Under Siege 3 - "Bored Review"

It’s 1:28am and the Red Phone in your critical care area rings. It’s the vice president who is notifying you personally that the HAZMAT team is enroute with Steven Seagal.

Seagal, who single handedly stopped a terrorist with a nondescript accent from setting off a nuclear weapon in your city, was exposed to ~2Gy of gamma radiation 6 hours ago.

He is currently complaining of nausea, vomiting and, according to EMS, is febrile but otherwise hemodynamically stable.

Even though you know that Steven Seagal will never die, you prepare your ED with a Radiation Emergency Area (REA) and gather your Personal Protective Equipment (PPE), including a personal dosimeter.

(1) What stage of the Acute Radiation Syndrome (ARS) is Steven Seagal experiencing?

ARS consists of 4 phases:

i. Prodromal (Minutes to days).

ii. Latent (After prodrome, can last minutes to 3 weeks depending on dose)

iii. Manifest illness (3 subsyndromes with different durations).

iv. Recovery or death.

Considering the timing (within 24 hours) and symptoms, this is likely the Prodromal Phase. The prodromal phase is a self limiting phase that can occur within minutes to days after exposure depending on the dose. Symptoms include: nausea, vomiting, anorexia and in high doses diarrhea. Additional symptoms may include pyrexia and fatigue.

(2) One week later, Segal develops epistaxis, cough and fever, but otherwise states that he feels strong enough to fight for Pandas and Freedom. What subsyndrome of manifest illness is he experiencing?

Considering the dose (2Gy), timing (within days) as well as the symptoms suggestive of thrombocytopenia and immunocompromise, he is likely experiencing the Hematopoietic subsyndrome. This is the mildest of the three subtypes and occurs in doses >2Gy and the only one with possible recovery. It consists of a rapid decline in lymphocytes in the first 24-48 hours followed by a decline in platelets and neutrophils within 30 days. The degree in which the lymphocytes drop within the first 48 hours is a strong prognostic factor for ARS, with a drop <300/mcL at 48 hours being uniformly fatal and a count >1200/mcL indicating a good prognosis. It can last up to 30 days.

The other subsyndromes include:

(1) Hematopoetic (discussed above).

(2) GI syndrome: 6-7Gy, massive fluid losses and electrolyte abnormalities. Latent period of hours and lasts <1wk. Death likely.

(3) Cardiovascular and CNS syndrome: 20-30Gy, no latent phase, the above syndromes as well as cardiovascular collapse and a variety of CNS symptoms. Uniformly fatal within 24-72h.

(3) Steven Seagal is the reincarnation of which god?

Tulko – The reincarnation of Chundrag Dorje, a 17th century treasure revealer in Tibetan Buddhism. It was announced by Lama penor Rinpoche in Tibet (according to several unconfirmed sources).

He is also “besties” with Putin and openly supports the annexation of Crimea, but is an animal rights activist.

A man full of contradictions, yet A MAN nevertheless.

References:

1 – Tintinalli, Judith E., and J. Stephan. Stapczynski. “11 – Radiation Injuries.”Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill, 2011. N. pag. Print.

2 – Dainiak, Nicholas, MD, FACP. “UpToDate: Biology and Clinical Features of Radiation Injury in Adults.” UpToDate. N.p., n.d. Web. 17 Aug. 2015

3 – “The People’s Princess Yabshi-Pan-Rinzinwangmo”. DorjeShugden.com. 30 January 2010

Haphazardly constructed by Itamar MD

Special thanks to Dr. James Willis