Management of Depleted Uranium Casualties

1. Management of Depleted Uranium Casualties COL Charles F. Miller, MC COL Eric G. Daxon, Ph.D., CHP U.S. Army Medical Command Ft Sam Houston, Texas Welcome to the Department of Defense’s training tape on the management of depleted uranium casualties. I am COL Chuck Miller, Chief of the Clinical Services Division at the US Army Medical Command, and over the next hour my colleague COL Eric Daxon and I will present the current DOD policies and recommendations about treating patients who have been wounded by depleted uranium munitions. Operation Desert Storm saw the first widespread battlefield use of a metal called Depleted Uranium or DU. Munitions made with DU were highly successful in destroying enemy armored vehicles and contributed greatly to the rapid completion of the war and resulting very low levels of US casualties. DU has clearly proven itself as the best material to penetrate enemy armor as well as protect our own armor troops. DU however, does present a POSSIBLE health hazard, not because of any radioactivity - it is actually lower in radioactivity than natural uranium to which everyone is exposed to in small amounts every day of our lives. No, DU’s possible health risk comes from the fact that it is a heavy metal and can be associated with the same toxicity that other heavy metals possess, such as lead, mercury and tungsten. Welcome to the Department of Defense’s training tape on the management of depleted uranium casualties. I am COL Chuck Miller, Chief of the Clinical Services Division at the US Army Medical Command, and over the next hour my colleague COL Eric Daxon and I will present the current DOD policies and recommendations about treating patients who have been wounded by depleted uranium munitions. Operation Desert Storm saw the first widespread battlefield use of a metal called Depleted Uranium or DU. Munitions made with DU were highly successful in destroying enemy armored vehicles and contributed greatly to the rapid completion of the war and resulting very low levels of US casualties. DU has clearly proven itself as the best material to penetrate enemy armor as well as protect our own armor troops. DU however, does present a POSSIBLE health hazard, not because of any radioactivity - it is actually lower in radioactivity than natural uranium to which everyone is exposed to in small amounts every day of our lives. No, DU’s possible health risk comes from the fact that it is a heavy metal and can be associated with the same toxicity that other heavy metals possess, such as lead, mercury and tungsten.

2. Depleted Uranium Introduction to Depleted Uranium (DU) Radiological Effects of DU Toxicological Effects of DU DU Casualty Management Policy DU Bioassay Policy Risk Management of DU Wounded Patients References Over the next hour we will give you an introduction to what Depleted Uranium really is, including a discussion of its radiological and toxicological effects. We will describe how DU is used in US military munitions and also talk about how to identify a patient with possible DU wounds or exposure. We will go into some detail about the correct way to diagnose and manage DU casualties as well as how to monitor these patients for possible toxicity from their DU. You will be given fairly detailed instructions about the proper way to collect and dispatch urine bioassays for DU - which is the single most sensitive method of actually proving DU exposure - and our program will end with a brief discussion of risk management of DU wounded patients. I will now turn the program over to COL Eric Daxon, Chief Radiation Protection Officer for the US Army Medical Command. COL Daxon will give you an overview and introduction to depleted uranium and then review some of the radiological and toxicological effects of this material. COL Daxon:Over the next hour we will give you an introduction to what Depleted Uranium really is, including a discussion of its radiological and toxicological effects. We will describe how DU is used in US military munitions and also talk about how to identify a patient with possible DU wounds or exposure. We will go into some detail about the correct way to diagnose and manage DU casualties as well as how to monitor these patients for possible toxicity from their DU. You will be given fairly detailed instructions about the proper way to collect and dispatch urine bioassays for DU - which is the single most sensitive method of actually proving DU exposure - and our program will end with a brief discussion of risk management of DU wounded patients. I will now turn the program over to COL Eric Daxon, Chief Radiation Protection Officer for the US Army Medical Command. COL Daxon will give you an overview and introduction to depleted uranium and then review some of the radiological and toxicological effects of this material. COL Daxon:

3. Depleted Uranium-Not New Substance Chemically same as natural uranium, 40% less radioactive Internalize natural uranium Eat, drink, breathe it daily One of many substances found in everyday life and on the battlefield Thank you COL Miller Depleted Uranium is NOT a new substance - it is chemically the same as natural uranium that is found every day life as well as on the battlefield. All human beings are exposed to and internalize small amounts of natural uranium on a daily basis and suffer absolutely NO untoward effects. DU is simply natural uranium that has had most of the more radioactive isotopes of the metal removed or DEPLETED, and it is actually 40% less radioactive than natural uranium. Personnel wounded by depleted uranium munitions pose NO risk radioactivity to soldiers providing first aid or military health care providers who provide more definitive care.Thank you COL Miller Depleted Uranium is NOT a new substance - it is chemically the same as natural uranium that is found every day life as well as on the battlefield. All human beings are exposed to and internalize small amounts of natural uranium on a daily basis and suffer absolutely NO untoward effects. DU is simply natural uranium that has had most of the more radioactive isotopes of the metal removed or DEPLETED, and it is actually 40% less radioactive than natural uranium. Personnel wounded by depleted uranium munitions pose NO risk radioactivity to soldiers providing first aid or military health care providers who provide more definitive care.

4. Properties of Depleted Uranium Toxicological - primary concern Heavy metal like lead, tungsten and nickel Kidney/Liver are the target organs Radiological- is a low level radioactive material Alpha and beta Low intensity gamma The chemical and radiological toxicity of uranium have been studied since the late 1940’s using both animal models and retrospective studies of uranium workers exposed to either natural uranium or enriched (more radioactive) uranium. The major health risk posed by DU is from its potential toxicity as a heavy metal if it is internalized in large quantities. In this respect it is no different than other heavy metals such as lead, mercury, tungsten or nickel. The primary health risk from DU is damage to the kidneys and to a lesser extend the liver. While low levels of alpha, beta and gamma radiation are given off, these are at levels so low as to pose a health risk only if internalized in large quantities. The chemical and radiological toxicity of uranium have been studied since the late 1940’s using both animal models and retrospective studies of uranium workers exposed to either natural uranium or enriched (more radioactive) uranium. The major health risk posed by DU is from its potential toxicity as a heavy metal if it is internalized in large quantities. In this respect it is no different than other heavy metals such as lead, mercury, tungsten or nickel. The primary health risk from DU is damage to the kidneys and to a lesser extend the liver. While low levels of alpha, beta and gamma radiation are given off, these are at levels so low as to pose a health risk only if internalized in large quantities.

5. OSHA Permissible Exposure Limits (PEL) The Occupational, Safety and Health Administration permissible exposure limits or PELs are those levels that workers can safely be exposed to throughout their working lives. This chart is presented to illustrate that the toxicity of uranium is comparable to other, more common, substances such as lead, tungsten and cobalt. The Occupational, Safety and Health Administration permissible exposure limits or PELs are those levels that workers can safely be exposed to throughout their working lives. This chart is presented to illustrate that the toxicity of uranium is comparable to other, more common, substances such as lead, tungsten and cobalt.

6. Uranium in the Body from Natural Sources This slide shows the levels of natural uranium we intake from natural sources like the food and liquids we ingest and the air we breathe. It is important to note that, as with other elements in the body, uranium is excreted in measurable levels in the urine and feces. On average, the natural uranium content in the urine ranges from 0.05 to 0.5 micrograms of uranium per day. The amount will vary depending primarily upon where the person is living. It should be noted that in some areas of the country, uranium urine levels can be one to two orders of magnitude larger. Analytic methods are available that will allow medical personnel to distinguish between natural uranium and depleted uranium.This slide shows the levels of natural uranium we intake from natural sources like the food and liquids we ingest and the air we breathe. It is important to note that, as with other elements in the body, uranium is excreted in measurable levels in the urine and feces. On average, the natural uranium content in the urine ranges from 0.05 to 0.5 micrograms of uranium per day. The amount will vary depending primarily upon where the person is living. It should be noted that in some areas of the country, uranium urine levels can be one to two orders of magnitude larger. Analytic methods are available that will allow medical personnel to distinguish between natural uranium and depleted uranium.

7. Military Uses Depleted uranium is used in the armor packages for some of our M1A1 Abrams main battle tanks and in a variety of anti-armor munitions. The picture on the right is a depleted uranium kinetic energy penetrator in flight. The arrow is solid depleted uranium. The pieces falling away are the Sabot which are designed to stabilize the depleted uranium arrow in the gun barrel. Depleted uranium is used in the armor packages for some of our M1A1 Abrams main battle tanks and in a variety of anti-armor munitions. The picture on the right is a depleted uranium kinetic energy penetrator in flight. The arrow is solid depleted uranium. The pieces falling away are the Sabot which are designed to stabilize the depleted uranium arrow in the gun barrel.

8. Properties of Depleted Uranium High Density Self sharpening as it penetrates armor Pyrophoric - small particles ignite and burn at high temperatures Depleted uranium is substantially more effective in anti-tank munitions because of its high density and the metallurgical properties that allow it to “self-sharpen” as it penetrates armor. Antitank munitions made from other materials like tungsten compounds tend to mushroom and become blunt as they penetrate. Conversely, armor containing depleted uranium is very effective at blunting antitank weapons. When the depleted uranium arrow strikes a target, small particles of depleted uranium break off and extremely high temperatures are generated which cause the small particles to ignite. Once the penetrator enters the vehicle it generates shards which incapacitate the crew and vehicle. The depleted uranium dust generated by this process settles in and on the vehicle and on the soldiers inside the vehicle. The Department of Defense and the Department of the Army have conducted a multitude of tests designed to characterize the levels of depleted-uranium aerosols generated both during and after a penetration and after fires involving depleted uranium munitions. The final point is that tungsten penetrators interact in much the same manner as depleted uranium. Breathable aerosols and high velocity shards are also generated. Depleted uranium is substantially more effective in anti-tank munitions because of its high density and the metallurgical properties that allow it to “self-sharpen” as it penetrates armor. Antitank munitions made from other materials like tungsten compounds tend to mushroom and become blunt as they penetrate. Conversely, armor containing depleted uranium is very effective at blunting antitank weapons. When the depleted uranium arrow strikes a target, small particles of depleted uranium break off and extremely high temperatures are generated which cause the small particles to ignite. Once the penetrator enters the vehicle it generates shards which incapacitate the crew and vehicle. The depleted uranium dust generated by this process settles in and on the vehicle and on the soldiers inside the vehicle. The Department of Defense and the Department of the Army have conducted a multitude of tests designed to characterize the levels of depleted-uranium aerosols generated both during and after a penetration and after fires involving depleted uranium munitions. The final point is that tungsten penetrators interact in much the same manner as depleted uranium. Breathable aerosols and high velocity shards are also generated.

9. Friendly Fire Incidents Operation Desert Storm was the first time depleted uranium munitions were used in combat. During the land war, thirty-one US vehicles (Abrams tanks and Bradley Fighting Vehicles) were struck by US-fired depleted uranium munitions during friendly-fire incidents.Operation Desert Storm was the first time depleted uranium munitions were used in combat. During the land war, thirty-one US vehicles (Abrams tanks and Bradley Fighting Vehicles) were struck by US-fired depleted uranium munitions during friendly-fire incidents.

10. Retained Depleted Uranium Friendly fire incidents result in soldiers with retained DU fragments Could not be readily removed surgically First time Office of the Army Surgeon General initiated this effort in 1992. Requested an assessment by the Armed Forces Radiobiology Research Inst. (AFRRI) Retained Depleted Uranium These depleted-uranium friendly-fire incidents resulted in personnel internalizing depleted uranium through inhalation, ingestion, wound contamination, and embedded depleted uranium fragments. Some of these retained fragments could not readily be removed because of their small size, the large number of these fragments. While we have medical experience with other heavy metal fragments, primarily lead, in the body, this is the first large scale experience with depleted uranium fragments. In 1992, the Office of the Army Surgeon General asked the Armed Forces Radiobiology Research Institute, AFRRI, to review the potential health effects of these retained fragments. Retained Depleted Uranium These depleted-uranium friendly-fire incidents resulted in personnel internalizing depleted uranium through inhalation, ingestion, wound contamination, and embedded depleted uranium fragments. Some of these retained fragments could not readily be removed because of their small size, the large number of these fragments. While we have medical experience with other heavy metal fragments, primarily lead, in the body, this is the first large scale experience with depleted uranium fragments. In 1992, the Office of the Army Surgeon General asked the Armed Forces Radiobiology Research Institute, AFRRI, to review the potential health effects of these retained fragments.

11. Actions Taken Armed Forces Radiobiology Research Inst. (AFRRI) initial assessment, 1992: No change in fragment removal policies Research and monitoring recommended Department of Veterans Affairs - personnel surveillance Research initiated in 1993 at AFRRI and the Inhalation Toxicology Research Institute The AFRRI review did not recommend a change in fragment removal procedures but did recommended long-term follow-up and additional research. The Department of Veterans Affairs agreed to conduct the follow-up of both active and non-active duty personnel at the Baltimore VA Medical Center. Animal research was initiated at AFRRI and at Lovelace’s Inhalation Toxicology Research Institute. The results of both are being published in the open literature as data become available. The AFRRI review did not recommend a change in fragment removal procedures but did recommended long-term follow-up and additional research. The Department of Veterans Affairs agreed to conduct the follow-up of both active and non-active duty personnel at the Baltimore VA Medical Center. Animal research was initiated at AFRRI and at Lovelace’s Inhalation Toxicology Research Institute. The results of both are being published in the open literature as data become available.

12. Summary of AFRRI and VA Results to date indicate Only change to current fragment removal policies: large fragments (over 1 cm) should be removed unless medically contraindicated Depleted uranium health effects are comparable to other heavy metals (lead, tungsten, nickel) Studies will be published in the open, peer-reviewed literature Results of the VA patient surveillance and laboratory investigations to date show that the only change to current fragment removal policies is that large (greater than 1 cm) retained fragments should be removed unless medically contraindicated. When the 1.5 cm fragment, discussed earlier, was subsequently removed, the level of depleted uranium in the soldier dropped from 15 micrograms per liter of urine to approximately 5 micrograms of depleted uranium per liter. In addition, health effects are in the range of other more common heavy metals. Studies and clinical reports will be published in the open peer-reviewed literature as they become available. I will now turn the program over to COL Miller who will discuss the current DOD policies and recommendations regarding the identification and management of military personnel who have been wounded by Depleted Uranium munitions. COL millerResults of the VA patient surveillance and laboratory investigations to date show that the only change to current fragment removal policies is that large (greater than 1 cm) retained fragments should be removed unless medically contraindicated. When the 1.5 cm fragment, discussed earlier, was subsequently removed, the level of depleted uranium in the soldier dropped from 15 micrograms per liter of urine to approximately 5 micrograms of depleted uranium per liter. In addition, health effects are in the range of other more common heavy metals. Studies and clinical reports will be published in the open peer-reviewed literature as they become available. I will now turn the program over to COL Miller who will discuss the current DOD policies and recommendations regarding the identification and management of military personnel who have been wounded by Depleted Uranium munitions. COL miller

13. Identification of DU Patients HX of vehicle struck by KE munition HX of vehicle struck by “friendly fire” HX of burning fragments “ *sparkler* ” HX of DU exposure on field medical card Thank you COL Daxon. The first step is obviously being able to identify those patients at most risk for a possible DU wound or exposure. A hx of being in a vehicle struck by a Kinetic Energy munitions, or of being in a vehicle struck by “friendly fire” should raise your suspicion of possible DU exposure and wounds. Additionally, if the patient describes fragments of the munitions that struck their vehicle as burning like a 4th of July sparkler should likewise raise your level of a DU munitions exposure Obviously, if the field medical card describes a possible DU exposure, this should be assumed the case until further evaluation can prove otherwiseThank you COL Daxon. The first step is obviously being able to identify those patients at most risk for a possible DU wound or exposure. A hx of being in a vehicle struck by a Kinetic Energy munitions, or of being in a vehicle struck by “friendly fire” should raise your suspicion of possible DU exposure and wounds. Additionally, if the patient describes fragments of the munitions that struck their vehicle as burning like a 4th of July sparkler should likewise raise your level of a DU munitions exposure Obviously, if the field medical card describes a possible DU exposure, this should be assumed the case until further evaluation can prove otherwise

14. Identification of DU Patients If DU contamination suspected: Annotate Field Medical Card “SUSPECTED DEPLETED URANIUM (DU) EXPOSURE” Briefly describe exposure scenario (Block 19) If you are one of the first line health care providers to come upon wounded personnel that you suspect could have been wounded or exposed to DU, you should annotate the field medical card with the wording as shown on the slide. In addition, a short description of the scenario that surrounded the exposure should be written in BLOCK 19 on the card - basically this should describe what happened to the soldier - how he received his woundsIf you are one of the first line health care providers to come upon wounded personnel that you suspect could have been wounded or exposed to DU, you should annotate the field medical card with the wording as shown on the slide. In addition, a short description of the scenario that surrounded the exposure should be written in BLOCK 19 on the card - basically this should describe what happened to the soldier - how he received his wounds

15. Identification of DU Patients RADIAC Meter - positive over wounds or fragments Urine Bioassay - most sensitive test for internalization of depleted uranium XRAYS - high density, highly visible Three methods of helping to confirm DU wounding or exposure are listed on the next slide. A urine bioassay is the most sensitive test for detecting internalized DU, and will be discussed at length later in the program A RADIAC meter will give a positive reading when held close to wounds burns or other suspected sites of DU fragments. The common AN/VDR-2 meter with the beta shield open will detect the presence of radioactive material but will not measure the radiation risk to the patient or medical personnel. Standard XRAYS will easily detect DU fragments in the body. Because of their high density they will appear as bright white objects similar to steel or lead fragments. The appearance of these fragments alone is not enough to confirm they are indeed DU. Experience in Operation Desert Storm found that there were soldiers in vehicles struck by DU munitions that had retained fragments that were NOT DU fragments. In addition, there are some KE penetrators that are made from tungsten which will have the same radiological appearance as DU. There are many countries whose armies are using tungsten in their munitions.Three methods of helping to confirm DU wounding or exposure are listed on the next slide. A urine bioassay is the most sensitive test for detecting internalized DU, and will be discussed at length later in the program A RADIAC meter will give a positive reading when held close to wounds burns or other suspected sites of DU fragments. The common AN/VDR-2 meter with the beta shield open will detect the presence of radioactive material but will not measure the radiation risk to the patient or medical personnel. Standard XRAYS will easily detect DU fragments in the body. Because of their high density they will appear as bright white objects similar to steel or lead fragments. The appearance of these fragments alone is not enough to confirm they are indeed DU. Experience in Operation Desert Storm found that there were soldiers in vehicles struck by DU munitions that had retained fragments that were NOT DU fragments. In addition, there are some KE penetrators that are made from tungsten which will have the same radiological appearance as DU. There are many countries whose armies are using tungsten in their munitions.

16. Embedded Fragments This slide shows the xray of a patients leg with embedded DU fragments scattered through out the soft tissues.This slide shows the xray of a patients leg with embedded DU fragments scattered through out the soft tissues.

17. Clinical Treatment of DU Patients Wounded patients pose NO Threat to medical personnel DO NOT DELAY TREATMENT! “Universal Precautions” - surgical gloves, masks and throw-away gowns offer adequate protection to medical personnel When health care personnel come upon soldiers they suspect may have been wounded with DU munitions they must remember while these patients may be contaminated with DU - they are not hazardous to medical personnel in any way - Under no circumstances should treatment be delayed because of suspected or confirmed DU injury. Normal “Universal Precautions” consisting of surgical mask, gloves and throwaway gown are sufficient to protect medical personnel from accidental contamination with DUWhen health care personnel come upon soldiers they suspect may have been wounded with DU munitions they must remember while these patients may be contaminated with DU - they are not hazardous to medical personnel in any way - Under no circumstances should treatment be delayed because of suspected or confirmed DU injury. Normal “Universal Precautions” consisting of surgical mask, gloves and throwaway gown are sufficient to protect medical personnel from accidental contamination with DU

18. Clinical Treatment of DU Patients Debridement should follow standard surgical techniques Radiation meters may aid in management of wounds DO NOT DELAY TREATMENT to obtain radiation monitoring equipment! Wounds and burns should be managed and debrided in accordance with standard surgical procedures. Use of a radiation meter such as the AN/VDR-2 RADIAC meter may assist in wound debridement and cleaning BUT: There should be no delay in treatment to obtain monitoring equipment.Wounds and burns should be managed and debrided in accordance with standard surgical procedures. Use of a radiation meter such as the AN/VDR-2 RADIAC meter may assist in wound debridement and cleaning BUT: There should be no delay in treatment to obtain monitoring equipment.

19. Clinical Treatment of DU Patients Remove embedded DU fragments using standard surgical criteria Large fragments (>1cm) should be removed unless the medical risk is too great Management of embedded surgical fragments should be the same as for any shrapnel wound, with the exception that DU fragments greater than 1.0 cm should be removed from the patient unless the medical risk is too great by the surgeon.Management of embedded surgical fragments should be the same as for any shrapnel wound, with the exception that DU fragments greater than 1.0 cm should be removed from the patient unless the medical risk is too great by the surgeon.

20. Clinical Treatment of DU Patients Monitor Hepatic and Renal Function BUN, Creatinine, Creatinine clearance, beta-2 microglobulin, urine Uranium standard liver function tests: AST, ALT, GGT, Bilirubin, PT, PTT Patients who have suspected or confirmed DU exposure should have hepatic and renal function monitored. The metal deposits primarily in the bones, liver and kidneys. The kidney is one of the organs most sensitive to uranium heavy metal toxicity. It is known that acute exposure to large doses - 15 grams or greater - can result in renal failure. Recommended tests are listed on the slide - a more complete discussion of the appropriate methods for the urine bioassay for uranium will occur later in the program. Patients who have suspected or confirmed DU exposure should have hepatic and renal function monitored. The metal deposits primarily in the bones, liver and kidneys. The kidney is one of the organs most sensitive to uranium heavy metal toxicity. It is known that acute exposure to large doses - 15 grams or greater - can result in renal failure. Recommended tests are listed on the slide - a more complete discussion of the appropriate methods for the urine bioassay for uranium will occur later in the program.

21. Clinical Treatment of DU Patients Urine Uranium Bioassay: Perform in all patients with suspected DU exposure Chelation therapy not indicated A urine bioassay for uranium should be performed on all patients who have proven or suspected depleted uranium exposure. It is the most sensitive test available for determining whether or not a patient has internalized any depleted uranium. Chelation therapy, while useful in some cases of lead and iron intoxication, has not been shown to be effective in enhancing the rate of DU excretion from the body. Thus, it is not recommended at this time for treatment of patients exposed to DU.A urine bioassay for uranium should be performed on all patients who have proven or suspected depleted uranium exposure. It is the most sensitive test available for determining whether or not a patient has internalized any depleted uranium. Chelation therapy, while useful in some cases of lead and iron intoxication, has not been shown to be effective in enhancing the rate of DU excretion from the body. Thus, it is not recommended at this time for treatment of patients exposed to DU.

22. Urine Uranium Bioassay Baseline urine specimen: Start collection immediately after injury Terminate @ 24 hours after exposure incident Initial DU urine specimen: Start collection @24 hours after exposure incident Terminate @ 24 hours Follow up urine specimen: Collect a 24 hr urine @ 7-10 days post exposure The correct procedure for collection of urine specimens to analyze for uranium is shown on the slide. If possible three separate specimens should be obtained. A baseline sample should be collected immediately upon arrival at a level III or IV battlefield MTF, as much urine as possible should be collected up until 24 hours after the suspected exposure. At this point the baseline collection should be terminated and the initial DU specimen collection started as a 24 hour collection. A third Follow UP 24 hour specimen should be collected beginning 7-10 days after the exposure. Collecting all three specimens will give the most accurate evaluation of DU exposure and allow for an estimate of the amount of DU that the patient has internalized.The correct procedure for collection of urine specimens to analyze for uranium is shown on the slide. If possible three separate specimens should be obtained. A baseline sample should be collected immediately upon arrival at a level III or IV battlefield MTF, as much urine as possible should be collected up until 24 hours after the suspected exposure. At this point the baseline collection should be terminated and the initial DU specimen collection started as a 24 hour collection. A third Follow UP 24 hour specimen should be collected beginning 7-10 days after the exposure. Collecting all three specimens will give the most accurate evaluation of DU exposure and allow for an estimate of the amount of DU that the patient has internalized.

23. Urine Uranium Bioassay Urine Uranium bioassay specimens should be forwarded to AMEDD-specified DOD clinical laboratories Spot urine collections should be performed if tactical/logistical issues prevent the collection of 24 hour specimens All specimens should be forwarded to laboratories that are identified by the AMEDD for bioanalysis of urine uranium. The US Army Center for Health Promotion and Preventive Medicine has additional information about where specimens can be sent. If it is not possible to collect a 24 hour urine sample, because of tactical/logistical or medical reasons, SPOT Urine specimens should be collected obtaining the largest amount of urine possible. Uranium values are reported in terms of micrograms of urine per liter of urine and per gram of creatinine.All specimens should be forwarded to laboratories that are identified by the AMEDD for bioanalysis of urine uranium. The US Army Center for Health Promotion and Preventive Medicine has additional information about where specimens can be sent. If it is not possible to collect a 24 hour urine sample, because of tactical/logistical or medical reasons, SPOT Urine specimens should be collected obtaining the largest amount of urine possible. Uranium values are reported in terms of micrograms of urine per liter of urine and per gram of creatinine.

24. Risk Assessment Department of Veterans Affairs has followed 15(?) patients who have retained DU fragments in their bodies for over 7 years. Highest Uranium Urine = 30-40 mcg/L No evidence of renal, liver, reproductive abnormalities has been detected in this group of patients The VA has been following a group of veterans who have retained DU fragments in their bodies. These veterans have shown higher than normal levels of DU in their urine since the monitoring began in 1993. They are being followed very closely for any evidence of health abnormalities and specifically for any potential toxicity that could be related to the retained uranium. So far all patients have maintained normal kidney and liver (?) functions, and in addition the reproductive health of this group appears to be normal in that all babies fathered by these veterans between 1991 and 1997 have no evidence of any birth defects.The VA has been following a group of veterans who have retained DU fragments in their bodies. These veterans have shown higher than normal levels of DU in their urine since the monitoring began in 1993. They are being followed very closely for any evidence of health abnormalities and specifically for any potential toxicity that could be related to the retained uranium. So far all patients have maintained normal kidney and liver (?) functions, and in addition the reproductive health of this group appears to be normal in that all babies fathered by these veterans between 1991 and 1997 have no evidence of any birth defects.

25. Summary Depleted Uranium - not a radiation threat! Heavy Metal Toxicity is the major concern Health Care Providers are not at risk Clinical Management is the same as other wounded patients Suspected exposures should have urine uranium bioassay performed To summarize - our presentation has reviewed the military uses of DU, covering the radiological and toxicological data known about the material. We have emphasized that DU poses no radioactivity threat to either wounded patients or health care providers. It major health toxicity comes from being a heavy metal similar to lead or mercury, and the kidney is the organ most at risk for this toxicity. The clinical management of patients wounded with DU munitions is the same as for any other patient, with every effort made to remove fragments greater than 1.0 cm. All patients with suspected DU exposures should have bioassay for uranium performed on their urine to confirm the diagnosis. We hope that the information in this program will be of benefit to all military health care providers who may be placed in the role of taking care of servicemembers who have been injured by DU munitions.To summarize - our presentation has reviewed the military uses of DU, covering the radiological and toxicological data known about the material. We have emphasized that DU poses no radioactivity threat to either wounded patients or health care providers. It major health toxicity comes from being a heavy metal similar to lead or mercury, and the kidney is the organ most at risk for this toxicity. The clinical management of patients wounded with DU munitions is the same as for any other patient, with every effort made to remove fragments greater than 1.0 cm. All patients with suspected DU exposures should have bioassay for uranium performed on their urine to confirm the diagnosis. We hope that the information in this program will be of benefit to all military health care providers who may be placed in the role of taking care of servicemembers who have been injured by DU munitions.

26. References Message, 141130Z Oct 93, DASG-PSP HQDA, Subject: Medical Management of Unusual Depleted Uranium Exposures. North Atlantic Treaty Organization (NATO) Standardization Agreement (STANAG) 2068, “Emergency War Surgery,” 1988. Army Regulation (AR) 40-5, 15 October 1990, Preventive Medicine. These next slides slide give some of the professional and governmental references that should be contacted or reviewed for more information about depleted uranium.These next slides slide give some of the professional and governmental references that should be contacted or reviewed for more information about depleted uranium.

27. References Draft AR 40-400, Patient Administration 1st Endorsement, MCHO-CL-W (ECMD/9 Jan 96), 23 Jan 98, Subject: Request for Guidance on the Medical Management of Unusual Depleted Uranium Exposures. Tech Guide 211, “Radiobioassay, Collection, Labeling and Shipping Requirements, US Army Center for Health Promotion and Preventive Medicine (USACHPPM), May 1996.