Emergency response and recovery from disasters—particularly those involving chemical, biologic, radiologic, and nuclear explosive materials—require a specialized skill set. This expertise, already scarce in the allopathic community, is even more elusive in the osteopathic community, which is composed of fewer practitioners. Many resources have been directed to planning for chemical, biologic, and explosive incidents, but relatively few resources have been directed to preparedness for R/N incidents. In the past few years, federal assets have been directed to an effort to improve planning and preparedness for response to and recovery from detonation of smaller nuclear weapons because of the more immediate concern in the terrorist environment in which we find ourselves. The National Library of Medicine's Radiation Emergency Medical Management website (
http://www.remm.nlm.gov/) serves as a repository for key response information for the public health and medical communities.
A number of registries record all reported international radiation accidents. Most of these registries—including the National Nuclear Security Administration's Radiation Emergency Assistance Center/Training Site (REAC/TS) in Oak Ridge, Tennessee—have a record of fewer than 1000 radiation incidents involving humans. According to Albert Wiley, MD, PhD, the director of REAC/TS, fewer than 600 R/N incidents with substantial medical consequences have occurred during the past 65 years (oral communication, August 2012). The incidents documented in the REAC/TS Radiation Accident Registry involve cases with 1 to several victims and with varying severity of acute radiation syndrome, cutaneous radiation syndrome, acute local radiation injuries, and a few criticality incidents. Because the rate of these incidents is very low, most physicians have never managed a radiation injury or illness, with the possible exception of practitioners of radiation therapy. Compare this small number to the hundreds of thousands of patients who receive a diagnosis of coronary vascular disease in the United States yearly.
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Of note, the following persons are not generally counted by registries as radiologic casualties:
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those affected by World War II–era military use of nuclear weapons in the Pacific theater
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those who were injured in military settings, such as nuclear-powered ships
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those who experienced adverse effects from radiopharmaceutical administration and radiation therapy
To compound their lack of experience, most US health care practitioners have very little knowledge about managing radiation-related injuries and illnesses.
7,8 Educational opportunities on this topic are scarce in both the allopathic and the osteopathic branches of medicine. Information about the topic is generally not provided in medical schools and residencies or is provided only superficially. Furthermore, there are very few CME activities on this topic available for physicians, and there is no requirement to complete this kind of CME either for board certification or state licensure.
The 2 preeminent agencies that provide CME courses related to managing ionizing radiation injuries and illnesses are REAC/TS
9 in Oak Ridge, Tennessee (3 courses), and the Armed Forces Radiobiology Research Institute
10 in Bethesda, Maryland (1 course). In all, fewer than 3000 people per year take these courses. Compounding the problem for osteopathic physicians is that many of these courses are not approved by the American Osteopathic Association (AOA) for Category 1-A CME credit. Currently, to be certified for AOA Category 1-A CME credit, 30% of the presenters in a course must (a) be osteopathic physicians or (b) be “MD's, PhD's, and other professionals with graduate degrees” employed as full-time faculty at a college of osteopathic medicine.
11 (As of publication, the AOA is expected to change the requirement from 30% of presenters to 50%.) Finding instructors who meet these criteria is extremely difficult in light of the smaller population of the osteopathic medical profession compared with the allopathic community and the level of specialization that is required.
Despite these impediments, 2 CME courses exploring R/N medicine have taken place. In 2008, REAC/TS offered a 1-day course in radiation medicine to attendees that was accredited for Category 1-A CME credit, but only because 1 of the authors (D.M.C.) delivered 4 of the 8 hours of didactic material. At that time, accreditation for Category 1-A CME credit required that 50% of the presentations in a program had to be delivered by an osteopathic physician. Then, in April 2012, REAC/TS delivered a 1-day course in radiation medicine awareness at Lincoln Memorial University–DeBusk College of Osteopathic Medicine (LMU-DCOM) in Harrogate, Tennessee. Finally—expanding on the hypothesis that early training in radiation awareness will produce a better-prepared, better-rounded physician—in September 2012 REAC/TS presented a combined 2-day program with the American College of Medical Toxicology to more than 350 attendees. The program was supported by the Centers for Disease Control and Prevention's Office of Environmental Health Emergencies and was entitled “Agents of Opportunity (AoO) for Terrorism: Toxic Radiological Materials, Toxic Industrial Materials & Toxic Industrial Chemicals.”