In a disaster, Homeland Security has plans for you

You’re enjoying a Sunday afternoon with the family and your spouse pulls you aside and in hushed tones tells you there’s been a terrorist attack. Moments later, the phone rings and it’s your hospital: Can you come down and help manage the flood of patients coming in? Would you be prepared?

“As radiologists, we need to realize that we play a critical role in the emergency response chain,” said Dr. Charles Kitley, from the Madigan Army Medical Center in Tacoma, WA. “Across the country emergency physicians prepare for disasters-some even have fellowship experience in medical response-however, radiologists play an ever increasing role in the diagnosis and workup of every patient who comes into the emergency department.”

In an effort to learn from past events like the atomic bombs dropped on Hiroshima and Nagasaki and the World Trade Center attacks, the Department of Homeland Security has outlined national disaster preparedness planning scenarios for different possible events. Among them are the bombing of a sports stadium using an improvised explosive device, detonation of a 10 kiloton nuclear bomb, an anthrax attack, a flu pandemic, a plague attack, a chemical attack, a chlorine tank explosion, and a radiation attack.

Radiologists stand at the crossroads of screening, decontamination, diagnosis, and treatment planning, said the authors of a study in Emergency Radiology that describes various disaster scenarios and the part radiologists will be expected to play in triage, diagnosis, and care (Emerg Radiol 2010;17:275-284).

PLAYING OUT SCENARIOS

In the stadium scenario, injuries will result from structural collapse, secondary and tertiary blast effects, exposure to products of combustion, thermal effects, and possible crowd surge where the bombing took place.

Primary blast injuries predominantly affect air-containing organs and result in pulmonary hemorrhage and edema, gastrointestinal hemorrhage, and perforation of eardrums.

The modalities radiologists would use in this situation include conventional x-ray, focused abdominal sonography, CT scanning, and angiography. Common radiologic findings within the chest may include pulmonary contusions, which appear as airspace opacities on radiographs and consolidations on CT scans, according to the study.

The x-rays can be used to triage patients with shrapnel injuries who need further CT scanning, Kitley said. The initial workup of the blast victim should include chest, cervical spine, and pelvic radiographs with additional images performed at the sites of penetrating injuries, he said.

During mass casualty exercises with military hospital staff, there was a paucity of dialogue with radiology staff, said Retired Col. Les Folio, an associate professor of radiology, radiological sciences, and military and emergency medicine at the Uniformed Services University of the Health Sciences in Bethesda, MD. As an exercise evaluator, he prompted those discussions because nuclear medicine staff and physicists know radiation better than most and can help, if they're prepared.

It's important to know this information in advance because radiologists don’t want to get stuck, he said. Disasters can happen anywhere, he said, and to not be prepared is naive.

PREPAREDNESS TRAINING

Those interested in becoming as prepared as possible can attend the Medical Effects of Ionizing Radiation course offered at the Uniformed Services University. It gives medical and operational personnel up-to-date information concerning the biomedical consequences of radiation exposure, how the effects can be reduced, and how to medically manage casualties. The training includes response to nuclear incidents that can occur on or off the battlefield and that go beyond nuclear weapons events.

Kitley said radiologists would be wise to develop procedures and protocols in hospital-wide settings to allow for interdepartmental discussion to communicate and define common goals and objectives.

“I know at our institution, a military facility, we have a contact roster in order to contact all of the physicians/residents in case of an emergency, either locally or nationally,” he said. “Each scenario would be different; however, this enables us to rapidly contact our physicians to inform them whether they need to report to the hospital in case of a disaster.”

Departmental protocols should be tailored to regulate patient flow in and out of the radiography, ultrasound, CT, or MR setting, he said. Protocols should also define what to do in the case of equipment or personnel contamination by biological, chemical, or nuclear material.

“Emergency providers rely on us to not only evaluate traumatic injuries; we must also be able to assess for other processes such as effects from chemical or nuclear attack,” he said. “As radiologists, we are trained to think outside the box and come up with a reasonable differential based on the imaging findings.”

Radiologists also have an understanding of radiation physics and the effects of radiation on biological systems, something rare among other providers in the hospital, he said. That makes the radiologists’ role extremely vital.