Global EM Totally Rad(-iological) Training for CBRNE Mass Casualty Incidents

Totally Rad(-iological) Training for CBRNE Mass-Casualty Incidents

By Mel Ebeling on behalf of the SAEM Global Emergency Medicine Academy

Radiation. You can’t see it. You can’t hear it. You can’t smell it. You can’t taste it. And you can’t feel it. It’s arguably the most insidious of the chemical, biological, radiological, nuclear, explosive (CBRNE)/weapon of mass destruction (WMD) hazards.

Unfortunately for us, exposure to ionizing radiation will not turn us into the Hulk, Daredevil, Fantastic Four, or Spider-Man. Instead we are met with the possibility of developing Acute Radiation Syndrome (ARS) after exposure to penetrating gamma/neutron radiation; cutaneous or local radiation injuries (CRI/LRI); and/or other devastating health effects following external or internal contamination with radioactive material. Without prompt recognition and treatment, these conditions can be fatal. This is especially important when considering that ARS can be difficult to diagnose due to nonspecific symptomatology and, without an obvious exposure history (i.e., nuclear weapon devastates an entire city), initiation of more specific treatments outside of supportive care may be delayed due to that delay in recognition and diagnosis. In fact, an analysis of four incidents involving orphan sources found that the average time to a confirmed diagnosis was 22 days. Depending on the dose, a patient with ARS may have already progressed through the prodromal, latent, and manifest illness stages at 22 days! Early management of these patients with appropriate supportive care and specific treatments can raise the median lethal dose (LD50). Thus, becoming and staying competent in the diagnosis and management of these high-risk, low-frequency scenarios is critical. Most recently, the fear of nuclear weapons use against the backdrop of the ongoing Russo-Ukrainian War is cause enough for us to evaluate our preparedness for mitigating mass casualty incidents secondary to nuclear materials. The general threat of nuclear weapons is not limited to this present conflict, however, as other countries are attempting to expand their nuclear capabilities. Additionally, the U.S. Government Accountability Office reports an increasing risk for attacks using “dirty bombs” (explosive devices combined with radioactive materials). Considering these threats, though, studies continue to report deficiencies in CBRNE preparedness in the health care sector. It should be considered by those of us in the health care sector that the threat of radiological emergencies extends beyond that of obvious, malicious attacks; in fact, radiological materials capable of causing severe harm or death are used every day in industry (e.g., industrial radiography cameras) and without proper education and well-maintained equipment, exposure could go unrecognized.

So where can you train for these types of incidents? As a trained HAZMAT specialist, there are three sites I have personally visited and recommend to all first responders and health care professionals looking to increase their preparedness for mass casualty incidents caused by radiological and nuclear materials:

Radiation Emergency Assistance Center/Training Site (REAC/TS) - Oak Ridge, TN

Alongside their 24/7 response capability for radiological emergencies, REAC/TS currently offers three in-person continuing education courses for health care professionals and emergency responders: Radiation Emergency Medicine (3 days); Advanced Radiation Medicine (4.5 days), and Health Physics in Radiation Emergencies (4.5 days). In contrast to the trainings, these courses, particularly the latter two, are primarily focused on the pathophysiology, diagnosis, and management of radiological emergencies. I found the Radiation Emergency Medicine course to be one of the best courses I have taken throughout the entirety of my prehospital emergency medicine and medical education. While it is a lecture-heavy course, learners are given the opportunity to participate in a practical exercise (simulation). Uniquely, actual transferable radiation is utilized alongside live patient role-players, which added to the realism of the simulation. The cost of attendance for all courses is very reasonable, especially when considering the length of the course and quality of the education.

Center for Domestic Preparedness (CDP) - Anniston, AL

The CDP is operated by the Federal Emergency Management Agency (FEMA) and the U.S. Department of Homeland Security and is a member of the National Domestic Preparedness Consortium. This membership means that “State, local and tribal, and territorial emergency responders’ training is fully funded, including round-trip transportation, meals, and lodging.” Over the past four years, I have trained at the CDP eight times, primarily completing courses dealing with hazardous materials response. One of my favorite courses, and one that I believe all emergency medicine physicians should take, is Emergency Medical Operations for CBRNE Incidents. This four-day course focuses on the proper use and donning/doffing procedures for CBRNE-specific personal protective equipment (PPE), triage, and decontamination procedures for nonambulatory and ambulatory patients. Physicians, nurses, and other hospitalbased professionals would also benefit from Hospital Emergency Response Training for Mass Casualty Incidents and Healthcare Leadership for Mass Casualty Incidents. From working in a toxic-agent chamber with live chemical and biological warfare agents to managing a masscasualty incident in a decommissioned Army hospital to monitoring for radiation in subway cars, you can be sure that the practical hands-on exercises you participate in at the CDP are the most realistic training scenarios nationwide.

Counter-Terrorism Operations Support (CTOS) Center for Radiological Nuclear Training - Nevada National Security Site

Similar to the CDP, the Center for Radiological Nuclear Training is also a member of the National Domestic Preparedness Consortium, meaning that their courses are at no cost to eligible participants/responders. I was fortunate enough to complete the in-person Response to Radiological/Nuclear Weapons of Mass Destruction (WMD) Incidents course, a three-day training program focused on responding safely to incidents involving radioactive materials, particularly following an act of terrorism. This course offers a good mix of traditional lecture and practical exercises that deal heavily with the proper use and decontamination of PPE and employment of radiation detection instruments. Not only are learners given the opportunity to practice detecting sources of ionizing radiation and establishing protective zones, they get to do so at a site with soil still radioactive after nuclear test detonations completed in the 1950s. While this course seems to be more suited for first responders, emergency medicine or EMS physicians, if eligible, would especially benefit from learning the best practices for decontamination.

Mass casualty incidents involving radiological/nuclear materials do not occur often, but when they do, being able to promptly triage, diagnose, and initiate treatment for those affected is critical. Emergency departments are the first receivers for these patients, and thus, physicians, nurses, and other providers staffing these departments have a duty to be prepared. Moreover, EMS physicians should encourage their first responding EMTs and paramedics to stay prepared as well. Hopefully, I have presented you with a few options to increase your preparedness for such incidents. Remember, while you can’t see it, hear it, smell it, taste it, or feel it, you CAN monitor for it, treat the effects of it, and train for it.

ABOUT THE AUTHOR

Mel Ebeling is a second-year medical student at the University of Alabama at Birmingham Heersink School of Medicine and a practicing Emergency Medical Technician (EMT). They are also trained as a Hazardous Materials (HAZMAT) Specialist. mebeling@uab.edu

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