*Enclosure 7-3*

S A M P L E

Radiological Event

And Terrorism Readiness Plan

1\. ***Introduction***. The Radiation Event and Terrorism Readiness Plan
is a component of the VA Medical Center's Emergency Operations Plan
(EOP). The Plan is used for any radiological hazard situation,
accidental or intentional. The Plan is structured to operate under the
umbrella of the Incident Command System (ICS), implementing the Standard
Operating Procedures (SOPs) specific to radiological events. The Plan
provides an emergency response framework to protect the physical
infrastructure, employees and patients of the VA Medical Center (VAMC).

2\. ***Purpose***. The purpose of the Radiation Event and Terrorism
Readiness Plan is to describe how the VA Medical Center responds to
radiological threats. The Plan identifies operating procedures and areas
of concern encountered for response to a radiological event. Specific
information and response protocols are detailed in the sample Standard
Operating Procedures (SOPs) Section (Section 6).

3\. ***Scope***. The Radiological Event and Terrorism Readiness Plan
applies to all employees and operates within the framework of The Joint
Commission (TJC), Nuclear Regulatory Commission (NRC), Occupational
Safety and Health Administration (OSHA), and Environmental Protection
Association (EPA) requirements.

4\. ***Policy***. In the event of a radiological emergency, the ICS
Incident Commander will initiate the ICS. This ensures that the
necessary services and functions are provided to ensure a safe working
and patient care environment. The VA Medical Center will work closely
with community response agencies to achieve effective interaction during
response and recovery operations. The Radiological Event and Terrorism
Readiness Plan and associated SOPs facilitate the preparedness,
mitigation, response and recovery efforts needed to minimize any adverse
impact on the VA Medical Center.

5\. ***Radioactive Material and Terrorist Events***. VA Medical Centers
must be adequately prepared to handle and treat victims exposed to
radiation or contaminated with radioactive materials. Radiation exposure
or contamination that result in acute high radiation doses can occur in
the following scenarios: nuclear detonation, radiological dispersal
device or an irradiation device or accident. The facility Health
Physicist (Radiation Safety Officer) is an indispensable resource when
dealing with radiation emergencies.

a\. *Radiological Dispersal Device (RDD)*. A Radiological Dispersal
Device (RDD), or dirty bomb, uses conventional explosives in combination
with radioactive materials. The explosion causes the radioactive
material to be dispersed over a wide area, contaminating bystanders,
buildings, vehicles and anything in the blast radius. Due to the
dilution of the radioactive material being spread out over a wide area,
the health impact of the radiation itself is expected to be low, and not
result in a significant increase in potential health effects on a large
scale. Acute localized radiation injuries are possible if radioactive
materials such as cobalt-60, cesium-137, or strontium-90 are used in the
RDD. The main concern with an RDD is injuries from the blast (shrapnel
and static overpressure), psychological effects and environmental
contamination. The fear of radiation exposure could cause a mass panic
reaction among the general public, and the cost of environmental clean
up could be very high.

b\. *Nuclear Detonation*. A nuclear detonation can produce extremely
high radiation dose rates during the first 60 seconds of the blast and
then from fission activation products in the form of fallout near ground
zero. Sources could be an Improvised Nuclear Device (IND), backpack or
suitcase device or a military weapon produced by one of the
terrorist-sponsoring countries or the former Soviet Union. This scenario
is least likely to occur compared to an RDD event or industrial accident
due to the difficulty in acquiring such a device.

c\. *Irradiation Device*. An irradiation device is a container with
radioactive material that emits radiation and exposes individuals in
close proximity to the source. The individuals receive exposure to gamma
or beta radiation but are not contaminated themselves with radioactive
material. Accidents have occurred with radioactive sources used for
industrial radiography. A variety of health effects are possible,
depending on the activity of the source and the amount of time spent in
close proximity. Health effects can range from localized radiation
injuries to death.

6\. ***Contamination and Exposure***. Radioactive contamination occurs
when radioactive material is deposited on or in an object or person.
Unlike chemical contaminants, radioactive material that is active enough
to constitute an exposure threat can be detected at great distances.
Gamma radiation (penetrating) can cause whole body irradiation; beta
emitters left on the skin can cause burns and scarring; and, alpha
emitters (non-penetrating) will not penetrate the intact epithelium. It
is highly improbable that a living patient would be so contaminated that
he or she would constitute a health hazard to responders.

a\. *External Contamination*. External contamination occurs when
radioactive material comes into contact with a person's skin, hair or
clothing. The radioactive material can be liquid, mixed with dirt or
dust or powder. The contamination is deposited on the outside of the
body.

b\. *Internal Contamination*. Internal contamination occurs when
radioactive material is internalized by inhalation, ingestion,
absorption through the skin or mucous membranes or entry through a
wound. Internal contamination may result in incorporation, which is the
entry of radioisotopes across cell membranes into the cell.

c\. *Incorporation*. Different radioisotopes have varying affinities for
different organs and have varying residence times in the body. Some may
collect in the bone, whereas others may collect in the thyroid or other
organs. The radioactive form of a substance is processed through the
same metabolic pathways as the non-radioactive form of that substance.
Thus physiological changes, medications and procedures that alter the
usual metabolic pathways for a chemical will alter the likelihood and
rate of incorporation. The radioactive material is eliminated from the
body through sweat, blood, tears, urine and feces. This process of
elimination is referred to as de-corporation, and the rate of release
may be increased by certain medications.

d\. *Exposure or Irradiation*. Radioactive materials give off energy in
the form of photons or particles. The photons or particles behave like
light waves coming from a light bulb, but at a much higher energy level,
and are invisible. When an individual is exposed to radiation (also
termed irradiation), he or she is not contaminated; but rather the
radiation passes through the body. A patient getting a chest x-ray is a
good example of irradiation; the patient has been exposed to radiation
but is not contaminated. An exposed individual is not radioactive, and
presents no hazard to response personnel.

7\. ***Adverse Health Effects***. To properly care for the radiation
accident victim, a timely diagnosis of the magnitude of the accident
must be determined. Adverse health effects of radiation exposure can
range from mild effects, such as reddening of the skin, to long-term
effects, such as cancer or even eventual death. The severity of health
effects is determined by the amount of radiation absorbed by the body,
the type of radiation, the route of exposure and the exposure time.
There are several resources for the management of the clinical
manifestations of the radiation accident patient. *(See the sample SOP,
Patients with Radiation Exposure or Radioactive Contamination in Sample
6-23, Section 6 for detailed information.)* An important resource is the
Radiation Emergency Assistance Center/Training Site (REAC/TS)
[www.orau.gov/reacts](http://www.orau.gov/reacts).

8\. ***Protection of Response Personnel***.

a\. *Time, Distance and Shielding*. Time, distance and shielding are the
three golden principles of radiation protection. These three principles
are common sense, when you think about them. The less time you spend
near a radioactive source, the less your radiation exposure will be.
Increasing your distance from the radioactive source is a very effective
tool in reducing your exposure. For gamma and x-ray sources (penetrating
radiation), every time you double your distance away from the source,
the exposure rate drops by four times; therefore, even a small amount of
distance can make a big difference in your exposure. Many materials can
be used as shielding; lead and concrete are two effective shielding
materials. Make use of existing shielding, such as concrete walls or
something as simple as stepping around the side of a building. Utilize
time, distance and shielding together to minimize your radiation dose.
(Example: when you do not have to be right next to the contaminated
patient, take a step or two back, reducing the time and increasing the
distance in order to lower your exposure.)

b\. *Respiratory Protection*. For situations involving airborne
particulate radioactive material, standard surgical masks are usually
sufficient. A higher level of protection would be a High Efficiency
Particulate Air (HEPA) filter, such as the N95 mask that is commonly
available in the hospital setting. Fit testing and training must be
provided for the N95 mask. If radioactive vapors (such as iodine 131)
are involved, a respirator with an organic vapor cartridge must be
employed.

c\. *Skin Protection*. Personal protective equipment (PPE) includes all
clothing and protective gear worn to protect individuals from hazards.
The wearer must demonstrate competency to don and doff properly and
provide proper maintenance. Protection levels for PPE are classified as
A, B, C and D, with D being the least protective. Level C is usually
sufficient when working with a radiation contamination event. Hospital
surgical gowns or Tyvek suits with nitrile gloves are examples of
appropriate protective clothing. *(Refer to the sample Healthcare First
Receiver Decontamination Readiness Plan in this Section for more
information.)*

d\. *Dosimetry*. Personnel handling contaminated victims must wear
radiation dosimetry badges in order to monitor the amount of their
radiation exposure. One type of dosimeter is a clip-on badge containing
film or other radiation-sensitive material, such as a thermo luminescent
dosimeter (TLD). Other types are pocket ionization chambers, electronic
dosimeters or electronic alarming rate meters that chirp when the
radiation level exceeds a pre-set level. The later has been referred to
as "radiation pagers." The Radiation Safety Officer will distribute
dosimeters.

9\. ***Medical Considerations of Contaminated Victims***. Medical
conditions and traumatic injury [must]{.underline} be assessed before
consideration is given to radiation contamination. Triage and
stabilization of patients take first priority before initiating
decontamination procedures. Removal of the clothing removes
approximately 80-90% of the contamination. The next priority will be the
decontamination of skin and wounds. Signs and symptoms of high radiation
exposure should be noted. An important step in radiation dose
determination is the time to onset of emesis. Swabs of all body orifices
should be taken for radiation analysis. Nasal swab activity represents
approximately 5% of the deposition in the lung. An initial blood count
should be taken and repeated every 4 hours to monitor the lymphocyte
count.

10\. ***Decontamination of Victims***. Decontamination procedures should
only be initiated after the patient is medically stabilized.
Conventional trauma injuries always take first priority, as skin or
wound contamination is almost never immediately life threatening. Open
wounds should be covered during skin decontamination to prevent
contamination from re-entering the wound. Clothing removal reduces
contamination up to 80-90%. Contaminated clothing should be placed in
plastic bags and held for proper disposal. Personal items should also be
placed in plastic bags for later decontamination and a proper
chain-of-custody procedure followed.

a\. *Skin Decontamination*. After clothing removal, the skin should be
gently washed with soap and water, using gentle brushing. Do not scrub
hard enough to abrade the skin; this could potentially cause
internalization of the contamination. The goal is to remove as much
contamination as possible. The radiation level should be reduced to
twice background or lower. If successive decontamination attempts fail
to reduce the contamination level by 10%, the contaminated area should
be covered and standard blood borne pathogen precautions should be
utilized when handling the patient. When covered, sweating will reduce
the contamination level to some extent. Hair may be decontaminated with
any commercial shampoo or by clipping. Fluid may prevent weak beta or
alpha emitters from being detected.

b\. *Wound Decontamination*. Abrasions, lacerations and puncture wounds
compromise the skin's integrity, thus increasing the route to
internalize the radioactive material. Following contamination with
radioactive material, wounds may contain radioactive dust or shrapnel.
Radioactive shrapnel should be handled with forceps and, if found to be
radioactive, placed in a lead-lined container (if available) at least
six feet from personnel.

c\. *Internal Treatment*. The first priority is to assess traumatic
injuries or other emergent medical conditions. When the patient's
condition permits, steps should be taken to assess if internal
contamination has occurred. Swabs from all body orifices and urine and
fecal samples should be taken and analyzed for radioactive material
content. If internal contamination is confirmed, treatment should begin
in order to reduce internal contamination. Internal contamination may be
reduced by minimizing absorption of radionuclides and increasing the
excretion. The chemical toxicity must also be considered when
eliminating internal contamination. Side effects of de-corporation of
radionuclides must be weighed against the long-term effects of the
radiation exposure. Available pharmaceuticals for immediate treatment
include the administration of potassium iodide (KI), if radioiodine is a
suspected agent; antacids to decrease gastrointestinal absorption for
uranium or strontium; and, cathartics to decrease residence
time/absorption in the bowel, such as biscodyl or phosphate soda enema
to flush the colon quickly. Aluminum-containing antacids are
particularly effective for decreasing the uptake of strontium between
50-85%. For large intakes of ingested radioactive material, gastric
lavage is effective, but only if given within one to two hours after
ingestion.

11\. ***Radiological Assessment and Biodosimetry***. Assessing injured
victims includes taking radiation measurements and collecting
information relevant to decontaminating and treating the patient.
Medically stable patients should not be released for ambulance transport
until a radiological survey has been performed. The instrument used to
conduct the radiation survey should be able to detect penetrating and
non-penetrating radiation (a Geiger-Mueller Counter with a pancake or
end-window probe). The probe should be moved about one inch per second,
taking care not to touch the probe to the potentially contaminated
patient. The distribution of contamination on the patient should be
recorded, and nasal swabs taken to assess if contaminants were inhaled.
Information about the nature of the radioactive source should be
collected from the patient. If details of the source and time of
exposure are determined, a reasonable radiation dose estimate may be
possible. Consult the facility Radiation Safety Officer for radiological
assessment information and interpretation.

12\. ***Biodosimetry Assessment Tool***. The Biodosimetry Assessment
Tool (BAT), developed by the Armed Forces Radiobiology Research
Institute (AFFRI), is a software program that aids in the collection and
interpretation of clinical manifestations of radiation exposure. The BAT
archives and analyzes clinical information, and provides a radiation
dose estimate for the patient. The program can be downloaded at:
[http://www.afrri.usuhs.mil/www/outreach/biodostools.htm -
software](http://www.afrri.usuhs.mil/www/outreach/biodostools.htm#software)

13\. ***Morgue Operations***.

a\. *Autopsies*. Performing autopsies of cadavers with minimal
contamination only requires contamination control methods and
appropriate protective clothing. Highly contaminated cadavers with
exposure readings of 0.1 to 1.0 mGy/hr should have several individuals
split the task. If the exposure event is being handled as a criminal
case, the case must be performed in coordination with the medical
examiner or coroner.

b\. *Embalming/Cremation*. Embalmers should wear protective clothing and
preferably have radiation safety staff present to monitor contamination.
Embalming and cremation are contingent upon the amount and type of
radioactive material the cadaver is contaminated with. Burial is usually
not an issue, unless there is long-lived radionuclides present that may
enter the environment. Cremation is dependent on the type and
concentration of radionuclides released to the environment by
incineration or by ash disposal. If the radionuclide is short-lived,
waiting a few weeks before cremation may be advisable.

14\. ***Psychological Aspects of a Radiological Event***. An attack with
the release of radioactive material can create fear, anxiety and mass
panic reactions among the general public. Following an attack, the
management of psychological and behavioral responses can be just as
important as the medical treatment and decontamination of the victims.
For the majority of the people, psychological symptoms related to the
traumatic event will fade over time. Although for others, symptoms may
persist, affecting function at work and home, and may result in further
psychiatric complications. Acute stress disorder, post-traumatic stress
disorder, depression, increased substance abuse, family conflict and
generalized anxiety disorder may also be experienced.

15\. ***Exercise Scenarios***.

a\. Radiological Dispersal Device (Dirty Bomb).

Scenario Description - A terrorist group has obtained approximately 250
grams of Plutonium-238 (Pu-238) and has constructed a radiological
dispersal device (RDD). The explosive device is constructed with plastic
explosives that incorporate immediate and delayed blasting caps and
flyer plate technology to penetrate a propane storage tank, and detonate
the expanding propane cloud within one second after the explosion. The
explosive device and radioactive material (Pu-238) are placed on a
1500-gallon propane tank located in a central area of the city. The
device is detonated mid-afternoon on a normal workday.

Effects - The explosion causes small fires in the vicinity of the
propane tank. The Pu-238 is dispersed primarily in the blast direction.
The wind speed is 15 mph from the north with humidity at 50%. A 500
mRem/hour zone extends 400 feet wide and one-half mile in length. Pu-238
deposition of 4 uCi/square meters occurs along the dispersion area.

Actions - Local police and fire units respond to the explosion, and
local area residents come to see the fire. Fifteen people in the
vicinity of the blast have traumatic injuries and radioactive
contamination. Forty-five individuals in the dispersion area are
contaminated, but not injured. The local newspaper has received a call
from the terrorist group claiming the explosion has spread radioactive
material all over the city. Greater than 1000 patients are estimated to
present for decontamination citywide.

b\. Improvised Nuclear Device (IND).

Scenario Description - A terrorist group has acquired a sufficient
amount of highly enriched uranium (HEU) and has constructed an IND with
a gun implosion mechanism. The IND is put in a car trunk on the top
level of a five-story parking garage. The parking garage is open on the
sides and top, and is located approximately 100 yards adjacent to the
County Court building in a large metropolitan city. The weapon is
detonated mid-afternoon on a normal workday. The explosive yield is 1.5
kilotons.

Effects - The explosion causes a shock wave of greater than 200-psi
static overpressure at ground zero. The parking garage and County Court
building are destroyed. All of the 750 individuals in the County Court
building are killed, and 50 people in the parking garage are also
killed. The blast radius projects 360 degrees, and the amount of
devastation varies from total destruction near ground zero to moderate
damage at the edges of the blast radius. The maximum overpressure at 440
yards from ground zero is approximately 15 psi, 5 psi at one-half mile,
3 psi at three-quarters mile, and 2 psi at one mile. Several thousand
individuals are killed, and many have sustained traumatic injuries from
the blast with second-degree burns from the intense heat generated.
Thermal burns are experienced as far as two miles out. Glass windows in
buildings in a one-mile radius are shattered, causing additional
injuries. Unprotected individuals within one-half mile of the detonation
have received lethal doses of gamma and neutron radiation. Radioactive
fallout is dispersed downwind, contaminating individuals and the
environment. Electric power in the area is knocked out, and water and
natural gas lines are ruptured.

Actions - Local police and fire units respond to the explosion. The
newspaper gets a call from the terrorist group claiming the explosion
was a nuclear weapon and that there are more bombs around the city.
Greater that 100,000 patients are likely to present for decontamination
citywide.

Attachment:

A. Radiological Performance Evaluation Matrix

*Attachment A to Radiology Event Readiness Plan*

**Radiological Performance Evaluation Matrix**

+------------------------------------------+--------------+------------+
| **Competency Areas**                     | **Awareness  | **         |
|                                          | Level**      | Operations |
| (Assess for basic or advanced knowledge  | (Employees)  | Level**    |
| in subject area.)                        |              | (R         |
|                                          |              | esponders) |
+==========================================+==============+============+
| 1\. Know the potential use for           |              |            |
| radiological weapons or accidents:       |              |            |
| Hazards, associated risks, outcomes.     |              |            |
+------------------------------------------+--------------+------------+
| 2\. Know signs and symptoms of           |              |            |
| radiological exposure.                   |              |            |
+------------------------------------------+--------------+------------+
| 3\. Knowledge of questions to ask caller |              |            |
| to get critical information.             |              |            |
+------------------------------------------+--------------+------------+
| 4\. Recognize trends that may indicate a |              |            |
| radiological event.                      |              |            |
+------------------------------------------+--------------+------------+
| 5\. Make proper notification and         |              |            |
| communication of the radiological event. |              |            |
+------------------------------------------+--------------+------------+
| 6\. Understanding of radiological terms. |              |            |
+------------------------------------------+--------------+------------+
| 7\. Knowledge of personal protective     |              |            |
| equipment (PPE) and proper use of such.  |              |            |
+------------------------------------------+--------------+------------+
| 8\. Understanding the risks of operating |              |            |
| in PPE during radiological events.       |              |            |
+------------------------------------------+--------------+------------+
| 9\. Knowledge of radiological            |              |            |
| decontamination procedures.              |              |            |
+------------------------------------------+--------------+------------+
| 10\. Knowledge of crime scene and        |              |            |
| evidence preservation.                   |              |            |
+------------------------------------------+--------------+------------+
| 11\. Knowledge of chain of custody for   |              |            |
| collecting legal evidence.               |              |            |
+------------------------------------------+--------------+------------+
| 12\. Knowledge of emergency first aid    |              |            |
| and triage priorities.                   |              |            |
+------------------------------------------+--------------+------------+
| 13\. Knowledge of hazard and risk of     |              |            |
| radiological agents.                     |              |            |
+------------------------------------------+--------------+------------+
| 14\. Understanding of handling and       |              |            |
| transport of contaminated items.         |              |            |
+------------------------------------------+--------------+------------+
| 15\. Operational knowledge of radiation  |              |            |
| detection instruments.                   |              |            |
+------------------------------------------+--------------+------------+

+------------------------------------------+--------------+------------+
| **Competency Areas**                     | **Awareness  | **         |
|                                          | Level**      | Operations |
| (Assess for basic or advanced knowledge  | (Employees)  | Level**    |
| in subject area.)                        |              | (R         |
|                                          |              | esponders) |
+==========================================+==============+============+
| 16\. Knowledge of contaminated patient   |              |            |
| transport procedures.                    |              |            |
+------------------------------------------+--------------+------------+
| 17\. Are "contamination zone" boundaries |              |            |
| clearly marked?                          |              |            |
+------------------------------------------+--------------+------------+
| 18\. Are personnel and equipment/samples |              |            |
| in contamination zone surveyed with      |              |            |
| radiation detection meter before exiting |              |            |
| area?                                    |              |            |
+------------------------------------------+--------------+------------+
| 19\. Is floor covered to prevent spread  |              |            |
| of contamination?                        |              |            |
+------------------------------------------+--------------+------------+
| 20\. Has the Radiation Safety Officer    |              |            |
| been notified?                           |              |            |
+------------------------------------------+--------------+------------+
| 21\. Are contaminated waste and items    |              |            |
| labeled with radioactive symbols?        |              |            |
+------------------------------------------+--------------+------------+
| 22\. Have patient symptoms, samples,     |              |            |
| timelines and contaminated areas been    |              |            |
| properly recorded?                       |              |            |
+------------------------------------------+--------------+------------+