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The benefits of deploying health physics specialists to joint operation areas.

Historically, health physics support to the Combined Joint Operations Area-Afghanistan (CJOA-A) was administered by a nuclear medical science officer (NMSO) assigned to Task Force-Medical built around a medical brigade. This officer was responsible for managing the theater health physics program and had no other health physics experts to serve as assistants. In late spring 2013, the NMSO (military occupational specialty [MOS] 72A) position was eliminated to meet force size reduction requirements. The US Forces Afghanistan (USFOR-A) Safety Office initiated a hiring action for a civilian radiation safety professional at this time, but the hiring action was never approved. An NMSO working as the senior medical planner at the International Security Assistance Force Joint Command Headquarters for most of 2013 was available to provide consultation assistance. However, the loss of the dedicated NMSO position left the CJOA-A without a full-time health physics expert when a surge in the health physics mission workload and a corresponding heightening of ionizing radiation exposure risks occurred in early 2014.

The reasons for the surge in health physics mission requirements in 2014 were varied. A primary cause was the acceleration of retrograde operations which led to progressively larger quantities of radioactive commodities arriving for processing and shipping at the Bagram Airfield (BAF) and Kandahar Airfield (KAF) Redistribution Property Accountability Team (RPAT) yards. The arrival rates of these commodities far exceeded removal rates, thus overtaxing the RPAT yard's management capabilities and creating problems in storage of such items. Another leading cause was a dramatic increase in base closures and increase in demolitions of structures. These activities led to the discovery of orphan sources (unwanted and uncontrolled radioactive materials) on the installations and also necessitated radiological surveys of foreign military equipment on some of the closing bases to clear for demilitarization and removal. Additionally, safety concerns about exposures to x-ray and gamma radiation sources in mobile vehicle and cargo inspection systems (MVACISs) found at installation entry control points spurred a requirement to begin monitoring and inspecting the operation of these systems.

Filling the health physics capability gap left by the departure of the NMSO forced medical planners in the CJOA-A to devise a solution within the mandated force management level constraints at the time. Under these constraints, reestablishing the lost NMSO billet was not deemed a viable option due to the General Officer level of approval necessary for such action. The developed solution was to substitute 2 health physics specialists (HPSs) for preventive medicine specialists projected to arrive in June of 2014 with the incoming 172nd Preventive Medicine Detachment (PM Det). As a stopgap measure, an HPS who had deployed as a Battle Noncommissioned Officer with the 31st Combat Support Hospital (Task Force 31) in February 2014, was employed to perform crucial health physics mission requirements on a part-time base until arrival of the 172nd PM Det.

The substitution of HPSs for PMS was made possible by the fact that HPSs are former preventive medicine specialists. The only difference between the 2 types of specialists from a qualifications standpoint is the HPSs have completed a 20-week course to earn N4 skill identifier. The HPS may be considered MOS qualified to perform PMS tasks and as such executed these tasks on a routine basis in Afghanistan. However, HPSs are consistently in short supply due to the rigors of their academic training and are usually assigned to health care facilities to support health physics programs. Their small number and high garrison demand have made long-duration deployments rare and deprived them the opportunity to prove their value in the combat theater environment. Therefore, their deployment to the CJOA-A beginning in 2014 was a unique event providing an opportunity for lessons to be learned about how to best employ them.

MISSION OVERVIEW

The HPSs assigned to the 172nd PM Det served on PM teams at BAF and KAF. The HPS at BAF supported Regional Command (RC)-North, RC-East, RC-West, and RC-Capital, while the other supported RC-South and RC-Southwest. When not performing health physics missions, they were engaged in standard preventive medicine technician duties such as sanitation inspections and water quality monitoring. The most common health physics and radiation safety missions performed are summarized in the Table. It is important to note these missions could have been executed by a NMSO. The medical imaging oversight mission was performed by a 2-person team comprised of a NMSO and a HPS from US Army Public Health Command (USAPHC) brought in for a 3-week period. The remaining missions shown in the Table were performed by the HPSs assigned to the PM Det.

MVACIS Inspections

Many entry control points used MVACIS to image local national vehicles for weapons and explosives prior to permitting their entry onto installations. The Nuclear Regulatory Commission (NRC) regulates the MVACIS radioactive sources in the United States. The Communications-Electronics Command (CECOM) holds the NRC license for these sources before they are shipped overseas. Although the NRC does not have jurisdiction, the MVACIS sources are managed by an Army Radiation Authorization given to USFOR-A by CECOM. Appointments as Radiation Safety Officers for NRC licenses and Army Radiation Authorizations are routinely held by NMSOs, civilian health physicists, or very specialized trained individuals.

United States and International Security Assistance Force (ISAF) uniformed personnel assigned security responsibilities for installations served as the operators of these systems. Many operators had no experience with MVACIS operations prior to their deployments and had never been enrolled in a radiation dosimetry program. Contractors were used by ISAF and USFOR-A to maintain and service these systems. The contractors would position contract service representatives (CSRs) at major bases and designate coverage areas for the representatives to support. The CSRs would travel to the bases to administer safety and operator training, and issue and collect thermoluminescent dosimeters. They also visited entry control points at a specified frequency to examine the daily exposure by reading records kept by operators, collect and reissue dosimeters, and troubleshoot any problems. Upon the completion of the visit, they would offer recommendations and advice to the site operators on improving work practices. The effectiveness of their visits was limited since they lacked the authority to hold operators accountable for failing to follow proper safety procedures.

In order to address radiation exposure concerns and improve radiation safety operational practices, in mid-2014 USFOR-A issued a directive implementing MVACIS inspection program (Figure 1). The inspection checklist was developed with input from the HPSs, USAPHC health physics experts, and the civilian radiation safety officer employed by the largest MVACIS contractor in Afghanistan. Prior to starting the quarterly inspections, an initial site assistance visit was completed at each ECP by the HPSs or uniformed PM personnel at bases not supported by the 172nd PM Det. The non-HPS inspectors received training by the CSRs on how to perform these inspections before initiating the initial site assistance visits. The scrutiny and attention garnered by the inspections improved operator adherence to safety policies and procedures. The inspections also improved the completeness of occupational and environmental health site assessments since preventive medicine elements had previously not been populating the Defense Occupational and Environmental Health Readiness System's (DOEHRS) DoD Deployment Surveillance Portal with information concerning the occupational hazards associated with MVACIS radiation emissions.

Radioactive Commodity Retrograde Support

Over the course of 13 years of continuous military operations, significant quantities of US equipment containing radioisotopes had been brought into Afghanistan. Examples of some of the more common items included weapon system optics, compasses, and chemical agent detection alarms. The processes and procedures for retrograding items varied based on the manager of the commodity and the type of radioisotope it contained. Many items had to be tested through the collection and submission of wipe tests to the US Army Test, Measurement, and Diagnostic Equipment laboratory in Pirmasens, Germany, to prove they had been surveyed with a radiation detection device and were free of leaks before final packaging and shipment. Prior to arrival of the HPSs, there was only one contractor in all of Afghanistan stationed at KAF qualified to perform wipe sampling.

When the push to retrograde commodities began, management and shipping processes were not sufficiently mature to handle the influx of turned-in items. The problem was further magnified by a lack of trained personnel to support these processes. Unlike the drawdown from Operation Iraqi Freedom, there was no Army Contaminated Equipment Team, a special team deployed by the Army Material Command, to lead the radioactive commodities retrograde effort in Afghanistan. Efforts to overcome personnel shortfalls were further hampered by delays in civilian hiring actions; stringent force management level constraints governing the number of contractors, service members, and Department of Defense employees permitted in country; and difficulties in modifying inflexible scopes of work to permit contractors already involved with in country retrograde operations to participate in radioactive commodity retrograde support activities.

By necessity, the HPSs were used to support the retrograde effort even though retrograding activities are doctrinally the responsibility of logistics rather than medical authorities. Their assistance was broad in scope and evolved throughout the deployment as new challenges were identified and previous problems were solved. The effect of their assistance was greatly amplified by their exceptional knowledge base in health physics, strong oral and written communication skills, and the credibility boost offered by their ranks as noncommissioned officers. Those areas of assistance where the HPSs had the most meaningful effect on retrograde support were in the administration of safety awareness training to retrosort yard personnel, reviewing and coauthoring pertinent standard operating procedures and policy documents, relieving the wipe sample collection backlog through additional sampling, surveying prepped shipments, participation in installation radiation safety working groups, and providing consultative services to aid the establishment of a consolidated radioactive commodities storage area on BAF.

Radiation Surveys

During the course of their deployment, the HPSs performed surveys of areas and equipment possibly contaminated with radioactive material. Some of these surveys were of an urgent nature and required prompt execution, while others were less time-sensitive. The urgent surveys were typically high profile and garnered intense interest from senior commanders. One such incident resulted after a report was received about possible acute radiation exposures from a malfunctioning X-ray emitting MVACIS received by North Atlantic Treaty Organization (NATO) soldiers manning an entry control point at the ISAF Headquarters in downtown Kabul. The guards were evacuated to a nearby NATO-run hospital and kept under medical observation for symptoms of acute radiation sickness after it was discovered that one of the 3 x-ray tubes of the MVACIS was not functioning properly, and high radiation readings were allegedly read from a radiation detection meter.

Within one hour of notification of the incident, a HPS was flown by air ambulance from BAF to the scene to investigate. Much to the relief of all parties involved, this investigation conclusively proved that no medically significant radiation releases had occurred. The malfunctioning x-ray tube was determined to be burned-out, meaning it could not emit any x-ray radiation. The alleged high radiation measurements were due to a 3 order of magnitude instrument reading error. As an additional precautionary measure, the HPS performed a radiation survey of the entry control point and found no radiation readings above normal background levels.

Another high-profile radiation survey was performed at the site of an MI-17 helicopter fire within a hangar at the New Kabul Afghanistan International Airport (Figures 2 and 3). The Russian-made helicopter was the property of the Afghanistan Air Force (AAA) and was equipped with instrumentation that contains radioisotopes. The hangar where the helicopter was parked was an important rotary wing aircraft maintenance location and also served as a training area where US military experts administered hands-on training to AAA maintenance recruits. Senior AAA and ISAF leadership wanted to remove the burned out helicopter hulk and resume hangar operations as soon as possible; however, a radiation survey was first required to assess the dangers posed from any radiation contamination. The survey results from the HPS found the hangar free of contamination, thus clearing the way for recovery operations.

Most radiation surveys performed by the HPS were not as spectacular as the two previous examples. The majority of surveys supported retrograde efforts and included surveys checking for contaminated areas at radioactive commodity storage locations and the aforementioned surveys of items prepped for shipment out of the CJOAA. The HPSs also surveyed items, often of foreign make, earmarked for demilitarization to certify those items were radioisotope free.

Orphan Source Management

There were several instances where the HPSs were called upon to provide assistance and consultative support in dealing with orphan sources discovered on ISAF installations. Examples of such orphan sources included a Soviet-era ice detector containing strontium-90, a beta emitter, found at BAF (Figure 4); thorium nitrate, an alpha emitter, encapsulated in concrete within a 5 gallon bucket in an abandoned building that once served as an East German Pharmaceutical Plant on Camp Phoenix (Figure 5); and 2 ion chamber survey meters improperly discarded, presumably by a contractor, in a dumpster at BAF. Though all the orphan source discovery incidents were judged by the HPS to pose low health risks, they were, nevertheless, documented and archived within DOEHRS.

Medical Imaging System Oversight

One of the basic responsibilities for HPSs in a nondeployed environment is to ensure medical imaging systems (x-rays, fluoroscopy machines, and computed tomography scanners) at medical treatment facilities, dental clinics, and veterinary clinics are functioning properly. The highly specialized equipment necessary to perform these checks was not available in Afghanistan. As such, the oversight role of medical imaging systems for HPSs within Afghanistan was limited to checking on TLD wearing and monitoring system operator work practices to determine their adherence to as low as reasonably achievable radiation exposure work practices. In order to satisfy the regulatory requirement for an annual check of imaging systems, a request for assistance was submitted by USFOR-A in collaboration with US Army Central Command to the US Army Medical Command for a team to perform these checks. This team spent 3 weeks in country checking 17 systems at 6 installations.

RECOMMENDATIONS

The health physics support provided by the HPSs proved to be of great benefit across multiple staff support areas (safety, logistics, and force health protection). As a first of its kind deployment, there was initially some confusion as to how best utilize them. The confusion abated as duties and responsibilities became better defined and beneficial partnerships with other organizations and commands were established. The following paragraphs offer several recommendations on how to best prepare, equip, and employ HPs should they be used for future long-term deployments.

Preparation

Since HPSs are not assigned to PM Dets in garrison, they should be afforded an opportunity to participate in the PM Det's predeployment certification training exercise. Doing so allows them to meet their deployment teammates, relearn basic PMS tasks, and advance their understanding of health physic mission requirements in the deployed environment before arriving at the deployment destination. The HPSs selected to deploy should be knowledgeable in performing medical imaging system surveys and conducting contamination surveys, and skilled in decontamination practices. Given the strong possibility of being asked to provide retrograde operation support and MVACIS inspections, completion of Class 7 shipment training and familiarization with MVACIS radiation safety fundamentals prior to deployment is advisable. In addition, they should have the necessary rank, experience, and initiative to successfully establish and maintain an effective health physics program in the absence of a NMSO or other officers well versed in health physics.

Equipment

With the exception of the medical imaging radiation surveys, all other surveys performed by the HPSs required use of an AN/PDR 77 radiac set plus its accessories to measure and detect radiation levels. This radiac set is not an item found in the modified table of organization and equipment of a PM Detachment. One of the 2 sets used in Afghanistan by the HPSs was a loaner from a USAPHC, while the other was acquired through logistic channels after submitting an operational needs statement. Had these radiac sets not been available, the scope and the overall effectiveness of the services provided by the HPSs would have been severely diminished. A commercial off-the-shelf portable gamma spectroscopy instrument will also be useful in a theater of operations since it can identify common radioisotopes, is more sensitive than the AN/PDR-77 in detecting gamma-emitters, and can detect some neutron emissions.

Employment

Since the bulk of the HPS mission services occurred at the retrograde hubs at BAF and KAF, this was logically the best location to station them. While stationed here, they had ample time to gain an understanding of the retrograde processes and learn where their services were needed most to support retrograde efforts. Also, BAF and KAF were installations where the 172nd PM Det had the lead for providing most PM support. This meant the HPSs were able to perform PMS mission work when there were lulls in the health physics missions.

Currently, there is only one HPS for the 224th PM Det which replaced the 172nd PM Det. This soldier is located at BAF where the majority of the health physics operations are concentrated. The USFOR-A is preparing to designate an Air Force Industrial Hygienist as their Radiation Safety Officer (RSO), in absence of an NMSO, and the HPS as the alternate RSO. A NMSO recently arrived in Kuwait and provides long-distance support to Afghanistan and other countries in the area of operations. The NMSO serves as a bridging solution until the safety community develops a permanent solution for the Radiation Safety Program.

CONCLUSION

Maintaining a capability to execute health physics missions is critical and likely to grow in urgency and magnitude during the drawdown phase of an overseas military deployment operation. In the absence of an available NMSO, medical planners should give strong consideration to deploying HPSs to assist with filling health physics and radiation safety capability gaps. An ideal place to assign HPSs is within a deploying PM Det. As members of the detachment, they are well-positioned to execute their health physics missions while also being available to perform routine PMS duties. The HPSs deployed to the CJOA-A in 2014 executed a multitude of crucial missions. Some of the missions were extremely high profile with significant diplomatic implications. Based on the notable success of their Afghanistan deployment, the HPSs have proven their worth many times over and should be considered for future deployments.

LTC Scott Mower, MS, USA

MAJ Joshua D. Bast, MS, USA

MAJ Margaret Myers, MS, USA

AUTHORS

LTC Mower was the International Security Assistance Force Joint Command and US Forces-Afghanistan (USFOR-A) Force Health Protection Consultant from January through October 2014 at North Kabul Afghanistan International Airport. He is an Environmental Science and Engineering Officer and Registered Environmental Health Specialist assigned to XVIII Airborne Corps, Fort Bragg, North Carolina.

MAJ Bast is an Army Medical Entomologist and the Commander of the 172nd Preventive Medicine Detachment, which deployed to Afghanistan from June 2014 through February 2015. He also served as the USFOR-A Force Health Protection Consultant from October 2014 through January 2015.

MAJ Myers is currently serving in Kuwait as the Theater Radiation Safety Officer at US Army Central Command Headquarters (Forward). Her duties require frequent travel to Afghanistan.

Health Physics and Radiation Safety Missions

       Type                 Frequency        Description

Mobile Vehicle and Cargo    Quarterly    Quarterly inspections of
Inspection System                        MVACIS at entry control
(MVACIS) inspections                     points to ensure safe
                                         system operation.

Radioactive commodity       Continuous   Consultation on the
retrograde support                       establishment and operation
                                         of a consolidated storage
                                         locations, offering
                                         radiation safety training
                                         to the workforce, leak
                                         testing turned-in items,
                                         and surveying packaged
                                         items prior to shipment.

Radiation surveys           As needed    Survey with specialized
                                         measurement equipment areas
                                         where a suspected radiation
                                         release and/or exposure has
                                         occurred, followed by an
                                         assessment of health risks.

Orphan source management    As needed    Provide assistance and
                                         consultation on how to
                                         manage items unexpectedly
                                         found on installations.
                                         These discoveries could
                                         prompt a radiation survey
                                         mission.

Medical imaging system      Annually     Inspection of HCF imaging
oversight                                equipment that emits
                                         ionizing radiation.
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Author:Mower, Scott; Bast, Joshua D.; Myers, Margaret
Publication:U.S. Army Medical Department Journal
Date:Jul 1, 2015
Words:3320
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