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Author: Georges C. Benjamin
The medical and public health community is still in its infancy in terms of preparedness for the detonation of a nuclear device.
The atomic age began in the 1900s and brought with it the promise of using nuclear technologies for peaceful purposes. It also brought with it the reality of nuclear weapons and a potential catastrophic public health threat.
Early nuclear weapons were large, heavy, and complicated to make and use. Most important, only nation states had them. As technology advanced, nuclear weapons have become smaller, lighter, and more potent. In addition, terrorists are now working diligently to get their hands on them.
Today, detonation of a compact, portable nuclear device by a small group of terrorists is a real threat. These devices, known by a variety of names—suitcase nukes, mini-nukes, or improvised nuclear devices (INDs)—are small enough to put in a backpack or suitcase and can yield an explosion of up to 20 kilotons.
Challenges to Emergency Medical Response
All nuclear detonations result in significant structural and environmental destruction from the blast, heat, and radiation. The level of physical destruction in and beyond the response area and the potential loss of critical medical infrastructure in surrounding areas at relatively remote distances will create significant barriers to normal emergency medical responses. In addition, dangerous levels of radiation in the immediate response area and downwind from the radiation plume will make it difficult to respond rapidly to victims of the blast. Opera-tional and logistical problems with the delivery of supplies, patient transport, and emergency communication will further complicate emergency medical response.
The medical effects will be catastrophic, both for people in the immediate area and for people within a radius of several miles. Survivability in the short and intermediate term will depend on the degree and type of physical injury combined with the degree of exposure to radiation (Waselenko et al., 2004). The radiation effects will have immediate, delayed, and long-term health consequences for both victims and emergency response personnel.
Under any scenario that includes the release of a nuclear weapon, there will be thousands, possibly tens of thousands, of casualties. In the immediate aftermath, there will be an urgent need for a large number of specialized beds for patients with burns, blunt and penetrating trauma, eye injuries, and other injuries that would quickly overwhelm the existing overtaxed health system. The number and variety of casualties, the lack of adequate emergent health care infrastructure (e.g., burn and trauma beds, respirators, supplies, and trained staff) in many areas, and the expectation of long-term disruptions of routine emergent and urgent health care services represent significant challenges to planners.
Preparing for the Worst
With these challenges in mind, how does one address the need for public health preparedness? First, achieving preparedness is a process, not a point in time. Preparedness requires training, practice, and an organized approach to the development of an emergency medical system. The investment in emergency preparedness must be persistent and sustained in a way that creates dual-use systems that will serve the needs of the public on a daily basis but can also be scaled up quickly to address a surge of patients in case of an overwhelming event.
Since the horrific events of September 11, 2001, the nation has been working toward improving preparedness to threats to public health ranging from infectious diseases to weapons of mass destruction. Preparing for any emergency begins with asking “what if” security officials fail to prevent the release of a biological or chemical weapon or the detonation of an IND in an urban area or a highly populated American city. The medical and public health community is still in its infancy in preparing to respond to such an unthinkable event (IOM, 2009).
Public health preparedness activities have been undertaken to address unintentional outbreaks of infectious disease, such as pandemic influenza (H1N1) and severe acute respiratory syndrome (SARS); large outbreaks of food-borne illnesses from pathogenic bacteria, such as E-Coli 0157:H7 and Salmonella; and intentional threats from potential bioweapons, such as smallpox and anthrax. These measures have improved the nation’s capacity to respond to infectious outbreaks and a variety of other basic health emergencies.
However, they are not sufficient to address a disaster with the range and scope of destruction that would be caused by the detonation of an IND. The profound loss of critical medical and response infrastructure would profoundly diminish the effectiveness of the emergency response. The only recent experiences that approach the scope of an IND event are Hurricanes Katrina and Rita and, possibly, the earthquake in Haiti, which also caused the acute loss of significant critical infrastructure.
The detonation of an IND would cause a level of destruction and risk to health that would be a mega-disaster of national significance (Figure 1). In such an attack, federal authorities would have to be immediately engaged in the emergency response and not wait for requests from state or local officials, as they would in a typical scenario. Medical preparedness for a nuclear detonation will require using all of the measures taken for many types of natural and manmade disasters. It will also require a radical change in thinking about how we provide emergency medical care.
In addition to planning a response to the effects of a large explosion, preparation will require addressing the problems faced in a radiologic hazards material (Hazmat) spill. Because of the radioactive cloud, the contaminated area would include not only the blast area, but also communities that may be many miles from the site. Planners must also be prepared to mount an emergency response in conditions that mimic an earthquake or tornado, such as the loss of physical infrastructure and widespread physical blockages of ingress and egress routes.
Finally, because this would be an intentional attack, planners must include preparations to respond to multiple detonations or the release of biological or chemical weapons. These challenges will require an all-hazards approach to emergency medical preparedness, which will be only one component in the general emergency response plan for a major disaster.
Response Plans for Weapons of Mass Destruction
Metropolitan Medical Response System Program
One of the earliest efforts to plan for responding to weapons of mass destruction was the Metropolitan Medical Response System Program (MMRS), which was started in 1995. This federal program was an early attempt to encourage integrated planning for large-scale disasters in several urban cities. The intent was to link first responders (e.g., police, fire, and emergency medical services) with public health and emergency management officials.
The MMRS program depended on local control and decision making. Although it was a good effort, because of the magnitude of planning and program needs, MMRS has remained generally undeveloped for responding to an event of the size and scope of an IND detonation.
Urban Area Security Initiative
Many other public and nonpublic efforts have been undertaken by a variety of federal, state, and local agencies to prevent, mitigate, or respond to the threat of a nuclear weapon. The Urban Area Security Initiative (UASI), for example, provided funds to multiple urban areas to address preparedness specifically for detonation of a nuclear weapon. The program was designed to improve capabilities and preparedness planning in response to improvised explosive devices in high-density, high-threat urban areas.
Like MMRS, this program is also still in its infancy in terms of planning. Although some progress has been made, it has not yet developed the kind of preparedness plans necessary to respond to a catastrophic event, such as the detonation of an IND in one of these cities.
Other Government Programs
The U.S. Department of Health and Human Services (DHHS) has a range of programs to support preparedness, including the Public Health Emergency Preparedness Program and the Hospital Preparedness Program. Both are designed to achieve all-hazard preparedness for public health emergencies. Additional programs that support emergency medical planning and response are run by the Federal Emergency Management Agency.
Training Health Professionals
Unlike health professionals trained to respond to bioterrorism or Hazmat spills, very few health professionals have received training in the management of nuclear emergencies. This is a major gap in our medical preparedness. The anthrax release in October 2001, followed by concerns about smallpox and an influenza pandemic, resulted in intensive efforts to educate people in a large number of health disciplines in medical responses to these emerging threats.
We need similar efforts for the emergency management of radiation and nuclear threats. But it will take federal leadership to jump start the process through public health and professional associations and educational institutions. Examples of such training include programs supported by the National Disaster Life Support Foundation (www.ndlsf.org) and others, which provide a variety of courses on the management and treatment of mass casualties. We will also need specialized training for leaders in emergency medical services, lay emergency managers, and public health directors to manage the unique aspects of nuclear emergencies.
Health Effects of a 10-Kiloton Nuclear Device
Our understanding of the full health effects of an IND detonation in an urban setting is still evolving. Real-life scenarios of nuclear and radiation events are limited to the military airbursts at Nagasaki and Hiroshima, nuclear weapons tests, the civilian tragedy of Chernobyl, the Three Mile Island accident, and occasional laboratory accidents.
Because there have been few experimental ground-level detonations, most of what we know comes from sophisticated models estimating the effects of an IND. Based on these models, current estimates for a 10-kiloton release (a small suitcase bomb) are about 40,000 to 50,000 people killed within the first 24 hours from blast effects and burns and more than 130,000 injured from radioactive fallout (Marrs, 2007). Factors that modelers use to estimate human casualties include population density, time of day, geographic location, wind speed, and so on.
Thus, even with conservative estimates, the health care system would quickly be overwhelmed (Bell and Dallas, 2007). The immediate types of injuries sustained from an explosion of this type would include a combination of blast, burn, and penetrating traumas. For initial survivors, acute and chronic radiation illness would be another problem, which, when combined with traumatic injuries, is known to increase mortality (Flynn, 2006). There are therapies for radiation exposure, but survival depends on the dose of radiation received.
The First 72 Hours
The management goal in a typical disaster is to move from chaos to controlled disorder as quickly as possible. In a disaster like an IND, the period of chaos would be magnified because of fear, the size of the affected area, and the loss of local response capacity, that is, responders who are used to working together. Traditional preparedness planning is based on the assumption that local communities will be the responders for the first 48 to 72 hours. Thus planning focuses on optimizing the response until outside assistance arrives, as needed. The mobilization of meaningful federal assistance is expected to take from 48 to 72 hours.
The explosion of an IND or other weapon of mass destruction, however, would be immediately understood as an event of national importance, and local, state, and federal planners must harmonize their plans in a way that immediately nationalizes the response. Although the local community may be on its own for some period of time for logistical reasons, it is clear that, without immediate nationalization, there cannot be a reasonable emergency medical response.
Because of the loss of a significant amount of the local critical infrastructure (e.g., ambulances, hospitals and clinics, and associated personnel), the response plan should be designed to use regional and national health resources for the most severely affected patients. Medical standards of care may also change dramatically, under appropriate medical supervision and ethical guidelines, in disaster situations. For example, critically ill patients might have to be treated in a school gymnasium instead of a hospital because of the volume of patients, and non-physician caregivers might be authorized to give injections and perform other procedures, even minor surgical procedures (IOM, 2010).
First responders will have to address the early loss of command and control and operational communications (mostly because of blast or burn effects, less so from the electromagnetic pulse). Situational threat awareness, accurate weather information, and the status of the medical system infrastructure are critical pieces of information essential for effective control and command of the medical response.
Risk communication to the public will be a major challenge; messages must be clear, consistent, and as accurate as possible. Maintaining public trust will be of great importance for health officials, who will have to make difficult decisions based on incomplete information. Managing fear, post traumatic stress disorders, as well as traditional mental health concerns (e.g., depression) will also be critical (Koenig et al., 2005).
In an emergency, immediate care (first aid) is often provided by bystanders and others in the general area of the event. In the case of an IND explosion, however, the area will be contaminated with radiation, and even able-bodied survivors may be unable or unwilling to assist because of concerns about the risk of lethal exposure. Significant search and rescue may also be delayed because of contamination of the site.
The decontamination of victims will be an essential medical procedure, not only to protect patients, but also to protect care providers from continued radiation exposure. In general, however, most experts recommend that emergency care not be delayed because of fear of a contaminated patient. Removing a patient’s clothing will usually reduce the amount of contamination by 90 percent.
Historically, emergency providers have recognized that the first few hours in a mass causality situation require sorting patients into priority groups, ranging from people who require care first to those who are not expected to survive and are, therefore, made comfortable and treated last. The biggest barrier to providing immediate care will be ensuring that it is safe for first responders to enter the affected area.
Planners must be clear about the level of radiation exposure a rescue worker will be allowed to receive and must maintain a system so that they know when a worker is approaching that limit. The level of personal protective equipment will depend on the level of risk and should also be predetermined as part of the operations plan.
Making decisions that limit exposure to ground radiation, airborne particles, and gases will be crucial for survivors in the affected area. Evidence clearly shows that sheltering in place is an effective strategy for limiting exposure and improving the chances of survival. Thus, finding shelter, or remaining sheltered, should be strongly emphasized in event planning and in the dissemination of plans and information. The science behind sheltering in place and when to evacuate a shelter to minimize exposure is clear, but communicating this to populations on a wide scale to achieve an orderly evacuation will be difficult.
The Federal Response
Early activation and prepositioning of national response assets upon notification of a threat warning will be critical. Rapid mobilization of medical response assets, such as the strategic national stockpile, military airborne patient transport, the National Disaster Medical System (about 1,500 hospitals and 34,000 beds), blood collection and delivery systems, and radiation detection devices will also be essential (Coleman et al., 2009).
Regulatory action by DHHS to authorize the emergency use of pharmaceuticals and emergency hospital transfer rules to optimize medical care should be taken soon. Medical transportation systems for large-scale evacuations should be activated and implemented immediately.
Beyond the First 72 Hours
The mapping of contaminated areas, continued search-and-rescue operations, and later recovery operations of remains will last long past the first 72 hours. These may seem like almost routine activities until one understands the complexity of mapping a contaminated area in a blast zone and that changes in the prevailing winds can make predicting the path of the fallout plume extremely difficult, except with computer models and on-the-ground radiation detectors. Simply put, relying on the traditional unidirectional plume model will not be adequate for determining which areas to avoid.
Medium- and long-term health effects of radiation exposure, combined with disabilities from trauma, will mean that the direct health effects will persist for several years or more. Long-term planning should address these issues.
Cleaning the environment of contaminants, radioactive materials, and other toxic debris will create significant health hazards. Safe removal and disposal methods must be included in the remediation plan.
Building Community Resilience
A great deal of work has been done in the last several years to help communities become more resilient in the face of emergencies. Resilient communities are characterized by the ability to mitigate the effects of a significant disaster and return to normal or near normal quickly. However, resilience in the face of a disaster means adding an element of human capital to planned systems that promote a rapid return to normalcy once the disaster is over. Communities where poverty levels are high, the built environment is dilapidated or not kept up, and the underlying health status is poor are less likely to rebound quickly. In the case of the recent earthquake in Haiti, for example, even a return to a baseline level of profound poverty is going slowly.
A community with significant resources, good underlying health, and a solid, practiced emergency plan will have the capacity to recover more quickly (NRC, 2006). However, after an attack with an IND, even a resilient community will face many challenges, depending on the extent of the loss of infrastructure, the degree of community disruption, and the forced migration of residents out of the affected and surrounding areas, probably for a significant period of time.
Ensuring that an emergency medical system can respond to a nuclear emergency requires a proactive, nontraditional approach to disaster planning and response. This can be accomplished within the traditional framework of all-hazard planning, but it will require immediate recognition of the national nature of the emergency, an “all in” response from the beginning, and complex decisions in response to an emergency that has elements of different types of disasters.
The prospect of responding under continued threat of multiple intentional detonations or the use of conventional or unconventional weapons could further complicate the situation. Moving successfully from chaos to controlled disorder will require that emergency planners effectively integrate response to the unique challenges of a particular event with the medical response scenario. In the event of the unthinkable, even a resilient community will be slow to recover.
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