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A 63 year old white man presented to the accident and emergency department with a 24 hour history of gradual onset of mild weakness of his left upper limb, which progressed to involve his left lower limb. There was no history of any other CNS symptoms. He also stated that the paresis varied with posturebeing worse on standing and sitting, while it was relieved by lying down; it was also associated with a noticeably diminished shortterm memory over the past few weeks. Clinical examination confirmed a mild left hemiparesis (grade 4/5), with brisk reflexes and an "equivocal" plantar response on the left. The rest of the examination was unremarkable: he was normotensive, no carotid bruits were auscultated and the fundi were normal. Haematological and biochemical investigations were normal.

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The Center for Disease Control and Prevention published two Radiological Terrorism Toolkits: Public Health Officials (PHTK) and Emergency Services Clinicians (ESCTK). The study consisted of training public health workers and Medical Reserve Corps volunteers to rate 10 distinct virtual survivors each and route them through a Community Reception Center (CRC) pretraining and post-training. The training's effect on the rater's radiation medical knowledge and willingness to respond (WTR) was also measured. Correctly routed survivors increased from a baseline 3.6-5.3, of 10 survivors per rater for the PHTK, and to 5.7 for the ESCTK (p = 0.000). Medical knowledge increased from a baseline of 50 percent to 66.7 percent for the PHTK (nine raters) and to 71.4 percent for the ESCTK (seven raters) (p = 0.000). WTR regardless of severity increased from 34.8 percent to 54.4 percent for the PHTK (p = 0.046). Odds of correctly routing survivors decreased with perception of confidence (0.569, 95% CI 0.375-0.863), while perceptions of preparedness (2.1, 1.4-3.2) and prior training increased the odds (1.8, 1.05-3.16). When taking into account raters unwillingness to respond, the odds of correctly routing survivors decreased with perceptions of confidence in detector use (0.556, 0.365-0.846), with confidence to process persons through a CRC (0.390, 0.215-0.709), and by training with the ESCTK (0.252, 0.12-0.53), while perceptions of preparedness (18.7, 8.4-41.6), and demonstrated medical knowledge (20, 3.26-122) increased ability to correctly route survivors. These findings support the local use of PHTK training to develop surge capacity for a radiological emergency and suggest the interaction between the level of confidence and medical knowledge be studied further.