**4. Unintentional injury: nuclear power**

After WWII, there was a significant interest in accelerating the production of nuclear weapons as well as promoting the use of nuclear energy in lieu of fossil fuels and other sources of non-renewable energy reserves. While we knew individual risk of the indiscriminate use of radiation, despite the application of nuclear weapons, little was known about the impact of risk upon the general population about accidents in the application of nuclear power and the secondary development of nuclear weapons.

and limitations in obtaining documentation, estimates of health damage, cancer, and current conditions can only be estimated. It is known that the East Ural region remains contaminated to this day and there were scores of documented cases of chronic radiation syndrome with an

Essentials in Accident and Emergency Medicine Radiation Injury: Response and Treatment

http://dx.doi.org/10.5772/intechopen.76863

7

In this situation, limited knowledge of reactor safety coupled with poor risk assessment resulted in an accident of significant magnitude, third only to the accidents at Fukashima and

In a similar manner, the British government initiated a nuclear weapons program after WWII using a plutonium-based platform. British physicists were involved in the Manhattan project and two reactors were built near the village of Seascale, UK, a few hundred feet apart from each other. The core of the reactors consisted of a large block of graphite with channels built for transport of uranium cartridges which would be pushed posteriorly into the back channel for cooling in a water filled channel. This was different from previous designs which had a constant supply of water that poured through the channels housed in the graphite. The first design was chosen because of fear of malfunction of the need for the constant water source. Filters were placed in situ in case one of the cartridges broke entering the water. Without water in the channels, cartridges did break and despite filters, radioactivity was documented around the site but not indicated to staff. One of the reactors was prone to heating and this was believed to be related to the graphite. It was known that neutrons created small fractures in the graphite which in turn could be annealed with increasing the heat of the system. This

There was considerable political pressure for quickly producing a weapon and the decision was made to generate Tritium which required augmented heating in the reactor. To produce Tritium, the cooling fins on the plutonium cannisters decreased in size to increase heat exchange. Windscale was modified by adding enriched uranium and lithium-magnesium to

On October 7, 1957, one of the reactors was heating more than norm and an additional Wigner annealing release was performed. This had the anticipated result except for one channel. A second Wigner release was performed which appeared to stabilize the situation. On October 10, 1957, a radiation detector in the chimney indicated a release of radiation. It was assumed that a rod had fractured. What was not recognized was the presence of a fire in the same channel likely started on October 7. To provide cooling, fans were augmented which unintentionally made the situation worse. Carbon dioxide and water did not extinguish the fire. It was estimated that 11 tons of uranium was ablaze. Leaders ordered evacuation and shut off all ventilation entering the reactor. This was successful and water flowing through the reactor

Radioactive material including Iodine 131 (740 Terabecquerel (TBq)), Cesium 137 (22 TBq), and Xenon 133 (12,000 TBq) was released. The presence of scrubbers and filters in the chimney proved to be important and likely limited damage. Both reactors were deemed unsafe for

elevated cancer rate including a high rate of death due to malignancy.

was known as the Wigner effect, named after physicist Eugene Wigner.

the fuel rods making the situation more vulnerable to combustion.

Chernobyl [5, 6, 8].

was cold within 24 hours.

continued use and fuel was removed in 2012 [5, 6].

**4.3. Windscale**

The International Atomic Energy Agency (IAEA) maintains as website reporting nuclear accidents. As of 2014, there have been more than 100 serious accidents associated with the use of nuclear power. It is worrisome that more than 50% of the accidents have occurred since the accident at Chernobyl (1986) and that more than 60% of the accidents reported have occurred in the United States. These accidents have occurred over time due to many circumstances including poor design of the reactor and human judgment error in the attempt to prevent and mitigate the problem. Many of the most serious events will be described as follows [5–7].

#### **4.1. Louis Slotin**

In 1946, Canadian investigators evaluating nuclear weapons brought two hemispheres of neutron-reflective beryllium around a plutonium core. The hemispheres were only separated by a screwdriver which was against policy. The screwdriver slipped which set off a chain reaction filling the room with radiation validated by the presence of blue light. Louis Slotin (physicist) rapidly separated the hemispheres preventing further exposure to co-workers; however, he died of radiation exposure 9 days later [5].

#### **4.2. Kyshtym**

This event was a radioactive decontamination accident in 1957. The accident occurred at Mayak which was a plutonium production site in the eastern Ural Mountains in the Soviet Union. The actual site was not marked on topographical maps, therefore the accident is named after a nearby town.

Because the Soviet Union was behind the US in the development of uranium and plutonium nuclear weapons, the facility was constructed over a short period of time between 1945 and 1948. Initially, high levels of radioactive material were dumped into a nearby river which flowed into the Arctic Sea. The reactors (six) were located on a lake which was used for the cooling cycle. The primary lake was Lake Kyzyltash which became quickly contaminated and a secondary lake, Lake Karachay, also quickly became contaminated. A storage facility for liquid waste was built in 1953. It was a simple design with steel tanks mounted in concrete base 27 feet underground. Because the nuclear waste generated heat, a cooling system was built around each tank. Facilities for monitoring the operation were primitive.

On the day of the event, the cooling system failed in one of the tanks containing 80 tons of liquid radioactive waste. The liquid evaporated, and an explosion ensued estimated at 1 kiloton. A 160-ton concrete lid was thrown into the air and an estimated 20 Millicuries (mCi) of radioactivity was released. Although most of the contamination was near the explosion, there was a plume of radionucleotides that spread over hundreds of miles through the air. The longterm contamination area is estimated to be more than 7000 square miles including cesium 137 and strontium 90. It is estimated that 22 villages were affected, and more than 10,000 people were evacuated from the site over a 2-year period. Due to secrecy surrounding the incident and limitations in obtaining documentation, estimates of health damage, cancer, and current conditions can only be estimated. It is known that the East Ural region remains contaminated to this day and there were scores of documented cases of chronic radiation syndrome with an elevated cancer rate including a high rate of death due to malignancy.

In this situation, limited knowledge of reactor safety coupled with poor risk assessment resulted in an accident of significant magnitude, third only to the accidents at Fukashima and Chernobyl [5, 6, 8].

### **4.3. Windscale**

of non-renewable energy reserves. While we knew individual risk of the indiscriminate use of radiation, despite the application of nuclear weapons, little was known about the impact of risk upon the general population about accidents in the application of nuclear

The International Atomic Energy Agency (IAEA) maintains as website reporting nuclear accidents. As of 2014, there have been more than 100 serious accidents associated with the use of nuclear power. It is worrisome that more than 50% of the accidents have occurred since the accident at Chernobyl (1986) and that more than 60% of the accidents reported have occurred in the United States. These accidents have occurred over time due to many circumstances including poor design of the reactor and human judgment error in the attempt to prevent and mitigate the problem. Many of the most serious events will be described as follows [5–7].

In 1946, Canadian investigators evaluating nuclear weapons brought two hemispheres of neutron-reflective beryllium around a plutonium core. The hemispheres were only separated by a screwdriver which was against policy. The screwdriver slipped which set off a chain reaction filling the room with radiation validated by the presence of blue light. Louis Slotin (physicist) rapidly separated the hemispheres preventing further exposure to co-workers;

This event was a radioactive decontamination accident in 1957. The accident occurred at Mayak which was a plutonium production site in the eastern Ural Mountains in the Soviet Union. The actual site was not marked on topographical maps, therefore the accident is named

Because the Soviet Union was behind the US in the development of uranium and plutonium nuclear weapons, the facility was constructed over a short period of time between 1945 and 1948. Initially, high levels of radioactive material were dumped into a nearby river which flowed into the Arctic Sea. The reactors (six) were located on a lake which was used for the cooling cycle. The primary lake was Lake Kyzyltash which became quickly contaminated and a secondary lake, Lake Karachay, also quickly became contaminated. A storage facility for liquid waste was built in 1953. It was a simple design with steel tanks mounted in concrete base 27 feet underground. Because the nuclear waste generated heat, a cooling system was

On the day of the event, the cooling system failed in one of the tanks containing 80 tons of liquid radioactive waste. The liquid evaporated, and an explosion ensued estimated at 1 kiloton. A 160-ton concrete lid was thrown into the air and an estimated 20 Millicuries (mCi) of radioactivity was released. Although most of the contamination was near the explosion, there was a plume of radionucleotides that spread over hundreds of miles through the air. The longterm contamination area is estimated to be more than 7000 square miles including cesium 137 and strontium 90. It is estimated that 22 villages were affected, and more than 10,000 people were evacuated from the site over a 2-year period. Due to secrecy surrounding the incident

built around each tank. Facilities for monitoring the operation were primitive.

power and the secondary development of nuclear weapons.

6 Essentials of Accident and Emergency Medicine

however, he died of radiation exposure 9 days later [5].

**4.1. Louis Slotin**

**4.2. Kyshtym**

after a nearby town.

In a similar manner, the British government initiated a nuclear weapons program after WWII using a plutonium-based platform. British physicists were involved in the Manhattan project and two reactors were built near the village of Seascale, UK, a few hundred feet apart from each other. The core of the reactors consisted of a large block of graphite with channels built for transport of uranium cartridges which would be pushed posteriorly into the back channel for cooling in a water filled channel. This was different from previous designs which had a constant supply of water that poured through the channels housed in the graphite. The first design was chosen because of fear of malfunction of the need for the constant water source. Filters were placed in situ in case one of the cartridges broke entering the water. Without water in the channels, cartridges did break and despite filters, radioactivity was documented around the site but not indicated to staff. One of the reactors was prone to heating and this was believed to be related to the graphite. It was known that neutrons created small fractures in the graphite which in turn could be annealed with increasing the heat of the system. This was known as the Wigner effect, named after physicist Eugene Wigner.

There was considerable political pressure for quickly producing a weapon and the decision was made to generate Tritium which required augmented heating in the reactor. To produce Tritium, the cooling fins on the plutonium cannisters decreased in size to increase heat exchange. Windscale was modified by adding enriched uranium and lithium-magnesium to the fuel rods making the situation more vulnerable to combustion.

On October 7, 1957, one of the reactors was heating more than norm and an additional Wigner annealing release was performed. This had the anticipated result except for one channel. A second Wigner release was performed which appeared to stabilize the situation. On October 10, 1957, a radiation detector in the chimney indicated a release of radiation. It was assumed that a rod had fractured. What was not recognized was the presence of a fire in the same channel likely started on October 7. To provide cooling, fans were augmented which unintentionally made the situation worse. Carbon dioxide and water did not extinguish the fire. It was estimated that 11 tons of uranium was ablaze. Leaders ordered evacuation and shut off all ventilation entering the reactor. This was successful and water flowing through the reactor was cold within 24 hours.

Radioactive material including Iodine 131 (740 Terabecquerel (TBq)), Cesium 137 (22 TBq), and Xenon 133 (12,000 TBq) was released. The presence of scrubbers and filters in the chimney proved to be important and likely limited damage. Both reactors were deemed unsafe for continued use and fuel was removed in 2012 [5, 6].

#### **4.4. Stationary low-power reactor number 1 (SL-1)**

SL-1 was a US Army nuclear power reactor located at the national reactor testing station 40 miles west of Idaho Falls, Idaho. The reactor became operational in 1958. The reactor used enriched uranium fuel and was cooled by water flowing through plates of uranium/aluminum alloy. The design relied on a primary central fuel rod. The reactor was closed for maintenance on January 3, 1961 and was being prepared to restart after the 11-day shutdown. Procedures that required the central rod be withdrawn to connect to the central drive mechanism. The rod was withdrawn too far, and the reactor instantly became critical. Within 4 milliseconds, the heat generated by the power excursion caused water to vaporize and explode. Radioactive water became a pressure wave striking the ceiling and a loose metal pin impaled one of the workers to the ceiling structure. It was determined on review that the 26,000-pound internal vessel had moved more than 9 feet in the superior direction and the control rod mechanisms struck the ceiling. There were three workers on site who each died quickly of their injuries. Their radiation exposure would also have been lethal, if they survived physical trauma. Review of the incident suggested that the central rod may have become fixed in position and one of the workers was able to free it; however, in the process the rod moved too far which generated the reaction.

and radiation levels were 300 times expected. The containment building was significantly damaged; however, the radioactive material remained in situ as it did not extend beyond the reactor

Essentials in Accident and Emergency Medicine Radiation Injury: Response and Treatment

http://dx.doi.org/10.5772/intechopen.76863

9

The incident became an example of managing authority and responsibility in the nuclear industry. Lines of authority between private plant ownership, state authorities, and the NRC were not clear and accordingly in the early phase of the accident, it was difficult to obtain accurate information for risk assessment. This resulted in delayed evacuation. Clean up was not completed for more than a decade and long-term risks remain not well defined. Most of radioactive gas release was xenon, which was not considered significant; however, radioactive iodine was also released and the impact of increase in thyroid cancers remains uncertain [5, 6].

The Chernobyl accident is one of the two most significant nuclear events in the history of unintentional radiation injury. The incident occurred on April 26, 1986. The irony of the event is that it occurred during a safety procedure evaluation and safety systems were intentionally disabled as part of the intended procedure. The reactor was brought to minimal activity with the expectation that cooling systems would manage the heat generated by thermal decay. The systems onsite unfortunately required more than 1 minute to activate and running the reactor at minimal power (below safety standard) resulted in the crisis. A series of events triggered by flaws in reactor design and poor decisions made by onsite personnel created situation where reactor cooling was inefficient and two steam explosions generated from thermal decay exposed the graphite core to air, which fueled the massive explosion. Exposure to oxygen fueled the explosion. The fires were extraordinary and sent radioactive elements and gas into the air for a week. Plumes of radioactive gas extended well into Western Europe for an extended period of time. Casualties were significant including first responders attempting to put out the fires as those involved were exposed to lethal levels of radiation. Scores of people were affected by radiation syndrome and estimates include thousands who will develop secondary cancers due to exposure. Cleanup continued for decades. It is estimated that more than 350,000 people relocated as part of a series of evacuations. Unfortunately, many evacuated during the initial phase of the accident were exposed to medically significant radiation as the exit road was directly under the parallax of the radioactive plume from the reactor fires. Reactor fires were eventually attenuated by helicopter droppings of cement, clay, sand, and boron to absorb neutron activity. The government decided to place a cover over the remains of the reactor and today this is referred to as a sarcophagus. Full understanding of risk and damage remains elusive due to limited access to information and lack of full disclosure for

The nuclear power plant at Fukashima sustained damage from a massive Tsunami 50 minutes after the Tohoku earthquake in 2014. At the time of the earthquake, a mandatory shutdown of the reactor took place; however, decay heat, despite the elimination of the fission component of the reactor energy generation, needed to be managed and cooled with backup generators

vessel despite that approximately half of the core uranium melted during the incident.

**4.6. Chernobyl**

years by government sources [5, 6].

**4.7. Fukashima**

Even without a containment structure, the reactor contained most of the radioactivity. In late 1961, the cleanup process began and all core and building materials were buried approximately 1600 feet from the site of the reactor. One of the conclusions was that design focus on a single central structure created untoward risk that could not be easily mitigated. First responders may have received significant compounded radiation dose due to increased radiation dose in the environment and during removal of the waste and remains of those who died. Those involved in the response were awarded certificates for heroism [5, 6].

#### **4.5. Three Mile Island, Pennsylvania**

During the evening of March 27, 1979, one reactor at Three Mile Island nuclear station was running at near full capacity, while a second reactor was shut down for re-fueling. The root cause of the accident occurred 11 hours prior to the declaration of the emergency, when the cooling system filters were cleaned with air compression and cooling water. A valve that was thought to be shut was open and water entered an instrument airline which caused a turbine trip. Three auxiliary pumps should have been activated when heat and pressure increased due to lack of cooling; however, these pumps were closed due to re-fueling. This was not NRC policy. A third valve opened to relive pressure; however, did not close when pressure was released, therefore coolant escaped and became root cause in core disintegration. Human factors delayed recognition of the problem as a light indicated that the open valve was closed and secondary safety procedures were not followed. Even though there was persistent loss of coolant, water levels increased through the open valve creating bubbles of steam in the liquid. At 4:15 am on March 28, 1979, the pressurizer in the relief tank ruptured and radioactive coolant leaked into the containment structure. In a series of activated pumping mechanisms, the coolant was then pumped beyond the containment area. At 6 am on March 28, 1979, the temperature in a pilot valve was noted to be excessive by an employee beginning his work shift and a back valve was used to stop the flow of coolant. However, by that time 32,000 gallons of coolant had leaked, and radiation levels were 300 times expected. The containment building was significantly damaged; however, the radioactive material remained in situ as it did not extend beyond the reactor vessel despite that approximately half of the core uranium melted during the incident.

The incident became an example of managing authority and responsibility in the nuclear industry. Lines of authority between private plant ownership, state authorities, and the NRC were not clear and accordingly in the early phase of the accident, it was difficult to obtain accurate information for risk assessment. This resulted in delayed evacuation. Clean up was not completed for more than a decade and long-term risks remain not well defined. Most of radioactive gas release was xenon, which was not considered significant; however, radioactive iodine was also released and the impact of increase in thyroid cancers remains uncertain [5, 6].

#### **4.6. Chernobyl**

**4.4. Stationary low-power reactor number 1 (SL-1)**

8 Essentials of Accident and Emergency Medicine

SL-1 was a US Army nuclear power reactor located at the national reactor testing station 40 miles west of Idaho Falls, Idaho. The reactor became operational in 1958. The reactor used enriched uranium fuel and was cooled by water flowing through plates of uranium/aluminum alloy. The design relied on a primary central fuel rod. The reactor was closed for maintenance on January 3, 1961 and was being prepared to restart after the 11-day shutdown. Procedures that required the central rod be withdrawn to connect to the central drive mechanism. The rod was withdrawn too far, and the reactor instantly became critical. Within 4 milliseconds, the heat generated by the power excursion caused water to vaporize and explode. Radioactive water became a pressure wave striking the ceiling and a loose metal pin impaled one of the workers to the ceiling structure. It was determined on review that the 26,000-pound internal vessel had moved more than 9 feet in the superior direction and the control rod mechanisms struck the ceiling. There were three workers on site who each died quickly of their injuries. Their radiation exposure would also have been lethal, if they survived physical trauma. Review of the incident suggested that the central rod may have become fixed in position and one of the workers was able to free it; however, in the process the rod moved too far which generated the reaction.

Even without a containment structure, the reactor contained most of the radioactivity. In late 1961, the cleanup process began and all core and building materials were buried approximately 1600 feet from the site of the reactor. One of the conclusions was that design focus on a single central structure created untoward risk that could not be easily mitigated. First responders may have received significant compounded radiation dose due to increased radiation dose in the environment and during removal of the waste and remains of those who died.

During the evening of March 27, 1979, one reactor at Three Mile Island nuclear station was running at near full capacity, while a second reactor was shut down for re-fueling. The root cause of the accident occurred 11 hours prior to the declaration of the emergency, when the cooling system filters were cleaned with air compression and cooling water. A valve that was thought to be shut was open and water entered an instrument airline which caused a turbine trip. Three auxiliary pumps should have been activated when heat and pressure increased due to lack of cooling; however, these pumps were closed due to re-fueling. This was not NRC policy. A third valve opened to relive pressure; however, did not close when pressure was released, therefore coolant escaped and became root cause in core disintegration. Human factors delayed recognition of the problem as a light indicated that the open valve was closed and secondary safety procedures were not followed. Even though there was persistent loss of coolant, water levels increased through the open valve creating bubbles of steam in the liquid. At 4:15 am on March 28, 1979, the pressurizer in the relief tank ruptured and radioactive coolant leaked into the containment structure. In a series of activated pumping mechanisms, the coolant was then pumped beyond the containment area. At 6 am on March 28, 1979, the temperature in a pilot valve was noted to be excessive by an employee beginning his work shift and a back valve was used to stop the flow of coolant. However, by that time 32,000 gallons of coolant had leaked,

Those involved in the response were awarded certificates for heroism [5, 6].

**4.5. Three Mile Island, Pennsylvania**

The Chernobyl accident is one of the two most significant nuclear events in the history of unintentional radiation injury. The incident occurred on April 26, 1986. The irony of the event is that it occurred during a safety procedure evaluation and safety systems were intentionally disabled as part of the intended procedure. The reactor was brought to minimal activity with the expectation that cooling systems would manage the heat generated by thermal decay. The systems onsite unfortunately required more than 1 minute to activate and running the reactor at minimal power (below safety standard) resulted in the crisis. A series of events triggered by flaws in reactor design and poor decisions made by onsite personnel created situation where reactor cooling was inefficient and two steam explosions generated from thermal decay exposed the graphite core to air, which fueled the massive explosion. Exposure to oxygen fueled the explosion. The fires were extraordinary and sent radioactive elements and gas into the air for a week. Plumes of radioactive gas extended well into Western Europe for an extended period of time. Casualties were significant including first responders attempting to put out the fires as those involved were exposed to lethal levels of radiation. Scores of people were affected by radiation syndrome and estimates include thousands who will develop secondary cancers due to exposure. Cleanup continued for decades. It is estimated that more than 350,000 people relocated as part of a series of evacuations. Unfortunately, many evacuated during the initial phase of the accident were exposed to medically significant radiation as the exit road was directly under the parallax of the radioactive plume from the reactor fires. Reactor fires were eventually attenuated by helicopter droppings of cement, clay, sand, and boron to absorb neutron activity. The government decided to place a cover over the remains of the reactor and today this is referred to as a sarcophagus. Full understanding of risk and damage remains elusive due to limited access to information and lack of full disclosure for years by government sources [5, 6].

#### **4.7. Fukashima**

The nuclear power plant at Fukashima sustained damage from a massive Tsunami 50 minutes after the Tohoku earthquake in 2014. At the time of the earthquake, a mandatory shutdown of the reactor took place; however, decay heat, despite the elimination of the fission component of the reactor energy generation, needed to be managed and cooled with backup generators and power. The secondary backup cooling systems were damaged in three of the reactors and consequently, heat generated explosions contaminated the environment with radioactive particles and gas. Unlike Chernobyl, three had no direct deaths associated with the explosions and radiation exposure; however, issues with the cleanup continue until today. In the construction of Fukashima, more advanced backup systems existed in modern construction sites and these withstood the injury. The affected reactor had an older cooling design. Deaths occurred as part of the evacuation process, due in part to damage to facilities and inability to move rescue supplies into the region. This also compromised restoring the cooling mechanisms to the backup systems as batteries and generators that may have been helpful could not be transported to the site. The damage to the environment continues to today. Fukashima and Chernobyl are considered as two most powerful nuclear accidents in our history [5, 6].

significant radiation, many of whom were first responders to the explosion and subsequent fire. These events demonstrated that safety precautions including well understood policy and procedure were and remain essential to mission if nuclear energy sources were being used [5].

Essentials in Accident and Emergency Medicine Radiation Injury: Response and Treatment

http://dx.doi.org/10.5772/intechopen.76863

11

In this section, we will describe a series of events that imposed injury to people and the environment from applications of therapeutic radiology and unintended overuse of imaging equipment. These events have significant consequence to unintended victims of equipment,

In 1984, an Irridium-192 radioactive source became dislodged from the safety container. A worker unintentionally took the source back to his residence which exposed himself, his family, and visitors to high doses of radiation with three people sent to the Curie institute for treatment. It is believed that eight deaths were caused by the accident and there is a report that some deaths were due to pulmonary hemorrhage. Similar injuries have been reported in patients with myeloma undergoing total body radiation therapy as part of preparation for

In 1985, a Cesium-137 source was inadvertently left behind when a private radiation oncology clinic moved to a new facility. The source was found 2 years later by two people who brought the source and source carriage home and eventually ruptured the capsule of the source. During this time, hundreds of people were exposed and at least four died of radiationrelated injuries. Cleanup processes took 6 months and at least 300 people were identified as

On December 7, 1990, maintenance was performed on a linear accelerator at the radiation therapy clinic at Zaragoza, Spain and it returned to patient care service on December 10. What was not known was the accelerator (14 years in service) was incorrectly repaired and there was a breakdown in the internal control mechanism, therefore not detecting that patients were receiving much higher doses than specified with a higher beam energy. Initially, after 10 days of treatment, patients were identified as having accelerated dermal injuries. The first death associated with radiation injury was in February 1991. In total, 25 patients died in the first year after the event and 11 were attributed to injuries imposed by the incident [5].

In 1989, an accident occurred in a facility using a Co-60 source to sterilize medical products. The device became frozen in the on position. The worker by-passed safety measures and

**5.1. Unintended injury from the application of radiation therapy and use of** 

bone marrow transplant noted at doses of less than 10 Gy [5, 11].

**diagnostic X-ray equipment**

safety measures, and human error.

**5.2. Radiation accident in Morocco**

**5.3. Goiania, Brazil**

**5.4. Zaragoza, Spain**

having exposure to Cesium [5].

**5.5. San Salvador, El Salvador**

#### **4.8. Aftermath**

The experiences listed depict the extraordinary damage created by nuclear accidents to people and the environment. Reactor design, poor secondary cooling backup systems for failure, poor response by onsite providers with decisions made in panic, and natural disasters with poor preparation have created an uncertain future for the safety and durability of nuclear power. Injuries for onsite providers are related to explosions, thermal and high dose radiation. The incidents can occur in fractions of seconds and the injuries and environmental impact can last generations. It is sobering to see the radiation injuries sustained by first responders and those who attempted to mitigate the disasters. Information for these people arriving onsite for disaster management was not clear and in retrospect was inaccurate. Their brave and self-sacrificing response could not overcome the power and danger imposed by the situation. The impact on the nearby population and environment will not be resolved for decades and the disaster at early accidents continues to haunt the environment. The impact on the lives of the victims has no clear limit or statute of limitations. We need improved safety, infallible design, and protective strategies moving forward. In the upcoming sections, we will describe what information is currently available for those involved in the triage of radiation injury for both acute and long-term injuries [5–11].

#### **5. Unintentional injury: nuclear submarines**

With the interest in nuclear power, efforts were developed to use nuclear power for transportation. Submarine technology for nuclear power was developed as it limited the need to refuel and missions could be extended for a significant period. However, as such issues and safety within the nuclear power community, safeguards, and measures of protection could not be provided with security. In the Soviet submarine fleet, many accidents occurred which limited the safety and security of the power source. In 1961, similar to a nuclear power plant, the cooling system failed on the K-19 Soviet nuclear submarine and the temperature rapidly rose as a result of decay heat. The captain ordered a secondary cooling built and sailors/engineers in the process of building a cooling system were exposed to lethal doses (LDs) of radiation in the process of building the system. More than 20 died of radiation injury. In 1968, nine sailors died during an explosion that released radioactive gas. In 1985, 10 died in an explosion caused by malfunction of a lid designed to keep fuel rods in position and 49 people were exposed to significant radiation, many of whom were first responders to the explosion and subsequent fire. These events demonstrated that safety precautions including well understood policy and procedure were and remain essential to mission if nuclear energy sources were being used [5].

### **5.1. Unintended injury from the application of radiation therapy and use of diagnostic X-ray equipment**

In this section, we will describe a series of events that imposed injury to people and the environment from applications of therapeutic radiology and unintended overuse of imaging equipment. These events have significant consequence to unintended victims of equipment, safety measures, and human error.

#### **5.2. Radiation accident in Morocco**

In 1984, an Irridium-192 radioactive source became dislodged from the safety container. A worker unintentionally took the source back to his residence which exposed himself, his family, and visitors to high doses of radiation with three people sent to the Curie institute for treatment. It is believed that eight deaths were caused by the accident and there is a report that some deaths were due to pulmonary hemorrhage. Similar injuries have been reported in patients with myeloma undergoing total body radiation therapy as part of preparation for bone marrow transplant noted at doses of less than 10 Gy [5, 11].

#### **5.3. Goiania, Brazil**

and power. The secondary backup cooling systems were damaged in three of the reactors and consequently, heat generated explosions contaminated the environment with radioactive particles and gas. Unlike Chernobyl, three had no direct deaths associated with the explosions and radiation exposure; however, issues with the cleanup continue until today. In the construction of Fukashima, more advanced backup systems existed in modern construction sites and these withstood the injury. The affected reactor had an older cooling design. Deaths occurred as part of the evacuation process, due in part to damage to facilities and inability to move rescue supplies into the region. This also compromised restoring the cooling mechanisms to the backup systems as batteries and generators that may have been helpful could not be transported to the site. The damage to the environment continues to today. Fukashima and Chernobyl are considered as two most powerful nuclear accidents in our history [5, 6].

The experiences listed depict the extraordinary damage created by nuclear accidents to people and the environment. Reactor design, poor secondary cooling backup systems for failure, poor response by onsite providers with decisions made in panic, and natural disasters with poor preparation have created an uncertain future for the safety and durability of nuclear power. Injuries for onsite providers are related to explosions, thermal and high dose radiation. The incidents can occur in fractions of seconds and the injuries and environmental impact can last generations. It is sobering to see the radiation injuries sustained by first responders and those who attempted to mitigate the disasters. Information for these people arriving onsite for disaster management was not clear and in retrospect was inaccurate. Their brave and self-sacrificing response could not overcome the power and danger imposed by the situation. The impact on the nearby population and environment will not be resolved for decades and the disaster at early accidents continues to haunt the environment. The impact on the lives of the victims has no clear limit or statute of limitations. We need improved safety, infallible design, and protective strategies moving forward. In the upcoming sections, we will describe what information is currently available for those

involved in the triage of radiation injury for both acute and long-term injuries [5–11].

With the interest in nuclear power, efforts were developed to use nuclear power for transportation. Submarine technology for nuclear power was developed as it limited the need to refuel and missions could be extended for a significant period. However, as such issues and safety within the nuclear power community, safeguards, and measures of protection could not be provided with security. In the Soviet submarine fleet, many accidents occurred which limited the safety and security of the power source. In 1961, similar to a nuclear power plant, the cooling system failed on the K-19 Soviet nuclear submarine and the temperature rapidly rose as a result of decay heat. The captain ordered a secondary cooling built and sailors/engineers in the process of building a cooling system were exposed to lethal doses (LDs) of radiation in the process of building the system. More than 20 died of radiation injury. In 1968, nine sailors died during an explosion that released radioactive gas. In 1985, 10 died in an explosion caused by malfunction of a lid designed to keep fuel rods in position and 49 people were exposed to

**5. Unintentional injury: nuclear submarines**

**4.8. Aftermath**

10 Essentials of Accident and Emergency Medicine

In 1985, a Cesium-137 source was inadvertently left behind when a private radiation oncology clinic moved to a new facility. The source was found 2 years later by two people who brought the source and source carriage home and eventually ruptured the capsule of the source. During this time, hundreds of people were exposed and at least four died of radiationrelated injuries. Cleanup processes took 6 months and at least 300 people were identified as having exposure to Cesium [5].

#### **5.4. Zaragoza, Spain**

On December 7, 1990, maintenance was performed on a linear accelerator at the radiation therapy clinic at Zaragoza, Spain and it returned to patient care service on December 10. What was not known was the accelerator (14 years in service) was incorrectly repaired and there was a breakdown in the internal control mechanism, therefore not detecting that patients were receiving much higher doses than specified with a higher beam energy. Initially, after 10 days of treatment, patients were identified as having accelerated dermal injuries. The first death associated with radiation injury was in February 1991. In total, 25 patients died in the first year after the event and 11 were attributed to injuries imposed by the incident [5].

#### **5.5. San Salvador, El Salvador**

In 1989, an accident occurred in a facility using a Co-60 source to sterilize medical products. The device became frozen in the on position. The worker by-passed safety measures and entered the room with two other workers to try and free the equipment. The exposure was so high that one worker died within 6 months of exposure and the two other workers sustained injuries requiring amputation [6, 7, 9].

for identification, similar to modern computer identification technologies. Written policies and validation that processes have been followed are crucial to successful clinical operation. Recent review of adverse events of radiation oncology devices from 1991 to 2015 revealed that adverse events increased over time and peaked in 2011. During this period of time, there was significant change in practice strategies including enterprise application of intensity modulation and the application of image guidance into daily therapy. About 50.8% of adverse events involved external therapy, 24.9% of events involved brachytherapy, 20.9% were mechanical, and 20.4% involved user error. While a department will perform 100 times more teletherapy treatments than brachytherapy applications, it was interesting to note that brachytherapy adverse events were only half of those reported for teletherapy, therefore potentially more prone to misadministration. Brachytherapy is done less often, and accordingly departmental processes may not be repeated frequently enough for flawless reproducibility and execution of care. Our department is responsible for more than 50,000 external treatments every year and each individual treatment and brachytherapy application must be correct. Injuries can be imposed by diagnostic X-ray equipment especially in situations requiring interventional radiology and the use of fluoroscopy. The radiation dose cannot be extracted once delivered

Essentials in Accident and Emergency Medicine Radiation Injury: Response and Treatment

http://dx.doi.org/10.5772/intechopen.76863

13

In these circumstances, injuries imposed are related to strength of the radiation source and distance to the source of radiation. Thermal and mechanical injuries are immediately lifethreatening. Within 15 minutes of exposure, victims exposed to high dose radiation can experience symptoms associated with the event. These symptoms are manifest with high exposure by neuromuscular changes and gastrointestinal effects. At very low-level exposure, the victim may appear well; however, gastrointestinal and bone marrow symptoms may become more visible in the upcoming month post exposure. Intermediate dose exposure results in upper abdominal symptoms and lassitude seen within hours of the exposure. High dose exposure results in more extreme symptoms including rapid fluid loss and hypotension associated with more pronounced neuromuscular symptoms. Often normal tissue sequelae associated with exposure can be divided into acute injury, sub-acute injury, and chronic injury. Unintentional exposure requires evaluation by a trained group of experts who can assess both injury to the victim and risk to others with continued exposure of radioactive sources either on or inhaled/ingested by the victim. The initial screening of victims requires evaluation by trained radiation safety officers and members of emergency services who can begin to apply best supportive care. In the initial phase of the evaluation, it is important to ascertain as accurate assessment of dose exposure as possible. Lymphocyte counts due to intermitotic death and chromosomal damage assessment can be qualitative surrogates for exposure in the early phase of response assessment. Healthcare workers will likely be monitored for exposure; however, the general public will not be monitored, therefore involving experts in radiation exposure early in response assessment is essential to mission in order to appropriately define

and the injuries imposed often have no cure [6, 7, 9, 13, 14].

**7. Impact of radiation therapy on normal tissues**

**7.1. Accidents and weapons: unintended exposure**

the extent of the damage and risk of injury [7, 9, 15].

#### **6. Modern accelerator safety issues**

The modern linear accelerator has a vast array of safety features including computer override systems which prevent improper application of therapy and internal monitoring diodes which monitor dose application. Safe operation of linear accelerators is a challenging task and users of modern equipment have to assume greater responsibilities for safe execution of patient care. Complex treatment plans and delivery system require thorough hands on understanding of machine operations and safety systems. Continuous process monitoring ensuring safe delivery of care is essential to mission to prevent abhorrent behavior of equipment. This includes well trained staff who can detect potential issues and report concerns to appropriate individuals for next step action to mitigate potential problems. Nevertheless, significant errors have occurred which continue to haunt patient care delivery. Advancement in therapy application often require tools that are developed by different companies and the tools must be harmonized through hardware and software adjustments to provide appropriate patient care. This has led to serious and life-threatening injuries when not applied appropriately. The most common errors in computer override situations are software flaws that indicate that a situation is safe when it is unsafe. Examples of software flaws include unintentionally reporting that multileaf jaws are moving appropriately during treatment when they are not and assuring the individual delivering therapy that system delivery is compliant to plan and calculation when the situation may be less secure. Treatments now require thousands of dynamic motions of individual leaves hidden in the gantry of the machine. Linear accelerators and radiation therapy treatment planning have become exceptionally complex. Treatment delivery capability has become exceptionally precise in its capability to deliver very high doses of treatment to small areas with submillimeter precision. The power of the new equipment is extraordinary; however, the power is often used as a marketing tool and does not recognize that new systems including training of personnel have not been appropriately vetted. This represents both the strength and weakness of modern care. The instrument is powerful; however, if not applied appropriately can cause significant harm. If not calibrated and executed properly, life-threatening injuries occur. In recent reporting through the New York Times, Walter Bogdanich accurately reported on misadministration of radiation therapy to multiple patients in several separate situations causing severe injury and death including injuries to tissues that could not be repaired. These are the innocent victims of our technology and their injuries are a sobering reminder that we must maintain a culture of safety [12].

Although software matters can be addressed, we must improve on right patient and right treatment. Human error remains too frequent in treatment delivery. Technology cannot resolve all causes of error and department processes including double identification and time out must be documented and validated to ensure patient safety. More sophisticated digital identification processes may be implemented into clinical operation including iris and fingerprint strategies for identification, similar to modern computer identification technologies. Written policies and validation that processes have been followed are crucial to successful clinical operation. Recent review of adverse events of radiation oncology devices from 1991 to 2015 revealed that adverse events increased over time and peaked in 2011. During this period of time, there was significant change in practice strategies including enterprise application of intensity modulation and the application of image guidance into daily therapy. About 50.8% of adverse events involved external therapy, 24.9% of events involved brachytherapy, 20.9% were mechanical, and 20.4% involved user error. While a department will perform 100 times more teletherapy treatments than brachytherapy applications, it was interesting to note that brachytherapy adverse events were only half of those reported for teletherapy, therefore potentially more prone to misadministration. Brachytherapy is done less often, and accordingly departmental processes may not be repeated frequently enough for flawless reproducibility and execution of care. Our department is responsible for more than 50,000 external treatments every year and each individual treatment and brachytherapy application must be correct. Injuries can be imposed by diagnostic X-ray equipment especially in situations requiring interventional radiology and the use of fluoroscopy. The radiation dose cannot be extracted once delivered and the injuries imposed often have no cure [6, 7, 9, 13, 14].
