Transcript Radiation Injury Treatment Network -Fortuna Favet Paratusest. 2006 Cullen Case Jr., CEM, CHEP RITN Program Manager National Marrow Donor Program 612.884.8402 wk | 612.214.3549 mbl [email protected] www.RITN.net.

Radiation Injury
Treatment Network
-Fortuna Favet Paratusest. 2006
Cullen Case Jr., CEM, CHEP
RITN Program Manager
National Marrow Donor Program
612.884.8402 wk | 612.214.3549 mbl
[email protected]
www.RITN.net
Reminder of why we are here
“I continue to be much more concerned when it
comes to our security with the prospect of a
nuclear weapon going off in Manhattan,”
-President Obama on March 25, 2014
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Objectives
• Describe the organization and history of RITN
• Explain RITN program and participant
responsibilities
• Describe the patient profile for RITN Centers
• Describe the expected response process at the
disaster site
• Describe the anticipated timeline of causality
distribution to RITN
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Bit of history…. and a little bit of science….
DreamWorks Animation SKG, Inc.
From of http://www.grogtard.com/five-more-characters-who-just-might-be-time-lords-too/ accessed on 4/2/14
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First the science….
From: http://www.epa.gov/radiation/understand/ Accessed 4/3/14
From: Medical Management of Radiological Casualties (Fourth Edition –
July 2013) Military Medical Operations, Armed Forces Radiobiology
Research Institute, Bethesda, Maryland 20889-5603
http://www.usuhs.edu/afrri/outreach/4thEdition.html accessed 4/3/14
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History of Be The Match registry
1979
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to
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April 10, 2014
to
Today
Path to RITN
National Organ Transplant Act of 1984 creates National Bone Marrow Registry
NMDP established 1987
Funding from the Office of Naval Research to improve
outcomes from transplant includes contingency planning as
a desired outcome
Reminder of the importance of
preparedness and possible threat
Leading transplant organization
champions need for preparedness of
Hematology/Oncology physicians
13 Hospitals form as RITN in 2006
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Now: 69 Hospitals, Cord Blood Banks & Blood Donor Centers
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RITN Center Locations
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www.phe.gov
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RITN is Incorporated into Federal Plans
• DHHS-ASPR: http://www.PHE.gov/about/oem/cbrne
• State and Local Planners Playbook for Medical
Response to a Nuclear Detonation
• RDD Playbook
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RITN Center Staff are Cancer Specialists
• RITN Centers are not 1st Responders or trauma
care specialists
• In the aftermath of a marrow toxic incident,
RITN centers may:
– Accept patient transfers to their institutions
– Provide intensive supportive care to victims
– Provide treatment expertise to practitioners caring
for victims at other locations
– Travel to other centers to provide medical expertise
– Provide data on victims treated at their centers
– Facilitate marrow transplant for those who require it
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Network to treat casualties with radiological injuries
• Military grade nuclear weapon
• Improvised Nuclear Device (IND)
• Radiological exposure device (RED)
• Radiological Dispersal Device (RDD)
• Industrial/nuclear power plant accident
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Hollywood or Hype?
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Wikipedia, June 2011
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Damage will not be as Catastrophic as a
Military Nuclear Device
From: Wikipedia
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Expected damage from 10 kT Device
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Effects of a 10 kT in Minneapolis (surface det.)
Fireball
3rd Degree Burns
Simulation created using NukeMap: nuclearsecrecy.com/nukemap/
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Fallout from 10 kT in MPLS
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Estimated Total Casualties
300,000
600,000
Waselenko et al. Annals Int Med 2004
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Are we ready?
• US recent experience with
Mass Casualties is limited
to hundreds at most
–
–
–
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Airplane crashes
Train wrecks
Oklahoma City 1995
Loma Prieta earthquake
1989
– Aurora CO 2012
– 9/11/2001
From: http://1918.pandemicflu.gov , accessed 31Oct2011
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Radiation Casualty Estimates for an Improvised Nuclear Device
Radiation Dose (Gy)
Care Requirement
High
Casualty
Estimate
(95 %tile)
Mild (0.75-1.5)
Outpatient monitoring
91,000
Moderate (1.5-5.3)
Supportive Care and possible inpatient
admission
51,000
Severe (5.3-8.3)
Intensive Supportive Care (most
possibly including HCT)
12,000
Expectant (>8.3)
Comfort Care
47,000
Combined Injury and Radiation
(>1.5)
Stabilization and monitoring, pending
resource availability
44,000
Estimate of 63,000
casualties for RITN
***Radiation doses are estimates based on clinical presentation and laboratory values.***
Table adapted from: Knebel AR, Coleman CN, Cliffer KD; et al. Allocation of scarce resources after a nuclear detonation: setting the context.
Disaster Med Public Health Prep. 2011;5 (Suppl 1):S20-S31
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2011 Capacity Survey Results
Radiation-only
casualties requiring
monitoring,
supportive care and
possible transplant
(~63,000)
2011capacity
of RITN
(13,000)
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Fallout May Cause the Most Radiation Injuries
Dangerous Fallout Zone
•The dose in the Dangerous Fallout zone could cause marrow injury
•Sheltering-in-place is key to reducing dose, as the hazard dissipates
relatively quickly
Illustration from: Knebel AR, Coleman CN, Cliffer KD; et al. Allocation of scarce resources after
a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5 (Suppl 1):S20-S31
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Critical Concern from a Smaller Device or RDD?
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Critical Concern: Public Panic
• 2014 – Waste facility contamination of workers
• 2013 – Mexico stolen radioactive Cobalt
• 2011 - Fukushima
– Citizens stockpiled Potassium Iodide
– Called public health officials as far away as Vermont and Massachusetts
• 1987 - Goiania, Brazil
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–
–
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Scrap metal recyclers steal abandoned cancer radiation device
Open device and release Cesium
4 die & ~250 people contaminated
117,000-180,000 panic and request screening
•
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http://en.wikipedia.org/wiki/Goi%C3%A2nia_accident
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Conceptual Flow of Victims to a RITN Center
*** This model does not account for victims with trauma or no injuries.
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Survey & Decon
NDMS
Contracted
Transportation
Survey & Decon
Radiological Survey
&
Spot Decontamination
First
Responder
Medical Aid
Stations
Radiological Survey
&
Gross Decontamination
Ad hoc
First Aid
Sites
State/Local
Public Health
Community
Reception
Centers
FCC/NDMS
Patient
Reception
Area
NDMS
Contracted
Hospitals
Specialized
Medical Care
Facilities (burn,
RITN, etc…)
Timeline of RITN Response
Alert and Notification
Early Symptoms – e.g., nausea and vomiting
Day 1
RITN Centers - review capabilities & prepare to receive casualties
Day 3
Earliest casualties arrive at RITN Centers near incident
Daily/Periodic CBCs
Day 7
Expected initial surge of casualties for RITN Centers
Day 30+
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Discharge and return to home region
Only small portion of all casualties would be
appropriate for RITN care
85% of casualties
will have trauma or
combined injuries
and receive
treatment elsewhere
15% will have
“radiation only”
injuries and be sent
to RITN centers for
definitive medical
care
Illustration of the small percentage of casualties with “radiation only” marrow-toxic injuries that likely would be moved
through NDMS to RITN centers.
Calculated from data provided in Knebel AR, Coleman CN, Cliffer KD; et al. Allocation of scarce resources after a
nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5 (Suppl 1):S20-S31
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Of the 15% there is further breakdown of what
care would be provided
Level of severity is due
to the level of exposure
From: Medical Management of Radiological Casualties (Fourth
Edition – July 2013) Military Medical Operations, Armed Forces
Radiobiology Research Institute, Bethesda, Maryland 20889-5603
http://www.usuhs.edu/afrri/outreach/4thEdition.html accessed 4/3/14
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Casualty Care
• Daily CBCs to determine clinical need for treatment
• Follow standard approaches for patients with bone
marrow toxicity from chemotherapy
– Blood products - irradiated and leukoreduced
– Antibiotics, IV fluid, other support and G-CSF (cytokines)
– Hospitalization when indicated
• Critical stopgap is access to pharmaceuticals (JIT)
• Biodosimetry using online algorithms (REMM)
– Blood counts (before and after arrival at hospitals)
– Geographic dosimetry
– Opportunity to apply new biodosimetry approaches
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RITN Initiatives
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Preparedness Efforts
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•
•
•
•
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Standard Operating Procedures at each center
Site readiness assessments
Annual tabletop exercise
Annual training/education requirement
Emergency communications equipment at each
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Totals since 2006:
• 265 REAC/TS
• 2,981 GR
• 3,680 BRT
• 2,826 Overview
• 541 Conference
2013 Highlights
• Site Assessments
• Tabletop exercises attended
• Web based training released (https:\\nmdp.sumtotalsystems.com)
1.
2.
3.
4.
5.
6.
•
•
•
•
•
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Intro to RITN
RITN Concept of Operations
GETS 101
Satellite telephone 101
Basic Radiation Training
Non-medical Radiation Awareness Training
Mayo Full-scale Exercise
2 x Web based tabletop exercises
Mobile REAC/TS held at Duke University
2 x resident REAC/TS courses
New Partnership with CMCRs
4th biennial conference w/ 175 attendees
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2014 Projects
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•
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Addition of 5+ transplant centers
Release RITN Referral Guidelines mid 2014
Collect triage guidelines for release late 2014
Regional collaboration meeting for NY-NYC
G-CSF distribution project with ASTHO and CDC
2 x Mobile REAC/TS training sessions (Boston & Chicago)
Review of updated REMM ARS guidelines
Medical staff risk communications training development
Exercises: Full-Scale Exercise in Boston, 3 x Web based TTX,
Communications drill with DHHS-ASPR
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RITN Preparedness Efforts
• Readiness exercises/events
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–
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Annual RITN directed tabletop exercise
Top Officials IV (TOPOFF) (2007) - DHS
Pinnacle 07 (2007) – DHHS-ASPR
ConvEX 2008 – IAEA
Democratic National Convention (2008)
Republican National Convention (2008)
National Level Exercise 2010 (NLE 2010)
• Emergency communications equipment at each center
– Government Emergency Telecommunication Service (GETS)
calling cards
– Satellite telephones
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Resources
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Free Resources
http://journals.cambridge.org/action/displayIssue?jid=DMP&volumeId=5
&seriesId=0&issueId=S1
http://www.remm.nlm.gov/PlanningGuidanceNuclearDetonation.pdf
http://www.phe.gov/Preparedness/planning/playbooks/stateandlocal/nuc
lear/Documents/statelocalplaybook-v1.pdf
http://www.usuhs.edu/afrri/outreach/4thEdition.html#acut
http://www.ritn.net/About/
http://www.remm.nlm.gov
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Additional References:
www.RITN.net
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Conclusion
http://www.singers.com/choral/mormonchoir.html accesses 6/3/2011
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Conclusions: Blinding Flashes of the Obvious
• Magnitude would overwhelm the nation
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–
–
–
The response will be chaotic; no matter what
Still need to prepare, educate and exercise
Work smart so efforts are a “twofers”
Dangerous fallout injuries could be majority of IND casualties
• History shows that a bomb isn’t necessary; as panic will
ensue following any radiological incident
• There is apathy at many levels of the planning process
– This is due to a lack of understanding, competing priorities and
lack of funding
• Cancer Treatment Centers are often overlooked
– Essential to response to a mass casualty radiological incident
• Logistical Nightmare: just in time inventory of Rx
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5 key things to remember about RITN
1. Not 1st Responders or trauma care
2. Expect to see surge 7-10 days after incident
3. If incident is local: the local RITN centers focus is
on incident response not RITN
4. Casualties should not be significantly
contaminated when they arrive at a RITN center
5. Affiliated with National Disaster Medical System:
a) Casualty distribution is through NDMS
b) Reimbursement is through NDMS
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http://Apctechnology.com.au accesses 6/8/2011
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