When It's Hot, It's Hot
Article Outline
The medical aspects of radiologic emergencies are the latest in a series of topics related to the consequences of terrorism. In the 1990s, the threat of chemical terrorism was underscored by the sarin attack in the Tokyo subway in 1995. The anthrax letter attacks in 2001 pushed bioterrorism to the forefront and helped redefine the concept of first responders to include emergency physicians and emergency departments (EDs). The latest perceived threat, that of a so-called dirty bomb or radiologic dispersal device, has splashed across the headlines and is even the subject of a chilling made-for-cable television movie titled Dirty War.
The article in this issue of Annals of Emergency Medicine by Koenig et al is the latest installment in a growing body of literature that supports the medical management of the so-called CBRNE (chemical, biological, radiologic, nuclear, and explosive) exposures.1 In their article, Koenig et al introduce the fundamentals of radiation biology and the principles of decontamination and initial management. They outline unfamiliar and emerging approaches to therapy, including colony-stimulating factors, bone marrow transplants, and several pharmaceuticals, including amifostine, potassium iodide, and Prussian blue. Despite the limitations of these medical countermeasures, emergency physicians should be familiar with them because several are prophylactic and others may require early use. The article further discusses the psychosocial and health policy implications of a radiologic emergency that may in fact be the area of greatest impact. In succinct style, they finish with 10 key points for medical management that are worth reading and remembering by any physician, nurse, or technician who may someday be involved in a radiologic exposure emergency.
Another notable effort by this journal and the American College of Emergency Physicians is a US Department of Health and Human Services–funded analysis of training content and goals and objectives.2 Also part of the American College of Emergency Physicians effort are collaborative multispecialty conferences and forums, follow-on grants to specify weapons-of-mass-destruction training needs, the vetting of recommended equipment lists, and development of educational courses and other training resources. The Model of Clinical Practice of Emergency Medicine now includes most of the major content categories in weapons of mass destruction,3 which ensures that residency programs, and ultimately measures of practice competency, will consider weapons-of-mass-destruction content.
Although tremendous nationwide gaps remain in funding, equipment, and training, the specialty of emergency medicine (and our partners in emergency nursing and emergency medical services) leads the nation in the drive toward hospital and medical preparedness. Other specialties, too, have contributed to greater awareness and knowledge of CBRNE topics. In particular, colleagues in infectious disease, radiology and nuclear medicine, and preventive medicine and public health have made substantial contributions. Each of these specialties has produced various monographs, treatment recommendations, and diagnostic algorithms. Often, they represent the best available material on the planning, mitigation, or recovery of specific types of CBRNE events, and emergency physicians should embrace these viewpoints. Crucial to effective preparedness, however, is the integration of specialty-specific information into a framework built on the fundamental “all-hazards” approach. The all-hazards paradigm is crucial to ensuring a coherent, effective response to a CBRNE event (or any disaster, for that matter). Two recent educational courses following this paradigm are the Advanced HAZMAT Life Support Course and the National Disaster Life Support series of courses.4, 5
Elsewhere, progress toward adopting an all-hazards approach is slow but steady. For example, there is a rising interest in developing diagnostic and treatment guidelines that focus on syndromic presentations as opposed to those based on discrete agents. Challenges remain, however, and the CBRNE abbreviation itself underscores the broad range of topics represented and the difficulty in integrating the disparate content.
Funding, equipment, and training needs aside, there are still specific areas of weapons-of-mass-destruction preparedness that lack scholarly dissemination and educational development. The article by Koenig et al is an excellent starting point for radiologic emergencies. More work is needed, however, on the syndromic aspects of radiologic events. The presentation of radiologic casualties will not always be preceded by a clear identification of the radioactive agent or even by a clear indication of whether radiation is involved at all. Some conceivable terrorist scenarios involve the subtle spread of radionuclides into the air, food, or water supplies. Much like the presentation of bioterrorism, such radiologic emergencies may manifest in EDs and medical clinics throughout a community, state, or even the nation. A more likely scenario is radioactive contamination resulting from a conventional explosive attached to the radionuclide source (ie, a radiologic dispersal device). In this case, multiple casualties will occur suddenly and present with a mixture of blunt, penetrating, blast, burn, radiation, and psychological injuries. An integrated “all-hazards” paradigm is needed to effectively treat these complex casualties.
Despite the perceived risk (and its obvious presence in the CBRNE acronym), nuclear explosions are infrequently discussed. Stolen weapons from the former Soviet Union, limited strikes from a rogue state, or a crude device built by a terrorist organization represents a threat worthy of preparation. Other terrorism-related topics ripe for more emphasis include blast, burn, shrapnel, and crush injury (conventional bombs remain far and away the weapon of choice among terrorists in the United States and abroad), the medical consequences of eco- and cyberterrorism, and the psychosocial implications of weapons of mass destruction. An evidence-based analysis of the clinical competencies involved in weapons-of-mass-destruction training and preparedness is another area ready for development. The latter is a pressing need as emergency physicians struggle to identify and achieve appropriate competencies for themselves and their ED staff.
The conundrum, of course, is the reality of disaster preparedness in general; despite increased awareness, consensus guidelines, short courses, tabletop exercises, etc, weapons-of-mass-destruction topics are a negligible part of routine emergency practice. It is difficult to find incentive to prepare for what may never occur. It will take a national effort, including funding and resources, to become prepared. Emergency physicians are poised to take a leadership role, whether at local, state, or national levels. The current “hot” topic is radiologic terrorism, and Koenig et al provide for us an excellent starting point. The challenge is to transform all of disaster preparedness from a series of hot topics and courses to genuine expertise.
References
- Koenig KL, Goans RE, Richard JH, et al. Medical treatment of radiologic casualties: current concepts. Ann Emerg Med. 2005;45:643-652.
- Executive summary: developing objectives, content, and competencies for the training of emergency medical technicians, emergency physicians, and emergency nurses to care for casualties resulting from nuclear biological, or chemical (NBC) incidents. Ann Emerg Med. 2001;37:587–601
- The model of clinical practice of emergency medicine. Ann Emerg Med. 2001;37:745–770
- University of Arizona Health Science Center. Advanced hazmat life support [University of Arizona Health Science Center Web site]. Available at: http://www.ahls.org. Accessed April 5, 2005.
- National Disaster Life Support Foundation. National Disaster Life Support Courses. [National Disaster Life Support Foundation Web site]. Available at: http://www.ndlsf.org. Accessed April 5, 2005.
Supervising editors: Kathy J. Rinnert, MD, MPH; Michael L. Callaham, MDFunding and support: The author reports this study did not receive any outside funding or support.Reprints not available from the author.Disclaimer: The opinions or assertions in this article are those of the author and do not necessarily reflect the official views of the Army Medical Department or the Department of Defense.
PII: S0196-0644(05)00456-7
doi:10.1016/j.annemergmed.2005.04.006
© 2005 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
