(i)(3)(v) requires thorough consideration in emergency plans of measures to mitigate doses to workers in

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an accident. The RCP, however, gives dose estimates for members of the l

public, criticized above, but no estimate for workers who might be exposed.

In particular, what would be the dose to a worker who was severely burned?

l The burned area with open blood vessels would be a portal of entry for the I

plutonium particles.

The dose would be even higher.

This issue has to be 11 l

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addressed in the RCP.

h Reliability and completeness o,f,information from,th_e, applicant, l

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10 CFR 70.22(e) states as follows:

Each application and statement shall contain complete and accurate disclosure as to all matters and things required to be disclosed.

Rockwell's _ application contains numerous material false statements. It should be denied on that basis alone.

First of all, we join in the thrust of the concerns expressed by Don Wallace regarding the reliability of the information in the Radiological Contingency Plan (RCP) regarding fire fighting arrangements. Our reading of the subsequent NRC inspection report and Rockwell's written response is that Mr. Wallace's assertions have been largely proven and admitted to. Excuses are provided about outdated information being retained in the RCP, to explain how language was included that would give the false impression of direct arrangements existing for fire response when such arrangements had not, in fact, been made.

As Judge Bloch noted in his Memorandum and Order of November 29, 1989, the inaccurate statements in the application about l

fire protection arrangements raise the possibility "that there had been a 1

l violation of NRC regulations by submitting misstatements -- apparently negligent or grossly negligent misstatements -- in an application for a license. 2 - The misstatements in the RCP regarding medical assistance raise

2. Judge Bloch also noted in that Order, as we do here, that the Inspection Report 70-25/89-05 determined "that two hospitals apparently were listed in

- the RCP as ' supportive in any emergency situation that may arise' but that no firm agreement existed to corroborate this conclusion."

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l a question of whether Rockwell has complied with the same regulatory requirements.

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A good test of whether the misstatements in the RCP section of the Application regarding fire protection arrangements was a mere oversight in the old RCP can be made by assessing whether similar false statements exist in the new RCP, submitted by Rockwell in late December in an effort to correct problems found by Mr. Wallace in the earlier RCP. We decided to independently assess the veracity of the claims by Rockwell in the new RCP i

by examining the sections on medical treatment facilities (Section 4.3.1) and medical evacuation service (Section 4.3.2).

tese are found on pages 4-6 through 4-8.

Los Angeles Physicians for Social Responsibility empaneled a working group of four physicians to make an independent assessment of these claims by Rockwell.

The working group included Dr. Richard Saxon, Dr. Walter Kearns, Dr. Jimmy Hara, and Dr. Samuel Roth. Our conclusion is that the new RCP badly misrepresents the arrangements-or lack of arrangements-me.de for medical assistance.

Se Contingency Plan states:

Rocketdyne has an association with Humana Hospital West Hills wherein the hospital has demonstrated and continues to demonstrate an appropriately trained professional staff, up-to-date equipment and facilities for the treatment of radiologically contaminated patients. Both the Medical Director and the Director of Nurses of the emergency room have been REAC/TS trained (Radiation Emergency Action Center / Training Site) by request of the Rocketdyne Medical Director.

However, this is not accurate.

The Medical Director at Humana who had this training is no longer at the hospital.

This leaves only one person 13

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capable of handling or directing the care of a radioactively contaminated 4

patient.3 210 was supposed to be an updated, revised Contingency Plan.

Humana is the primary hospital for which arrangements have been made by Rockwell.

The RCP says that "We hospital is not only prepared to accept contaminated patients, but has participated in readiness training. drills with Rocketdyne involving hospital personnel and equipment." One must question the adequacy of those arrangements if Rockwell is apparently unaware that the Medical Director whom they had arranged to have trained in handling radioactively contaminated patients is no longer at the hospital.

We note also that Rockwell has repeatedly been criticized by the NRC for failing to update the RCP, for having it not accurately reflect current arrangements. In addition to the most recent inspection report based on Don Wallace's pointing out the inaccuracies in the last RCP, NRC on its own in an inspection in May and June of 1988 found that Rockwell had not updated its Radiological Contingency Plan in six years!

"The current RCP dated March 31982 was noted to be significantly out of date with the numerous d

C ages-in equipment, facilities, and emergency organizations, which have.

occurred since 1982." Rockwell continues to have problems keeping its Radiological Contingency Plan up-to-date--this can have very serious consequences in an true emergency.

Pages 4-7 and 4-8 indicate that only one patient al a time can be 3.-

In addition, Mrs. Carol Brower, the chief nurse, who is the remaining REAC/TS trained person at Humana Hospital, told Dr. Walter Kearns of IAPSR in a personal communication on January 26, 1990, that the facility used for decontamination of affected personnel was a necropsy room at the hospital.

There is floor drainage in this room.

Is this floor drainage captured?

If not, any radioactive substances in the effluent will go into the los Angeles sewer system to be introduced into the environment, l

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treated at Humana Hospital West Hills.

It is clear that in a radiological i

i contingency, even if there were still a medical director at Humana trained in treating radiologically contaminated patients, the hospital would very quickly cease to be able to provide assistance, as it can help only a single patient at a time.

Additional patients, the plan states, will be directed to Nd-Med Regional Medical Center or the Northridge Hospital / Medical Center, i

Pages 4-7 and 4-8 provide a " list of available hospitals for radiation j

contaminated patients." In that list, the following hospital emergency rooms are listed as " Capable of Radiation Accident Management":

Humana Hospital West Hills Northridge Hospital / Medical Center NU-MED Regional Nedical Center Kaiser Permanente Hospital, Woodland Hills UCLA Medical Center Olive */iew Hospital Medical Center Page 5-16 describes this as "a partial list of area hospitals that are qualified in the treatment of radiation accident victims...for use when more than one contaminated patient needs emergency service."

We have made inquiries to determine the veracity of those claims.

The facts are that neither of the two primary hospitals identified by Rockwell as the places where contaminated patients would be taken are in fact equipped to treat these patients. On January 31, 1990, Dr. Walter Kearns of IAPSR spoke to the supervisor of the emergency room at Nu-Med, Linda Kerner, who stated.that a training session had been held three years ago, but none has been held since. No one at the hospital has had REAC/TS training and there are no. physical facilities or equipment to deal with a contaminated patient. Likewise, Sherry Klevens, the Director of Nurses for Trauma at Northridge Hospital stated that equipment, personnel and training were 15

c yg lacking at her hospital.

(Both these individuals ' expressed their o

willingness to cooperate at any time with Rocketdyne with any suitable patient they were capable of treating.) Further conversations were held with John D. Arterberry, M.D., Head Physician of emergency services at Northridge Hospital.

He was an extremely knowledgeable physician in emergency care.

His personnel are extremely well trained in toxic substances, but they have

been trained in radioactive decontamination of a patient. At present they do not have a room for decontamination, but this facility is now under construction at the hospital.

There is only one local hospital with a burn unit in this area.

It is Sherman-Oaks Community Hospital, but this medical unit has no capability to care for a radioactively contaminated patient.

In fact, it would be hazardous for the other patients in the burn unit for a contaminated patient l

to be hospitalized in this unit.

In a personal communication on January 29, 1

l-1990, with Richard Grossman, M.D.,

the chief of the burn unit, Dr. Grossman l

told this intervenor, Richard G. Saxon, that he would not accept a burn case 1

with radioactive contamination, because the danger to the other patients and l

the personnel would be too great. Dr. Grossman also stated that the Sherman 1

L Oaks Community Hospital has no personnel or facilities to decontaminate a 1

burn victim.

L The entire question of treating a burn victim with radioactive l

L contamination has yet to be fully answered by the medical community or by the technical experts who are doing work with radioactive material. In order to clarify this important topic, this intervenor contacted Jennifer Leaning, M.D., of Boston, an expert in emergency medicine who has investigated and

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published work on accidents involving radioactive substances. This personal communication was held on January 30, 1990.

She expressed the opinion that 16

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little was known about this subject. It was apparent to her, as it was to this intervenor, that plutonium, an alpha emitter, would find a ready portal O

.of entry to the body in the area of a burn. The direct access to the cells and open blood vessels would make the decontamination in this type of wound impossible.

A general anesthetic would be necessary to cleanse and scrub the damaged area, and the staff doing this would be placed in jeopardy.

Even the sophisticated staff and excellent facilities at Sherman Oaks Community Hospital could not deal with this type of patient. On February 2, 1990, Marc Bayer, M.D., head of emergency services at Olive view Medical Center, told this intervenor in a personal telephone conversation that to his knowledge, no personnel had the training and that there were no l

facilities for this contingency. Jimmy Hara, M.D., (LAPSR), assistant chief of family practice for the Kaiser Foundation Hospitals of Southern j

i California, questioned twelve different physicians at Kaiser Foundation l

i Hospital in Woodland Hills, California. He found that no one had REAC/TS j

i training but that there was a room that had been designated for-f decontamination of a patient.

This room would be useless without the i

trained people to use it. Two of the personnel that Dr. Harh spoke to were Michael Lafemina, M.D.,. chief of Emergency Services and Andrew Bonin, M.D.,

chief of Urgent Care Services.

On February 5,1990, Samuel Roth, M.D. (LAPSR) spoke to Mr. Baxter Larmon, who is in charge of emergency room admissions at the UCLA Hospital i

Medical School. he stated that there were no personnel who had REAC/TS i

i training, but that the morgue would be used for the decontamination process.

i The water from this room could be collected.

-In summary, of the six hospitals identified by Rockwell as having the training and equipment to handle radioactively contaminated patients, none were accurately described by Rockwell.

Five of the six do not have trained 17 L

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personnel and/or appropriate equipment, and the only one that has any trained personnel, has only one such person, a nurse.

The second person claimed by Rockwell to be trained at that hospital, the medical director, is no longer at the hospital.

In short, there is only one hospital, not six as claimed by Rockwell, capable of handling contaminated patients, and it has only one trained staffperson, not two as claimed, and can handle only one patient at a time.

If there were an accident involving a number of people, they would have nowhere to go for medical assistance that is trained and equipped to help them.

It should also be noted that on-site medical assistance is only available eight hours a day.

What about the other sixteen hours?

If an accident occurs at other than working hours, how will the injured employee (s) receive care?

One other matter deserves note regarding the proper treatment of plutonium-contaminated patients.

In paragraph 6.4 of the Radiological Contingency Plan, Rockwell states that "the Medical Director has on hand...

the chelating agents trisodium calcium pentamil and trisodium zine diethylene-triaminepenta-acetate, new drugs limited by Federal law to investigational use for -the treatmen't of human contamination with plutonium."

If these drugs have not been approved, how hazardous are they to any victims of an accident? It would not seem proper to administer these -

agents without having legal approval for human use.

Chelating agents tend to be highly nephrotoxic and have to be administered with extreme caution.

(See "The Medical Basis for Radiation Accident Preparedness," Proceedings of the REAC/TS International Conference:

October 18-20, 1979, Oak Ridge, Tennessee, attached; see particularly pp.

318-319).

There is no reference in these proceedings relative to a serious 18

O r e-burn case contaminated with radioactive particles. The Burn Unit at the Sherman Oaks Hospital would probably not be able to handle any of these patients.

The care of a contaminated patient is a part of medicine requiring trained physicians and personnel who treat the patient on a continuous basis.

In addition, the facilities for this care have to be isolated from ordinary hospital facilities in order to insure that regular hospital patients are not contaminated. For example, urine and feces will have to be iso' lated in some instances, and the personnel gathering these body excretions will have to protect themselves as well as patients. none of the l-hospitals in the Contingency Plan are equipped to deal with these problems.

l (Manual on Early Medical Treatment of Possible Radiation Injury, International Atomic Energy Agency, Vienna,1978, pp. 39, 4.3 Internal j

Contamination.)

Both documents, attached, make clear the extreme complexity of treating l

radioactively contaminated patients.

It is our view that the appropriate arrangements for such medical care in radiological contingencies have not been made by Rockwell, and that false statements about the actual arrangements appear in the Radiological Contingency Plan submitted by Rockwell as part of its Application for license renewal.

In light of this, the requested renewal should be denied.

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L Transportation risks.

l 10 CFR 70.23(a)(4) requires adequate procedures to protect health and minimize danger to life or prcperty. The crash last fall of a truck carrying radioactive material from Rockwell's SSFL raises serious questions about the adequacy of those procedures and whether t.he attendant risks associated with 19

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i transportation of radioactive materials-to and f rom' the SSFL site are Jacceptable.

An article about the recent shipping accident, published in the simi-Valley Enterprise.of -October.25,1989 (attached), quotes-NRC spokesman Lee Bettenhausen as saying, " Measurements of the truck 'after the incident have been confirmed as being 250 millil rems 1 per hour."-

Department' of

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Transportation. regulations apparently do not allow vehicles. carrying radioactive equipment to exceed 200 millitems per hour, Bettenhausen in p'

I quoted-as saying.

Rockwell apparently released from its site a truck carrying radioactive j

materials that was at levels in excess of regulatory limits. The truck then crashed.

Serious questions are raised about Rockwell's procedures and the safety.of permitting radioactive materials to be shipped in and out of.

Rockwell's SSFL.

LAPSR recommends that further l'nformation on this issue be obtained by getting records of all shipment incidents that may have occurred during the existence of the plant. If this event a.few months ago was the first they have had, that would be'one thing; if there have been other such incidents, serious questions would be raised about the safety of permitting continued-operations with nuclear materials at the site, r

CDNCLUSION-7

'We believe that the appropriate NRC action is denial of the requested

license, q

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.r 2d I affirm under penalty of perjury that the foregoing is true and correct to the best of my knowledge and belief.

r Richard G. Saxon, M.D.

dated at Los Angeles,' California this 19th day of February, 1990 i

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176 EFFECTS OF EXPOSURE TO LOW LEVELS OF ION! ZING RADIATION TABLE 4 4 Comparison of Lifetime Excess Cancer Riss Estimates from the BEIR til and IIEIR V Reports Conimuous L.ifetime Expnure. I mGy/3 Instantaneous fixpmure.

(deaths per lHO.Olun u I Gy ideaths per 100.I4140 Males Females Males Fe' males I.cu A emm d

HEIR lil 15 9 12.1 27.4 IN h IllilR V 70 Ni llo su Rateo llElR VI BEIR 111 44 50 40 43 mmleukemia f

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( N ASMty The major difIerences between the two sets of estimates in Thble 4-4 i

are for the BEIR III Committee's additive risk models. It is the opinion of this committee that the assumption of a constant additive excess risk is l

no longer tenable in the face of the data now available and that the risk estimates from this model provided in the BEIR 111 report are therefore too low. The estimates presented in this report are also higher than those based l

on a simpic additive risk model in the latest UNSCEAR report (UN88) but are not quite as high as those based on the simple multiplicative risk model in that report.

UNCERTAINTY IN POINT ESTIMATES OF LIFETIME RISK The total uncertainty in the Committec's risk models is discussed in Annex 4E in this section, the discussion is largely limited to the statistical uncertainty in the risk estimates made with the Committee's preferred models. Lifetime risk projections are subject to three types of uncertainty.

The first is simply random error owing to sampling variation in the fitted coefficients of the final models; this is thought to be the largest component of uncertainty and is expressed in terms of confidence intervals on the fitted model parameters and the estimated lifetime risks. Second, there is I

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d The Medical Basis for xy Radiation Accident 4

Preparedness Proceedings of the REAC/TS International Conference:

The Medical Basis for Radiation Accident Preparedness.

October 18-20,1979, Oak Ridge. Tennessee, U.S.A.

Editors:

Karl F. H6bner, M.D. and Shirley A. Fry, M.B., Ch.B.

Oak Ridge Associated Universities

[Jf:" }

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Elsevier/ North-Holland New York. Amsterdam. Oxford

m NOTICE.

This report was prepared as an account of werk sponsored. in part, by an agency of the United States Government. Neither the United States

~, "

Government nor any agency thereof, nor any of their employees makes any warranty, expressed or implied, nor assumes any legal liaNiity or responsibility -

for any third party's use or the results of such use of any information.

Contents

" apparatus, product or process disclosed in this report, nor represents that its use by such third party would not infringe privately owned rights.

Contenta Copyright (c 1980 by Elsevier North Holland. Inc. All rights reserved IYeface xi In the interest of a rapid publication, this book has not received the standard gg ggg attention of the Ibk Editorial Department and thus. Elsevier North Ilolland.

Inc. bears no editorial res;wnsiNiity for this volume.

Dedication XV --

Introduction xix Published by:

List of Palt..cipants

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52 VanderNit Avenue. New York. New York 10017 Sectice I: Radiation Accidents: Total-body Irradiation ~

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Total-body Irradiation: A 11istorical Rev.iew and Elsevier/ North-liolland Biomedical Press 335 Jan van Galenstmt. P.O. Box 211 E

y Amsterdam 'Ihe Netherlands C. C. Imhbaugh, S. A. Fry K. F. Hebner, and R. C. Ricks Library or Congress Cataloging in rublication Data Addendum: Overview of Seriou.; Radiation Accidents 6

REACJTS International Conference: The Medical Basis for Radiation Accident What Ilappened to the Survivors of the Early Los 17 Preparedness. Oak Ridge. Tenn. 197" Alamos Nuclear Accidents?

The medical basis for radiation accident pieparedness.

L. H. Hempelmann, C. C. Lushbaugh, and G. L. Voelz Includes NNiographical references and indes.

I. Reliation-Toxicology-Congresses. 2. Radiation workers-Diseases and hygiene-Congresses. 3. Nuclear facilities-Accidents-Follow-up Studies over a 25-Year Itriod on the Japanese Congresses. I. Il0bner. Kast F. II. Fry. Shirley A. III. Radiation Fishermen Exposed to Radioactive Fallout in 1954 33 Emergency Assistance Center / Training Site T. Kumatori. T. Ishihara, K. Hirashima. H. Sugiyama.

IU.S.) IV. Title. (DNLM: I. Radiation infuries-Prevention and n

S. Ishe..,nd K. Ma.yosht control-Congresses. WN650 R106m 1979)

RAl231.R2R23 1979 616.9'89707 80'16567

. An Update of the

.55 -

ISBN o.444-004319 The 1954 Bikini Atoll incident:

Findings in the Marshallese Itopie

-Mcnufactured in the United States of America R. A. Conard

.s

l'

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rgshbleed 199 by f%evier Nath Itoeland. Inc.

6. f. siebner and S. A. Iry. eds. The Med. cal nas tw Radianum Accodent Preyerednegg 319-

13. SchimpfT SC: Infection presention during granulocytopenia. Curr Cfur 7of.i.. tyr,.

Dis: in press.

14. SchimpfT SC: Therapy of infection in patients with granulocytopenia. Afra (7in N w Current Approaches to the Management 61:1101-lllR,1977.

15. Schiffer CA: Principles of granulocyte transfusion therapy. Afed Clin N u OfInternally Contaminated Persons 61:1119-1131. 1977.

16. Schenck RR, Gilberti MV: liiur-extremity radiation neciosis. Arcir Surg 100.729 74:

1970.

George L. Voelz 1.n Afamen Scientofc buhoratory, bn Alamos, New Me.tico.

l lhe use of radionuclides in industry, research, nuclear power. and medicine is increasing. As a result, there may also be increased possibility,.

of human exposure to internal depositions of radionuclides. Preventative -

measures should continue to reduce the number of these exposures, but it is important that the physician-in-charge uses the available techniques

.md drugs to reduce these internal depositions. This paper summarizes -

mportant considerations in the management of these cases and outlines

+me available major therapeutic regimens.

liasis for Treatment the need for treatment in an individual exposure case should be based on an understanding of the consequences or risk of late effects on the 5calth of the individual. If discomfort. side effects, or risk accompany

'>e therapy, it is especially important to understand the need and basis

' t treatment. Our understanding of the dose-effect relationship due to

' aliation is limited, especially at lower doses and at the dose rates often

- ciated with internal despositions. I know of few data which demon-

'raic thr.t current treatment regimens for internal radionuclides are itective in reducing health effects. The benefits of treatment are assumed s' be present, based on a reduction in the amotmt of radionuclide present i an organ. The benefit of therapy is, therefore, understood no better.

im our imperfect unde standing of radiation risk at low dose and dose tes The basis for treatment is thus based on "as low as readily uhievable" dose. On this basis, at some point therapy will yield a Sminished return.

- ' - ~

w.

c.,e

313 312 and Victor Smith. A comprehensive report'" of their study will be With proper application of currently available treatments, it is possible published in NCRP Report 65 in early 1980. The therapeutic measures to reduce the internal dose by a factor of about 2 to 10 for some of the described below are discussed in more detail in that report.

radionuclides. To be sure, the goal of reducing dose is a worthy objective.Reduction of internally deposited radionuclides can be accomplished That health effects do result from radiations caused by internal radio.

by the use of two general processes: (i) reduction of absorption ami nuclides has been amply demonstrated in radium dial painters, uraniuminternal deposition and (ii) enhanced elimination or excretion of absorbed miners, thoratrast. injected persons, and the Marshallese Islanders es.nuclides. Both are achieved more effectively when therapy is begun at posed to radioactive iodine in fallout. In all these cases the exposures the earliest time after exposure.

were orders of magnitude above those permitted by the regulatory Treatment is most effective if the absorption of contaminants into the i

i f diluting systemic circulation is prevented although the admin strat on o guidelines applied to the radiation worker.The value of treatment of cases with smaller exposures, for e and blocking agents is nearly equally effective in some instances because below the so-called permissible guidelines, is not known. Currently, the it enhances the elimination rates of the radionuclide or reduce decision for treatment in such cases is based on the perception of risk h quantity of radionuclide incorporated in tissue. Therapeutic measures 3

ii the physician responsible for the case and his patient. The phys c an that use mobilizing agents or chelating drugs are less effective when the must make a judgment concerning the ultimate benefit versus the poten-radionuclide has already moved into the tissue cells.

tial harm or side effects of the therapy, ajudgment common to all medical h.und irrigation and fa.caston All treatments for internal sadionuclides are most effective if applied After emergency first aid to control hemorrhage and treat shock, any practice.

i i d within minutes to a few hours after exposure, a period when l m te potential radioactive contamination in wounds must be located. Weal information upon which to base a treatment decision is available. The beta-and alpha-emitters present special problems unless special instru earliest information after the accident will consist perhaps of some scant >

mentation is available. An example of such equipment is the thin information on the accident, probable identification of the major radio-unshielded NalOh detector

used to measure plutonium in wounds a ki l nuclides by history or early spectrometric data, a few radio ig ca the les Alamos Scientific Laboratory. It will detect as littic as 0.0' measurements (contamination surveys, air concentrations, and retsal nanocurie of mPu with a single 500-sec count.This screening instrenent f

smears), and no clinical symptoms or signs except possible trauma rom unfortunately cannot be used easily to evaluate wounds with complicate.

an accident. De absence of clinical features places the physician at a ceometry or mixtures of radionuclides. All such wounds and those witi more than 2 nanocuries of plutonium activity are measured with a Si(Li great disadvantage in trying to determine the need for immediate treat-ment. Fortu detector. Longer analysis times are necessary, but the X. ray and gamma essentially no risk, and so errors of therapy omission are likely to be ray lines of interest are easily resolved identified. and quantified.

Irrigation of the wound with sterile water or saline, free bleeding, an-more serious than those of commission.The cessation of treatment is another decision that is depende occluding venous return with a tourniquet have been advocated fo experience and judgment of the physician-in-charge. His decision is immediate action.* A pulsating water jet lavage has been used wit based on the relative risks and effectiveness of the particular treatment some additional success.*

This question arises primarily in connection with possible continuing use After thorough wound irrigation, long-lived radionuclides, such a h

of mobilizing or chelating agents. His decision is not as crucial as t e plutonium and americium, may be removed by excision of the woun decision to initiate treatment and can be made after duc deliberation on area. A block excision of a smail wound area is often more efTect the results and after consultation.

lesser wound debridements. Primary closure of the wound is performe af ter the results of a check for residual activity are satisfactory. Use.

a skin biopsy punch is a convenient way to excise small punctor i

wounds. All removed tissue, gauze sponges. and irngation water, Therapetttic Treattnefits rossible, should be retained for radiochemical analysis.

For the past several years. Committee 37 of the National Council ""

Radiation Protection and Measurements (NCRP) has been studying the WJuction of Gastrointestinal Absorption d with subject of the management of persons accidentally contaminate (;astrointestinal absorption can be reduced either by washing out or I Voelz. chair-radionuclides. The committee members include George L.

the use of medications selected for specific elements. These medicatio thmn A. I.incoln: lierta Spencer: Niel Wald: H. David Bruner;

F

' 314 315 combine with the radionuclides so that they are less available for phosphate gel given immediately after exposure will decrease the intes-absorption and are then eliminated in the stool. Such treatments are tinal absorption of radioactive strontium by about 85%.""'Is5' A single summarized below.

Jose of aluminum hydroxide gel. 60 to 100 ml. given immediately after Use of a nasogastric or gastric tube to empty the stomach (stomach exposure will reduce the uptake by about 50%. Both drugs are nontoxic lavage) would generally be used in the highly unusual circumstance and well tolerated. A mixture of aluminum and magnesium hydroxide where the known intake of a large quantity of radionuclides will pose a can also be considered as a possible agent to reduce gastrointestinal significant threat to the present or future health and where it has occuned absorption.

recently enough that the material is in the stomach.

Alginates, s:Its of alginic acid, are jelly.like substances obtained from In most cases, stomach lavage would be the procedure of choice but the brown algae known as kelps. These substances inhibit the intestinal may not always be successful. Emetics act by stimulating the gastric absorpiion of radioactive strontium by 80 to 901"*' The principal mucosa, by stimulating the vomiting center in the brain (medulla), or b3 Jisadvantage to their use is the viscosity of the material which makes it a combination of the two. Their use is contraindicated if the state of difficult to swallow.

consciousness is impaired or after the ingestion of corrosive agents.

Harium sulfate is a highly insoluble salt used as a contrast medium for Apomorphine hydrochloride and ipecac age the most likely drugs to roentgenographic examination of the gastrointestinal tract. Except for consider for this use.

constipation, no adverse effects have been observed. The principal Selection of a purgative to speed the elimination of the coments of the indication for barium sulfate in this application is as an immediate intestinal tract should include the consideration of the treed of action.

antidote for ingested strontium and radium. Formation of insoluble Of particular concern is the effect of relatively inactable radionuclides sulfates of these elements will markedly decrease their intestinal absorp-i that may remain for many hours in the colon and rectum.These portions tion.

of the gastrointestinal tract will receive the Mrgest radiation doses but Significant amounts of phytates are found in grains and grain cereals, the damage can be reduced by prompt ter:9 val of the radionuclides from particularly in oats and soya bean products. Phytates contain phosphorus, the intestinal tract. Some purgatives nay have special advantages be-as phytic acid phosphorus, which combines with calcium, magnesium, cause they produce a less soluble campound of the radionuclide. Mag-rinc. and iron to form insoluble salts. Absorption of these elements from nesium sulfate, for example. M a saline cathartic that can produce the intestinal tract may be reduced by the administration of phytates.

relatively insoluble sulfates wnh some radionuclides, for example, rad ium, and thus reduce absorption. Use of enemas will empty the colon in II/od, s,ng and Diluting Agents a few minutes and may dso be a consideration in some cases. Purgatise A blocking agent saturates a specific tissue with the stable element, drugs taken orally, sta.h as biscodyl. castor oil, or phenolphthalein.

thereby reducing the uptake of the radionuclide. Isotopic dilution is require several hours before taking effect, but these have faster action achieved by the administration of large quantities of the stable element-than otners.

or compound so that. on a statistical basis alone, the opportunity for The basis for oral administration of strong catiou-or anion. exchange incorporation and exposure of the radionuclide is lessened. Displacement l

resins to aid in the removal and reduced absorption of redionuclides from therapy is a special form of dilution therapy in which a nonradioactive the gastrointestinal tract has weakened because of increasing evidence element of a different atomic number successfully competes with the I

of toxic side effects. Activated charcoal would seem to be a potentiall>

radionuclide for uptake sites.

The use o~ a stable iodide to prevent the uptake of radioactivity in the f

useful substitute.

fierric ferrocyanide (Prussian blue) has been found effective in accel thyroid is an example of an efTective blocking agent. A dose of 300 mg erating the removal of cesium, thallium, and rubidium by the fecal route of potassium or sodium iodide achieves maximal blocking and will stop in animals."+ Prussian blue is essentially nonabsorbed from the gav further uptake of radioiodine by the thyroid. Six drops of a saturated trointestinal tract and has low toxicity. One gm of Prussian blue gwen solution of potassium iodide in a glass of water is a convenient form of three times per day from several days up to 3 weeks is well tolerated in administration also. The iodide should be administered as soon after man."" The compound has been used in man to remove cesium.*" "' 11 esposure as possible because, once iodine is in the gland. its turnover is reduces the biological half. time of "'Cs to a third of the usual value.

slow. He biological half-time in the gland is about 120 days."" Only Aluminum-containing antacids are effective in reducing intestinal up about 507c of the uptake is blocked if the iodide administration is take of radioactive strontium. A single oral dose of 100 ml of aluminum delayed 6 hours6.944444e-5 days 0.00167 hours 9.920635e-6 weeks 2.283e-6 months , and little effect can be achieved if administration is

311 317 -

delayed more than 12 hours1.388889e-4 days 0.00333 hours 1.984127e-5 weeks 4.566e-6 months .""'If stable iodide has been given promptl.

are absorbed from the gastrointestinal tract within 20 to 30 minutes; their.

3 it should be continued at about 30 mg/ day for a week or two to prevent blocking action on thyroid hormone formation, however. lasts only about the small amount of radiciodine that leaves the gland from being recp 6 to 8 hours9.259259e-5 days 0.00222 hours 1.322751e-5 weeks 3.044e-6 months . Administration of the dmg every 8 hours9.259259e-5 days 0.00222 hours 1.322751e-5 weeks 3.044e-6 months would probably cled.""

be required for maximum effectiveness. In three human volunteers,40 Stable strontium is useful as a diluting agent for radiostrontium. It is mg of methimarole given daily starting several days after "'I administra-available as tablets tstrontium lactate. 300 mg. to be given two to fne tion reduced the biological half-time about 50% and the efTective half-times a day) or intravenous solutions (strontium gluconate. 600 mg of time about 257c."" If the thyroid already has an ample supply of stable strontium per day infused with 500 ml of 5% glucose in water over 4 hrt infine, the response of the thyroid to these drugs is greatly reduced.'2" The tablets are well tolerated if given with meals and are nontoxic at this Ammonium chloride given orally (I to 2 gm four times a day) is dose. This agent can be given daily for several weeks.

effective in mobilizing radiostrontium deposited in the body. Its efTec-Phosphate can be used to decrease the intestinal absorrtion of radio-tiveness can be enhanced by simultaneous use of intravenous calcium active strontium. It may also be useful as a diluting agent in case of gluconate. 500 mg of calcium in 300 mi of 5% glucose in water over 4 medical misadministration of 82P. Oral phosphates can be given in hours, on 3 to 6 consecutive days."2' An estimated reduction in the body inorganic (sodium or potassium phosphate) and organic forms (sodium burden of radiostrontium between 40 and 757c may be obtained if glycerophosphate). Vomiting, diarrhea, or both, may occur from phos.

treatment is started soon after exposure. Ammonium chloride frequently phate administration in doses exceeding 2 gm per day. Phosphate is used causes gastric irritation. nausea, and vomiting and should not be used in as a saline cathartic. Intravenous phosphate infusion is an unlikely drug persons with severe liver disease.

candidate for use in treating radionuclide uptakes. Rapid intravenous Diuretics are untested for the treatment of internal radionuclide dep-administration can cause severe hypotension, renal failure, and myocar.

osition. Enhanced excretion of sodium, chloride. potassium bicarbonate, dial infarction. Serum calcium and electrocardiograms must be monitored magnesium, and water in the urine occurs with induced diuresis. Some during such infusion.

corresponding radionuclides that coukt be associated with radiation in cases of exposure to tritium, a high level of fluid uptake by mouth accidents are 22Na, 2'Na, '"CI. K. and 8H.

will increase tritium excretion. Fluid forcing should be continued for at Studies on the effect of expectorants and inhalants on inhaled radio-least I week or until further reduction in dose is limited. The half-time active particles have been disappointing!* None provides effective i

of tritium in the body can be reduced from the normal 10 to 12 days to action that would be dependabic or particularly useful in treating persons 5 days or less by forcing at least 3 to 4 liters of fluid per day. The after the inhalation of radioactive particles. Here is need for further l

radiation dose may thus be reduced by a factor of 2 or more by careful scientific study to confirm the initial studies with animals: for this purpose management, the use of some of these agents, such as oral ammonium chloride or Orally and ir travenously administered calcium increases the urinar3 inhaled sodium chic ide solution acrosol.can bejustified for a therapeutic.

excretion of radioactive strontium and calcium in man. Zinc administered trial.

orally can be used for isotopic dilu: ion in cases of exposure to *5Zn.

Injections of parathyroid extract promote the urinary excretion of I

calcium and phosphorus. Removal of radioactive strontium from the Afohilizing Ager:rt tvdy can be induced as a result of the increased excretion of calcium Mobilizing agents are compounds that increase a natural turnover proc-and strontium which results from bone breakdown caused by parathyroid ess, thereby inducing a release of some forms of radioisotopes from body estract. l'arathyroid hormone has been used efTectively to treat an i

tissues. This results in an enhanced rate of elimination of these radioiso-accidental overdose of radiophosphoms. P. in man 12" topes. These agents are more effective if they are given soon aftet exposure, but some still Produce an effect if given within about 2 weekt When radioactive iodine has already been taken t;p by the thyroid.

(7sclaring Agents treatment with stable iodine is not effective. Antithyroid drugs may be

\\ number of chemical compounds enhance the elimination of metals considered in tliese cases if the radioactive dose is high enough tojustify.

Irom the body by chelation, a process by which organic compounds the use of these drugs with their potentially dangerous side effects

'ljgarids) exchange less firmly bonded ions for other inorganic ions to Propylthiouracil and methimazole directly interfere with the oxidation of form a relatively stable nonionized ring complex. This soluble complex l

the iodide ion and bk)ck the formation of thyroid hormone. nese drugs can be excreted readily by the kidney. A properly selected and admin-m.-

-___,. +, ~

' 3 19 '

318 over a 44-week period.'2" Teratogenicity and fetal death have occurred istered chelating drug will enhance the excretion of some radio,ctive in mice given five daily injections of 720 to 2880 mol/kg given throughout.

elements and thus reduce their residence times in the body. Therapy with gestation.<rr.2" Daily doses of 360 pmol /kg in mice about ten times the a chelating agent is most effective when it is begun immediately after human daily dose, produced no harmful effects rn exposure while the metallic ions are still in circulation and before the3 The zinc salt of DTPA is less toxic than CaDTPA and therefore is have been incorporated into cells.

advantageous to use for longer-term treatments and especially for frac-The calcium salt of ethylenediaminetetraacetic acid (calcium edetate, tionated treatments.* ZnDTPA also did not cause teratogenicity or fetal CaNa, EDTA or CaEDTA) is the most common form of chelator used in death in experiments with mice.

man, primarily to treat lead poisoning. It can also be used to chelate No serious toxicity in man has been reported as a result of CaDTPA 7inc. copper, cadmium, chromium, manganese, and nickel. It has some administration in recommended doses. Long-term. Iow-dose administra-efTectiveness for the transuranium metals, such as plutonium and amer-tions in man. I gm per week, showed no adverse effects after 4 years.'"'

icium but CaNa,DTPA (described next) has been found to be more CaDTPA is more effective than ZnDTPA in rats when given promptly effective by an order of magnitude for those radionuclides.

The edetates are nephrotoxic and must be used with extreme caution after exposure to 2"Pu. rCf. or 2"Am."" This finding led to the in patients with preexisting renal disease. Transient bone marrow depres-general recommendation that CaDTPA be used during the first 24 to 48 hours5.555556e-4 days 0.0133 hours 7.936508e-5 weeks 1.8264e-5 months after exposure and then that 7nDTPA be used for continuing sion, mucocutaneous lesions, chills, rever, muscle cramps, and hista-mine-like reactions (sneezing, nasal congestion, and lacrimation) hase treatments.

The effectiveness of DTPA in enhancing the excretion of plutonium is also been described.

In the treatment oflead poisoning, CaDTPA is usually administered by markedly affected by the chemical form of the plutonium. For both wounds and inhaled particles, the absorption of relatively insoluble intravenous injection in 250 to 500 ml of 5% glucose in water or isotonic saline. The maximal dose is 75 mg/kg of bmly weight daily given in two plutonium compounds, such as plutonium oxide, into the circulation divided doses, up to a maximal dose of 375 mg/kg weekly. The maximal occurs over many days and weeks. DTPA is not effective in these cases because of the small amount of plutonium present soon after exposure in dose for a total regimen normally should not exceed 550 mg/kg. Doses of the blood or intracellular fluids. Soluble compounds, such as plutonium about one-half of those listed above may be effective for radioactise nitrate, have relatively rapid uptake and translocation. and so the metals. The infusion time should be about I hour for each I gm of EDTA. Urine should be tested for albumin before and after EDTA plutonium is more available early after exposure for chelation. Data from persons treated with CaDTPA soon after exposure (on the first day) administration. Treatment shoidd be discontinued if albuminuria occurt indicate that about 60 to 7(YT of the soluble forms of plutonium is The powerful chelating agent diethylenetriaminepentaacetic acid (pen-tathamil. DTPA) is generally more elTective in removing heavy-metal.

removed as compared to cases without CaDTPA treatment.2' Hoth CaDTPA and ZnDTPA are available as an investigational new multivalent radionuclides than CaEDTA. It is effective for the transur-anium metals (plutonium, americium, curium, californium, and neptun-drug in the United States and can be obtained through the Radiation Emergency Assistance Center and Training Site. Oak Ridge. Tennessee.

inml. the rare carths (cerium, yttrium, lanthanum, promethium, and These drugs have been administered by both intravenous injection and scandium), and some transition metals (zirconium and niobium).

aerosol inhalation. The intravenous form consists typically of I gm of CaDTPA also binds trace metals present in the body, such as rinc and CaDTPA or 7.nDTPA in 250 ml of normal saline or 5% glucose in water manganese. It is the reduction in these two trace metals that probabis accounts for the toxicity to high doses in animal experiments. Dose' given over I hour in a single daily dose. De dose may be repeated on 5 mol/kr' to 6 successive days. The aerosol form usually consists of I gml of over 2000 pmollkg (the clinical human dose range is 10 to 30 CaDTPA or ZnDTPA placed in a nelmliier. He entire volume is usually can prmfuce severe lesions of the kidneys, intestinal mucosa, and hver.

inhaled in 15 to 30 minutes. Administrations by inhalation can also be and may be lethal.'2" increased toxicity from fractionated dose schedule' has been demonstrated in experiments with beagle dogs in which injec-repeated daily. It is prudent not to use the inhalation route in persons tions at the human dose levels,5.8 mol/kg of CaDTPA given every 5 with preexisting pulmonary disease. The drug is contraindicated if hours, were fatal as early as 4 days after the onset of treatment.'2* The significant leukopenia, thrombocytopenia, or kidney dysfunction exists.

most significant injury occurs in the intestinal epithelium. No untoward Urinalysis should be normal prior to each treatment. Hall et al.'2r' have effects in rats was noted with doses of 100 mol/kg given twice weekl>

developed a model for plutonium excretion after DTPA treatment that

I-

~ 321 320 suggests an optimal dosage schedule is provided with treatments on days iron poisoning. Its use for radionuclides should be considered only under 1,2,4,7, and 15 after exposure.

circumstances of serious exposure.

Dimercaprol (HAL) forms stable chelates with mercury, lead, arsenic, gold, bismuth, chromium, and nickel. Although seldom the agent of first choice, dimercaprol should be useful in accelerating removal of ionic g

g.

metals that are attracted to sulfur.

Deposition of rade.oactive particles in the lung is one of the more common Unfortunately, dimercaprol is toxic; approximately 56 of suliects types of ccidental exposure of humans to radionuclides. Insoluble receiving 5 mg/kg intramuscularly will experience toxicity.'8" There is particles, once mhaled into the lung, may be mobilized and transkicated frequently increased blood pressure and tachycardia. Other unpleasant to other organs at a low rate over many months or years.

but not dangerous reactions are nausea, vomiting, headache, a burning Lavage of the tracheobronchial tree has shown promise as a treatment sensation in the mouth, conjunctivitis, chest pain, and a feeling of technique for mdividuals who have inhaled relatively insoluble radionu.

anxiety. Sterile abscesses occasionally develop at the site of injection.

clides.""" The procedure requires placement of an endotracheal tube The drug is given by intramuscular injection. The doses for stable mio the trachea and major bronchi while the patient is under general arsenic and gold intoxication are 2.5 mg/kg or less administered at 4_

anesthesia so that the lungs can be lavaged with isotonic saline.

hour intervals during the first 2 days, twice on day 3, and once daily for Dogs treated after inhaling insoluble radioactive particles have shown 3

5 to 10 days.""

reductions m their long burdens from about 25 to 50% (average,44% in Penicillamine, an amino acid derived from the degradation of penicillin.

eight dogs) after five lavages of each lang"'-*" Radiation pneumonitis chelates with copper, iron, mercury Icad, gold, and possibly other heavy and early deaths were prevented in 75% of the treated dogs in contrast metals. It is superior to dimercaprol and CaEDTA for the removal of to the untreated dogs."" De same regimen of ten lavages removed 35 to copper. The incidence of adverse effects with penicillamine is low. He M "I ".'u nd "Pu, polydisperse aerosols of different chemical most common and serious are hypersensitivity reactions manifested by characteristics."" Sixty to 96 of the lung burdens of plutonium oxide a maculopapular or crythematous rash. One fatal case of granulocyto-in baboons were removed by treatment with ten pulmonary lavages.""

penia has been reported.

In one c se in which a person had inhaled a "Pu aerosol, three lavages 8

Penicillamine is given by mouth,250 mg four times a day, on an empty at 8,12, and 17 days removed about 13% of the estimated initial lung stomach between meals and at bedtime. The dose may be increased to burden." The aerosol proved to be more soluble than was assumed 4 or 5 gni daily in divided dose. If the person has a penicillin sensitivity.

. initially and this may have reduced the e"ficacy oflavage therapy.

the drug should be given cautiously. If adverse reaction occurs, discon.

Nssible use of this experimental technique in man requires a careful tinue.111ood cell counts should be taken and urinalysis should be done nsk-benefit assessment. The risk lies primarily in the administration of every 3 days during the first 2 weeks of therapy and at least every 10 a general anesthetic. The overa'l mortality risk may be 0.2 to 0.5% for days thereafter.

each procedure. Thus, this procedure should be considered only in high Deferoxamine (DFOA) has been used effectively in the treatment of exposures in which a reduction 25 to 56 of the dose could be expected iron storage diseases and acute iron poisoning. If given promptly, DFO A to prevent acute or subacute cITects, such as radiation pneumonitis or surpasses CaDTPA in the enhancement of excretion of plutonium (ly,

%n) sis. The nsk from the procciture is immediate, whereas late effects compounds.'"3* -" Its effectiveness declines rapidly, which makes its of radiation exposure to the lung may occur many years later.

clinical use for this purpose questionable.'" The combination of DFO A and CaDTPA yields better results than either drug separately."

DFO A is given by intramuscular injection, I gm initially, followed b)

$00 mg every 4 hours4.62963e-5 days 0.00111 hours 6.613757e-6 weeks 1.522e-6 months for two doses. Then 500 mg can be given every t

.lherapy for Selected Radionuclides to 12 hours1.388889e-4 days 0.00333 hours 1.984127e-5 weeks 4.566e-6 months to a maximal total dosage of 6 gm in 24 hours2.777778e-4 days 0.00667 hours 3.968254e-5 weeks 9.132e-6 months . Intravenous administration (the same dosage) shouki never exceed 15 mg/kg of full the treatments listed above summarize the available therapy for inter-weight per hour. Toxic reactions, usually manifested as a generalized nally deposited radionuclides. Examples of their use for some of the more common radionuclides that may be encotmtered are given in erythema, flushing, tachycardia, urticaria, or sudden hypotension, are serious enough to contraindicate use of DFOA m the treatment of mild lable 1.

~ ^ ^ - - - - - - - - - - -.

323.

322

4. Gromer MF. Bhaskar SN: EfTect of pulsating water jet lavage on radioactive contam-Table 1.

Therapy for Selected llemerits inated mounds.J I)ent Res $ltNo.2t3%.1972.

3. Negrovic V: Enhancement of the excretkm d radiocesium in rats by ferric cyanoferate Commen

Nutlide, Derapy 4 tt} fnt j gadiat, j7 1g7,%3 C'l DI A may be used if DIPA is um

6. Richmond. CR: Accelerating the turnover d meernally dermited radmcevum, in i

Transuranium elements:

CalH PA or immediately avaHaHe. but it is less Kornberg II A. Norwml WD seds.t Draenmis and Trrarment of f)rpmited Radi+

amerkium. c aht ornium, inDIPA egrective. DI O A may be consiJt'rnt nmfides. New York. Excerpta Medica ihmdation, l%R. p. 315.

t urium, neptimium, for high plutonium espmatesit

7. Stather JW: Influence of prussian blue an metabolism of '"Cs and "Rh in rats. ficulth plutonium DIPA is not available. I mse j,/r n s 22:1. 1972.

contaminated wemnds.

R. Richmond CR. Drake GA. lendon Jih Enhanced removal of radswuNdmm fnwn Cal DI A may be used if DIPA is m+t rodents and beagles with ferric ferrocyanije tabstractl. Radiar Res 55:546. 1975.

Rare carths:

Ca D I PA or immediately anilable. Consider ncett

9. Ducousso R.Causse A.15minier C: Comparative affects of acetarolamide ami Pruwian cerium. t.snt h anum.

InDIPA lor stomach laure and pgaen blue on '"Cs retention in the rat.1/ruh4 Mpio 2R 75.1975.

promethium. scandmm.

yt t rium

10. Stromme A: Increased escretion of '"Cs in humam. in Kornberg fl A. Norumd WD Conside need for tavage and purgatives.

ledG Diarnosis and Tirarment of Depmired Radiemm6 des. New York. Excerpta prussian blue Cnium W D M O N. M B LY nerapeutie trial of penWarnine h

(. b';'

lyckinamme useful. Consider need for stomach II. Madshus K. Stromme A. Rohne F. Nigrosic V: Dimimtkm d radmcevum N4y-lavage and purgatives.

burden in dogs aml hinnan beings by Pntssian blue. Int J Radiar Rh410 $19. IW..

12. Mad <.hm K. Strewnme A: Increased excretion of '"Cs in insmam by Pnswian blue. /

KI "Y NdI "' SSKI s' uuess depends on early administratinu Naturforu h. 23b 391.1%R.

lodine af ter esposure.

II. Spencer 11. I cuin I. Samachson J: Radimtrtmeium abuwption in man. fermer I:l%.

Aluminum hydrmide Comider sk"nat h lavsre Se'e'c 1%7.

phos ph"$

overdosage may be treated uitti

14. Spencer 11. I emin I. Helcher MJ. Samachson J: InhiNthm d radkwtrontium absmptkm parathyroid extract and oral phosphorut abstwptkm. Int 1 Appi Radiar imropa 20:507. 1 % 9 Mdf""i"m suuate che e er H. ew n L mactwn L etc er ett alununum phate gel on R.nhum Consider stomach 1.svace early.

radimtrontium absorption in man. Radiar Ret 3R 307. I % 9 3 9 m3,es Ammonium ( hlork!c

16. Ilesp R, Ramsbottom. H: Effects of sodium alginate in inhiNting uptake of radkntron-Cakium tium by the human bidy. Naturr 20R:114I. I%5.

Aluminum phosphate thrium sulfate and alpinates are

17. Hernard SR. lish BR. Royster GW, Farabee I.B. Brown PE. phtfersim GR: Iluman s'"i" tium alternatives to blotk GI uptaire.

thyroid uptake ami benhly eliminatism M "'I for the case d single ami contmual gl C"'"ida simnach lavage early.

ingestion of boumi inline in resin. treated rmik.1/raith I'hpir s 9:107. 1 % 3.

Sirontium or cakium

14. Ramsden D.15nant 111. Italwx!y CO.Speight RG: Radkiimime uptakes in the thyrtml.

Ammomum tbloride Studies of the blocking and subscipient recovery d the gland following the admimstra-teon stable imime.1/entr'r Mnks 13 M3, I%7.

I "'Ce ! U"id' I ritium

19. Von llenreich flG. Gath EE. Memeke B. Whang 011. Kuhnan J. Quantitative in sho-tmter suchemgen rur volktamimgen hemmung der gesamtkorper inktwporierung und retention der "'I4eim memchen. Ar.wrArrnenrrric I1.1/2.81.19%

20 Janaka S. Mochiruki Y. Yabumoto E. timema TA Kumatori T. Yamane T. Akiyama T. Matsusaka N: Priwection of thyroid gland and total twuly from radiation delivered References by radioactive infine,in Kornberg II A. Norwom! WD teds.L Drarnosis and Trrarment 4 Dermired Radiemmlides. New York. Escerpta Medica ihmdation.1%R. p. 29R.

I' " Management of Itrsons Accidentally Contaminated with Radionuclides. Commi,,ec II. Gilman A(i. Murad F: nyroid and antithyrtml dnses, the The l'harmm otorno/ Rasis Report No. 37. Washington. D.C.. National Council on Radiation Protection am!

of Theracewrin 5th ed Gm=! man LS. Gilman AG veds.t. New York. Macmillan Co..

Measurements. in press.

Inc. 1975, p.14 80.

2. Vasilik DG, Martin RW. Umbarger CJ: A sensitive. yet simple. plutonium woumt

. Spencer 11. Samachsen J. liardy. Jr. EP. Rivera J: Effects of intraven es calcimn and monitor. IIrnhh Mpio 35:557.197R.

ally cred ammonium chltwide on strontium.90 excreekm in man. Railmt

3. Normoi=1. WD: Therapeutic temoval of plutonium in humans.11ralth Mysio R.741 1%2.

n'

.%.-+.

.w m_

l' l.

o

329-

- 324 5tadionuclide contamination and rermval. in Prrrgren in Nud w -

4L Migng BA. Maudery Ji_ Boecht BR. Hh W. Mhh Nemum ed.

Vil:

i*

i"'*"

Y**

I' l'

XII 11rnish Physics. New York. IWaa"" Y"*

S S mons CS. Meyers MC: Accidental overdosage with radiophosphmuy Rcse ins 181:795.1975.

24.

u CI by induced phosphate diuresis. Am J Med Sci 254:453.1967.

44. Muggenhurg BA. Meshinny J A. Mig %o JJ. Slamon DO, McCleMan PO: he removal d WW % ad % ha M % h % 6 age AWh neawnejn thera F' lehbrier 1: Toticological studies on IIRA. in hnks R INagmnis arrd Treatment af Imvwp wared Radiammlides. I AEA Ptut44 cation No. ST11 '

cIs : Dia nosis and Trrarment ofImswporateel Radiamuclides. 3AIA PUR/411. Vienna. International Atomic Energy Agency 1976. p. 341; f

o Ff ply) oil. Vienna. International Atomic Energy Agency.1976. p.

at m

45. Nolibe D. Nenot JC, Metivier H. Masse R. Lafuma J: Traitement des inhalations accidenteHes d'osyde de p4utonium par lavage,

-_., in rim. in (Normnis aml '

l

26. Tayhw GN, Williams JL. Robert; f. Asheston DR. Shabestari 1 - Increased tosicity 84 M

niwion, Jfedth Physics 27;#25. 1974 Trcarment <(lacewpewared Radumw7 ides. IAEA Put4ecation No. STl/ PUB /AII; Vi...

- Na,Ca Dl'PA when given by prot enna, laternational Atomic Energy Agency.1976, p. 373.

ty n the mmise fetus. Ifrofrh

27. Fisher DR. Slays CW.

)

46. McCleMan RO Boyd H A. Benpamm SA.Cuddehy RG. Hahn FF. Jones RK. Mauderly :

Physics 2W. N Ca UTPA-induced fetal death and Ji, Memhinny J A. Muggenburg R A. Pfleger RC: BiW, msy lavage and DTPA.

28. Fisher DR. Scott EC Mays CW. Tay'w GN:

treatment of an accidentalinhalation"Pu esposure case,in FNhm Prodmv inhalati.m i

l l

malformation in mice. Trrd!'daKy 14:123, 1976.

I^'#'** A"""8# ##P'wf.1971-1972. Report LF-45. Albutsuerque. N.M.. levelace nsbyIJIPA

29. Slobalier> MJ. Brodsky A. Ke Cll, lloem 1: Remov fiumdation for Medical Education and Research.1972, p. 237.

chelation therapy. fredth Physics 24:327. 1973-tha narsis and Treatment ofincorpewared di, If g/411. Vienna. International Atomic Energy Agency.1976, p. 307.

31. Seidel A: Removal of "Cf and."Am from the rat by means of Ca DTPA and 7m ITI~PA. in Diagnosis and Treatment ofincewpewated Radionurtides. I AEA Pubhcatium No. STl/ PUB /411. Vienna. International Atomic Energy Agency.1976. P. 323.

32. Itall RM. Ihla GA. Fleming RR Smith JA: A mathematical model for estimation of plutonium in the human body from urine data inHuenced by DTPA therapy. Ifenkh Physics 34:419. 1978.

33. I evine WG: IIcavy metals and heavy-metal antagonists,in Goodrmn LS. Gilman AG.

leds.t. 7he Pharmacedogica! Basis <rf Therapeutics. 5th ed.. New York. Macenlan Publishing Co.,1975, p. 920.

34. Rosenthat MW. Lindenbaum A: Effect of desfeniosamine-methane sulfonate (DFOm 9 1948.

on removal of plutonium in ritro and in rirer. Proc Soc Erp Kid Med i17:74

35. Smith Vil: Prevention of plutonium deposition by desferriosamine-#. Naterre 209-8%

1964.

36. Taykw DM: He effects of desferriosamine on the retention of actinide elements in the -

rat. Elenkh Physics I3:135, l967.

37. Volf V: The effect of combinations of chelating agents on the translocation et 29-61. 1975.

intramuscularly deposited "Pu nitrate in the rat. Ifcafth Physics

38. Volf V. Seidel A.Takada K: Comparative effectiveness of Ca DTPA desferriosamine

p. and their comhination in removing tramuranium elements from rats. firalth PhyWe

32:155. 1977.

39. Catsch A. Ilarmuth-Hoene AE: New devekipments in metal actidotal properties of chelating agents. Biorhem. Pharmared 24:1557,1975

40. Pfleger RC. Wilson AJ, Cuddihy PG. McCleMan RO: Bronchopulmonary lavage f(*

removal of inhaled insoluble materials from the lung. Dis. Chest 56:524.1969.

41. Pfleger RC, Wilson AJ McCleMan RO: Pulmonary lavage as a therapeutic measure et the lung. //ratrh Physics 16:758. 1969.

42. Boecker BB, M.m.b.g BA. McCleMan RO. Clarkson SP. Mares FJ. Hensamin S A Removal of *Ce in fused clay particles from the beagle dog by Lkgimon.ns o

lavage. livahh Phy.ics 16:505. 1974

.-w-

M

)*~s.

yassp. 9,9'

IWfed 99MO by f hevier Nath iIcIlaM. Inc.

K. I'. IItsbner and s. A. Fry eds. The needecal Raws for cadiatwo Accident PreWs Decontamination and Decorporation:

The Clinical Experience George A. Poda E.1. die nmt de Nemoters and Connpany Sarannah River Phmt. Ailen. Samth Carolina.

l'or the sake of brevity. I shall not give a historical account of decontam-ination techniques used over the past 25 years or so: rather I will briefly touch on recent clinical usages in a major transuranium-processing facility. The contaminants of clinical concern at the Savannah River Plant are isotopes of uranium, plutonium, americium, curium, and cali-fornium. The processes of decontamination and decorporation of the actinides are often very difficult to separate in clinically dealing with a contaminated individual. During this procedure, health physics and medical personnel work as a team.

We have a plan for heavily contaminated persons. To minimize the time of exposure, a decontamination unit is placed in the manufacturing area of the plant. This unit (Figure 1) consists of a hot-water tank with how plus a box which contains protective clothing and survey instru-ments to be used by the helpers; also present are a venous tourniquet, detergents, scrub brushes, sanitary pads, hair clippers, a blanket, and a change of clothes for the one exposed. The gross contaminant can be quickly removed by using the materials in the decontamination unit and the contaminated person is then taken into the second-stage unit, the health physics decontamination unit, where he can shower and do a -

more finite job of cleansing. If hair won't clean up here, it can be iemoved and more sophisticated means can be used to cleanse the nose

.md skin. Should this fail, the contaminated person is taken by ambulance lo the third-stage step, the medical decontamination unit (Figure 21.

Thus far, we have not needed to use drastic approaches. Rather, some commoc-sense techniques have been used, quite successfully.

Ilair is scrubbed and scrubbed with detergent and water; if heavily

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-332 References -

1. Vernon Pfl. Ilatl RM.1% GA: Monisming decontamination and bioanay of a plutonium <tmtaminated injur y. flentti f%ysi< s 12:1539-1541. 19s%.

2. Jolly J Jr. McClearen IIA. Ibda GA. Walke WP: Treatment and evaluation or Discussion for Section III s*- -:>a i">'e - i=*dr"-'- - + '~r - *"'~r:"~<,s ib.a s 23.331 141.1972.

3. Itall RM. Ibda GA. Ihming RR. Smith JA: A mathematical meufel for estimatiem t plutonium in the human bcdy from orine data influenced try IITPA therapy.1/m/r4

(%ysie s 34:419 J'2.1978 i

I.I. SAENGTR-A legend states that if one shaves the eyebrows, there a relatively high probability that they will not grow back. Is th statement true? If so, what shall we do?

u.A. ronA: Women have been domg it for years. It is not very ofte i

necessary. At one of the REAC/TS courses the question was a swered. About M of them will not grow back entirely, but the will have enough that they can use an eyebrow pencil and be fm R.V.DoRN: In partial answer to the general question regarding shavis -

of eyebrows, this seemingly trivial rivia..., has become serious (

occasion. Here have been successful lawsuits for malpractice w ht the eyebrow has been shaved, even when this was felt to i necessary for proper medical care (e.g.. cleaning and suturing of brow faceration). Plastic surgeons, for example, will frequently ni shave the eyebrow to aid in skin repair because of these successfi lawsuits. Just some food for thought!

I.1-. SAENGER: Dr. Voelz would the effect of blocking doses of stah' iodide be affected by a continued release of radiosodme: that i should blocking doses be given over a period of days, and if se what woukt its efficiency be?

G I. VOEt1.: After tl:e initial blockage, which is 300 mg for sodiut

. iodide, there will be a recycle piut,bT., with the radioactive iodir:

i being reabsorbed. Derefore it shoukt be followed with a daily do =

ofiodide, which can be as low as 30 mg per day: so 30 to 100 mt

SAFETY SERIES No. 47 G

MANUAL ON M

EARLY MEDICAL TREATMENT vk OF POSSIBLE RADI ATION INJURY with an appendix on sodium bums A JOINT UNDERTAKING BY TilEINTERNATIONAL ATOMIC ENERGY AGENCY TIIE WORLD IIEALTil ORGANIZATION AND Tile INTERNATIONAL LABOUR OFFICE INTERNATIONAL ATOMIC ENERGY AGENCY VIENNA 1978

~

T - m% sme.c I

25Q,gy E

a FOREWORD

. The International Atomic Energy Agency, the' World llealth Organization and the International Labour Office issued in 1968 a joint publication in ahe I Al'A Safety Series entitled Medical Supervision of Radiation Workers tSafety Series --

The contents were restricted to the medical supervision of th'e radiation '

No.251.

1111% SAITIY SERIES WILL ALSO HE P'UlillSilED IN FRENCil worker imder notmal' working conditions..

The present manual complements Safety Series No.25. being escitsivelyr directed to first-sid and early medical treatment of workers:who might be -

concerned in an accident involving eurosure to radiation, whether external or internal.

The three organizations asked the following experts to prepare' the present L

~

Dr.J.C. Nenot of the Commissariat a l'energie atomique. Departement de.

marnal:

protection. Service de protection sanitaire. BP No.6.92260 Fontenay-aut-Roses.

Dr. C.C. Lushbaugh of Oak Riige Associatetl Universities. Oak Rkige.-

France:

Tennessee 37R30. USA: and Dr.T.A. Lincoln. Medical 1)irector. Oak Rklge The National Laboratory. PO Box X. Oak Rhlge. Tennessee 37830. USA.

following staff members of the three organizations helpett the consultants in their Dr. II.T. Daw. I AEA: Dr. E. Komarov. WilOs Dr. D. Djedievic. ILO.

work:

An appendit on procedures for dealing with possible smlium burns en--

countered in liquid metal technology is included. written by Dr.W.M. Elder.

Senior Medical Officer. Medical Centre. Y Bhwk. United Kingdom Atomic Encrey Authority. Reactor Group lleadquarters. Risley. Warrington, Cheshire United Kingdom. This material does not involve exposure to radioactivity but deals with a typ-of accident which would reqttire specialized skillin treatment.

The views expressed are those of the authors and do not necessarily represent the decisions, the scientific opi tion or the stated policy of the three te-spimsoring ;

organizations.

M ANUAL ON E ARLY MEDICAL TREATMENT OF POSSIBLE RADIATION INJURY I AEA. VIENN A.1978 STl/ PUB 1506 ISBN 92-Oil 23278-0 Printed by 1he I AEA in Austris October 1978 n

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e mniasainatem leset alwulute etsettneness an nuticasetm by wh.et is sf IItere were no twatment at all; there is littes flee etsk of semms tmk nephratet un in the Levage theids compyred with chest mtmting measurements. Iow on_

Or* the other haml. the complex formed by the tercrtyi hm with smimm bicarlwmate (titeness with timeiami physical and gwycho..ogical tolerance r f the operai.m:

is staMe cod is elemina?est by flee kidney 5. Ihe brac treatmeQt h Iherefare the rhorosis prescriphm fitting all cases is possible.

adminktration of a bicarlwmateil selution l42l whkh h ge.ven hvally ami m mirasemus perfu:iem tone Imttie of 250 ml at I. 83 p.

SPlil AL CAMS: PLU IONIL"d-SODIU\\l Al.1 OY. URANIUtf.

POLONIUtl AND NLPIUNIU'.f DIPA k enef fective for the treatinent of polornium porummg. liritnh Anti-Lewkite. It Al.,,3 e 24 dimers aptopropanoit is to umte degree etles tive. thougir Some alpha emtf ters are ordy slightly amenabk or not amenable at all to invarial ly becauw of their physico-chemical state an.,.

the effectiveness is variable with Ihe compound ar=1 with time llMl. Despite stment with DIPA crMy. their valern.iIn.s weakness of the tieerapeutic armamentarium may the uncertainty, llAL9 sleould be prew:t heti tsee Append:s Q l

f lit tie vahen serious here l'ecause substitutes have ptoren to e o 2_S.4. Neptunium

I. plutoniunesodium (41 l 1he sery: nng radetsctive half-hte 71 neptimium-2.47 means that stupecitic Ihe irviusttial use of breeder reattors ernploying lejuid sothum as coolant activity islow (l190 that of plutonium-239 and I/25tyJO that of plutomum-2.Ml.

ans that omtaminthon by a plutonium 4 odium misture is a possibility that brMogically significant etmtamination of the hings is thtes unkkely because of

- ~

I "

st be musidered. The 3 hitonium would then be present in the hesavaient or its soluNhty in the Imdy is greater than that of plutonium 4:

the ther or kidneyst omid well be Just as important as its radentoxicity 1the lethal DIPA coo 4 dose has been calculated at almut 12 mg - kg-8. i e.tl knq ag-8 :M.4 pri kg-8tt.

Cavalent form 8

eer forms and would accordmgly entail a large body etmtent.

of doubtf ut elfectiveness. at ali events it would be less effecthe the k mnmally In gevieral, the rtetabolism of neptunium places it sloser to the alkalme earths the urine and case with the more usual forms of pluton um. Its ett.ectiveness wondo vary.

than to the trarnphittmics. It is rapodiv almtbed. excreted (hiefly m.

it midd certainly be related toiln degree of instabih.ty of 18 e plutonium-fised in tbe bonc l32l DI PA should net be prewribed.as the comples Np-DI PA is Smce no other form of treatment k avaibbie. th-re is no other irse than to twe DI PA. but action shouhl not be postponed if an operation I e recerved if no treatment'were giwn at ali l431 Unfortunately. there k no tium mntur' or caws of neptunium the woumi or lung b entkaged. Ilowever. if the plut mium4 odium mixttire therapy that can le proposed at the prescat time f.

. ca ased smhurn burns. their treatment tsee Appendis 11 should always be contammat km en priority over treatment of the cori!aminatism by plutonium.

23>. CONCLUSIONS

2. Uranium Only ennchtti uranium presents a radiotoxicolagical pre.blem; natural The general prmciple that emerees from the above tonsiderations is the Treatment uith DIPA.cren if admmhtered only mium is problematic elely f rom tae standpoint of. itemical,oxicology.

Principle ofimmediate aethm.

c anium enists m two valences: 4' and 6. T he 4. form is amoluble and gradually locally in the first smtance to a uouruf or in aerosol form to Ihe lungs etfers

omes wnserted to the 6' form. which r. tratoformed into the uranyl ion protection for the target organ. enables an overall idea of the contamination to s

h I n.e biological behaviour of' flu.s son wotdd be wmparable with that of be gained and procures time (cr the dechion whether or rmt there is indication alkahne carths. were it not for t.oe fact that it h precipitated m. the kidneys.

for surgery. Surgical intervention entads only problems of surgit al detail.

m k phpito-(hemical state leads to a fairly rapid difTosion despite tlw apparent wheress pulmonary lavage remains an exceptkmal form of treatment; its maior olub lity of ntunerous salts. Altitotagh chelating zgents undoubtedly.et o:

disadvantage is not so much the rhk involved which is very slight. Imt the need mmm. they ',aouhl not be uwd becau.e the increned migrant fraction leads to repeat the treatmertt. thereby imgwnrng a comiderable strain on the etmtammated r

29 n

L_ -

--w M" *

I ef fetineness m reemnmg mtern efly dero eted plutommm e s. Il shutthi eso4 % ausp % o..

s lit

linarilotts ( as sti Itte osse ol' ut stittitti lIhj NORO001).U 87. ItIrA s al insiics stiellhlhe antf tuay <* vert from humam. J t bur. Med 2 e 8%4p.t71.

If I D.G fl. L) NN J (1. \\ measure of the ellertnence of Itf P \\ s helatwm I nepitinittno.

{17l 9 1801 20 therapy m ta<s t.f pintemmm mhalatwm and pintonem wmmds. flealth I'hys e las7.1p 317 111.1 I ItIACI310 til AI'll'R 2 lIn) C \\ f st II. A. Frienasteve Metaf \\loNWatum m Aleda me. Owmias Sprmef w IM RMM DOI NI~ A I-.ll %VI.H i l S. I.. C AMPY. L "Interattwm li tlR. W J. fi tf l ott. J I. P A R K. J li. S \\NDI RS C l.. "Pintimmm m wlt thmes eqGWR hetse n shetaan ami cmf.vemms rem". m Durm.m amt Ireatment of IApowted I temeria.

ti with emph.sm <m the resp +tator) trae;f'. m Uramum. Mutonmm. I ramplutemic Radwmmtwin tlLORN Rf RG. If A.. NORROOD.

I. I d*t. l sarrea Mrdn a t 19M D t h !I titolM;l. 38 C.. Sl ANN AR D. J N. IIURSil. J B. I dst. Stwts ect.Verlag. Bevim.

j'u) I l'QU t.P A DIPA lossuty.USAI C flealth to or.l es em D1PA" Ipragnmes and

~~ Meet me. Anrusta. Georgu e l'av.mp 2l t Al (TM T. J. NI NOI. J C. MORIN. M. M \\SSI R.. Mi IIVll R.M. NOl lPI U -

g;g g pt3N gs,ltoggNf. I,, LOllgR p II R, J.,-Im o a HO Semmar V senna, lu 75 9.

licidellierg. New Yorts e 197.1i f reatment of Inwrporased Radwmentnin e Pro, a

%ITINSKl. W. "Re-peratory (arrsmigennes in rats atter mhalatwm of rz.l>= astm i'. I spetr*nent al y4ymamag

t se therapentet dmarn. Radel acrosols of attin, des and isnthamdes in varums phywwhernetal fewm l ung t an(er t K A RHl. f, PAR K. J I'.. I Jst. Sprenger. Vert.eg. New York (19716 413 l 22l SM ll ti, lI. MORG AN. R., t he toswit) or

5-2 Nrical Ancen+vit of P

MJ 2iM7h H etretts of a thelatr'g seert mm) the,v ll H \\1R. W J. Rffil\\tOND.C R, W Artif fOt Z, R W, A Radphn+1 l21) 5%i NI RION. II IIURI l V. l. S. Ierat.ec s USAIC R p the Spattal Dissetbutum of Radiatwm Ihwe frtmiinhaled Mtst<meum, presevitsem by imc kiem-e 17J t 197 8 8 62 I spermiental cudeme smf peastaal M VOU'.V..~rlutemme decorparatwm m vats:

W ASil 1324 419746 L R;lC AL PROII CIlON. RfP""I mp,K,,,m, g gtmw,,,m, g,c,,,r,,,, g,yp,,,,e,g g, g,,m g,,,,, p,,c, g 39 37g g gg 2l INil RN \\llON AL COMMISSION ON R ADIO (t ommittee il on PerrmwsNe Ibc for internal Radsatwm. SCRP Pubhratwm 2.Pergamo=

3,,,,,y,,,,,g,7gg,ggg ( y,,n,a3,76, 19 7, 1

Am f r m, the rat 13 meam et i a i#f P \\ amt W

Prew. Os f ord i 19591 W(g,a bl lNII R N \\ LION \\L t 'O\\f MGSION ON R A DIOl OGICAL PROII CIION R't"'"***I

g g y gpg L g-Rev og g ggpg. y, g y twms of the 14 Mr.1CRP Pubhcatum 26.Pergsmrm Press.Osford f lW78 5l INIl RN AIlON AL AIOMIC I NI.RGY AGI NCY.14auc Safety Stamferds for Radutum

( s.I 1. AGE ROUIS T. C R. II AMMONil. S E m FUI Zll R.1. A. Pil.ilNG f esq Dg r A treatments m t wu ty pes of pintonmm esgweres m immam.

3n Prutedion.19671 ditum. Safety Serws No 9. I \\t: A. Vsenna f 1967 9

27), gy,.'h3s II (19655 I 8 77.

{r.l INil RN AllON Al COMMfSSION ON RADIDI OGICAL PROll rilON. the MetaMam lie teh l d Amernmm ( ontammat*on of a Pam 8me

. A I AYLOR 8 T, Mat.mmm an Pergavm m Frtw.

of Compounds of Mittemium amt Of her Attmmfes. ICRP Publxatwm 14 Wrmml ami t*y inhat.stum. rrogr. Rep AI Rf.-f*rif MS 2 81V7.5 7 32 a fm J,-Study of two sasnof tontammetvon by Osford t I972 8 q JI: AN Alpi,L,8gltAD

[7l V Al'Gli A N. J "lpistriheum. escretsoft and cf fetts ni plutemstem as a Imrie seeker _ pgg ggg mg g %

g,,,,g g %,,o Aatwuhe.

m l'ranmm. Phasemmm. Itamplutemic I lements e f fOlM;l.. Il C. 5 i ANN AR D. J N.

,,%,, g7 g, $ y g,

g

,p,,

og gy,,,

11tf RSif. J B I dst. Sprmger-Verlag. Berlm,lleidelberg, New York i1973 L y,

g as, g

2.e Industrial hygwne, health phyucs smi related aspetts,

mhalaten. Ilealth Phys 27tl4748359 2*?q m.

pl P ARKI H. Il M. -Plutomum g gg g y 3 33 7, y p pg, g 33,, y y, 3,,,y,,,,g, y,,,,g

,,,,,g gm,,,,,,,,,,,,h

'Nd l'8l INil RNT ilON AL % f 0\\flC f Nf RGY AGI NCY. Inhalatum Risks from Radw*acitwe Dmb rbp 2101971) G hmcal Regwnts Settes No 142. I Al A. Vsesma (1973 6 R M. Iwo cahformam-252 mhalatwm cases. Ileafth I'hyt 29 Contammants let pll FOD L G A. Il M I 10l DURBIN. P R. -M crabolism arnt t*,olog, cal ef fetts of f be transplutonmm elemetfs".

g g7$ pgn7, m Uranmm. Plutonmm. Irampluttmic I lements tilODGI:.ll C.. ST ANN ARD. J N.

l t2l NORwOOD,W D.~rtatoneum and other trarwurannum elements"J h 13.llcaltet if U RSif. J. H. l dO. Sprmger.Verlag. Berlm. flewlett' erg. New York ( 1973 8 Pr.wettum of Radeatum Wmker*. C. T hemies. Srrmgfield. II. t f 975 )

IIl NI NOf. J C.. MORIN. M.SKUPINSKI. W L AI UM A. J.. I sperimentai removal ofl11) Iharnom and irratment of Inomporated Rademninfes t rros. l al A, Wif 0 Semmar 2"ru f rom the rat skeleton. ffealth Phys 23 t 19726 635-y,,,,,,g,73,,yg,4,y,,,,,,g,73,

'**Cc, 2*' A m. 2:erm ared l 2l NI NO T. J C. M \\SSI:. R MORIN. M. L AI UM A. J. An experimerital comparative l 44l St IIOl 111f t. G lt. IIORf I LS If., WARf. f.. Li NN. J C. DOI MIIN,G W. Asscemie

Cm ire Nme. llealth Ph)5 748541.

study of the behawwmr of '"Np,2*Pa "Pu.

Am and and enanagement of a piutemmm torttammated wemnd case,llcalth Phyt 26 e 19

{ t tl Lag UM A, J,

D. agnostic et traveement d'un ces d'entoucatwin par le plut+meum.

22t19725657.I AYLOR. D M.. DIPA therapy for chelaten of "Per in bone:

los al craterd et generahd ensmve". Iharnoses ami Treatment cf Radnactree Poexmme 2

the 13l JTMl S. A C milueme of the re-modellmg. licalth l'hyt 2111971631.

iProc. Scwritific Meetmg Vienna.1962L I AI A.Vierms i1963 9 3R I.

14l DOLPflIN,G W,-Review of wmee problems and recent rescarsb work aswctated with from humam' II,e use of shelatmg acents fur the removal of mcorpmted radwmuctwies Dugnoses and t reatment of Incorporated Radumutlwies (Proc. I AL 4;WilO Semmar Vwnna, l975 9. I \\1 A. Venna t19769403.

.I. l 30 I

3NI.. L Govu:R A A l3nl rit t i RON J r. J AMut T.C.it.Al tntA. J..CcNot:-Com(ermng a coe of s penetrat mg wnand made by a foreign twf y highl EMERGENCY LOCAL DECONT AMON ATK7N

. rtuommm-239.in ticomtammainn segery..th Nudes < tietector Mam*oeme 4in l'renth6. Mem. Acad. Cher ;l'aris 99 419646 323.

i therarcut k

. l37) r1 tiGI R. R C.. mit SON. A J., MWLi'l L AN. R.O.rulmonary nare as a mes ure for removing mhsted mvehrble materials frown the lune. llealth rhys. t6

' i The general prini;iples governing emergency local decontar.vination

( tw6ve 75M lAUSON. D O.

. l3?] AttCGI NHtJRG. B A.. Mi ufilNNI.Y.J A.. Mit;tlO J.L $Md tt LLAN. R O. *1he remavat of mkaled "ru arra "ru from b simple. The actions to be taken have the same aim. namely to remove 2

tune inage and chetaene therary". Diagnom and t reatment of Incorro sted Ret +

gg rm g gy g g % ggy, gg g gg,gg 34*.

CaN Wernal(mta-mechdesieroe. Al. A;uno semmar vienna. t=75s. I AI A. Vienna e 1976:

e n an a nan pa i m) Nutlet:. It. NI NOT. Jr MI 11Vil R.11.. M AS$1. R.. t Al UM A. J,- t raument dnmmation (one should never assume a contaminant to be insolubleL and the v mhslatums atxtdentelles d'os)de de plutonmm rar Israce rulamnatte m wrvn.s'nd objective being to prevent the contamination spreadine either on the

~

l40[ MW1I t.LAN. R O. BOVIL 11 A. Bl Nj AMIN. 5 A.,et al Retmery or "ru folloung or to the other areas and other people in the vicinity. Accordinely the correct p yg immth.orutmanary tware and t>tFA tre3tment of an statentat inhalaten c=rmure procedure is as follows:

ca c. llealth rhn 23 t 19726 r/ 502-

]4 8) % F TIVil R. II.. M ASSE. R., Nf NOT. I C.. NOLIBE. D LAf UM A. J

t twde "I

esrfrimentale dela tvntamination rae on mflange esses de la combusterm du mimr= en as w as pMD presence d'osyde de rinfoemm, iharnom and Treatment of Incorrarated Rade-lhe Contaminated surfact shouId be quirkly dehneated; 7

nutledes t rris I AI A/WilO Semmar Vierma.1975 9,1 AFA.Vienne t t976) 10.

{ J2l Ni tl I AN. W.. II AVEN. F.. IKDUN( t; A L,llO L AN. T.. ROtti. Ri$.f:.."Af tempiedThe contaminated person (st should be isolated.

rresenten and therapy of uranam rov <enmg in Pharmamlog> and inucningy of

~

Ura emm Compmmds eVOf G111N.C.110101. Il C.. Idst McCrow Ifoff. New Yark Care must be taken to avoid damaging the physiotocical barriers in any w

'8953' 2"Nr wr the rat. IleaHh g g

] *3] MORi% M, NITO1. I C.. t At UM A. J Jhe behavame of employed must not be aggressive to the skin not shedd any substanc rhn 24 e 19731318.

which would solubilire the contaminant.

12. PRACTICAL MEASURES For the initial decontamination meawres on the spot to be eff ettive it i necessary for the radiatio i protection staff Io be specially trained; it is who are the first on the spot. who make the initial aswssment of alw cem and whose task it is to perform the first meawres. They send the victim medical service as soon as emergency decontamination has fre i

t'

. heing particularly essentialif there is residual contaminalion.or if c(mtam is accompanied by injury. or if a sensitive part of the body such as the eyes mouth is affected.

Of course. if urgent surgery is called for. this stage shoidd be skipped victim evacuated immediately to a speciafired centre.

As soon as the patient arrives at the medical centre. several measures mu checking of the parts of the body apparently free of contaminat undertaken:

. delineation of the contaminated surface. so a on of the patient.

i l ti 32

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Certain parts 'm > have been overlooked in the initralimswtum an't tite on P oi 12.m d.i.E

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=-

9 to establish the precise areas of contamination is to make o close examitration

- whi h C catrses in the surface layers. for instance,uramom licoride penetrates the skin harrier mtxh more readily when C is in su pemum in o fatty substance s

the patient with all his clothes off. using suitable detection equipment for the

.such as lanolin than w hen it is in an aqueous solution 131 pose. The contaminating substances can spread beyond the original limitsof As it is sittually impossihie to reduce the tramportable fraction of the ctmta-

ctmtiminated surface either by themselves or as a result of the treatment -

minating radamutlide by surface treatment, et soidd seem logical to try and lettaken. Appropriate measures must be taken to prevent the contar-nant influence the tramfer mechanism. Theoretica'ly, the met semple method would eading. if necessary by covering the contaminated surface with an ocausive be to set up a mechanical barrier to the circulation by means of a tourniquet (4)_

ssingc Special care must be taken to avoid the contaminant spreading to any Ilowever. the medical roks associated with tournigrets ami the strict rules governing

> contaminated wounds, which should be covered with a waterproof dressing.

their use must make this an emergency measure strictly reserved for severely to 9.he natural orifices. It must alw be borne in mind that any movement of a haemorrhagic contaminated wounds of the limin: moreover. tourniquets met be itami=ted person could result in spreading of the contamination. T r refore applied under medical sureniskm. Armther means of reducing tramlocation is by contaminated patient should have his working clothes and slues removed so reducing the blood flow ming hypothermia 151. Cooling not only reduces the

it he ccn be transported in as clean a state as powihle. Dispmable covering blood flow in the area af fected but also reduces.he rate of absorpti m by the ots m de of plastic, a smock or overall may be used to cover contaminated skin [I1. T his is a minor but risk. free technique which facilitates the executiem as. Disposable plastic sheets may be placed under and over the patient on tfx of the netessary measures. for example tramportation by ambulance.

etcher and on ihe floor of the ambulance to prevent contamination. On his T he use of chelates for decont2minating the skin in the case of rare earths.

iv 1 tt the medical service the patient should be kept in the room reserved for plutonium and the transplutonics haslong been a subject of contrmersy. Autin

-fontamination until treatment has been completed.

opposed to that method argued that there was an im.rease in penetration throug This treatment can and should be extremely simple in the majority of cases.

the skin due to the formation of a complex. This is undeniable l2] and ak.o quite e simplest measures and those least harmful to the skin should alwa) be used comistent with the Irposolubili;y of the complexes formed by the chelates with the start, tnd only after complete or partial failure should more specific types the heavy metals. This argument would certainly be valid il the compkx were -

treatment be considered. depending on the nature of the contaminant. One unstable in the body and distributed the contaminant to the retentive orgam oblem which often arises is that of choosing the criteria for deciding when after its translocation. The real situation is quite different.since DIPA has been etment should be stopped. Each case is a special case depending on the general

' proved to form perfectly stable complexes 'in vivo' with elements of vakntes

.nditions of the accident and the nature of the contaminant, but the practitioner greater than 2' which are eliminated very rapidly via the urine with a very high

ust draw a balance between the risk of residual contamination. resulting in doses clearance rate. When it is a question of elements involving f airly comiderable excess of the current limits, and the risks associated with certain drastic methods risks.such as alpha emitters. it does not seem reasonable. on the one hand. to decontamination.

refuse to accept the risk of a minor expmure, which is extremely limited in time The first means to employ is washing with pure water. then soapy water; and space.due to tramfer of the element into the blomt and then through tlw e acid soap offers the double advantage of often possessing a higher decontami-renal system, and. on the other hand to accept the risk of quasi permanent tramfe ition factor than alkaline soaps and of not being very aggresive to the skin. In to the skeleton of a fraction which. though minute. can represent a comiderable

. ee mijority of cases water and soap are sufficient to remove met of the conta-dose integrated over the life of the indisklual. As it is impowible to predict the ination iI1. The water should be tepid. never hot: as this would cause hyperacmia.

extent of penetration of an 'imoluble'. this being a function of multiple exoria-

occial care must be paid when the patient suffers from skin disorders,in particular tions of the skin it would seem essential to perform decontamination of the skin fremn 121 and esen more so decontamination of a wound with a DIPA solution.

It is only after the failure of repeated washing that one should consider using Some special cases call for special techniques. For example. any contaminatio

,ecial techniques. Such techniques are described in Appendix B. Some of these of the eye must be treated immediately by copious washing with tap water and th all for a few comments. The method of applying paraffin or wax at a temper-with an isotonic solution in the medical service. In view of the aim of the tr

~ tire of tbout 50*C. allowing it to set and then peeling it off with the.ontamination one should never use eyebaths or the like but rather a continuous and copious xed in it. is recommended by several authors but in fact is sarely used. no doubt ccause of the long time it takes. The use of grease solvents is to be strictly supply of fluid.

coided ill; not only is this method completely ineffective but it can also facilitate 35

~ ~ *

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Decontamination of the skin. the prime objectise of whih is to avoiti trcnsfer of the contr_minating radionuclide, should be performed with simple methods and FRLCAUT IONS TO BE TAKLN IN THE EVENT Ol' HOSFff'ALIZATION should be accompanied by continuous monitoring. It should never be allowed to delay general treatment and sometimes comtitutes the first stage of such treatment.

as for example washing of a contaminated wound with DTPA. The dressings.

washing water and any appendages of the skin removed from the bmly.e n. hair.

should be carefully stored away for subsequent examination to help establish the 4 I. IN f RODLCIION level of contamination and the cffectiveness of the decontamination procedures.

In certain cases the contaminated or irradiated person enust le revetoved to a hospital Ihe decision to heritalize a person should be taken by the plant REFERENCES 10 Cll APT ER 3 physician. but the victim can also be sent straight to the hmpital if the physician or his staf f are not available. As streswd in Chapter 6. preplanning between the

[Il H AIR. w.L. sstii11. V.fl.. Ralsomniale omtammathon and renmal, l*rog. Nucl. I nergy.

tuedit;al wrvice and the hospital unit is nece%ary to a%ure that the latter is series XII.IIcalth rhysks. rergarmm Press.osfont t 1%96157.

prepared f or the special problems powd by a contaminated or irradiated patient.

{2) NORWOOD. W 1).. llealth rrotection of Radiatwm brkers.C. Ihomas. Sprmglicid.11.

lhe c%treme caw. what h should be avoided by such plannir*g. is for a hospital to i1975)

E# " " "

I"""

[3) ORCUTI. J.A., "Ihe tosicology of compounds of uramum follom mg arrheation to tLe skin". rharmacology and Tosicology of tiranium Compounds t VOI GTLIN.C..

gwemiws and staff.

IlODGl. ll C.. I do. rt. I. Md; raw 4 fill. New York i1949 9 377.

As w(Il as a%uring that the hepital is provided with the necessary scientific (4l C LACK. R.H.. I'rotecting and cleanmr hands contammated l'y sy nthetic fallout under and technical information,it is important that the particular problems associated field conditions. Am. Ind. flyz. Assoc. J. 21 t 1960616 2.

with the nutlear nature of an accident are put in their proper perspective with lSl UIRill. J I. " Man.ecement and treatment of caposed personncI'. Industrial Medicme respect to medkal and/or surgical problems; moreover, we should not forget the on the Plutomum Protect (sTONI. R.S.. I d I. McGraw4 tilt. New York I195 8 ) 241 d W @W W% W *@d @b'-

These secondary but important aspects are trdaced to a minimum if the hospital wrvice is trained in the handling. of radioactive sounces as is the case. for example, with a nuclear medicine seriice llepitalisation of the affected person can be justified for two different reasons: either on account of the wale or the nature of the acident and the resultimt treatment requirements, or simply for reasons of consenience as. for example. for the purpmc of making a (linical and biological

.nssesstnent requiring numerous specialist servitrs and diffitutt to conceive of t,n an ambulatory basis.

It is clear that the measures to be taken. whether they belong to the radiation protection. diagnetic or Iherapeutic category. differ fundamentally depending on whether an irradiation or a contamination accident is involved.

This chapter deals almost exclusively with the special measures necessitated by the nature of the accident. showing how they fit into the framework of a umsentional hospital service. Thus no reference will be made to current medical.

wrgical and bi-3ogical techniques nor to the specific treatment of irradiated or tontaminated patients as emergency treatment is dealt with in the preceding thapters and the appendixes and extended treatment is beyond the scope of the tvewnt study.

M 37 4

e n. <.o.. u.

~'

J..'. ISI) ItNAl. IltitAl#I A IION Ilre contrast between a case of exp<ntire and ore of t ontamination can be In the caw of a patient eispi* sed to adiation im encasures are necewan to readily understood when we omsider the measures that have to be taken in 0 protect the premises or perstmnel, Since cases of wholeJwly espmure are rare fiospital. Whereas in the case of expmure, efforts are directed towaids protectmg and there b no urgency in i se medical sense of flw term. there is no point for all the victim. in the case of a contaminated patient varying measures have to be t

hospitak in permanently witing aside a room for the admiwinn of gmuible victinn considered for protecting the staff and the premises and sometimes the pubirc as of radiation actidents lloweser. in view of the rarity of sut.h con and tire por.i-well. Aloreover, an externally irradiated patient does not generally constitute a bility of their being serious it is essential that a plan le drawn up an I adherett to.

ruedical emergency; rm the other hand. the progrmsis of contamination depends In particular it is netosary to coordinate the actions of the sarious spedahst m4 of ten on the speed with which treatment h commenced. Generally speakmg.

d often senite4 intohed fairly frequently. 'I bese specialist ser ices are numenms an accidental contaminatiem of perstms occurs at levels not representing any risk of far remmed from each other. Imth as reg;nds the nature of their normal atierties contaminatiori to other persons or to the environment. It is only in the excepti and their geographical location, and it is ewential that cmtinuous liaison slumk!

case of incorporatim of a very large quantity of a highly active radionuclide.for exkt between them. Thus. to name only the principal tmo. it will be necenary e ample as a result of a misadministration for diagnostic purposes. that measures on the dinical side - to be able to call upon specialkts in dermatology. neuroh,g).

have to be taken to prevent irradiation of personnel.

gern> enterology. cardiology, dentktry and otolaryngology. as well as a reliable resuscitation tmit and a wide range of biok>ghts from fields such as pathology.

43.1. Measures for dealing with contamination with its highly specialized forms as, for example. citogeneties. bacterinh'ry-immtmology, cellular kinetics and histopathokigy.

Adminion to hospital does not generally pose any special problems, because

'I he ideal hospital service for the admbsitm of a w hole-twly exposure victim.

in the majority of cases the external contamination of the victim has been treate whose progrwsk is uncertain. is a resuscitation unit or a tmit for the treatment and there is no further risk of its spreading. In exceptional cases the patient may of burns; the staff of such a department is familiar with aff the methods of holation have cc/me directly from the pixe where he was contaminated (case of a person A major problem is whether or not to confine t e patient in a sterile h

room. As it is unthinkable that a room should be permanently reserved as c cerile both injured and contaminated, for example); in this case it is desirable for the and asepsis nmm and as moreover it might not always be pouible to make sush a soom avail-patient to be admitted by another route than that normally used by patients.

l Except in cases of rnedical emergency the patient should be taken to a Miower able for an exposure case by dispfxing another patient it would seem preferable to u e a light plastic isolation tent. kept folded away and regularly inspected.with room or to an autopsy table. i.e. a place where decontamination will be facilit and spreading of the contamination within ihe hospital avoided.

its own independent filtration system and preferably maintained at overpressore The risk of staff being contaminated is very small in the majority of cases.

while in me. Such a tent can be erected quickly inside any ordinary hospitel room.

particular attention should be paid to residual contamination of the skin which can The choice between sterile isolation and simple isolation against exogenous infec-be spread during residual desquamation. or contamination of a wound which ca tions tinfections of dental origin should not be overlooked here)is lef t to the be spread when the scab is shed. s well as to contamination which could specialkt or team of specialists taking charge of the exposed patient. In any case.

by excreta. The i,se of dkposable gloves and disposable plastic containers apart funn specialiicd personnel. the hospital should have some special facdities Special vigilance is called for in the case of an uncons.cious patient possible riskt available. indudmg at the very least a means of isolating the patient.

who is incontinent or vomits in the period following a digestive contamination. as Although an isolated patient should not as a general rule teave his place of well as in the handling of dressings placed on a contaminated wound. Not only isolation during his illness and it is rather the various specialists who should come should the t,sual precautions be observed in handling these dressings but arrange-and visit him. it is desirable to release the patient to his family at home until ments should be made for keeping and labelling them for subsequent examinat changes in his blood values suggest that further hospital care will be needed to estabhsh the level of contamination.

(atmut the 21st day 1. As it is clearly not desirable to expose a patient with ideally. apart from the equipment usually available in a hmpital. the follo agranulocytosis to the attacks of microorganisms w hich he is bound to encounter facilities should be available:

in moving about. it is a good plan to have individual scaled transport systems such 7

as stretchers covered with a transparent plastic bubble. Provi ions should be made An isolated room that can be used for external decontamination of for the isolated patient to have an audio-visual contact with family and friends.

patient. with a shower and an ocular douche; J

1 to proent psychological pressures.

.M !

JM y

omsidered as a contammai.t. as kmg as no g >= m u h id Wasuring equipnyent (for alpha. beti gammi and X-radiation L capable ut -

material such as facces and urine should be stored in c frecier. W if the necessary l

detectmg low-level mntaminatism that can be med for the stia and active omtaminant has a short half.hfe. it is o good idea to keep t or Cith certain clothes. the ground and walls; period in a hocked. ventilated room with a warning on the door.

Containers for taking bioh>gical samples for radioanalysis; A suf ficient stock of sheets. towels. masks.glovo. general and surgical highly contaminated materials it is often better to disp >se of them lt decontami-

~ instruments. and plastic bags for storing corstaminated solid waste.

authoriied than to undertake a h ng. diffkult, cmtly and incomp e e nathm procos.

Clearly these facilities and equipment can only be of availif a minimum h

h i d appropriate ntial numtvr of staff knows how to use them and as t us rece ve 43.4. Meawres to be taken in the event of a surgical procedure ruction or been provided with.ali the necessary Irasic information.

To avoid loss of time, which could have serious consequences in the case ofT he measures to be taken in the event of surgical prowd il onal contamination. it is essential that informal or, better still, formal pulmonary lavage are dealt with in Chapter 2. I 2.43. Only the sp d

ll d bric0y mgements exist between the facility medical service and the hospital unit an cautions intended for protecting the hmpital and its staf f will be reca e s

t the persons working together know each other personally. This is aim i

lved.so that each ows exactly the possibilities and limitations of the other.

l'rotect the operating theatre, covering the table. floor.e

.irable in cases where two different nations are nvo If the level of contamination is high. the staff who has treated the contami" plastic sheets; ted patient shouhl be required to undergo medical examinations con uc e provide detection instruments appropriate to the nature o

(

d t d by d gloves.

ysicians or ancillary medical staff)of a kind and at a frequency depending on some for monitoring the operative fields. surgical instruments an

^

e nature and amotml of the contaminant Ifor more detailed information see and others for monitoring the theatre and waste; Monitor the respiratory or digestive probes

?I.IIIl 3.2. Measures to protect perumnet against irradiation Use disposable materials as much as gmssible and mns dige from a contaminated patient contaminated clothing worn by the surgical team.

So far, there has never been a case where the irradiated patient has been a 31 idh> active threat to hospital personnel. If such a case should arise it would be 43.5. Measures to be taken in the event of death of a conta f

ecessary to cut down the time spent on both medical and general treatment o it is difficult to formulate general rules conarning the autopsy he patient and to check that the sum of the doses received during the time spent cremation of a body containing a certain amotmt of radhuctive mater i l because limits. It is near the patient and/or from his excreta is less than the public dose the laws on these subjects vary from one country to another.blem when li ti )

ven more unlikely that recourse to the use of screens or markers (zone de nea onseveral days at ~ 20*C or -30'C helps to overcome ti;e pro

, vill be necessary. Isolation of the patient in a room with one bed usually solves l

be such as emitters are involved. It is in fact rare for the contaminat l h to pose problems for burial. On the other hand. it is necessa nost problems.

d r to be regulations if the body is to undergo special preparatkm, to be c j ti 433. Measures for dealing with waste embalmed. This practice should be avoided unless it simply invo h ld take Contaminated waste should le dealt with in accordance with the generally fixing substance. Nevertheless, the persons performing the emb all the usual precautions for handling radioactive mntaminants.

' As far as excreta are concerned, the problem is not one with which the The same precautions should be taken during the autops

accepted regulations for handling radioactive waste {21 l

aw the j ho pital must concern itself directly since radiotoxicological tests are performed made as brief as possible if the contamination leselishigh. In the atter throughout the patient's stay in hospital and the laboratory concerne pathologist should be assisted by a radiation protectium officer.

s d is used to dealing with the problem of waste. On the other hand the hospital service may 41 ft)

---'"-+-Al---.m,

==

RLI LRLNUS IO C:Al s tn t

=g ASSESSMENT Of FITNESS TU RESUME WORK

[Il TNT CN AIIONAL AlOMIC I;Nt:RGY AGI NCY. Medwal Supervision of Cadiation AITE] CONTAMINATION OR BRRAIHATION ACCll)EN15 Corliers. S _fet y Series No. 25. l Al. A. Vienna t 19M t.

{2] INTI R N AT ION AL AT OMIC i Ni RGY AGI,NCY. Safe llandling of Radumottedes.

1973 I ditkin. Safet y Series No. I. R AI. A. Vienna t 1973 L l3) I ROSI, D, JAMMI T. II., Umcated Scurses. Vol. 2 of Manual o i Radiation Protectitm I-

^'

in limpitals and General l'ractke. Secmwred t*y ILO. l Al A.WilO. I'ub8ohed t>y WilO.

Geneva t 1975 t Any accident involsing internal contaminatkm or external exposure requires certain dethions to le taken by the physician; as some of these decisxms can has impewtant consequences for the worker concerned. all the factors must be weighe scry carefully. In all cases lew>ns should le drawn from the accident and steps le taken to improve plant operation protectiem of workers. To this end.the investigation of the accklent eould:

Esamine the t-iremnstances of the accident in umsultatiem with the radiatio-(a) protection stalf and those responsible for the operaticm of the facility in question; eto Record all the results of measurements carried out. noting carefully the dov to organs or tiwucs. as well as dethium of a medical and/or adminntrative nature that hase tven taken as a re< ult of dose hmits having Iven eweeded.

In addition. the physician should conduct follow-up esaminations en such persons todetermine whether or not the accident has physical or biol vical sequelae. Any thange of a medical nature occurring some time after the accident should be retorded.

T he physician should ensure that the worker (oncerned is f ully informed of the situation. In particular he simuld inform him of all the risks to which he h subjett as a result of his contamination or oposure. thh being especially nnportant when the worker is returning to hh former job. ~Ihus,in Ihe case of a job involving the rkk of further contaminatkm or esposure the physkian should explain cleanly in terms comprehernible to the worker the pattudogical eliects w hi(h could resuit in the long term. Talking to the worker in this way is also hkely to make him take extra care so as not to allow the accident to happen agas The adminhtrative dechions which the physician has to take are rarely sim it b only exceptionally that one encounters clear <ut iwucs that are easy to reso!

as is of ten the case in ordinary occupational pathology, with concrete leskms or clueix determining whether a person is physically or phpiologically capable of doing a gurticular job. In the case of a nuclear type accident resulting in slinical thanges it es clear that the job must be changed or adapted so that the thL of aggravating these sequelae is redaced as much as powible. The powitwlity of another accident occurring. which would result in the person concerned e

42 g

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ut be the wie determining tactor. Ilowe:er. attention shoulif lie paid to ehether J

ORCANI/A IlON. PLANNING AND T R AININC ll--:l 1

te worker was personally partly to blame for the accident which could then be decisise argument for moving him to another job.

In the majority of cases. management in consultation with the physician and

I WIRUIKID ie radioh>gical health and safety officer must take into account nonobjective riteria such as wcio-economic status. age.ses and job espertise tu arrise at a lhe proper funethming of any first-aid station,lepemis on the planning and ecision on the patient'sjob fitnest The problem is not just to evaluate the outfitting of Ihe facihty. and the training and organitation of its perumnel. ~lhis robability of sequelae but to evaluate the possible risks in the far distant future.

is particularly true for first-aid establishments with respemsibilities for caring for he rnanagement team must base its decision on several coroiderations: knowlettge injured personnelin radiation accidents. It is,however.quite dif ficult to maintain f the risk with all the uncertainties which this involves. knowledge of the high levels of readiness and efficiency because dedicated ratliohegical safety roblems of re-classification for the person concerned, and knowledge of the practices successfully reduce the indience of radiation acchtents by many orders sychological problems which a decision of unfitness for w ork could result in for of rnagnitude bcSw that of heavy indmtry at large. Organizatitm.P anning ami l

he worker. his colleagues and his family. Ilowever, the phpician himself should training must therefore be testeti by well-planned dri!!s held at unpredictable ecide on the frequency and nature of the medical examinations the patient times which address the potential problen* of a specific site of some specific plant.

l bould undergo, taking into account the nature and the grasity of the accitlent.

In this section suggestiems are made concernine organizati<m. outfitting planning.

training and drilling.

6.2. Gl:NI RAL MI. DICAL ORGANIZAllON - PRINCipLl.S The rules governiny medical awistance tietermine the mirastructure that must exist in aavance amt rmest be capable ofI eing put into operati<m at any moment. Whatever tive nature of the accitlent irradiatism or contamination -

the various stages in medical treatment form a chain in which each successive link is of an enhanced degree of sophisticatiem.

6.2.1. On-site emergency treatment Clearly.only first aid for a contaminated indisidual is involved here. since an irradiation casually does not require any emergency treatment. The principle that emergency treatment slumlJ be given when there is any sunpici<m of ccmramination, as discussett in Oapter I. f l.3.2. calls for the implementation of this treatment even before the doctor arrives,in ortler to reduce to the minimum the time between contamination and treatment. It is therefore desirable that anylxxty exposed to any risk of timtamination shoukt have a first-aid kit (see Appendix D) of compact site and containing a small selection of simple mm-toxic medicaments put up in individual dera tmits and intended to be taken by the contaminated patknt himself at the she of the accilent.1his first-aid kit can only be used if the stal7is properly informed amt trained. Therefore education and instruchn must be one of ahe main tasks of the metlical service.

84

moreover, make it pmible to transport tlk contaminated imlivsdualeven when

'Ihis senice constitutes Ihe secom! stage her the casualty. Whereas first he is also injured.

sid as describett aime can. if necessary be dispensed trith it is incimccivabic that tiie medical senice respomible for the casualty shouki not intervene in an

6. 2.3.

Rgismsl hospital appropriate manner. Ihe means at its disposal are extremely variable in their ntext.as they depend on the sire of the facility amt the harards incurred there.

The eswntial role of the regional Imspitalis to make up for the inadequacies Ihe isleal is a medical service on the site of the facility itself, having Ihe resources of the local medical service. 'Ihe regi< mal hospital must also be providett with a tecessary for isolatiim, decimtamination and rapid measurement of external and list ef experts in a variety of disciplines (surgery. harmatokigy, internal dosimetry.

nternal contamination of casualties,in aildition to premises suitable for these etc.) m ho can be called in for consultation or awistance. T he names. addresses.

mrposes. The service must possess equipment and laboratories enabling it to phone numbers.etc. have to be incorporated in the overall energency scheme.

santile these casualties in an efficient manner,ix.:

It may be essential on surgical groumis for example. to hospitalire the patient urgently amt in thie case only a regional hmpital can cope with the situation. It at Rapidly to perform the necessary sampling and binhyical examinations; may also happen that it is preferable for social.cconomic and/or psychological b) To treat several contaminated pers<ms at the same time without spreading reasons noi to move the patient and that tiec regional Imspitalis sufficiently well the contamination fi c. availability of rimms for undressing amt others for equ:pped. Tuis is Ihe case whcre. for example, a contaminated wound requires only showers or haths, separated by airlocks and of a one-way system ensuring simple surgicalintervention; here the operation can only be done with the that a decontaminated individual does not go back into a suspect areal; attendance of a specialist in radioprotectitm and it is this specialist who enust c)

'Io provide radioactivity measuring equipment adapted to the hazarils involved.

tome to the patient together with his measuring equipment.

ranging from a portable detector to a wholchly cotmter:

Thus, although it is desirable to reduce the involvement of the regional di To ensure that Ihe facility has a list with names. phone numbers and addresscs Inspital, the latter shoukt be in a positi<m to deal with a certain number of of specialists who may be called in for auistance; situations. Althoug.h it is inconceivable that vast resources simukt be devoted to el To provide -- and this is most important the medicaments needed for equipment at this level, e.g. isolation t hambers and operating theatres designed treat:ng these particular casualties. In small-or medium-sire medical services from a nuclear viewpoint,and built and maintained against the eventuality of an it is desirable' to have first-aid kits similar to those for individual use on the accident,it is none the less necessary to make a survey of existing resources and site of the accident, but intended for Ihe physician himselfIsce Appendix IH.

to adapt them to specif;c needs. Thus it is for example, preferable to have a special entrance for contaminateti patients, with direct access to a suite of rooms

'Ibe staali sire of many nudear facilities th>es not justify a medical service that can be adapted for purposes of decontamination and that are immediately with such resources and a large staff. It is here that an accident couki present available. Stambrd operating theatres equipped for aseptic condititms are suitable nost problems. In large facilities the first two stages in treatment - emergency for tyrical operations. ami eIIective external dertmtamination of the casualty reatment ami treatment at the facility medical service - can be combined in time makes it possible to avoid spreading radioactive cemtaminatism to any extent.

md space, normally without any undesirable effects for the casualty, but in a mail fatility with only a small medical service this is more difficult.especially if 6.2.4 Central hospital he medical service is situated away from the site. In this case the physician in harge. who would not have at his disposal large-scale resotirees for the purpose it is at the level of the centralImspital and only at this Icvel that the large-

! if making a preliminary assessment, can only refer the casualty to the nearest or scale medical treatnvent resources are to be concentrated. One central hospital

sest equipped Imspital. In every case transport must be adapted to the person's is sufficient for a country of medium size and can even cope with accidents l ondition. Whereas an irradiated individual can be evact,ated without particular occurring in several countries. 'Ihere are two conditkms governing the design of l irecautions,in the case of a contaminated patient it is r.ecessary to take steps to large-scale resources to be used in cases of irradiation or contamination: (a) t hest ryoid spreading the contamination,especially if the facility has no means of external resources should be tesed throughout the year for other..outine purposes, on lecontamination. Certain items of special equipment.such as stretchers with groumis Imth of economic viability and of reliability; (b) they should be solithm sheets that are air-tight and adaptable to various uses, ambulances lined immediately available in case of accident.

l l

l

, in 47 i

i k

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-l A 1i p's.it e%unple is atut on a posen.n sar.ione o us o,

u.a em s..o up.o.u, of irradiatbn and of omtaminatbn accidents, although the resources used in each involved and the resources employed must be adapted to each case. ~Ihm. Ihere '

-]

case are sery dif ferent. Iloth cases can be handled efficiently only if there is close is r.o strict rule governing evacusthm of the casualty: it h dearly preferable to co-operation willi specialized laimratories. some of chich m;y not hase any evac; ate the person to the specialized tmit in whicli he will find the treatment normal relatiomhip uith the cer-eral hospital; i.e. it is important at this level that best adapted to his condition. Ilowever. it may be that for medical. logi tic or the various measures to be taken should be effectively co-ordinated. final decisions psycfmlogical reasons the best solution is to minimire the movement of the naturally remaining the respimsibility of the chief physician of the centralImspital.

tasualty and to keep him in the local hospital. In this case it is the specialht Unfortunately, in many countries flee existing hospital infrastructure th'es team, accomparied by the necessary equipment, that comes to the beddle of not provide for such a service, and the procedures adopted must be based on what the patient.

is.rvailable. In the case of an irradiati<m accident. the cinice of the appnspriate procedure, and hence of Ihe medical service involved,is relatively limited. Re-susdtation units and units for severely burned rasualties are anmng those which

63. I:IRST-AID STATION provide the optimum conditions for the patient; the staff of such units h familiar with all techniques for isolation and asepsis. Confinement in a sterile atmosphere.

63.1. Organiisthm and planniny if it is decided that this is necessary, can be achieved by setting up a light plastic The complexity of the organization of first-aid stations is depemient on the isolation tent. which has the advantage of being immediately disposable and member of people employed. the particular hazards of the operation and the portable and making it unnecessary to more an ordinary patient in order to permit potential seriousness of the radiati(m accidents. For imtance.large radiopharma-treatment of the irradiated imlividual. The specialists imolved are very numerous ceutical manufactaring plants do not have to take precautiems agaimt the potential and among these are the members of the dosimetry team. Alt!mugh in most accidents hkely to occur at fuel fabrication plants and power reactors have less cases the latter have no organic Imk with the hospital, they must go into arti(m po?cntial for accklents than fuel reptoressing plants of similar sire. 'Ibe first step rapidly. Apart from the preliminary results which indicate an order of magnitude therefore in the organizati<m of a specific first-aid programme depends upon an c,f the irradiation. reconstitution of the accident provides informati<m on the intimate knowledge of the operations of the plant und the radionuclides involved.

spatial dose dhtribution, which is a vital element in prognosis.

Such an analysis must also include the identificati<m of geographical and trampor-A contaminated patient presents problems of a very different nature.

ration problems in relation to the sire of work-forces at satellite sites. I rom this A nuclear medicine or radiopathok>gy service can handle such a situati(m witimut the numtwr and location of first-aid stations ansl their stafI and equipment needs undue adjustments having to be made. as it will possess measuring equipment and facilities to store and dispose of radioactive effluents: in particular,it will have a are determined. The station and staff then are integrated into the metlical manage-ment of the central plant dispensary. The complexity of the commtmicatiem staff that is used to the problems presented by the handling of radionuclides.

Ilowever, t he special conditions attending surgical intervention on a contaminated network is defined by IIm need for back-up support between indivklual first-aki imlividual must be met by insistingon cooperation between the surgeon and the stations as well as by the dependence of their staff opem central dispemary specialht in radioprotection. In this case information plays an important role.since direction. A redundant communication system in an accklent response plan. where certain mamieuvres are quite unusual for a ctmventional operating theatre.

the central and outlying sites are integrated. rnakes it unnecessary for all sites to in general, the central hospital, however sophisticated it may be. does not have the same capabihties for responding to the maximum credible accident at have on its staff all the specialists needed for a nucitar accident of any size -

the plant or to be equally equipped. The respome plan to be developed starts whether involving internal contamination or external irradiation - since the therefore with an analysis of the harants in the immediate territory of a particular dheiplines called for are numerous and sometimes go beyond the medical sphere.

first-aid station and plans are tailored individually to meet them. The plans simuki Co-orination of these numerous specialists, each of whom has different responsibili-then provkle for increasing levels of inter-site support ami all-facility respome as ties, is essential, even if only in order to draw up an order of priority for the

- the seriousness of an accident and the number of people involved increase beyond measures to be taken. It is with this in mind also that relations between the the capabilities of one or several first-aid stations.

medical service of Ihe facility and the central hospital must be maintained, and the Lven though a small plant or laboratory may not require a full-time physician.

latter mu t be regularly kept abreast of the particular problems posed by casualties paramedical staff or health physicist. it will need a consultant physician. a well-involved in nuclear accidents.

trained first-aid team and an experienced radiological safety officer. In the event 49 48

o y-of an mcident. the firsNid team coukt handle immediate first anl witile t ontacting by tin

rnemtwrset ahe T.t-aed tratie tietors' ttwy entisse e,si asee uti..: 4:e At.nece 4 [

the consulting physician who woukt direct the next c-tiom. Based on o presiously O may have to be changed if C becomes excessively ctmtaminated diering the established plan. the pitient could be taken to an ares hospital which has a

' initial ticomtaminatbn effort.

- decontamination facility and a trained medical staff.or he could first be transported if possible. the patient simuki have all contaminated clothing removed at or to another, larger and better equipped in-plant elecontamination facility or close to the site of the accident. If he is ambulatory he can shower amt wash occupational medical department and later to the hospital if necessary.

himself under mimitoring supervisiem. The patient is covered with sheets or Pre-planning is obviously of paramount importance. Knowing the potential blankets ifit is necessary to keep him thermally omifortable. If the initial de-radiation hazards in a particular plant or laboratory and having a careful action omtaminatism cannot be completed a plastic bag or sheet is used to prevent -

plan designed to handle all credible accidents is far more important than elaborate spread of contaminatism to the tramporting schicle.e.g. the ambulance. If the tml expemive facilities.

weather is warm. it should be remembered that a patient placed in a plastic bag The basic first-aid team member is a physician trained in the management of can be subjected to comiderable heat stress when transpirted 30 70 km in an radittion accidents. The other first-aid team members are radiation workers who enbulance.

have received special first-aid training. and/or traincti nurses and/or tecimicians.

A well-equipped first-aid kit with splints.bamlages, tourniquet, life support One or several health physicists or radiological safety officers familiar with radiation medications, airway, basic emergency surgical imt ruments. intravemms fluids.

detection instrumentation and the special radiatitm protection problems associated etc. shouhl be provided at all designated sites ami periodically chet-ked to emure

- with accidents are also essential. A designated central manager, not actually that all supplies are in gixxl functieming order ami sterile if necessary. lhe contents involved in administering first aid, must be available to perform the valuable service of such a kit are described in Chapter I and in Appemlices D and E.

of otwordinating communication. technical support tramportation and manage.

'The amtents of a group medical kit containing medications that prevent the ment of pers<mnel in the accident area who have not been obviously contaminated uptak of radiemuclides are describett in Apperatices D aml E. Skin deomtamina-or exposed, but who require careful monitoring for radioactivity.

tion supplies and techniques are described in A prendices Il and IL The required omtainers amt instructions for collecting blomi and urine sampics in cases of 4.3.2. Fac;1ities ami equipment esposure to penetrating radiati<m are includt sl in Appemlix A.

Each first-aid facility shoukt have plastic 1 ags for collet; ting aml labcIling A minimum first-aid facility should have an area where both decontamination clothing.jewc!; cry.etc c mtainers for collectin urine amt facces, and specimen -

imitles with formalin if freezing facilities are not available nearby. A portable and first aid can be performed. It may consist only of a room painted with strippible paint, equipped with an autopsy table with a central drain. and hot tape recorder em. lased in a plastic bag.with the microphone smpended near the and cold water which can be mixed and delivered in a flexible plastic or rubber tiecontamination table.can be helpful to record details of the history of the tube with a simwer head. A moveable lead shield, lead aprim and lead gloves xcident. rhysical findings ami details of the decontamination effort ami treatment.

covered with plastic gloves should usually be all that would be required for most felt pem tblack and red) are mefut for marking areas of ctmtaminati<m when the actidents involving skin or wound contaminati(m with beta and gamma emitters.

patient has to be moved fer further decontaminatiem. Several extra pairs of Alpha-emitting radionuclide contaminati(m requires no shickling. but inhalation large hamlage scissors shoukt be included in any first-aid kit.since cinthing may and skin contamination of team members must be avoided. Elaborate decontami-need to he cut ofI the patient.

n; tion facilities have been designed and constructed for large plants 12-4]. but l

some tre probably overdesigned and unnecessarily expensive.

l The waste vrater from the decontamination table should be collected in a 6 4. ~lR AINING AND DRILLING l

holding tank for later monitoring and special disposal as required. Special rectilition and air-conditioning may be necessary to prevent air contaminated Since radiatism accidents are relate'ely rare, personnel who will have to handle with alpha-emitting radionuclides from flowing to other rooms. The members of the first-aid care cannot expect to derive their skill from experience. They minst the first-aid team must have effective respiratory protective devices that have ret cive car-ful t; ining at formally hekt courses. by practice dedls ami by taking tm l

been prefitted to that they are protected from inhaling radionuclide contamination responsibilities fcr impecti m aml review of their own facility and. of possible. other which may become airborne during the decontamination effort. Full protective prmhicti<m or research facilities. The results of the drills shoukt be secorded and clothing, including coveralls, shoe-covers, caps and plastic ;Ioves, shouil be put on kept incitkling records of first-aid exercises.

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, can identify deficiencies in the preparatisms for an accident. Af ter a drill, a critique uIS" 8' ail *In R

1 shoukt alw ays be held. Experienced observers can then advise all participants of.

. their mistakes or lack of judgement and Gill.- Revisions in plans anti unrading of I. Apri! 1977 the IALA entered into an agreement with the United Niions iills, w hich should occur after each exercise. help prepare for tl e reai accident.

Ibaster Relief Organicthm 4 UNDRO by whicle recimical support will be provided if and when it occurs.

in the eeent that desaMer relief involves ratiological avects.

Inspections of pn+ duction anti research facilities at least by senior members of the first-aid team, enable the team members to challenge titeir supervisors to

' speculate ou possible accidents. They learn what radiation devices, sources or PEI I HENCES TO Cif AFTER 6 radionuclides are Ixing used and how an accident rniglet occtrr. Armed with the knowledge of the possible xcident the preparati<m for handling it should be lIl IN IS.it scrNL ArwlC I Ns.RGY AGl.M Y.f'tannme t.= tree it,.milmg..t Redestaan relJtively easy. Members oi a team can be required to develop written plans for Tsudenh. htely ScrW M. I U A. Vsenna 41969L accident responses which can then be reviewett for completeness and clarity.

I'I NWOOD.

D Deal'h rmtette.n of Radestum Worliers.C IImwnas. Sprmetseld f L eI475t 13l IN5flB MLlf.C C. f.NDRt WS.t. A. llt BNI R. K.lMLOUlti R. R J ttt C3L.w I...

Rf RGt R. J D.. * 'Rc sstC A prarmatw appr. acts for prmning medwal sste aml ghtsen e incat >m for s minat am enserirentsei. Diacenses ami T erstment ett incewporated 6.5. NATIONALLY AND INTI:RNATIONALLY AVAILAllLli RADIATION R,,tmm.ti.les rrm. t att Am tlo sernmar vienna.19758. I AI-A. Vernna t I476 565 -

ASSISTANCI PROGRAMMES gig o,g,,,,,,,,4 9,4,,i 3 persom of r.-twms Wmlung with lonumg Radistum Semtres 4GUSKrWA. A K I d 8. Atomudat.Eww (1975p tm Ruwiant Since 1959 the I AEA has had an act. ion plan to arrange for assistance after lt) INit RNAitON AL A tOMIC i NT RGY AGt NCY. Mutual mersefwy Assrstance lof 7,7,,,73 3,,,,,,,,,,,,,p,,,,,,,,,,,, i.,7 n.

an accident involving radioactive materials. There are three main aspects to the current plan:

(al Member States are encouraged to determine in advance what outside assistance would be needed in the event of an accident and then enter into a multilateral assistance agreement with neighbouring states. In 1963. the ' Nordic Agreement' was signed by representatives from Denmark. Finland. Norway.

Swetlen an I the I AEA.

ib) Through training programmes Member States have been enco. raged to develop their own capabilities to handle emergencies. Such programmes have been contlutted in Manila. Teheran and Buenos Aires, fc) The I AEA is prepared to arrange for specialized assistance after an accident. e.g. for medical and raJiological support. Starting in 1963. the IAEA has issued periodically an internal report on Mutual Emergency Assistance for Radiation Accidents 15 ] which identifies what assistance can be made available at the request of another state. Wilo. FAO and ILO have participated in later resisions of this publication; the most recent was issued in 1971.

The IAEA maintains the capability to have a senior tecimical person available through a duty officer roster in the event of a telex or telephone request for assistance and to act as the intermediary in transmitting requests for assistance.

The programme also includes the capability to send a sma:I group of observers or consultants o the site. The facilities of the Agency's laboratory for radiocinemical 5:

53

+

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Al'gytitist L 2nrJual comunematwe pctets af ter the memesliste xtem drwnbed aNese,se, ore spuiskred deomiammant* msy eave to N o,ed.

11 ( IINIQUI:S l'Olt i OCAL DI A UNI AMIN AIION Cf ~1113 SKIN Wash wdh an ased 10 IllPT.luim tat Pare eart hs pistonem. t ransplut onnt a pli Mt. eab gen fy. workme from the cerette of 1he c etammated spot toeatds ahe e

Of. 01 NI R \\l Rt:1.33 sf $31P A e not available use an aquemrs lit I elutwm apil I t. repeat as many 16mes as re but alwayu*op ef hypoxstaa of the Am octurs 14ef ore any other xtum, the f olbwmg steps must be taken

- - 8' **I **M *"CI"'

Pro-nt*m of radiobgwal first akt if Ihe radwminInte es k rmwn to be rspidly abwrbed te contnred. m the cao of strontmm.thetk tarefelty to see whether there are any w,mewis en g g Yestf katum that there ts no wouml;

~

abp t reatment of skm wemmis before dealmg ettle the cemtammatwm m the event of mjury by I

to the 4m f rom themnal omtammants tumsentrated mod or be,c. or a beern tauwd I"' *"** M"#"E#"# #

4ce I#*

she wx!mm in a plutemmm/sodmm mtsterre,for esampiet.

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c. pMWent spots an ww.ved prompt eersfkatam of the omtammatum lesel es was n

P ru nr. ah" O eng tdi in ihe tase of an esitemely Ngh omtammatam level et may be omgwrf ant to omwler -

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the wearms of a mask t y the pateent and attemlant perwnnel, s m for one than 2 mnmto Pron *pt. rough and read) dromtammatwm. af ter vmmedeate renw* val of all(lothmg In wree cases. locabred twet pots of mwduble matetsal embedded m the homy rentam en aanted e the cbthesbemg preserved m leak-premf g*lastec bage to avmd wtmichdy over-if6 layn a4

skm can N wmoved h sand papn m hay say np 11 possible

A", all clottimg sbmlJ be femmed before transportatum; les all;ases, adoptiem of meawres required to prevent the spread of (tmf arermatem; B 2 4. Final precedures in the use of umtammat em of the c3cs. nme ami'or buccal cavity,ihnhmg of the tee If mes stormg of the dry 4m sbrus that there es a lated residual omtammatym, the efn af tetted part toppmsty with rernnmg water.

spg*bcatir*n of a neutral fat such as lanoim edt prevent cenk formatum othe mtegnment m have fren sobyct1 to methamtal or themwal atf son 9 amt spreattmg of Ihe sontammatwm As an adderweal pretautum an octluvre protestne drewmg dwing natural desquamatum I he <tecume may be sneld be appl:-d; tNs shmkl be kept amt rewm tored upon ablatom of the plastse type.or apphed mlequal form or as a spray.

D 2.

II CllNIQ UI 5 D2.1. Skin contamination covering a very large area Il.t. Spirl AIS Asl s t he paitent sNmid be given a warm shower. T he water sned sNmid be collected and Wash prof tswely; a speoal t aNnet slami.f als a} s be asahble 8

his t

Cemfamenatum of t re cyrt numetored before disposal. herne the advantare of spetial faoletses set up solely for t 4

Use only wit soap. preferably acwf. Always wash from the for eye wa9mg at the we of the risk.

purpewe at the ute of the ink d

top tiownwartis; af ter the pateent has been dried off. forther m.mrtormg stmuld be carrie in the tase of reudual omtammat um. puweed as moscated m Setti-m B-2).

out ro(assicm sbodironate-i mpnical farmula : r.oA3; the wwf,um ute r30%3 3

D2.2. toe *,lised emitamination Avmd mtrodissma trnf ammatirm through esistmg escoriations and microcuts.

es rust as r(f ecient t he <fuctural formula es; I

snds Any broshmr that prown necewery should be done gently with a enft brush. With a large O

asumber of small omtamma'ed spots. speual care shmsid be taken not to spread the coa-the trystal form es twelet. et n wiluble m wster l

tamm1trem and thereby prmfun a t-mtammated sterface larger than the sum of the oregma t)cIh1= ttranget. l'1%e*Iuble ist altofwel, witstw*ns

'):

8 A 25'; N411Clo, wluten is partwalarly helpful g p' py3 g

sp *

% ash repeatedly with vier making sure thst the cemtammatum does rmt get into g

str in some cases the harr will need to be clipped the e3cs mouth or nose slutmg rmsmg a

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deamns of the matrils and mre bhewing on compvse have been collected for nmmeurms 7CASIC T. EADIENI' INIC JNilON 170R lilE PIIYSICIAN Nasal errigati,n is inwally leadle nr.ly umter hmpital comf at wms.

pur g=,ses.

1 I QLitrMI NI ANID SUrrt il S IO I41-PRt)Vitpl in 04 cimtaminst um No special medwat equipment es cerenary.but um'c any thame of th demntammatam evalisated. the spreadmg has to be avonico and the rf fettivenen of the Provisam sfumild therefewe This information in the tivem of data sheets is arranged in alphabetical order number of temprews. swabs.etc. fe4mred es always sery targe.

be rnade f or a large stmL of smh materiels.i.e, bones of comprese amt gaure. rolls of by radionuclide; st,vrtJ radionutlides are dealt willt in groups wheti their bat h md sof a bruJie5.

cot ton wool, cotton we=4 plugs. subber skives, tongue depressors, eye hiolog.ical behnvicter and therefore the treatment is similar. Ihese groups are Ihe medical comp mnds ami dents requned are quite specif ec. and rrerare n8""<'"5 d

the rare earths. i c. the entire tant.nanide series.and the actinide seriesincluding appropriate f or the type of f achty red mvolved sfumid be available. ilhe weahird ra m-the pietomcs. in the tanthankle series only the main elements,i.e. La.Cc. Pr.

haml equipment n dewuwd m e harter e.J Pm. Yb arst Lu. ate (liaracterireJ. and in the transphitunic series Am.Cm. Bk.

Of and Es are charatterized. A special data sheet is used for fiuion products as it is conceivable thst contammation could be caused by a misttere of thsion products; this shaet describes the principles of treatment in a generalired For details of treatment.one need then only refer to each element concerned.

The data on each sheet are given under the following headings:

1herapy T1H entergency treatmer,t to be given.cither at the site of the accident or in the plant medical servie:c or clinte.it summarized here. Suinequent treatment possibly prolonyd or requiring a high degree of specialization. is hardly to on. since the techniques involved call for the sersices of trained itospital sta Further, no attempt is made to prescribe treatment for special ca es lying outs the normal ouupational context i for exatuple, children and pregnant women).

}

First-akt treatnant should,in cases of females, be applied with cautiem when pregna* icy is susp-:eted.

Note on metabolic behaviour This brief ren-inder is intended to supplement tite information in the a

precet ngsection. Th:2 part is sometimes intentionally omitted when it does n t

add a:ty'hing stth while.

t Personnet s.,onitoeing The mett: mis of ptrsonnel monitoring for work-rs work:ng with the cierr,e i

{

imloes: son are summarized here. The techniques of greatest vahre to the

)

j radio!cgkal piotection experts are emphasized.

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, truck Liat,g;;g!gst in Pennsylvania i

while entry rq radioactive mdprial from Knemaync~n_ s.nntn 9gna Field is horatory cacceded th<se allowed by the U.S. Department of L._...

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"WP' Measurements of the truck after J e

the incident have been confirmed as being 254 milligrams per hour," said 14e Bettenhausen, a spokesman for the NRC in Pennsylvania, The Department of Transportation does

. i not allow vehicles carrying radione.

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A Rocketdyne spokmman would not comment today on the accident g involving the truck, which was car.

rying radioactive material from the company's Field Laboratory in the hills above Simi Valley.

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1 BE! ORE THE A'IOMIC SAFETY AND LICENSING BOARD 00t Klia U.S. NUCLEAR REGULMORY COMMISSION UbNRC-

% FEB 20 P2 :41 In the Matter of

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OUfCE Of SECRfiARY ROCKWELL INTERNATIONAL CORPORATION

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Docket No. 70-25-ML 00CKE hNG 6 sti>vict; e

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BRANCH (Rocketdyne Division, Special

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Nuclear Materials License SIN-21)

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CERTIFICATE OF SERVl:i 1

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'I hereby certify that copies of the foregoing DIRECT CASE OF LCS ANGELES f

PHYSICIANS FOR SOCIAL RESPONSIBILITY have been served upon the following persons. by U.S.

mail, first class, except as otherwise ncted and in accordece with the requirements of 10 CFR 24712.

' Administrative Judge

Office of the General Counsel

t Peter B. Bitch U.S. Nuclear Regulatory Commission Presiding Officer Washington, DC 20555

Atomic Safety & Licensing Board t).S. Nuclear Regulatory Commission Docketing & Service Section(3)*

Washington, D.C. 20555 Office of the Secretary U.S. Nuclear Regulatory Commission Administrative Judge

Washington, DC 20555 Gustave A. Linenberger, Jr.

Special Assistant Prof. Jerome E. Raskin, et al.

Atomic Safety & Licensing Board 18350 Los Alimos U.S.' Nuclear Regulatory Commission Northridge, CA 91326 Washington, D.C._20555 P.D. Rutherford

I Administrative Judge

Manager, Nuclear Safety &

. Christine N. Kohl, Chairman Reliability Engineering Atomic Safety & Licensing Appeal Board Rocketdyne Division U.S. Nuclear Regulatory Commission 6633 Canoga Avenue Washington, D.C. 20555 Canoga Park, CA 91304 Administrative Judge

Dr. Estelle Lit Howard A.'Wilber 18233 Bermuda Street Atomic Safety and Licensing Appeal Board Northridge, CA 91326 U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Donald W. Wallace 1710 North Cold Canyon Road Administrative Judge

Calabasas, CA 91302 G. Paul Bollwerk, III

~ Atomic Safety & Licensing Appeal Board Dr. Sheldon C. Plotkin U.S. Nuclear Regulatory Commission Southern California Federation Washington, D.C. 20555 of Scientists 3318 Colbert Avenue Los Angeles, CA 90066 O'

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i Cecelia Riddle 4

Senior Librarian Daniel Hirsch i

Chatsworth Branch Library Committee to Bridge the Gap

-l 21052 Devonshire Street 1637 Butler Avenue, Suite 201 Chatsworth, CA 91311 Los Angeles, California 90025 Barbara Johnson President l

Susana Knolls Homeowners Ass'n c/o 6714 Clear Springs Road l

Susana Knolls, CA 93063 f-Mary Nichols, Esq.

Natural Resources Defense Council 617 S. Olive #1210 l.

Los Angeles, CA 90014 John Scott i

'6 Roundup Road j

Bell Canyon, CA 91307 T

by exptess i

n Richard G. Saxon, M.D.'

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Dated at Los Angeles, California this 19th day of February, 1990 i

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ML20006F462

Text

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