(3) Patient Management 2: Decontamination: (a) Radiation decontamination should not interfere with medical care of patients with life-threatening injuries or illness. (b) If possible, staff should screen and survey for levels of contamination before moving a patient into the facility; this will minimize staff and equipment exposure. As a control, staff should attempt a background reading of the facility before surveying the patient. (c) Only properly trained personnel should use radiation survey equipment. (Web Site links to many basic radiation training courses can be found at www.umt.edu/research/eh/radiationsafety.htm). (c-1) Most things needed for decontamination are already available in a hospital: the only additional recommended equipment is radiation survey equipment to measure beta and gamma rays. Radiation survey equipment to detect contamination includes a Geiger counter to detect beta and gamma radiation. Although not specifically designed to quantify alpha radiation, pancake probes that are available for Geiger counters will detect the presence of most alpha radiation sources, as well as beta and gamma radiation. (See Appendix C) Many hospitals have at least one survey instrument in-house. Make certain that trained personnel are always on duty and know how to use survey instruments properly. (d) Hospitals should ensure that personnel have proper personal protection equipment. Universal precautions as practiced with any other mass casualty incidents (trauma, chemical, biological, etc.) is generally sufficient for protection from radioactive contamination. (e) Under Standard Precautions, surgical masks are used to reduce the possibility of blood splashes to the mouth and nose and hand-oral contamination (reference: Gusev, et. al, p. 432). Surgical masks do not protect against inhaling all respiratory hazards. A higher level of protection is provided by fitted particulate respirators such as N95 or higher. These respirators should be available in hospitals because they already are recommended for health care worker protection against SARS, tuberculosis, and certain other infectious diseases. However, these respirators must be used in an OSHA-compliant respiratory protection program that includes medical clearance, training, and fit testing. Experience in human decontamination indicates that careful procedures for removing clothing and decontaminating patients prevents aerosolization of radioactive particles, and dosimetry of health care workers using surgical masks has not found evidence of contamination (Reference: personal communication, Dr. Robert Ricks, Department of Energy REAC/TS, Oak Ridge TN, July 17, 2003). This suggests that if N95 respirators are not available, surgical masks should provide adequate protection if other precautions are observed. (f) Responders should attempt as much decontamination as possible either at the designated assessment center or outside the hospital. Minimize the amount of contamination that actually enters the emergency department or the hospital. Decontamination areas should be separated from the hospital. (g) Removing the clothing from the patient should remove 70 to 90% of the contamination (6). Staff or responders should bag and tag clothing, dressings, etc., for future evaluation and potential use as criminal evidence and small personal belongings (jewelry, wallet, etc.) should be surveyed for contamination. If the personal belongings are not contaminated they can be returned to the patient. Otherwise, steps must be taken to decontaminate the items before giving them back to the patient. If the patient is medically able to remove his/her own clothing and wash, then the patient should do so; however, providers should maintain communication during the process. (h) Staff should address privacy concerns of patients who are undressing. Disposable dressing gowns should be provided for patients concerned about modesty and to ensure that the environment is appropriate to remove clothing (e.g., not too cold). (i) The patient should be washed with water and soap, taking care not to abrade or irritate the skin. Water is the most important ally in this setting. Ambulatory patients can be washed easily; however, non-ambulatory patients must be on gurneys that can be washed. (j) Staff trained in using survey instrumentation should resurvey the patient after washing and rewash until no further reduction in contamination is achieved or a set threshold is attained, generally considered less than two or three times background. Providers should isolate and cover any area of the skin that is still positive after washing with a plastic bag or wrap. (k) Care should be taken with the washing procedure, ensuring that radioactive materials are not incorporated into a wound. (l) If a patient has both wounds and very high, localized levels of internal contamination, this may indicate that the patient has a radioactive fragment or fragments internally. The physician, in consultation with the hospital radiation safety officer if possible, should consider surgically removing the fragment(s) using forceps to avoid potential local radiation injury to the hands of the provider. (m) To ensure best use of the health care providers time and resources, hospitals should consider having other personnel perform the decontamination process. But the other personnel should be appropriately trained to prevent injury to the patient and to minimize the possibility of contaminating themselves during decontamination of the patient. (n) Hospitals should decontaminate the facility and staff who had contact with contaminated patients to prevent the spread of contamination. Staff should consult their radiation safety officer for step-by-step procedures. (Also refer to Gusev, et al. Medical Mgt. Of Rad Accidents). (o) If the patient does not show any signs of contamination or meet hospital admittance criteria, providers should recommend that the patient take a thorough shower as soon as possible