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FOR TRlP REPORTS SUEMITTED TO TEE OFFICE OF ENERGY RESEARCH Destin z tion( s) and Dates for Which Trip Reoorr Be in s Sub c it : e d : Mcxico City, Mexico ?larch 8-12, 1989 Joint Trip Report Lg Yes Roqer J.C lou tier
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TEAM FOREIGN TRIP REPORT Medical Sciences Division Chief, Radiation Medicine, EtEAC/TS Oak Ridge Associated Universities DESTINATION AND DATES: Mexico City, Mexico PURPOSE OF TRIP: To assist in the medicalhealth physics management of irradiated victims for IAEA and the governments of El Salvador and Mexico in the February 5, 1989, 6oCo accident that occurred in San Salvador, El Salvador.
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Tuesday, February 29, 1989, REAC/TS received a request from Mr. Ephraim Asculai, Coordinator, Emergency Assistance Services, International Atomic Energy Agency (IAEA), Vienna, Austria, for assistance to the government of El Salvador concerning a radiation accident that occurred February 5, 1989, in San Salvador, where three workers had received high radiation exposures (Attachment A). REAC/TS confirmed to IAEA that expert assistance was available to travel radiation biologist, and Mr. Roger Cloutier, Health Physicist. Expenses for Despite extensive staff assistance by IAEA-Vienna, U.S. Department of State, and the Pan American Health Organization, local conditions in El Salvador prevented immediate establishment of a local working contract. difficulty was overcome finally when two of the three irradiated patients were transferred to the Hospital Angeles del Pedregal in Mexico City whose staff then renewed the request for REAC/TS assistance from IAEA. As a result, Drs. Lushbaugh and Ricks traveled to Mexico City on March 8,1989, and were joined there by Kr. Roger Cloutier on March 10. staff of the Mexican Nuclear Safety and Safeguards Commission who also provided local travel to a clinical briefing at the hospital with Dr. Rafael Hurtado Clearing customs was expedited by HOW THE ACCIDENT HAPPENED: A gamma-ray facility (DEIMED) for sterilizing plastic products for medical use, located in San Salvador, El Salvador, S.A. was entered on February 5, 1989, by three workmen intent on restoring it to use after a malfunction (see instructions since these had been by-passed without injury several times since the machine was first installed in 1974 by Atomic Energy of Canada (AECL). They ignored safe operational (NORDION, Inc. is responsible now.) Built to contain up to 500,000 curies of 6oCo, it now contained 18,000 curies; had not been senriced since installation; and the radiation monitors controlling the door interlocks to prevent entry
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during operation had failed and not been replaced. country caused frequent power failures which randomly stopped the operation of maintenance all led to the situation on February 5 when such a power failure caused the radioactive source holder to "fail safe" but bind in the slot-like shroud and not return to the protective pool of water under it. entered the device (see diagram) to correct this malfunction and were exposed for 3-10 minutes in so doing. facility later that day). The civil war in the These malfunctions, the age of the equipment, and poor (We learned later that 13 others entered the Questioning the three early victims, 33-40 days later enabled the team obtain the best available information about the location of the men in the facility in relation to the source and the length of time they were there. Previously the physical size and strength of the 6oCo source had been obtained from the NORDION company whose repairman had visited the facility during the first week after the mishap and had decommissioned it to prevent further accidents. (The NORDION staff were not told of the radiation injuries.) Our best guess is that the victims were exposed for perhaps 3-4 minutes. Patient A (the operator) was closest to the source rack and partially shielded the patients and the nature of their skin injuries and the areas of epilation that the most likely exposures (air) were: The health physicists estimated from their conversation with The drawing from the health physics report which are the basis of these estimates are attached (Attachment D). (These early estimates were much larger than those made by Drs. Ricks and Lushbaugh on the basis of the skin injuries - Mexico Trip Repore
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RADIOBIOLOGIC AND MEDICAL IMPRESSIONS: Patient (F.R.) (REAG/TS CASE 1039.02) was a small dark skinned man who was Except for persisting wisps of head His anterior skin surfaces were He suffered acutely from the machine operator and trouble shooter. hair and he had almost completely epilated. much more darkly pigmented that those of his back. severe small tremors, weakness, and emaciation. The medical staff attributed these symptoms to the GMCSF drug he was receiving by way of an indwelling I . V . tube (said to end in his superior vena cava). He had a "guesstimated" loss of weight of -90 pounds. His eye sockets and cheeks were sunken. His sclerae were slightly yellow. There was a crusted hemorrhagic lesion on the left naries (herpes?). The mucosa of the mouth was dry and covered with thick mucus. The deeply pigmented skin of the anterior surface of his torso was undergoing dry desquamation which left a much lighter pigmented skin surface.. (less than 1 cm2) flakes were being shed. This process extended to just above the ankles where it abruptly changed to wet desquamation down to a depigmented pinkish epidermis and dermis of the feet and ankles which contained punctate hemorrhages. The wet appearance of the feet (top and bottom were similar) was enhanced by copious amounts of a thick clear salve (Aquaphor) that covered them. There were numerous small (<1 cm) up to large ( 4 - 5 cm) islands of light pink skin which were difficult to interpret grossly the ankles. The lateral side of the left foot and contiguous bottom showed a large depigmented area that was irregularly epithelialized. This area covered approximately one-third of the foot. of dry desquamation and depigmentation. pigmented and small for the patient's age. The exudative process of the feet extended about 4 - 5 cm above The right knee had a large but dry area The penis and testes were darkly He was uncircumcised. (sleep?) (attributed to a cerebral drug reaction). "seizures" his eyes would roll back and he would lose consciousness but would become instantly alert when the physician or nurse spoke to him. hyperpigmented and had mild dry desquamation of the lower abdomen and anterior aspects of his thighs and lower legs. However, he was passing in and out of a semi-comatose state During one of these He was not His scalp hair was thick and black but Mexico Trip Report
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could be pulled out in the frontal area but with difficulty. scabbed ulcerated lesions of the upper and lower lips were present (herpes?). He appeared shaven. His eyelashes and eyebrows were still present; axillary and pubic hair were partially epilated. slight ankylosis of the terminal phalangeal joints which, on their dorsal surface, had "Heberden- like nodes." The feet were more seriously deformed by an ankylosis of all toes and a deformity that can best be described as severe desquamation in which large sheets of epidermis were being shed but was still semigelatinous dressing (Aquaphor) under which there was a superficially exudative surface of pink skin that showed many fresh petechial to small His hands were thin and deformed by a The dorsal and plantar surfaces showed severe superficially wet This man's feet were also covered by copious amounts of the clear The external genitalia were atrophic but not darkly not overly concerned about the situation. His dense, black scalp hair could be plucked out over both temples. His mustache, eyebrows, and lashes were intact. H i s eyes and pharyngeal surfaces were normal. His skin color was swarthy but definitely did not show pathologic pigmentation. His axillary and pubic hair was sparse. The beard on his chin was not evident. He had no lesions of the mouth or pharynx. There was a 2 x 3 cm superficial hyperkeratotic healed broken blister that involved the base of the left large toe and the sole in that area. This may represent an area of chronic fungal dermatitis. Active dermal desquamation was not evident. The genitalia were those of a young uncircumcised The medical impressions of these men were compatible with their operative roles and stated positions at the time of their exposures as described in their scenarios, in that patient A obviously had the greatest exposure to the largest area of the front of his body, patient B had had about half of Patient A's dose and Patient C had had the least dose, about half of patient B's dose. Patient C ' s radiation dose to his feet as well as his body skin was thought to be less other men were in the 20 to 30 Cy range rather than the 100 to 200 Cy range. The estimate is supported by the medical facts that some of the skin of the left lower foot of patient A was spared, his right knee suffered only dry This low estimate suggested that the doses to the feet of the
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desquamation (10 Cy) and none of the skin lesions of both men were "full thickness" and completely desquamated. These low dose estimates and the superficial nature of all of the skin lesions are radiobiologically illogical in contrast with the severe granulocytopenia and the prolonged white blood cell nadir, both of which suggest severe gamma ray damage to the bone marrow. in the 5.0 to 10.0 Gy dose range. lymphocytes support the bone marrow dose estimates. Littlefield and Mr. G. Joiner are attached - Attachment E) The acute doses to the feet of both patient A and B were estimated by the health physicist status of the two men at 80 days post exposure was so much better than the condition of their feet then that more objective clinical information is obviously needed before a clinical dosage estimate can be given with any certainty de novo. The prognosis for both men's survival was poor at the time of our departure on May 12, 1989 (Patient A - least likely to survive, Patient B - probable survival if infection was prevented). likely to survive. was obtained he should be allowed to be ambulatory at home. The cytogenetic studies of the damage of cultured to have been in excess of 100 Gy, possibly 200 Gy. The clinical Patient C seemed most We suggested that once evidence of his marrow's restoration The clinical laboratory results, particularly those of the blood counts, were also confusing in light of the skin lesions (see attached (F) measurements and graphs) since unusually delayed nadirs were found which persisted in spite of 800 micrograms daily of GMCSF to patients A and B. We conclude at this time that cytogenetic analyses of the cooled and transported blood samples of these patients by Dr. G. Littlefield and Mr. Eugene Joiner, ORAU REAC/TS staff, provided the best (most certain) objective lymphocyte (BM) dose was computed from the analysis of chromosome breaks as - not help explain the prolongation of the (expected) severe granulocytopenia or the severe (unexpected) anemia seen early in the course of patient A and left unexplained by the clinical evidence of an uneven dose distribution of lower and ventral body exposures. m e cytogenetic studies demonstrated apparently These estimates did Mexico Trip Report
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At this time (May 1, 1989; 85 days post-accident), the high (acute lethal) probability for Patient A has proven to be overly pessimistic: the good prognosis for Patient C has been borne out; the poor prognosis for the healing of the superficially irradiated feet appears to be correct. the impression of there being a complicating congenital connective tissue lesion underlying the injuries of the feet of Patient B that would force a surgical approach to the rehabilitation of Patient B is yet to be assessed. The correctness of The absence of serious infections in these patients was seen as a measure of the excellence of hospital, staff, and the attending hematologists, dermatologists, and infectious disease experts. REAC/TS has maintained contact with Dr. Rafael Hurtado Monroy in order to receive updated information on the progress of the three Salvadoran radiation accident victims. On Tuesday, March 21, 1989, Dr. Hurtado reported that the patients were no longer receiving GMCSF and that all three appeared to be recovering from their radiation-induced hematopoietic insult. April 13, 1989, Dr. Hurtado reported that the patient with the least whole body radiation had been released from the hospital and returned to his home in San recovered from their bone marrow suppression but were still unable to walk due to their severely irradiated feet. Dr. Hurtado also reported that the feet of these two patients were healing slowly. Vascular imaging did not reveal any circulatory embarrassment at this time, but the two tests used (Thallium scan and Doppler study) are difficult to interpret. delayed information is that 13 other workers entered the DELMED radiation facility (without film badges) some time later than the three workers we The other two patients who were more severely irradiated had Our most recent but greatly visited in Mexico City. Argentina for analysis are said to have shown the largest lymphocyte dose to be 0.4 Gy. (This is a personal communication by Dr. C. Barros, PAHO.) Blood samples from these persons that were sent to Mexico Trip Report
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Copies of photographs taken by REAC/TS staff on Thursday, March 9, as well as reference material requested by Dr. Hurtado were forwarded to Mexico City. Dr. Hurtado has indicated that additional information will be shared with REAC/TS at a later date, but it may be necessary for REAC/TS staff to return to Mexico C i t y in the near future to complete retrieval of all pertinent clinical information and to visit the facility itself in San Salvador in order to learn the complete truth about this accident. Mexico Trip Report