**3. Intentional injury**

and events. Injury can be catastrophic, immediately life-threatening, and survivors of exposure remain with a lifetime risk of secondary events including chronic health changes and malignancies. Even with the development of radiation protection standards and oversite organizations, accidents and misadministration of radiation deviant from intent continue to haunt daily application of radiation therapy. There is no antidote to radiation exposure and the fingerprints of injury remain for a lifetime. In this chapter we will review major incidents of public radiation exposure and accidents in history including cause and effect. We will review the application and evolution of standards and how this affects both the public and healthcare worker in modern care. We will review modern patient care and response assessment to radiation exposure including agents that may protect or mitigate radiation damage from radiation exposure. We will identify strengths of modern radiation therapy and the need for continuous process improvements to ensure optimal application of X-ray in a safe

X-rays were discovered in 1895 by William Roentgen. In part due to the century old use of electricity in medicine, X-rays were rapidly assimilated into the medical armamentarium portfolio as beneficial applications of X-ray treatment were identified by early radiologists. Due to protracted exposure times and minimal knowledge of risk, early practitioners of the application of X-rays to treatment situations became victims themselves. Friedrich Otto Walkoff took the first dental radiograph in 1895 by placing a photographic plate between his teeth and tongue. He was able to generate an image with a 30-minute exposure time. He applied similar techniques to patients and reported epilation and skin blistering. Walkoff developed the first dental imaging laboratory in 1896 with Fritz Geisel. Geisel died in 1927 of metastatic carcinoma caused by heavy exposure of radiation to his hands. In 1896, a child was accidently shot in the head and was brought to a laboratory at Vanderbilt University (Nashville, TN). Investigators sought the location of the bullet by X-ray and a plate holder was tied to the head of the patient. The X-ray tube was placed at the patient's head. The exposure was 1 hour. About 21 days after exposure there was epilation at the site of X-ray application. In 1896, HD Hawkes gave a demonstration of an X-ray unit in New York City. He had to discontinue work after 4 days due to injury to the skin of his hand and chest. Within 2 weeks he had significant skin injuries, his fingernails deteriorated, and he exhibited systemic signs of radiation injury. In the same year, William Levy sought out to localize a bullet that had been lodged in his skull for 10 years. He was warned about the potential of injury; however, chose to move forward. Images were created over a 14-hour period from three static positions at his forehead, his open mouth, and behind his right ear. Within 24 hours, the dermal surfaces of his head were blistered and within days his mouth and lips had sores and epilation occurred within 3 weeks. The bullet was found within an inch of the occipital protuberance. In this circumstance, the absorbed dose by the victim was at least 15 Gray (Gy). Clarence Dally worked at the Edison laboratory and had the role of being a glassblower for Thomas Edison. He is thought to be the first individual to die from chronic radiation workplace exposure in 1904 from metastatic carcinoma at the age of 39. It is thought that his exposure was at least 30 Gy. Numerous deaths were reported in X-ray manufacturers and workers with noted deaths of Nobel Laureates Marie Curie and her daughter

environment.

4 Essentials of Accident and Emergency Medicine

**2. History**

As the benefits and power of X-rays and radium matured, the use of nuclear tools for weapons of mass destruction came to power. During WWII, efforts for harnessing nuclear power for destruction reached application on August 6, 1945 with the use of a 9000-pound uranium-235 bomb known a "Little Boy" over the manufacturing city of Hiroshima, Japan. The bomb was dropped with a parachute and detonated 2000 feet above the city with blast equal to 15 kilotons About 2–3 days later, a plutonium-239 bomb known as "Fat Man" was dropped over the city of Nagasaki. The primary target was Kokura; however, clouds shrouded the primary target area. The plutonium bomb was more powerful than the bomb used on Hiroshima. The bomb weighed 10,000 pounds and produced a 22-kilotons blast. The topography of Nagasaki limited the radius of impact as the city is in a narrow valley between mountains. Initial destruction and death was due to heat and fire as well as associated trauma related to building damage and other structural/public health-related matters; however, those not at the epicenter of the blast were exposed to radiation as a function of distance from the epicenter. Early impact resulted in microcephaly and mental retardation in the most vulnerable unborn and young population with lifelong health risks including chronic health issues in multiple organ systems and cancer risks affecting all survivors. We have earned much about studying the population of survivors and have been able to apply this knowledge to risk assessment for the general population, healthcare workers, and pregnant/potentially pregnant patients [5–7].
