nyc remac - The Regional Emergency Medical Services Council of ...

In reviewing ePCRs in Division One for a thirty (30) day period, OMA conducted a study toidentify compliance in use of the 12 lead EKG in cardiac cases where ALS units responded. Thefollowing are the findings of this review.‣ Total patients over age 12 where “chest pain” or“cardiac symptoms” were indicated 35‣ Patients over age 12 where “chest pain” or “cardiacsymptoms” were indicated and received a 3 leadEKG 28‣ Patients over age 12 where “chest pain” or “cardiacsymptoms” were indicated and subsequentlyreceived a 12 lead EKG 27This review indicates good compliance with the ALS protocol in Division One keep up theexcellent work!• As a result of the Pulse Oximetry – QA Form sent into OMA by field paramedicsthe extension cable for the SpO 2 monitor will now be included in the cable packagefor the Life Pack 12. We will continue to accept Pulse Oximetry – QA Forms untilFebruary 6 th , 2005. EMS Operations and the Office of Medical Affairs would like tothank you for your continued cooperation and support. Keep up the great work!

NYC REMACAdvisory No. 2004-16Title: Identification of ACUTE Stroke PatientsTransport to NYS DOH Designated Stroke CentersIssue Date: December 6, 2004Effective Date: ImmediatelySupercedes: N/A Page: 1 of 5The Regional Emergency Medical Advisory Committee (REMAC) of New York City has been advised that the New York StateDepartment of Health is now designating Stroke Centers for the care of patients identified as having suffered an “Acute Stroke”. Thisadvisory contains information to properly identify and transport “Acute Stroke” patients to appropriate facilities.With the permission of FDNY, this advisory contains information excerpted from:‣ Office of Medical Affairs Directive 2004-18 (November 18, 2004) – Prehospital Evaluation of Stroke Center Candidates‣ EMSC OGP 115-10 (November 18, 2004) – Prehospital Identification of Stroke Center Candidates‣ EMSC OGP 115-10, APPENDIX A (November 18, 2004) – Using the Prehospital Stroke ScaleFDNY information has been modified for use by non-FDNY/911 System ParticipantsOwners/operators of Ambulance and ALS First Response Services providing prehospital medical treatment within the fiveboroughs of the City of New York are responsible to ensure their Service Medical Directors and EMS PrehospitalProviders are informed of all changes/updates to the NYC REMAC Prehospital Treatment Protocols.Lewis W. Marshall, Jr., MD, JDChairRegional Emergency Medical Advisory Committee of New York City

NYC REMACAdvisory No. 2004-17Title: ALS Protocol # 504-BCardiogenic ShockIssue Date: December 6, 2004Effective Date: January 1, 2005Re-Issued: N/ASupercedes: Protocol Issued July 1, 2004 Page: 1 of 2The Regional Emergency Medical Advisory Committee (REMAC) of New York City has revised the Advanced Life Support Protocol504-B: Cardiogenic Shock. The revision is limited to the addition of the administration of a fluid challenge prior to theadministration of Dopamine.The following changes were made:New Medical Control Option has been added, as follows: (New language is double-underscored and bold)MEDICAL CONTROL OPTIONS:OPTION A:Administer a 250 ml IV bolus of Normal Saline (0.9% NS). Repeat once for a maximum total dose of 500 ml.Remaining Medical Control Options will be re-numbered accordingly.A copy of the revised protocol is attached.Owners/operators of Ambulance and ALS First Response Services providing prehospital medical treatment withinthe five boroughs of the City of New York are responsible to provide copies of the NYC REMAC PrehospitalTreatment Protocols to their personnel, and to ensure that Service Medical Directors and EMS personnel areinformed of all changes/updates to the NYC REMAC Prehospital Treatment Protocols.This revised protocol revision will be effective January 1, 2005.Lewis W. Marshall, Jr., MD, JDChairRegional Emergency Medical Advisory Committee of New York City

504-BCARDIOGENIC SHOCKEffective Date: January 1, 20051. Contact Medical Control for implementation of one or more of the following MEDICAL CONTROL OPTIONS:MEDICAL CONTROL OPTIONS:OPTION A:OPTION B:OPTION C:Administer a 250 ml IV bolus of Normal Saline (0.9% NS). Repeat once for a maximum total dose of 500 ml.Administer Dopamine 5 ug/kg/min, IV/Saline Lock drip. If there is insufficient improvement in hemodynamic status, theinfusion rate may be increased until the desired therapeutic effects are achieved or adverse effects appear. (Maximum dosageis 20 ug/kg/min, IV/Saline Lock drip.)Transportation Decision.WWW.NYC.GOV/FDNY 8

NYC REMACAdvisory No. 2004-18Title: General Operating ProceduresAirway Management – Nasal IntubationIssue Date: December 6, 2004Effective Date: January 1, 2005Re-Issued: N/ASupercedes: N/A Page: 1 of 1The Regional Emergency Medical Advisory Committee (REMAC) of New York City has revised the Airway Managementsection of the General Operating Procedures to clearly state that nasal intubation is an unacceptable form of airway managementin the prehospital environment. This mandate is effective January 1, 2005.The following changes were made:The Airway Management section of the Prehospital Treatment Protocols – General Operating Procedures has been updated, asfollows: (New language is double-underscored and bold)AIRWAY MANAGEMENTAll patients require continuous monitoring of their airways to ensure airway patency. Wherever the term "Monitor airway" is usedthroughout these protocols, the following elements shall be utilized:• Position of the patient's head• Need for airway adjuncts• Need for oropharyngeal suctioning;• Need for Advanced Life Support airway management techniques• Use of Pulse Oximetry (S p O 2 ) ‘if available’• Use of secondary form of Endotracheal Tube confirmation (Example: End Tidal Capnography (ETCO 2 ). Secondaryconfirmation devices are not a substitute for primary confirmation techniques that rely upon direct visualization andauscultation, but serve as an additional method of documenting proper endotracheal tube placement.NOTE:NASAL INTUBATION IS CONSIDERED TO BE AN UNACCEPTABLE FORM OF AIRWAYMANAGEMENT WITHIN THE NEW YORK CITY REGION.Owners/operators of Ambulance and ALS First Response Services providing prehospital medical treatment within the fiveboroughs of the City of New York are responsible to ensure their Service Medical Directors and EMS personnel are informed ofall changes/updates to the NYC REMAC Prehospital Treatment Protocols.Lewis W. Marshall, Jr., MD, JDChair, Regional Emergency Medical Advisory Committee of New York CityWWW.NYC.GOV/FDNY 9

NYC REMACAdvisory No. 2004-19Title: NEW Advanced Life Support Protocol529: Pain ManagementIssue Date: December 6, 2004Effective Date: January 1, 2005Re-Issued: N/ASupercedes: N/A Page: 1 of 2The Regional Emergency Medical Advisory Committee (REMAC) of New York City has developed a NEW Advanced Life Support Protocolfor the management of pain. Implementation of this protocol is limited to patients with isolated extremity injuries, in cases with prolongedscene/transport time. Head injury is a contraindication for implementation of this protocol.A copy of the New ALS Protocol # 529 – Pain Management protocol is attached.Owners/operators of Ambulance and ALS First Response Services providing prehospital medical treatment within the fiveboroughs of the City of New York are responsible to provide copies of the NYC REMAC Prehospital Treatment Protocolsto their personnel, and to ensure that Service Medical Directors and EMS personnel are informed of all changes/updates tothe NYC REMAC Prehospital Treatment Protocols.This revised protocol revision will be effective January 1, 2005.Lewis W. Marshall, Jr., MD, JDChairRegional Emergency Medical Advisory Committee of New York CityWWW.NYC.GOV/FDNY 10

529PAIN MANAGEMENT FOR ISOLATED EXTREMITY INJURYEffective Date: January 1 st , 2005For patients with isolated extremity injury, if there is severe pain with prolonged scene/transport time1. Begin Basic Life Support Procedures.2. Begin cardiac monitoring. Record and evaluate rhythm strip.3. Begin pulse Oximetry monitoring (if available).4. Begin an IV/Saline Lock infusion of Normal Saline (0.9% NS) at a KVO rate.5. Monitor vital signs every 5 minutes.6. If there is severe pain with prolonged scene/transport time, contact Medical Control for implementation of one or more of the followingMEDICAL CONTROL OPTIONS:MEDICAL CONTROL OPTIONS:OPTION A:Administer Morphine Sulfate 2 – 5 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2 – 5 mg IV/Saline Lockbolus, may be given as necessary. (Maximum total dosage is 15 mg.)NOTE:IF HYPOTENSION, HYPOVENTILATION, OR STUPOR DEVELOPS, WITHHOLD MORPHINE SULFATE,ELEVATE THE LEGS, AND ADMINISTER NALOXONE 2 MG, IV/SALINE LOCK BOLUS.WWW.NYC.GOV/FDNY 11

NYC REMACAdvisory No. 2004-20Title: General Operating ProceduresAirway ManagementMANDATORY USE OF PULSE OXIMETRYIssue Date: December 6, 2004Effective Date: July 1, 2005Re-Issued: N/ASupercedes: N/A Page: 1 of 1The Regional Emergency Medical Advisory Committee (REMAC) of New York City, in order to maintain optimal standard ofcare protocols, has made the use of Pulse Oximetry mandatory as part of the Advanced Life Support protocols. Use of PulseOximetry remains optional for Basic Life Support. This mandate is effective July 1, 2005.The following changes were made:The Airway Management section of the Prehospital Treatment Protocols – General Operating Procedures has been updated, asfollows: (Deleted language is struck-out, new language is double-underscored)AIRWAY MANAGEMENTAll patients require continuous monitoring of their airways to ensure airway patency. Wherever the term "Monitor airway" is usedthroughout these protocols, the following elements shall be utilized:• Position of the patient's head• Need for airway adjuncts• Need for oropharyngeal suctioning;• Need for Advanced Life Support airway management techniques• Use of Pulse Oximetry (S p O 2 ) ‘if available’:• Mandatory for Advanced Life Support• Optional for Basic Life Support• Use of secondary form of Endotracheal Tube confirmation (Example: End Tidal Capnography (ETCO 2 ). Secondaryconfirmation devices are not a substitute for primary confirmation techniques that rely upon direct visualization andauscultation, but serve as an additional method of documenting proper endotracheal tube placement.NOTE:NASAL INTUBATION IS NOT CONSIDERED TO BE AN ACCEPTABLE FORM OF AIRWAYMANAGEMENT WITHIN THE NEW YORK CITY REGION.Owners/operators of Ambulance and ALS First Response Services providing prehospital medical treatment within the fiveboroughs of the City of New York are responsible to ensure their Service Medical Directors and EMS personnel are informed ofall changes/updates to the NYC REMAC Prehospital Treatment Protocols.Lewis W. Marshall, Jr., MD, JDChair, Regional Emergency Medical Advisory Committee of New York CityWWW.NYC.GOV/FDNY 12

FEEDBACKThank you for participating in the Journal CME program. The response so far has been terrific, with over 6000certificates for ONE HOUR of CME credit issued thus far. As we present this month’s edition, we would like to hear fromyou. Please take a moment to answer a few questions and return them with your CME answer sheet. Thank you for yoursupport and we look forward to sending you this month's completion certificate.Journal CME StaffPlease Print!Are you enjoying the Journal CME program? _______________________If not, why?__________________________________________________________________________________________________________________________________________________________Do you find the articles informative and educational? _______________What topics would you like to see addressed in the future?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________Your comments and ideas are greatly appreciated:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________WWW.NYC.GOV/FDNY 13

Paramedics are encouraged to read the article ("Radiation Part Four" written by Dario Gonzalez, MD) and then answer thefollowing 10 questions on the answer sheet below. Paramedics receiving a minimum grade of 80% will receive (1) one hour ofOnline/Journal CME. Forward the completed answer sheet by Department Mail to theFDNY Office of Medical Affairs – ATTN. Paramedic Steven GoldsteinOr FAX (718) 999-0119Or U.S. MAIL 9 MetroTech Center, Brooklyn, N.Y. 11201-3857Participants are strongly advised to keep a copy of their submitted question sheets for their own record.• Please submit the CME answer sheet only once, please DO NOT fax it if you've sent it via e-mail or inter-office mail (pony express).NAME: ___________________________MAC#:_________BATT# / HOSP AFFILIATION: ______________E-MAIL ADDRESS: ______________________________________HOME ADDRESS: ____________________________________________________________________________WWW.NYC.GOV/FDNY 14

Radiation Trilogy Part FourTransport Incident:You are assigned to a MCI 32 involving a truck and a school bus.The text identifies multiple injured children and overturned tractortrailer. As you approach the location you note multiple rescuepersonnel on scene including many ambulatory victims. As youapproach the bus you note that the involved truck has been tapped offwith barrier tape. You also note this placard; additionally there is nonoted leakage from the truck payload.Transport Incident Potential:The risks associated with a range of different types of shipment of radioactive material, focusing on the transport of used fuel from powerplants, which accounts for the bulk of the radioactive inventory transported each year. Currently the U.S. has about 47,500 metric tons of spentnuclear waste stored in 43 states. It is projected that by 2040, there will be 108,000 metric tons of spent nuclear waste. For the long term, onsitestorage is not an efficient method. Risks can include leaks and destruction of waste storage containers by natural disasters and terroristattacks. Shipping would (is) via trucks, trains and barges carrying irradiated nuclear fuel and high/low-level radioactive waste. To date therehave been ~ 2,500 to 3,000 irradiated nuclear fuel shipments U.S. for well over 50 years. Each truck-sized container would hold up to 40 timesthe long-lasting radioactivity released by the Hiroshima atomic bomb. The much larger train/barge containers would each hold over 200 timesHiroshima’s long-lasting radioactivity. As with all commercial shipping the potential for accidents is always present. Even a fraction of a singleshipping container’s radioactive cargo escaping into the environment could prove catastrophic consequences for an area downwind anddownstream. The shipment containers are also theoretically vulnerable to terrorist attack, thus making them potential targets.RADIATION BASICS“There is no safe level of exposure and there is no dose of (ionizing) radiation so low that the risk of a malignancy is zero”; therefore cautionand understanding of the risks are critical.WHAT IS RADIATION: Radiation is energy that travels in waves (i.e. visible light, ultraviolet light, radio waves). Non-ionizing radiation canshake or move molecules. Ionizing radiation can break molecular bonds, causing unpredictable chemical reactions. This includes energy wavesand particles. You cannot see, feel, taste, smell or hear ionizing radiation.WHERE DOES IONIZING RADIATION COME FROM: Ionizing radiation is matter or energy that is given off by the nucleus of an unstableatom in the process of decaying and reaching a stable (ground) state. This energy is released in the form of alpha and beta particles or gammaand x rays waves.TYPES OF RADIATION:Alpha particles are high energy, large subatomic structures. They cannot travel very far but can be stopped by a piece of paper or skin. Alphaparticles hit hard and can do a great deal of damage to cells. If inhaled, ingested, or injected into the body (through a break in the skin), theycan release energy to cells in organs or blood to surrounding tissue causing significant damage. A track of an alpha particle can deliver a largedose of radiation to cells along that line of travel. Alpha emitters include Plutonium, radon gas, uranium, and americium (smoke detectors).Beta particles are electrons. They are smaller than the alpha particles, can travel farther and are more penetrating. Betas pose an internal andexternal body risk, depending on their energy level. External exposure can result in beta penetration through the surface to the most sensitivelayers of skin. Inhalation or ingestion of beta emitting substances poses the greatest risk. Externally, a ½ inch of Plexiglas or water can stop abeta particle. Strontium-90 and tritium are beta emitters; these are often byproducts of nuclear power reactors during normal operations.Physiologically Strontium-90 can be mistaken for calcium by the body and concentrated in bones (location for blood cell production). Thisincreases the risk of bone and blood cancers (leukemia). Many people probably have some strontium-90 in their bodies as a result of nuclearbomb testing. Gamma rays are the most penetrating type of radiation and can be stopped only by thick lead or concrete shielding. Cesium-137is a gamma emitter often released from nuclear reactors. It mimics potassium, and may be collected in muscle. Iodine-131/129 are also gamma-WWW.NYC.GOV/FDNY 15

emitters released through bomb testing and at nuclear reactor plants. Radioactive iodines collect in the thyroid gland (emitting beta and gammaradiation to surrounding tissue) and may result in thyroid cancer. X-rays are like gamma rays except they are most often generated electricallyby a machine. X-rays are normally used for medical or industrial diagnostic procedures and requires lead shielding.HALF-LIVES (T ½ ) AND DECAY CHAINS: Half-life is the time it takes for ½ of a radioactive element to decay (toward stability). Someradionuclides decay to a stable element in a relatively short time or like uranium, stability may be a long, complex process. Uranium-238 has aT ½ of 4.5 billion years, 17 decay steps, before reaching a final, stable form of lead. Half-lives can range from fractions of seconds (Polonium-214, .00016 seconds), to days (Iodine-131, 8.04 days) to billions of years. It is also possible for a radionuclide to decay to another radioactiveelement that has a longer half-life than the original radionuclide. Xenon-135, which is regularly produced by nuclear reactors, (9-hour half-life)decays to Cesium-135 with a half-life of 3 million years. Xenon-135’s hazardous life is defined as 10-20 times the half-life. This is how long itwill take for a given quantity of the radioactive element to decay to undetectable levels. Some radioactive atoms may give off more than onetype of radiation. Radium for instance (which can collect and concentrate in humans), gives off gamma and alpha radiation. This nucleotidewas implicated in the death of Madame Curie, the discoverer of Radium (by inducing an aplastic anemia). Children and the developing fetusare especially susceptible because of their rapid cell division during growth. Cancers linked to ionizing radiation include most blood cancers(leukemia), lung cancer, and many solid tumors of various organs. Birth defects have also been associated with radiation exposure. Radiationmay permanently and unpredictably mutate the human gene pool.What is radioactive waste?Radioactive waste is the unusable byproduct from using, refining, and processing radioactive materials, and from decommissioning equipmentand facilities that use those materials. Radioactive (or nuclear) waste is a byproduct from nuclear reactors, fuel processing plants, andinstitutions such as hospitals and research facilities. It also results from the decommissioning of nuclear reactors and other nuclear facilities thatare permanently shut down. The Nuclear Regulatory Commission separates wastes into two broad classifications: high-level or low-levelwaste. High-level radioactive waste results primarily from the fuel used by reactors to produce electricity. Low-level radioactive waste resultsfrom reactor operations and from medical, academic, industrial, and other commercial uses. Spent (used) nuclear reactor fuel (rods) resultsfrom producing electricity at nuclear power plants (Indian Point) or research reactors, after the usable fuel has been expended, highlyradioactive fuel assemblies remain. Spent fuel is shipped as a solid and is packaged in specially designed containers called "casks" for transport(see below). The spent nuclear fuel results in high-level waste after reprocessing resulting in the recovery of usable radioactive materials. Highlevelwaste includes liquid waste produced directly during reprocessing and solid material derived from such liquid waste that contains fissionproducts. The United States does not presently reprocess spent fuel from power plants, but has in the past. This requires their transport (incasks) to extended storage facility (Yucca Mountain).Transuranic waste contains manmade elements heavier than uranium, thus the name trans (or beyond) uranic. It results from defense productionactivities and includes contaminated protective clothing, tools, glassware, and equipment. Although most transuranic waste is no moreradioactive than low-level waste, it is radioactive for a much longer period of time.Types of Radioactive WasteThe following is generally accepted terminology:• Exempt waste - excluded from regulatory control because radiological hazards are negligible.• Low-level waste (LLW) - contains enough radioactive material to require action for the protection of people, but not so much that itrequires shielding in handling or storage.• Intermediate-level waste (ILW) - requires shielding. If it has more than 4000 Bq/g of long-lived (over 30 year half-life) alpha emittersit is categorized as "long-lived" and requires more sophisticated handling and disposal.• High-level waste (HLW) - sufficiently radioactive to require both shielding and cooling, generates >2 kW/m 3 of heat and has a highlevel of long-lived alpha-emitting isotopes.Low level nuclear waste represents about 90% of all radioactive wastes. It includes ordinary items, such as cloth, bottles, plastic, wipes, etc.that come into contact with some radiation. These low level wastes are generated anywhere radioisotopes are produced or used such as nuclearpower plants, local hospitals and dentist's office, in university research laboratories, in manufacturing and food irradiation facilities. It is notdangerous to handle, and can easily be disposed off in a dry engineered landfill. There, low level wastes are less dangerous than the chemicaland organic wastes from our homes that are sent to municipal landfills. The distinguishing factor of low-level waste is that it contains virtuallyno alpha emitters. Alpha radiation is more dangerous, and, therefore, needs better protection. For regulatory purposes, low level wastes areclassified into three classes (A, B, and C), according to the activity of the waste, the concentration, and the types of radioisotopes it contains.The Nuclear Regulatory Commission has set requirements for each type, so that they are disposed properly and safely. Class A (about 95% ofall low level waste), contains radionuclides with the lowest concentrations and the shortest half-lives. Classes B and C contain greaterconcentrations of radionuclides with longer half-lives, and must meet stricter disposal requirements than Class A waste.Low-Level Radioactive Waste: Federal regulations require that nuclear waste be solid and structurally stable so that it can be transportedmore. Waste that meets these requirements reduces the risk of radiation exposure to humans. Low-level radioactive waste is generated in solidor liquid forms. Very little of it is structurally stable. Therefore, the waste must be converted to an acceptable form for disposal. Low-levelradioactive waste is also treated to reduce its volume. While treatments can reduce the volume of low-level waste, the amount of radioactivematerial present remains essentially unchanged.WWW.NYC.GOV/FDNY 16

Compacting Low-Level RadioactiveWasteSolid Low-Level Radioactive Waste: Most of the low-level radioactive waste generated by nuclear power plants, industry, hospitals, andresearch institutions is in dry, solid form (such as cardboard, paper, plastic, cloth, and glass). To reduce the amount of space required to storethe low-level waste, three processes are used to reduce its volume: compaction, incineration, and shredding.Compaction involves compressing the waste to reduce its volume. Compaction is a relatively inexpensive and widely available option, which isused by many low-level radioactive waste generators.Incineration can be used to reduce the volume of solid low-level radioactive waste. This produces gases and ash radioactive particles. The gasis filtered to remove radioactive particles. The filters become contaminated and must be treated as radioactive waste. The ash is mixed withconcrete or other material to prevent radioactive particles from blowing away. Compaction and incineration are performed in conjunction withshredding. Shredding involves cutting solid low-level radioactive waste into smaller pieces. This allows for more efficient compaction and amore uniform burn for incineration. Any non-radioactive trash that is put in a container with radioactive waste must also be treated asradioactive waste because it might have become contaminated.Liquid Low-Level Radioactive Waste: Liquid low-level radioactive waste is generated primarily by nuclear power plants during purificationof cooling water as well as lubricating oil and sludge’s from filters. Liquid low-level radioactive waste must be solidified for transportation anddisposal. Usually, as much water as possible is removed from the liquid waste, and the remaining material is immobilized. Methods forremoving water include evaporation and filtration. The remaining material is immobilized with solidifying agents such as cement or asphalt.The cement or asphalt is in a structurally stable form which can then be sent to a disposal facility.Short-Lived Low-Level Radioactive Waste: Medical facilities produce both solid and liquid low-level radioactive waste. That is, they decayquite quickly. Some wastes are stored in a container at the hospital until they decay (depends on the half-life of the radioactive materials). Afterthe wastes are analyzed for radioactivity to confirm that they have decayed, they can be disposed of as ordinary trash. This method of handlinglow-level waste is called storage for decay. It reduces the volume of waste to be sent to a low-level waste disposal facility. Low-levelradioactive waste stability requirements and the rapidly rising cost of disposal have encouraged widespread treatment of waste and substantialreductions in volume. In 1981, 2,960,000 cubic feet of commercial low-level radioactive waste were accepted for disposal in the United States.Ten years later, in 1991, the amount of waste accepted for disposal had declined 54% to 1,369,303 cubic feet.High Level Waste:High-level radioactive waste is uranium fuel that has been used in a nuclear power reactor and is “spent” or is no longer efficient in generatingpower to the reactor to produce electricity. Spent fuel is thermally hot as well as being highly radioactive, requiring remote handling andshielding. The fuel assemblies can be as long as 16 feet and can weigh up to 1,200 pounds each. The basic fuel of a nuclear power reactorcontains Uranium 235, which is in ceramic pellets inside of metal rods. Before these fuel rods are used, they are only slightly radioactive andmay be handled without special shielding. During the nuclear reaction, the fuel “fissions,” which means that an atom of uranium is split,releasing two or three neutrons and a small amount of heat. The released neutrons then strike other atoms, causing them to split, and a chainreaction is formed, which releases large amounts of heat. This heat is used to generate electricity at nuclear power plants. The splitting ofrelatively heavy uranium atoms during reactor operation creates radioactive isotopes of several lighter elements, such as Cesium-137 andStrontium-90, called “fission products,” that account for most of the heat and penetrating radiation in high-level waste. Reprocessing is amethod of chemically treating spent fuel to separate out uranium and plutonium. The byproduct of reprocessing is a highly radioactive sludgelikeresidue. Fuel assemblies are treated as high-level waste. The disadvantage of this nuclear fuel cycle is that partially used nuclear fuel istreated as waste, thereby increasing the volume and complexity of disposal. High-level waste is very radioactive and requires special shieldingduring handling and transport. It also needs cooling, because it generates heat because of the high radioactivity level. A typical large nuclearreactor produces 25-30 tons of spent fuel per year. If the fuel were reprocessed and vitrified (after reprocessing the liquid high-level waste canbe calcined (heated strongly) to produce a dry powder which is incorporated into borosilicate ([Pyrex] glass to immobilize the waste), the wastewould be only about 3 cubic meters per year. High-level wastes are hazardous to humans and other life forms because of their high radiationlevels that are capable of producing fatal doses during short periods of direct exposure. For example, ten years after removal from a reactor, thesurface dose rate for a typical spent fuel assembly exceeds 10,000 rem/hour, whereas a fatal whole-body dose for humans is about 500 rem (ifreceived all at one time).WWW.NYC.GOV/FDNY 17

Transuranic Waste: Transuranic (TRU) waste is a regulatory classification of waste that applies only in the U.S. Some uranium atomsalso capture neutrons from fissioning uranium atoms nearby to form heavier elements like plutonium. These heavier-than-uranium, or“transuranic,” elements do not produce nearly the amount of heat or penetrating radiation that fission products do, but they take much longer todecay. Transuranic wastes account for most of the radioactive hazard remaining in high-level waste after a thousand years. This type of wastecontains more than 3700 Bq per gram of elements heavier than uranium. TRU waste is comprised of certain wastes from reprocessing andnuclear weapons production. The commercial nuclear science and technology industry produces no transuranic waste.TRANSPORTATION:About twenty million packages of all sizes containing radioactive materials are routinely transported worldwide annually on public roads,railways and ships. At sea, they are generally carried in purpose-built ships. Since 1971 there have been more than 20,000 shipments of spentfuel and high-level wastes (over 50,000 tons) over more than 30 million kilometers. There has never been any accident in which a containerwith highly radioactive material has been breached, or has leaked.CONCLUSION:Under normal circumstances exposures from radioactive transportation is very low.Estimates for radiation dose from transportation, based on the exposure of a person standing 100 feet from a vehicle that is carrying waste andmoving 15 miles per hour, is about 0.0004 millirem. A person would receive 5,000 to 12,500 times more radiation dose on a round-trip flightfrom Los Angeles to New York on a commercial airline (2-5 millirem). If a person were to stand 100 feet from a transportation route 24 hoursa day for 24 years, and were exposed to all truck shipments (approximately 50,000), that person would receive a total whole-body radiationdose of about 20 millirem. During the same 24-year timeframe, that same person would receive over 7,000 millirem from natural backgroundradiation. This emphasizes the need to approach these motor vehicle accidents in an appropriate and organized manner. An incident involving anuclear transporter does not necessarily result in massive radiation exposure. To date there have been a total of: 2,799 highway truck Casks and720 rail casks shipments through New York, without a major incident. Full-scale tests conducted in 1977 included crashing tractor-trailerscarrying cask prototypes into concrete walls at about 98 and 135 kilometers (61 and 84 miles) per hour. At about 135 kilometers (84 miles) perhour, the cask was slightly dented, but it did not release its simulated radioactive material.Written by:Dario Gonzalez, MD, FACEPDivision 2 Medical DirectorWWW.NYC.GOV/FDNY 18

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NAME: ___________________REMAC# ___________BATT# / HOSP AFFILIATION______________ADDRESS TO FORWARD RESULTS (IF NOT A FDNY EMPLOYEE): ________________________February, 2005 - JOURNAL CME TOPIC - "Radiation Part Four"1. Shipping would (is) via trucks, trains and barges carrying irradiated nuclear fuel and high/low-level radioactive waste.To date there have been ~ 2,500 to 3,000 irradiated nuclear fuel shipments U.S. for well over 50 years.a. Trueb. False2. Large train/barge containers would each hold over 200 times Hiroshima’s long-lasting radioactivitya. Trueb. False3. Radiation is:1. Energy that travels in waves (i.e. visible light, ultraviolet light, radio waves).2. Non-ionizing radiation can shake or move molecules.3. Ionizing radiation can break molecular bonds, causing unpredictable chemical reactions.4. You cannot see, taste, smell or hear ionizing radiation but can feel it on skin.a. 1,2,3b. 2, 3, 4c. 1, 2, 3, 4d. none of the above4. Alpha particles are:1. High energy, large subatomic structures.2. Can not travel very far but can be stopped by a piece of paper or skin.3. Can do a great deal of damage to cells.4. If inhaled, ingested, or injected into the body, they can release energy to cells in organs orblood to surrounding tissue causing significant damage5. Increase the risk of bone and blood cancers (leukemia)a. 1, 2, 3b. 2, 3, 5c. 1, 2, 3, 4d. 2, 3, 4, 55. Half-life:1. The time it takes for ½ of a radioactive element to decay toward stability.2. Some radionuclides decay to a stable element in a long time.3. Uranium-238 has a T ½ of 4.5 billion years, 17 decay steps, before reaching a final, stable formof lead.4. Half-lives can range from fractions of seconds.5. Cancers linked to ionizing radiation include most blood cancers (leukemia), lung cancer.a. 1, 2, 3b. 2, 3, 4c. 1, 3, 4, 5d. all of the aboveWWW.NYC.GOV/FDNY 20

NAME: _______________________REMAC# ___________ BATT# / HOSP AFFILIATION__________________ADDRESS TO FORWARD RESULTS (IF NOT A FDNY EMPLOYEE): ________________________February, 2005 - JOURNAL CME TOPIC - "Radiation Part Four”:6. There has never been any accident in which a container with highly radioactive material has been breached, or hasleaked.a. Trueb. False7. High-level waste (HLW):a. 1, 2, 3b. 2, 3, 4c. 1, 3, 4, 5d. all of the above1. Sufficiently radioactive to require both shielding and cooling, generates heat and hasa high level of long-lived alpha-emitting isotopes.2. Hi level nuclear waste represents about 90% of all radioactive wastes.3. Radioactive waste, uranium fuel that has been used in a nuclear power reactor.4. Also contains Transuranic (TRU) waste.5. Cesium-137 and Strontium-90, called “fission products,” that account for most ofthe heat and penetrating radiation in high-level waste.8. Liquid low-level radioactive waste is immobilized with solidifying agents such as cement or asphalt.a. Trueb. False9. Medical facilities:a. 1 onlyb. 2 onlyc. 1 and 2c. none of the above1. Produce only solid low-level radioactive waste.2. Wastes are stored in a container at the hospital until they decay (depends on thehalf-life of the radioactive materials.10. Estimates for radiation dose from transportation, based on the exposure of a person standing 100 feet from a vehiclethat is carrying waste and moving 15 miles per hour, is about:a. 0.004 milliremb. 0.0004 milliremc. 0.0004 remd. 0.0004 gyWWW.NYC.GOV/FDNY 21

Citywide CMEQUEENSFDNY - Bureau of Training:Host: Dario Gonzalez, MD, FACEPDate: February 23, 2005 1030 - 1430 hoursPlace: Fort Totten, Building #325Topic: Call ReviewLocal 2507 – Uniformed EMT’s and Paramedics Union Headquarters:47-09 30 th Street, 3 rd Floor, LIC - QueensDate: February 24 th , 2005 1800 – 2100 hoursTopic: Case Presentations and Call ReviewSnacks and Beverages served, please call (718) 371-0310 to register.New York Hospital of Queens:Lang AuditoriumTopic: Trauma RoundsEvery MondayCall George Bennedetto @ (718) 670-29291600 - 1730 hoursSaint Anthony's School of Allied Health175-05 Horace Harding Expy, Fresh Meadows, NYTopic: Call ReviewCall (718) 357-0500 ext. 193 for more informationThe Parkway HospitalTopic: Call ReviewDr. Robert AquinoBoard room (1 st Floor)Contact Robert Collins @ (718) 423-0808 - Food and Beverages ServedElmhurst Hospital:Date: February 2 nd , 2005 1600 - 1700 hoursTopic: Grand Rounds/Call ReviewPlace: Auditorium A-122Queens Hospital Center:Date: February 10 th , 2005 1615 - 1815 hoursDate: February 24 th , 2005 1615 – 1815 hoursTopic: Call reviewHost: Dr. Morgan's office in the EDContact the Division 4 ALS Coordinators, for more information on CME activities in Queens.WWW.NYC.GOV/FDNY 22

MANHATTANBellevue Hospital Center, Dr. MenloveTopic: Call Review - "Morning Report"Conference room (behind) ER - Bring two forms of IDEvery: Monday, Tuesday, Thursday and FridayHarlem Hospital Center, Dr. TrowersDr. Trower's OfficeTopic: Call ReviewEvery Thursday - Emergency Department0815 - 0900 hours1600 - 1730 hoursContact the Division 1 or Division 2 coordinators to inquire about CME activities.STATEN ISLANDSt. Vincent's Hospital/ Catholic Medical Center-Staten Island:Topic: Call ReviewLocation: MLB Conference RoomStaten Island University Hospital (SIUH North):Location: Emergency Department Trailer Conference RoomCall David Roshetar @ (718) 226-9089 for more information.Contact Division 5 ALS Coordinator for more information on CME activities.WWW.NYC.GOV/FDNY 23

BRONXNorth Central Bronx Hospital, Dr. Rajesh Verma:Place: CME Sessions held in the ED Conference RoomSt. Barnabas Hospital:Host: Juan Acosta, DOTopic: Call ReviewDate: TBA 1600-1900 hoursEmergency Department conference roomCall: (718) 960-9000 for more informationOur Lady of Mercy Medical Center:Department of Prehospital CareTopic: Call Review3 rd Thursday of every monthCall Jamie Dalton @ (718) 920-9962 for more informationFDNY/EMSC - Battalion 18:Host: Dario Gonzalez, MD (Division Two Medical Director)Topic: Call ReviewDate: February 2 nd , 2005 1600 - 1900 hoursFood will be provided RSVP by 10/06 – Call your ALS coordinator @ (718) 829-6069FDNY/EMSC - Battalion 55:Host: Dario Gonzalez, MD (Division Two Medical Director)Topic: Call reviewDate: February 9 th , 2005 1400 - 1600 hours"BYOS"Call Paramedic Steve Pilla @ (718) 918-7719 for more informationFDNY/EMSC - Battalion 20:Host: Dario Gonzalez, MD (Division Two Medical Director)Topic: Call ReviewDate: February 9 th , 2005 "BYOS" 1800 - 2000 hoursLocation: Jacobi Hospital - Room 1 West 10Call Paramedic Steve Pilla @ (718) 918-7719 for more informationWestchester Square Medical Center:Host: Juan Acosta, DOTopic: Call Review (Please call Dr. Acosta @ (718) 829-6215)Contact Division 2 ALS Coordinators for more information on CME activitiesWWW.NYC.GOV/FDNY 24

BROOKLYNFDNY – Quarterly CME:SUNY – Downstate Medical CenterTopic: Pediatric Emergency Medicine Forum• Recognition of the Sick Child – Nooruddin Tejani, MD• Pediatric Respiratory Emergencies – Evan Mahl, MD• Pediatric Toxicology Potpourri – Mark Su, MDDate: March 24 th , 2005 1800 – 2200 hoursLocation: SUNY Medical School – Basic Science Building395 Lennox Road, Brooklyn, NYRSVP M. Delgado @ (718) 999-2790 by 03/18/2005 – Food and Parking provided!(Parking at E. 34 St/Lennox and Linden)FDNY – Battalion 58:Topic: Call ReviewHost: Glenn Asaeda, MD – Division Medical DirectorDate: February 24 th , 2005 1500 – 1800 hoursLong Island College Hospital:Topic: Call ReviewPlace: Othmer Conference RoomCall Edward Caballero @ (718) 780-1859 for more informationMethodist Hospital:Topic: Emergency Medicine Residency ConferenceDate: Wednesday - Weekly 0830 - 1400 hoursCall (718) 780-5040 to confirm conference scheduleWyckoff Heights Medical Center:Date: TBATopic: Call ReviewCall Jack Finkelstein @ (718) 386-7778 to confirmConey Island Hospital:Topic: Call ReviewDate: Every Wednesday 1000 -1100 hoursLocation: Dr. Soltani's trailer next to hospital Emergency RoomKings County Hospital:Host: Dr. PiusDate: Last Tuesday of every odd month 1800 - 2200 hoursPlace: E.R. Conference RoomCall: (718) 968-9750 for more informationBrookdale University Hospital and Medical Center:Topic: Call ReviewHost: Department of Emergency MedicinePlace: ED Conference RoomCall (718) 240-5570 for more information1700 - 1900 hoursWWW.NYC.GOV/FDNY 25

MonthJanuaryFebruaryMarchAprilMayJuneJulyREMAC OralExaminationPart A Part BTuesday Tuesday1/18/05 1/25/05Part A Part BTuesday Tuesday4/19/05 4/26/05Part A Part BTuesday Tuesday7/12/05 7/19/052005 REMAC Examination ScheduleREMAC Registration Starts Deadline Date NYS/DOH ExamsRefresher (for refreshers only)Wednesday01/26/05 12/1/04 12/31/04 01/2005Wednesday02/23/05 01/1/05 01/31/05Wednesday03/23/05 02/1/05 02/28/05 03/2005Wednesday04/27/05 03/1/05 03/31/05Wednesday05/25/05 04/1/05 04/30/05 05/2005Wednesday06/22/05 05/1/05 05/31/05 06/2005Wednesday07/20/05 06/1/05 06/30/05Wednesday08/17/05 07/1/05 07/31/05 08/2005AugustSeptember Wednesday09/21/05 08/1/05 08/31/05Part A Part B WednesdayOctober Tuesday Tuesday 10/19/05 09/1/05 09/30/0510/11/05 10/18/05November Wednesday11/16/05 10/1/05 10/31/05 11/2005WednesdayDecember12/14/05 11/1/05 11/30/05 12/2005Paramedics with current REMAC certification must register for upcoming refresher examinations by calling (718)-999-7074 during the respective registration periodslisted above. All refresher exams are held at the EMS Division of Training starting at 0700 or 1800 hours. The REMAC Challenge Examination is given on a quarterlybasis, seating is limited so register early. The challenge exam consists of two parts: Part A is a written exam, Part B are orals. All parties interested in taking achallenge examination should plan accordingly (expired REMAC, inadequate CME) and submit their requests in writing to: FDNY - Office of Medical Affairs, 4thFloor, 9 MetroTech Center, Brooklyn, New York 11201WWW.NYC.GOV/FDNY26