1. A New Paradigm and Protocol for Use of the CDG to Enable Local Health Care Professionals to Participate in the Medical Management of the Stochastic Risks Associated with Internal Contamination,Following Radiological Mass Casualty Scenarios Albert L. Wiley, BNE, MD, PhD, FACR REAC/TS and WHO Collaborating Ctr. At Oak Ridge Emeritus Professor, Human Oncology, Univ. of Wisc.-Madison albert.wiley@orise.orau.gov U.S. Department of Energy (DOE)

2. Example: Inhalation of Cs- 137(There are worried populations, “in” and “out” of the plume !) Example: Inhalation of Cs- 137(There are worried populations, “in” and “out” of the plume !)

3. Collect Samples from: Nose Mouth Wounds Also: Baseline urine, then 24- hour samples of urine and feces

4. Medical Countermeasures Are Generally Element Specific NuclideMedicationComments Am-241Ca and Zn DTPA by IV, aerosol,?IM Clelation,Works on liver even after long deposition Cf-252Ca and Zn DTPA Cs-137Prussian BlueBinds Cs,hepato-enteric cycle Co-60penicillamineGastric lavage,?DTPA Fission ProductsDepends on mixtureSpectroscopic identificationnuclides isotope,specific RX H-3Forced H 2 OIsotopic dilution I-131KI or SSKIGive in first 1-6 hours P-32PhosphatesIsotopic dilution Pu-239Ca and Zn DTPAEDTA less effective Sr-89/90Sr,Ca gluconate,ivConsider alginates

5. The goal is to reduce the stochastic and the deterministic risks by averting,as much as possible, the committed radiation dose(CED) from internalized radionuclides by use of medical countermeasures. Generally, reduction of the stochastic risk is the primary and possibly only risk of concern. But,in some scenarios, such as the Goiania and London Po210 incidents, death can rarely occur from internal contaminat ion.

6. The Goiania and Po-210 Incidents ( where many thousands of people insisted on being monitored promptly for internal contamination) demonstrate the need for the CDG in altering/supplementing our current US medical emergency response plans to internal contamination (following radiological,mass casualty scenarios) with a new paradign,because

7. -current US mass casualty medical emergency response plans direct people to reception centers ; but, past experience from such incidents confirms that probably most people will instead seek their medical management from their personal, local providers (most of whom have No Knowledge of radiological issues, and there will be no time to train them !) -current US mass casualty medical emergency response plans direct people to reception centers ; but, past experience from such incidents confirms that probably most people will instead seek their medical management from their personal, local providers (most of whom have No Knowledge of radiological issues, and there will be no time to train them !)

8. Accordingly,in order to deal with this situation, a new paradigm is now proposed. Specifically, emergency planners should understand that there is neither the time nor the logistics in the US to deliver sufficient radiological training to the many hundreds of local providers who will surely be called upon by their patients to manage the possibility of their IC.

9. Purpose of CDG(NCRP 161) The Clinical Decision Guide(CDG) may be used to simplify for general health care professionals the emergency triage and the medical management of inhalation or ingestion of intakes of specific radionuclides ( i.e., to expedite the decision on whether decorporation drug therapy is needed or not,and to monitor the response to such therapy).

10. Clinical Decision Guidelines (CDG) CDG = the maximum, once-in-a-lifetime intake of a radionuclide that represents: “Stochastic risk, as judged by the calculated ED over 50Y for intake by adults and to age 70Y for intake by children, that is in the range of risks associated with guidance on dose limits for emergency situations (DOE, 2008a; FEMA, 2008; ICRP, 1991a; NCRP, 1993; 2005a)” “Stochastic risk, as judged by the calculated ED over 50Y for intake by adults and to age 70Y for intake by children, that is in the range of risks associated with guidance on dose limits for emergency situations (DOE, 2008a; FEMA, 2008; ICRP, 1991a; NCRP, 1993; 2005a)”

11. Clinical Decision Guidelines (CDG) CDG = the maximum, once-in-a-lifetime intake of a radionuclide that represents: “Avoidance of deterministic effects as judged by the calculated 30d RBE-weighted absorbed doses to red marrow and lungs, with allowance for the significant uncertainties often involved in an initial evaluation of the chemical and physical form of a radionuclide and the level of activity taken into the body during an incident.” “Avoidance of deterministic effects as judged by the calculated 30d RBE-weighted absorbed doses to red marrow and lungs, with allowance for the significant uncertainties often involved in an initial evaluation of the chemical and physical form of a radionuclide and the level of activity taken into the body during an incident.”

13. NCRP 161 (2010) Bair, W; Bloch, W; Dickerson, W; Eckerman, K; Goans, R; Karem, A; Leggett, R; Lipstein, J; Stabin, M; Wiley, A

14. This table can easily be simplified by asking those laboratories which are providing the 24 hr. urine analysis results to report to the health care provider who ordered the test results in intake units of CDG(rather than dpm/24 hr collection). Therefore,any CDG value by definition above “1” CDG will prompt and facilitate the clinician in making triage and treatment decisions.

15. In the US one can expect that there will be many thousands of worried people in the region of any radiological dispersal incident ;and, (as local physicians,and we at REAC/TS often heard during the Po-210, the Fukushima and other incidents) they will say : “Prove to me that I am not contaminated –and,if I am contaminated, I want treatment now !)

16. In lieu of trying to provide emergency training of hundreds of providers on radiological training in the area of a radiological dispersal incident,it is proposed that the necessity for the training of and understanding of radiological issues and terminology can be eliminated by use of the CDG. In lieu of trying to provide emergency training of hundreds of providers on radiological training in the area of a radiological dispersal incident,it is proposed that the necessity for the training of and understanding of radiological issues and terminology can be eliminated by use of the CDG.

17. Specifically, clinicians generally manage medical, conditions in their patients by the use of laboratory tests which involve changes in simple numbers –i.e., as with the PSA test, an increase from “4” to “10” prompts a medical treatment decision. Use of the CDG is similar. It simplifies medical management by use of simple, “non-radiological” numbers.