1. MEDICAL ASPECTS OF RADIOLOGICAL ACCIDENT IN GILAN, IRAN MEDICAL ASPECTS OF RADIOLOGICAL ACCIDENT IN GILAN, IRAN Module XIX

2. Module Medical XIX-(16) - 2 Summary l Morning of 24 July 1996 a worker (KZ) at Gilan Combined Cycle Fossil Power Plant, while carrying insulation material for lagging pipes, noticed a shiny pencil sized metal object beside of trench l He put it into his loose overall pocket on right side above chest

3. Module Medical XIX-(16) - 3 Summary-2 l The metal object - “pigtail” of radiograph with iridium-192 source, led to severe haemopoetic syndrome (bone marrow depression) and unusually extended local radiation injury of chest requiring plastic surgery l Surgery successfully performed a month later in Curie Institute, Paris

4. Module Medical XIX-(16) - 4 Source

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6. Module Medical XIX-(16) - 6 Development of symptoms, recognition of accident l At 9.30 am, 1.5 hrs after start of exposure, he experienced dizziness, nausea, lethargy and burning feeling in chest l Believing object cause of symptoms, he put it back into trench l 13:00, KZ told colleagues about strange shiny object and weak, lethargic feeling l 13:30 he was sent for blood sampling

7. Module Medical XIX-(16) - 7 Investigation of accident l Team of AEOI inspectors investigated accident on site next day l Recommended blood checks for all 600 personnel l All samples normal except for KZ’s

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11. Module Medical XIX-(16) - 11 Course of lymphocytes

12. Module Medical XIX-(16) - 12 Course of leukocytes

13. Module Medical XIX-(16) - 13 Treatment in Iran l Prophylactic antibiotics l Analgesia l Topical silver sulphadiazine (on chest lesion) l Platelet transfusion (7 units on Day 20) l Cytokine (G-CSF) — Leucomax 400  g 2x/d (subcutaneously)

14. Module Medical XIX-(16) - 14 Bone marrow sampling

15. Module Medical XIX-(16) - 15 Transfer to Paris l Need for bone marrow transplantation ? l Transfer to Radiopathology Unit of the Institut Curie in Paris on Day 24 (16 Aug96). l Findings on examination Total loss of epidermis on right anterior chest/ upper abdominal wall — 30 x 15 cm — with necrotic epidermis around the edge Area of moist desquamation on medial side of right antecubital fossa — 6 x 7 cm L arge hard bulla on palm of left hand — 5 x 5 cm Small area of increased pigmentation and erythema on anterior middle surface of right thigh — 2 x 2 cm

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18. Module Medical XIX-(16) - 18 Status in June 2001 Status November 97 (as examined by IAEA medical staff, confirmed June 2001): 1. Chest lesion showed no necrosis but graft was firmly fixed to the chest wall Fibrosis leading to some retraction, adversely affecting posture

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20. Module Medical XIX-(16) - 20 Status in June 2001 2. Elbow lesion completely healed, but movements restricted in both flexion and extension - from 45 o to 135 o 3. Some thickening of left palmar observed, but with full function and strong grip

21. Module Medical XIX-(16) - 21 Status in June 2001 4. Right thigh lesion: hard and fibrotic, but completely healed and non-painful 5. Complete recovery of all lymphocyte subpopulations in 18 months

22. Module Medical XIX-(16) - 22 Lessons – medical l For non-homogeneous whole body irradiation (as in most accidents), initiate cytokine treatment at earliest opportunity when bone marrow recovery not detected l G-CSF may be drug of choice, but then direct particular attention to monitoring platelet counts

23. Module Medical XIX-(16) - 23 Lessons - medical l Use thermography, where available, to assess viability of radiation induced skin injuries for potential spontaneous recovery or suitability for grafting l Where dermal tissues are viable after radiation induced skin injury, and spontaneous re- epithelialisztion is likely to be prolonged, consider early skin grafting to reduce physical and psychological morbidity

24. Module Medical XIX-(16) - 24 Lessons - radiation protection Teach radiographers safety culture by organizing more training courses for them l Computerize and regularly update records of existing radiation sources, systems, equipment, projects and personnel l Provide psychological support to workers and public affected by any radiological accident