1. Hospital Management of RAM Contaminated Patients René Michel, M.S., RSO VA San Diego Healthcare System, La Jolla, CA 92161

2. Introduction  RAM are among the many hazardous substances hospitals may have to deal with after certain accidents.  It is important for hospitals to be prepared should radiation accidents occur in their communities.  This presentation provides an overview of VASDHS’ decontamination procedures. Potential Emergency Scenarios: 1)Power Plant 2)Research Lab 3)Terrorism

3. Introduction (cont.)  Topics addressed during this presentation include procedures for: 1.Donning PPE 2.Preparing Decon Areas 3.Removing Contaminated Clothing 4.Surveying for Contamination 5.Decontamination of Skin and Open Wounds

4. Introduction (cont.)  VASDHS’ Training Program 1.Initial for new Decon Team Members 2.Annual Refresher 3.Training includes slide shows, demonstrations 4.Exercises are performed regularly

5. Dressing To Prevent the Spread of Radioactive Contamination  Very similar to the universal precautions already in place  Give yourself a layer of clothing to keep your own clothes and body from becoming contaminated

6. Dressing (cont.) 2  Start with an ordinary set of scrubs  Shoe covers are worn over the shoes and come up under the pants leg  Tape the pants hem to the shoe cover  Make a folded tab in the end of your tape

7. Dressing (cont.) 2  Then we put on a surgical gown as an outer cover  It helps to assist one another with getting it all tied up.  It also helps minimizing mistakes

8. Dressing (cont.) 2  Double glove (blue and white) is recommended  Blue for you and white for the patient  The blue pair of gloves goes under the sleeve of the gown and is taped to the sleeve  The white glove goes on over top of the blue

9. Dressing (cont.)  Don a hat and a mask  A mask is as much for the patient's protection as the caregiver's  A face shield or a pair of goggles can be used to provide splash protection

10. Preparing the Area  The arrival of patients contaminated with RAM can occur any time.  What to do now?

11. Preparing the Area (cont.)  Radiological Emergency protocol  Stay calm  Top priority: medical condition  No significant threat to caregivers

12. Preparing the Area (cont.) If possible,  Use a separate entrance  Lay plastic/paper in path  Cover floors

13. Preparing the Area (cont.)  Lay paper on path  Cover ½ of hallway

14. Preparing the Area (cont.)  Tape edges and seams securely  Some facilities have non-porous floors and choose not to cover

15. Preparing the Area (cont.)  No exit without survey  Remove equipment needed elsewhere  No normal "come and go"

16. Preparing the Area (cont.)  Survey meter  Warning signs & security tape  Supply cart Supply Cart Materials: Extra 4 x 4's Small and large sample bags ABD pads Drapes and tape Irrigation solution, etc.

17. Preparing the Area (cont.) You will also need:  Waste containers, large, plastic lined  Several waterproof sheets

18. Preparing the Area (cont.)  Most contamination is found in clothing  Wrap in sheet; then GO!

19. Removing Contaminated Clothing  Treat life threatening problems first  When medically stable, remove clothing  Approximately 80% of contamination is removed by disrobing patient

20. Removing Contaminated Clothing (cont.)  Careful techniques prevent spread of contamination  Protect face from splashes

21. Removing Contaminated Clothing (cont.)  Shoes are a likely spot for contamination  Plastic prevents direct contact

22. Removing Contaminated Clothing (cont.)  Cut clothes from the head towards the feet  Do it carefully and don't use the cut and rip method

23. Removing Contaminated Clothing (cont.)  Roll clothes outward  Keep contamination away from patient

24. Removing Contaminated Clothing (cont.)  Change outer gloves before log rolling patient  Change outer gloves whenever you suspect you have handled contaminated material

25. Removing Contaminated Clothing (cont.)  Log roll  Protect cervical spine, if necessary  Fold sheet over clothing

26. Removing Contaminated Clothing (cont.)  Complete log roll  Roll sheet from head to feet  Keep contaminated material away from patient's skin and airway

27. Removing Contaminated Clothing (cont.)  Remove contaminated material from immediate area  Survey patient's back for contamination

28. Removing Contaminated Clothing (cont.)  Double bag contaminated linens and clothes  Remove from immediate area  Keep in designated holding area

29. Removing Contaminated Clothing (cont.)  Medical problems come first  Treat life threatening problems immediately  If patient is stable, remove clothing and survey for radioactive contamination

30. Surveying For Radioactive Contamination  GM radiation instrument  Radiation induces electric pulses which are counted by the meter  Make reading in counts per minute (CPM)  Document background radiation

31. Surveying For Radioactive Contamination (cont.)  Probe held ~1 cm from surface  Move at a rate of 2 to 4 cm per second  Document readings in CPM  Log roll to survey the back

32. Surveying For Radioactive Contamination (cont.)  Avoid alarming the patient  Document areas of contamination on an anatomical chart  Remove contaminated clothing  Decontaminate

33. Surveying For Radioactive Contamination (cont.)  Patient discharge  Clean paper path  Clean stretcher  Clean team members  May walk to control line with clean foot covers

34. Decontaminating A Wound  Radioactive contamination in an open wound presents a pathway for internal contamination  Always treat life threatening medical needs first  Removing contaminated clothes when appropriate

35. Decontaminating A Wound (cont.)  Remove dressing with tongs  Bag wound dressing  Label with name, date, time and meter readings  Remove from immediate area

36. Surveying For Radioactive Contamination (cont.)  Survey and define area of contamination at wound site  Document initial reading in cpm  Washing out radioactive contamination similar to normal wound cleaning  cover surrounding clean skin so contamination is not spread

37. Decontaminating A Wound (cont.)  Drape area with water proof drapes  Tape edges of drapes to skin  Direct run off into lined garbage can

38. Decontaminating A Wound (cont.)  Wash and irrigate wound  Avoid high pressure flushing  Only blot wound one time with each 4x4  Do not spread contamination

39. Decontaminating A Wound (cont.)  Cover and protect wound  Remove drapes and pads  Place clean chucks  Bandage and wrap decontaminated wound

40. Decontaminating Intact Skin  Define the area of contamination  Mark the area of contamination

41. Decontaminating Intact Skin (cont.)  Drape the area  Tape edges of drape  Protect clean areas from splashes

42. Decontaminating Intact Skin (cont.)  Use a pad, mild detergent and water  Clean team member passes pads to caregiver  Clean outside to in

43. Decontaminating A Wound (cont.)  Blot once and carefully discard pad  Protect area while removing drapes  Resurvey area  If residual contamination is left, repeat the process

44. Decontaminating A Wound (cont.)  Medical treatment comes first  Decontaminate open wounds first, then in and around body orifices and finally intact skin

45. Any questions? René Michel (858) 642-1059 rene.michel@va.gov