Public Health Emergency - Leading a Nation Prepared
Comment on this Playbook
Casualties from a nuclear detonation result from blast, heat (thermal energy), and ionizing radiation. The distribution and severity injuries seen depends on device yield (kilotons), height of burst (air versus ground burst), atmospheric conditions (weather, wind pattern), protection afforded by shelter/topography of the terrain (e.g., urban landscape vs. rural open spaces, robustness of buildings construction)
Rescue efforts after a nuclear detonation will be complex due to potentially high radiation levels, severe infrastructural damage, the number and severity of causalities, and the inaccessibility of many victims at least initially. A summary of the key principles of the medical and public health response of the nuclear detonation is found below.
Concept of operations*: using Damage Zones to organize response activities
[*The Concept of Operations, or CONOPS, describes how the response will be organized and how the various components and sectors will relate to one another.]
Response tasks (including search and rescue) that are likely to be safe and effective are organized by four concentric physical damage zones around ground zero, some of which also include radiation. Starting from ground zero and working outward the four damage zones, for 3 sized detonations, 0.1, 1 and 10 kilotons (kT) [equivalent size of TNT] are:
The following description of zone sizes is for a 10kT ground burst detonation:
Severe Damage (SD, previously called No-go) Zone
Moderate Damage (MD) Zone
Light Damage (LD) Zone
Dangerous Fallout (DF, some refer to as Hot) Zone
A fifth zone, circumscribed by a “line” reflecting an environmental exposure rate of 0.01 R/h, is also useful in managing the response. It is in Figure 2, below. It has also been called “a Radiation Caution Zone”. This “line” and the zone within it will enlarge initially as fallout is deposited but will then contract quickly, as radiation levels decrease due to rapid radioactive decay in the hours and days after a blast. This is not a damage zone per se, but it is area outside the DF zone where response activities can be conducted. However, responder time will be limited by federal Protective Action Guides or recommendations adopted by the local Incident Commander. The ALARA (As Low As Reasonably Achievable) principle will also apply (keeping radiation levels for responders as low as reasonably achievable (http://www.fema.gov/good_guidance/download/10260).
Number and spectrum of injuries
There will be hundreds of thousands of casualties. Injuries will vary by type and severity. Many people will have trauma only (especially in and beyond LD zones), others will have radiation exposure only (especially in DF zone), and some will have both. The list below reflects the major kinds of injuries expected.
Response Worker Safety
Search and rescue operations will be markedly impeded by the relatively high levels of radiation in and around the MD zone. Protective Action Guides (PAGs) and the As Low As Reasonably Achievable (ALARA) principle will guide actions (http://www.fema.gov/good_guidance/download/10260). Safeguards for responders include but are not limited to the following:
Scarcity of Resources affects Triage Priority and Standards of Care
Venues for the medical response
The Radiation TReatment, TRiage and TRansport System (RTR System) presents a functional approach to the various activities of the medical response. The figure below illustrates the various kinds of activities and where they would likely be located in relation to the zones of response noted above and regional assets. There will likely be multiple RTR 1, 2 and 3 sites each with different types of activities. Using this terminology allows responders to have common language for situational awareness, deployment or resources, and planning.
The medical response following a nuclear detonation requires identification of Assembly Centers (AC) and Medical Care (MC) centers equipped to handle medical surge and the ability to assess where the damage zones are located relative to the AC and MC sites. The medical response is organized following the RTR system and MedMap. The MedMap is an HHS system that contains GIS-based information on many aspects of the response. It can be accessed on an as-needed basis in coordination with HHS.
RTR system and MedMap
RTR Response Organization System (Radiation TReatment, TRiage and TRansport). The RTR is a functional approach, with a focus on TRiage, TReatment, and TRansport. There will likely be multiple RTR 1, 2 and 3 sites. The designation of three subtypes is to help organize the response that allows a common understanding and language for situational awareness, deployment or resources, and planning.
RTR 1 sites will be near the SD zone and within the MD zone. Physical infrastructure damage and radiation will limit the ability both to reach the victims and to help evacuate and administer medical support. Over time, the radiation dose will decrease and victims who had adequate shelter may conceivably survive.
RTR2 sites will have radiation that will limit the time for responders and victims to be present with acceptable risk. Most of these will be within the LD zone and DF zone.
RTR3 sites will be away from the LD and DF zones and will not have radiation that appreciably limits the victims’ and responders’ time there. Glass and blast damage may be present miles from the epicenter where the conditions are not complicated by radiation so structural damage to buildings does not necessarily mean radiation is present.
Medical Care (MC) sites may include
Assembly Centers (AC) will be
Evacuation centers and drop zones
Intent of Operations
All response and recovery planning and operational activities should be initiated and executed in compliance with the National Response Framework (NRF), National Incident Management System (NIMS), and the HHS ESF #8 Concept of Operations Plan for Public Health and Medical Emergencies. Nuclear detonation response and recovery planning should focus on developing and coordinating collaborative, interagency and multi-jurisdictional operational activities and capabilities to provide for:
Response and initial recovery planning and operational activities will consider medical evacuation and shelter-in-place (SIP) options and resources for individuals with medical needs in hospitals, nursing homes, assisted living facilities, and persons living at home. Individuals with functional needs, including individuals with disabilities and individuals with limited English proficiency, that do not require medical support/intervention but do require other means of support such as the assistance of an interpreter, the assistance of a personal caregiver to accomplish activities of daily living or the assistance of a caregiver to provide guidance in daily decision-making, or other auxiliary aid or service is a shared responsibility between Mass Care and Medical And Public Health responsibilities.
This playbook contains actions steps which outline the medical and public health response to a nuclear detonation while allocating scarce resources. In essence, it presents the response by a complex system. The action steps stages are outlined below:
The medical response unfolds in stages
Also contained in this playbook are additional resources. These resources serve as informative references with definitions, discussion points, and recommendations about topics related to medical response to a nuclear detonation. The information contained in the resource section is to be used in concert with the Action Steps.
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