I very rarely republish items on EMR and HIPAA. However, every once in a while something is so good that I think it’s worth sharing so that more people can read. The following is one such case. I loved reading Dr. Rowley’s perspective on the Japan disaster and potential radiation health risks. The article was originally published on the EHR Bloggers site. As Dr. Rowley, our thoughts are with those in Japan who are suffering amidst this terrible disaster. Hopefully the following thoughts will clarify a confusing situation.
The horrific events we have seen unfold in Japan as the result of the recent earthquake and tsunami, and subsequent instability of a large nuclear facility in the disaster zone with (at least) partial melt-down of the uranium fuel, raises questions of health risks from radiation exposure.
Granted that the West Coast of the U.S. is some 7000 miles away, and disbursement of any radiation leaked into the air in Japan, carried by the jet stream eastward, would expose people here only trivially. Even close to the reactor, as nicely illustrated by a New York Times graphichere, the amount of ambient radioactivity is less than the average annual dosage experienced from all sources by Americans in a year, though spikes in exposure can be higher. The potential for a full meltdown with much larger escape of radiation still exists, with differences of opinion as to the probability of this.
The more likely health issues related to radiation exposure from this catastrophe is from people who were nearby, and leaving the highest-risk areas (see BBC article here). Because of crippled infrastructure and shortages of food in many grocery stores in a widespread area, people have been not only leaving the area, but also leaving the country. And those exiting the country may end up in the U.S., seeking medical attention.
What should practitioners do? Are there any precedents to a situation like this?
Historical experience from 35 years ago
I am reminded of an experience in the mid 1970s, when I was a medical student at UCSF. I was part of an organizing effort that included UCSF and several local community organizations, which helped with outreach to local hibakusha – survivors of the Hiroshima and Nagasaki atomic bombs, now living in the U.S. The atomic explosions (one was uranium-based, like what is now used in nuclear power plants at much lower levels; and one was plutonium-based) killed over 200,000 people and injured 150,000 more. Many of these survivors remained in Japan, but some 30,000 of them were American-born and many returned to the U.S. (see an in-depth article that appeared in People in 1990 here). They were often Japanese-Americans visiting Japan when the war broke out, were trapped there unable to return during the war, survived the Hiroshima and Nagasaki atomic bombs, and afterwards came home. During the 1970 outreach campaign I was involved with, there were about 400 hibakusha living in the Bay Area.
Nuclear survivors were often afraid to make their history known, partly due to social stigma, and partly dueto fear of losing health insurance coverage for radiation-related illnesses – an increased risk of thyroid disease and thyroid cancer was seen in this population (long-term effect), with increased risks of multiple other cancers seen (medium-term effects), and blood and immune system suppression (acute effect).
Besides the actual health risks, there was also fear and discrimination – a stigma of being “exposed” – with the unfounded belief that those exposed to radiation were themselves radioactive, and would expose others to ill effects of this imagined “radioactivity.” It took education to overcome these mistaken beliefs.
Post-war, Japan had enacted specific government-funded programs for hibakusha, and periodically assessed their health and treated their illnesses. This included sending teams from Hiroshima that would travel to the U.S. to reach out to survivors here – this was the program I was involved in. UCSF hosted the Hiroshima team, and a variety of community groups helped reach out to hibakusha, and bring them to “Hiroshima clinic day” in San Francisco.
In the context of history, the scale of radiation exposure, and how to take care of people significantly exposed, is nowhere near what has been seen in the past. However, the issues of exposure to radioactivity from a compromised nuclear power plant should not be minimized – the risks are real, particularly for those living nearby.
Hawaii and the West Coast of the U.S. may experience some measurable increase in background radiation levels, not unlike a solar flare, or flying in an airplane at 30,000 feet. Our instruments for detecting such radiation are very sensitive. This is not likely to be the source of impact on the health care system.
More likely, practitioners may face the issue of taking care of someone who was near the disaster zone in Japan, who has now left and is in the U.S., and is concerned about radiation exposure. There is (unfortunately) much experience in dealing with such issues at orders-of-magnitude higher levels of exposure.
Based on the hibakusha experience, monitoring of blood counts (CBCs), thyroid functions and a comprehensive metabolic panel (which includes liver function tests) are about all that is indicated. For practitioners looking to code for such encounters, the ICD9-CM codes E926.8 (exposure to other specified radiation) or E926.9 (exposure to unspecified radiation) can be used.
The larger issue is reassurance and adding the calming effect of reason on a situation of fear and rumor. Unless one ingests a radioactive substance that remains in the body, being exposed to external radiation does not render one “radioactive” and there is no risk of “contaminating” others. The levels of radiation seen, even right at the nuclear power plant during times of reactor explosions, have remained less than that experienced by someone undergoing a full-body CT scan (compare the levels in the New York Times graph here).
The impact of modern health IT
Another difference in the world since the 1970s (now-vs.-then) has been the emergence of health information technology (HIT), including web-based Electronic Health Records (EHR) systems. This kind of technology is capable of capturing clinical encounter data from practices in all settings, and identifying issues among those with radiation exposure. Reporting these findings – whether to the CDC or to Japanese health authorities – can be done more systematically, and much more quickly than was ever dreamed possible in the 1970s.
In addition, the source of the health information can be much more grass-roots. Modern web-based EHR systems are used by local ambulatory clinicians in their private practices, and not necessarily affiliated with an institution. The need for travelling teams, university-to-university, is not as much of a requirement as it was in the 1970s, given modern HIT.
Our hearts go out to those who have suffered tremendous loss and upheaval in Japan. Assisting with the rebuilding of a devastated infrastructure is something everyone who can should do. The health effects seen outside the immediate area, however, should be put into their proper perspective – those leaving the disaster area will need our help. But the risk to U.S. populations – even those on the West Coast (7000 miles downwind) – is not where our attention should be.
Robert Rowley MD
Chief Medical Officer
Practice Fusion EMR