Radiation Injury Treatment Network Cullen Case Jr., CEM, CHEP RITN Program Manager National Marrow Donor Program 612.884.8402 wk | 612.214.3549 mbl [email protected].

Radiation Injury Treatment Network

Cullen Case Jr., CEM, CHEPRITN Program ManagerNational Marrow Donor Program612.884.8402 wk | 612.214.3549 [email protected] Favet Paratus-

est. 2006

mailto:[email protected]

http://www.ritn.net/

Avera McKenna Workshop April 10, 20142

“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

Reminder of why we are here


• 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

3

Objectives


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

http://www.grogtard.com/five-more-characters-who-just-might-be-time-lords-too/


First the science….

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

From: http://www.epa.gov/radiation/understand/ Accessed 4/3/14

http://www.usuhs.edu/afrri/outreach/4thEdition.html

http://www.epa.gov/radiation/understand/


1979 to 1987 to Today

History of Be The Match registry

http://youtu.be/uXwUzEkrWf0

7

Path to RITN

National Organ Transplant Act of 1984 creates National Bone Marrow Registry

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

NMDP established 1987

8

Now: 69 Hospitals, Cord Blood Banks & Blood Donor Centers

RITN Center Locations

9

1010

www.phe.gov

11

• DHHS-ASPR: http://www.PHE.gov/about/oem/cbrne• State and Local Planners Playbook for Medical

Response to a Nuclear Detonation• RDD Playbook

RITN is Incorporated into Federal Plans

http://www.phe.gov/about/oem/cbrne


• 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

RITN Center Staff are Cancer Specialists


Network to treat casualties with radiological injuries

13

• Military grade nuclear weapon• Improvised Nuclear Device (IND)• Radiological exposure device (RED) • Radiological Dispersal Device (RDD)• Industrial/nuclear power plant accident


Hollywood or Hype?


Wikipedia, June 2011


From: Wikipedia

Damage will not be as Catastrophic as a Military Nuclear Device


Expected damage from 10 kT Device


Effects of a 10 kT in Minneapolis (surface det.)

Simulation created using NukeMap: nuclearsecrecy.com/nukemap/

Fireball

3rd Degree Burns


Fallout from 10 kT in MPLS


Waselenko et al. Annals Int Med 2004

300,000

600,000

Estimated Total Casualties


• US recent experience with Mass Casualties is limited to hundreds at most– Airplane crashes– Train wrecks– Oklahoma City 1995– Loma Prieta earthquake

1989– Aurora CO 2012– 9/11/2001

21

Are we ready?

From: http://1918.pandemicflu.gov , accessed 31Oct2011

http://1918.pandemicflu.gov/


Radiation Casualty Estimates for an Improvised Nuclear Device

22

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

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

***Radiation doses are estimates based on clinical presentation and laboratory values.***

Estimate of 63,000 casualties for RITN

23

2011 Capacity Survey Results

Radiation-only casualties requiring

monitoring, supportive care and possible transplant

(~63,000)

2011capacity of RITN (13,000)


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

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


Critical Concern from a Smaller Device or RDD?

25


• 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– 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

• http://en.wikipedia.org/wiki/Goi%C3%A2nia_accident

26

Critical Concern: Public Panic


Conceptual Flow of Victims to a RITN Center

27

Ad hoc First Aid

SitesFirst

Responder Medical Aid

Stations

State/Local Public HealthCommunity Reception

Centers

NDMS Contracted

Transportation

FCC/NDMS Patient

Reception Area Specialized

Medical Care Facilities (burn,

RITN, etc…)

NDMS Contracted Hospitals

Rad

iolo

gic

al S

urv

ey&

Sp

ot

Dec

on

tam

inat

ion

Rad

iolo

gic

al S

urv

ey&

Gro

ss D

eco

nta

min

atio

n

Su

rvey

& D

eco

n

Su

rvey

& D

eco

n

*** This model does not account for victims with trauma or no injuries.


Timeline of RITN Response

Day 1

Day 3

Day 30+

Day 7

Alert and NotificationEarly Symptoms – e.g., nausea and vomiting

RITN Centers - review capabilities & prepare to receive casualties

Earliest casualties arrive at RITN Centers near incidentDaily/Periodic CBCs

Discharge and return to home region

Expected initial surge of casualties for RITN Centers

Initiate G-CSF as soon as

possible when indicated

Clinical

management

Patient collection

and transport

to FCCs


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


Of the 15% there is further breakdown of what care would be provided

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

Level of severity is due to the level of exposure

http://www.usuhs.edu/afrri/outreach/4thEdition.html


• 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

31

Casualty Care


RITN Initiatives


Preparedness Efforts

• Standard Operating Procedures at each center• Site readiness assessments• Annual tabletop exercise• Annual training/education requirement• Emergency communications equipment at each

center

10,293 total

Totals since 2006:• 265 REAC/TS• 2,981 GR• 3,680 BRT• 2,826 Overview• 541 Conference


• Site Assessments• Tabletop exercises attended• Web based training released (https:\\nmdp.sumtotalsystems.com)

1. Intro to RITN2. RITN Concept of Operations3. GETS 1014. Satellite telephone 101 5. Basic Radiation Training6. 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

35

2013 Highlights


• 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

36

2014 Projects


RITN Preparedness Efforts

• Readiness exercises/events– 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


Resources

Free Resources

http://journals.cambridge.org/action/displayIssue?jid=DMP&volumeId=5&seriesId=0&issueId=S1

http://www.remm.nlm.gov/PlanningGuidanceNuclearDetonation.pdfhttp://www.phe.gov/Preparedness/planning/playbooks/stateandlocal/

nuclear/Documents/statelocalplaybook-v1.pdf http://www.usuhs.edu/afrri/outreach/4thEdition.html#acuthttp://www.ritn.net/About/


http://www.remm.nlm.gov

http://www.remm.nlm.gov/


www.RITN.net

Additional References:


http://www.singers.com/choral/mormonchoir.html accesses 6/3/2011

Conclusion

http://www.singers.com/choral/mormonchoir.html


• Magnitude would overwhelm the nation– 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

43

Conclusions: Blinding Flashes of the Obvious


1. Not 1st Responders or trauma care2. Expect to see surge 7-10 days after incident3. If incident is local: the local RITN centers focus is

on incident response not RITN4. Casualties should not be significantly

contaminated when they arrive at a RITN center5. Affiliated with National Disaster Medical System:

a) Casualty distribution is through NDMSb) Reimbursement is through NDMS

5 key things to remember about RITN


http://Apctechnology.com.au accesses 6/8/2011

http://apctechnology.com.au/