Management of medical and psychosocial consequences of a radiological or nuclear terrorist event

ORIGINAL PAPER NUKLEONIKA 2010;55(3):393−399 Management of medical and psychosocial consequences of a radiological or nuclear terrorist event Marek K. Janiak Abstract. Medical, psychological, and social consequences of a terrorist event involving the release of ionizing radiation will differ significantly from attacks with “classical” explosives. Victims of a detonation of a “dirty bomb” or a nuclear device can actually or allegedly absorb various doses of radiation and should be viewed as radiologically contaminated patients. Hence, both first responders and medical personnel should behave and act accordingly. General rules, guidelines, and procedures are described that should be implemented at all levels of medical management from the on-site emergency care until admittance to and treatment of the victims at a specialist hospital ward. The causes, manifestations and management of psychosocial sequelae of radiological terrorist incidents are also discussed. Key words: radiological/nuclear event • medical and psychosocial consequences • management Introduction M. K. Janiak Department of Radiobiology and Radiation Protection, Military Institute of Hygiene and Epidemiology, 4 Kozielska Str., 01-163 Warsaw, Poland, Tel.: +48 22 681 8518, Fax: +48 22 810 4391, E-mail: Received: 23 June 2010 Apparently, most national emergency response plans have been focused on accidents at nuclear reactor sites or other nuclear installations. Recently, however, possible threats by disaffected groups have shifted the focus to malevolent use of ionizing radiation aimed at creating disruption and panic in the society. Such malevolent acts have lately been categorized as the CBRN (chemical, biological, radiological, nuclear) terrorism which, according to some experts [6], “is a low-probability, high-consequence threat” that may be “serious and often underestimated, but not apocalyptic” [2]. Indeed, as judged by the outcomes of such radiological emergencies as the Chernobyl disaster in 1986 [8], or the radiation accidents in Goiânia (Brasil) in 1987 [1, 25] and in San Salvador (El Salvador) in 1989 [17], as well as based on the computer simulations thereof, radiological/nuclear terrorism may represent a difficult challenge for the authorities, responders, and the general public, but also the one which, when adequate planning and preparedness had been prearranged, can be effectively handled. According to the current view, the most probable radiological/nuclear terrorist scenarios (“radioterror”) include spreading of radioactive material in the environment (air, water, plants, soil, food products etc.) performed either by a direct dispersal of the material (e.g., from a mobile system such as airplane, truck, train or otherwise) or by detonation at a populated location of 394 M. K. Janiak the so-called “dirty bomb” (composed of a conventional explosive such as trinitrotoluene – TNT, intermingled with one or more radioisotopes); both these methods fall under the category of the radiological dispersal device (RDD) [20–22, 24]. Possible sources of radioactive isotopes include theft from industrial, medical or scientific facilities or an attack on transport of radioactive material. In scenarios based on the dispersal of radioisotopes most likely only a small area (one or few city blocks in an urban milieu) will be affected and most exposures will be low-level (both from external irradiation and/or contamination with radioactive material). Another possibility, called the radiological exposure device (RED) [22] refers to a hidden radioactive source (typically emitting X or gamma rays) that will irradiate people externally. More spectacular, but less plausible scenario involves detonation by terrorists of a stolen or self-made (improvised nuclear device – IND) atomic bomb. Indeed, most of these devices and material for their production are properly stored and protected from theft, but there are “nuclear” countries or regions where the security measures are much more lax. Although, in all probability, an atom bomb which the terrorists can take hold of will be a low-yield device, when detonated, it will certainly wreak havoc on the people and area at a considerable distance from the epicenter. In addition to ionizing radiation (both initial and residual which, in fact, will contribute to no more than 15% of all the issuing injuries) other effects such as the air blast (“shock wave”) and thermal radiation will predominate and lead to about 85% of injuries in the victims. Consequently, most casualties of such a detonation will present with combined injuries including wounds, fractures, and burns compromised by absorption of various doses of ionizing radiation [7, 15, 20, 24]. Any attack involving the release of radiation will create significant uncertainty, fear, and terror among the affected (or purportedly affected) population. Indeed, such outcomes may predominate and overwhelm the available medical and social resources in the aftermath of an attack with a dirty bomb and a low-yield nuclear device [21, 24]. Terrorists, by definition, strive to provoke severe psychosocial and economic disruptions in the society, and radiation – an invisible, odorless, and poorly understood agent – is viewed as the extremely insidious and appalling threat. Hence, there are important differences between setting off a conventional explosive and use of a radiological or nuclear device by a terrorist (Table 1) which will determine the necessary medical and otherwise measures to treat the victims and cope with the consequences. Phases of the management of an attack Prior to or concomitantly with the introduction of a medical response the general objectives of the conse- Table 1. Differences between a conventional and a radiological/nuclear terrorist attack Conventional explosion Radiological/nuclear attack Victims only at the site of attack (the attack is bounded in time and space) Possible victims also further away from the site of attack (the attack is unbounded) The debris and the environment is not hazardous and the cleanup is localized Not only the immediate site of the attack but also more remote areas may be radiologically contaminated and hazardous and cleanup will require appropriate monitoring equipment and trained personnel Will require routine forensic investigation Forensic investigation complicated by the need to wear protective equipment and by the contamination of evidence No medical outcomes in witnesses without direct injuries Postponed medical complications possible in victims with no visible injuries No specific safety measures and treatment procedures necessary during first response and medical management along the evacuation chain Specific safety measures and treatment procedures required during first response and medical management along the evacuation chain and final care provided by well trained and experienced personnel The trauma and injuries experienced by the victims are (...truncated)