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U.S. Department of Health and Human Services

Action Steps: Phase 0

State and Local Planners Playbook For Medical Response to a Nuclear Detonation



Phase 0: Pre-incident planning:
Preparedness activities for a Nuclear Detonation

Line number


Information Source

General Readiness Planning and Emergency Management


Access pre-incident general education - for responders, medical personnel, general public, and responsible officials. Prepare list of where to find information when a disaster strikes.

IS #1


Educate public safety agencies on the impact of a nuclear detonation and operational zones (SD, MD, LD and DF zones). Work with medical care and public health entities to define possible Medical Care and Assembly center sites per Planning Guidance for Nuclear Detonation including Radiation TReatment, TRiage and TRansport (RTR) system

IS #2
IS #3


Educate public - Duck and cover if you witness a bright flash of light. Seek shelter as you would for a tornado following any catastrophic explosion in the community until further advised. Information about the advantage of time, distance, and shelter to increase survival likelihood.



Develop checklist for possible nuclear detonation specific to community that incorporates initial actions and notifications.



Establish plan to immediately activate Emergency Alert System (EAS) in wake of detonation for those areas immediately adjacent the blast.



Establish plan to liaison with National Weather Service and visual sources of information about plume



Ensure Continuity of Operations plans for emergency management that include consideration of electromagnetic pulse effects around likely target zones



Establish Emergency Operations Centers (EOC) planning including law enforcement, fire, transportation, communication, medical care networks, medical distribution (pharmacies), debris removal, public information, utilities, private sector



Educate non-federal planners how to access Federal information including DHS and HHS via state and local means. Radiation and plume modeling expertise will assist in situational awareness, even within the first few hours.



Ensure that general and medical planners should work with HHS (ASPR) for familiarization with MedMap GIS mapping of medical infrastructure in surrounding region

IS #4


Utilize NIMS terminology and ICS structure for consistency among responders.

IS #5


Consider transportation issues including: creating immediate access along roads clogged by disabled vehicles and broken glass especially, transporting injured out of area by non-ambulance means, transporting response personnel and supplies; transporting non-injured.
Identify key transportation routes and modes that will need law enforcement to open and safeguard.



Designate regional staging areas for incoming personnel and supplies (e.g. ambulances) and plan allocation and orientation (maps, etc) mechanisms



Designate forward movement points (rail, air, ground) for evacuees / patient evacuation via NDMS and other means

IS #18


Assess fragility of 911 and other key communications systems relative to likely locations for a nuclear detonation and the impact (out to 2 miles) of electromagnetic pulse (EMP)



Validate public communication plan for settings where many usual technologies may be unavailable or not work to reach displaced persons or those within the range of EMP effects. See Planning Guidance for information on communication.

IS #7


Gain familiarity with concepts behind planning for Scarce Resource situations.

IS #8

Emergency Medical Services (EMS)


Understand resources available under local MOUs, the Emergency Medical Assistance Compacts (EMAC) and the Federal Ambulance Contract and their timeframe for arrival



Define aero-medical resources available within the region and neighboring regions and establish MOU and/or coordination mechanism for catastrophic circumstances



Establish plan with regional partners to automatically report to designated staging areas within the region following an nuclear detonation for briefing and assignment



Educate providers on zones of operation following a nuclear detonation (as above) as well as sheltering actions should they be in the Dangerous Fallout zone at the time of attack. Providers should be aware that immediate response may not be possible due to requirements for sheltering from fallout.



Educate providers on variation of a nuclear detonation from usual incident response plan, basic triage after a nuclear detonation, principles of mass casualty care and triage, appropriate PPE, and focus on patient care rather than decontamination



Plan with public health and medical system for EMS support for and transport to Medical Care and Assembly Center sites as well as evacuation hubs



Obtain radiation detectors and dosimeters for response vehicles, facilities and individuals- plan for distribution and use according to community planning and risk profile



Assure coordination mechanism and communication plan for the multiple EMS agencies that will be involved with the response



Review and update Continuity of Operations plan including for situations where 911 system may be non-functional in certain areas (i.e. what instructions are conveyed to public and how does EMS provide coverage)



Assure crisis operations plans for agency/system are accomplished including triage of calls at Public Safety Answering Point (PSAP), medical dispatch centers, and on-scene, and also including staffing configurations, transport destinations (e.g. delivering patients to non-hospital locations such as RTR3 / Medical Care locations)


Healthcare Facility Response


Understand the implications of the Declaration of a Public Health Emergency on facility and provider liability



Assure internal and external communication redundancy in case of EMP or other effects



Understand and practice coordination mechanisms with the area hospitals (Health and Medical Coordination Center – HMCC)



Define surge capacity assets and develop plan for maximal expansion of facility capacity



Identify sites close to the facility that may serve as appropriate referral area for minor injuries (Medical Care center)



Assure facility infrastructure damage assessment and evacuation planning completion



Assure adequate Continuity of Operations (COOP) planning for utilities failure, other logistical and service interruptions



Develop a strategy for crisis medical care including management of critical medical supplies. Consider what to potentially stockpile and contingencies for vendor delivery interruption

IS #8


Consider resource sharing arrangements within locale and region. Include medical care facilities and suppliers.



Based on threat assessment, stockpile ‘dry decon’ kits allowing patients to control clothing or plan to accommodate large numbers of these patients.



Establish plan for victim flow, decontamination / clothing control, control of hospital environment in regard to radiation contamination. (Note that after a nuclear detonation, priority is on patient care with containment of contamination rather than full decontamination which would be emphasized in RDD or other limited exposure events.)



Assure personal dosimeters and Geiger-Muller counters available to the ED and assure radiation safety/nuclear medicine personnel who can assist with radiation monitoring are involved in planning process
Establish radiation exposure guidance, possibly in collaboration with other facilities in the region for consistency. Protective Action Guidelines available.

IS #19


Consider radiation portal-monitor system for emergency department EMS entrance to identify individuals requiring further decontamination.



Understand the Radiation TReatment, TRiage, and TRansport system (RTR).

IS #3


Work with local/state/regional/tribal planners to define Medical Care (MC) facilities, including alternate care facilities, and Assembly Centers (AC)

IS #3


Define plans for receipt and distribution of supplies from Strategic National Stockpile. (including basic medical supplies and cytokines, etc)

IS #9
IS #11


Define plans for requesting resources from air and ground EMS services. Understand the physical limitations of facility helipad and anticipate excessive demands on external EMS services.



Establish tools and/or methods for patient and victim tracking which integrate into community plan. Disaster plan to include how documentation may be simplified during mass casualty incident.

IS #6


Establish plans for missing persons / patient hotline at facility

IS #10


Download REMM and join REMM ListServ

IS #11

Public Health (PH)


Educate staff on impact of a nuclear detonation, likely effects, priorities, and the terminology of the RTR system

IS #7


Understand process to request any emergency health declarations / powers and their implications



Exercise with EOC and HMCC coordination between PH and hospitals/EM/EMS which will be critical to the successful response



Assure coordinated Medical Reserve Corps planning with neighboring jurisdictions and a mechanism to request assistance from these and other jurisdiction and state-based assets



SNS plans must include ability to staff reception point in conjunction with other demands on PH personnel – consider MOA with adjacent region – vendor managed inventory (VMI) of cytokines and push-packs among other supplies will likely be enroute shortly after the incident



Plan to provide guidance for Sheltering-in-Place and for evacuation. Initial decisions on sheltering based on plume must be made immediately by emergency management/public safety. PH must be prepared to liaison rapidly with EM and, based on initial models define additional shelter and evacuation instructions

IS #7


Identify mass emergency shelters for evacuees of Dangerous Fallout and other impacted zones



Identify sites for Assembly (screening) and Medical Care centers

IS #3


Coordinate Medical Care site planning with assistance from medical system and EMS



Develop registration / screening form to include demographic information and symptom / epidemiologic assessment of radiation exposure for use at AC, shelters, MC areas



Plan to coordinate messaging about who should NOT go to a medical facility, in order to allow resources to be used for seriously injured as well as provide instructions for self-care

IS #7


Gain familiarity with issues regarding Scarce Resources and facilitate public discussions regarding what a Scarce Resources setting will mean.

IS #8


Education for public for in-home and in-office emergency supplies and initial actions (see also first section of table EM)



Education for public regarding decontamination and how to self-decon (pre-incident and just-in-time) – this may not need to be specific for radiation but could address a broader range of exposures



Assure mass fatality management plan incorporates aspects of victim contamination and catastrophic casualty numbers

IS #12


Establish plans for psychological support including risk communication, psychological first aid, and targeted interventions by local and regional/national means (hotlines, designated referral locations) – offer training in psychological first aid

IS #13

Medical System Response


Assure Health and Medical Coordination Centers (HMCC) that include the hospitals in the area are region are practiced and that there is redundancy in case select facilities/personnel are rendered inoperative



Determine the actions that adjacent regions and HMCC will take automatically following a nuclear detonation – is there also a plan in place for succession if the local HMCC is rendered non-functional due to the scope of the incident?



Assure the HMCC is integrated into a multi-agency coordination center (such as an EOC) so that requests and issues may be sent via proper channels and to improve situational awareness



Assess regional medical capacity (surge capacity) including planning for alternate care sites (Medical Care centers)



Communications system compatibility and redundancy planning between agencies and facilities



Prepare list of potential critical medical supplies and develop local strategy for obtaining them



Resource sharing plans and mechanisms for request of necessary resources



Understand and practice mechanisms for healthcare facilities to move requests to appropriate EM partners at the local/regional/state level



Prepare to provide consistent information on medical triage to assure fairness. Consider using information from the Scarce Resources Project

IS #14


Download REMM and join REMM listserve.

IS #11


Be aware of National Disaster Medical System (NDMS) and other HHS assets, and how these are requested during an incident



Be aware of local / regional resources for blood supplies.



Be aware of the Radiation Injury Treatment Network (RITN).

IS #16


Work with local Veterans Affairs hospitals and military facilities to assure Federal facility integration


Evacuee Medical Care and Fallout-related Radiation Illness


Educate population regarding importance of
  • "duck and cover" after a brilliant flash is seen,
  • sheltering-in-place immediately after the incident,
  • avoiding fallout by sheltering, evacuating based on official advice.



Provide educational material regarding radiation injury and that small amounts of radiation are not as harmful as many people assume.



Provide educational material regarding decontamination including self-decontamination.

IS #16


Provide education to public that Potassium Iodide is not a part of a nuclear detonation response.



Emphasize family resilience planning (food, water, other supplies for 96 hours)



Emphasize for any major disaster the effects on the 911, EMS, and medical care system and to avoid all non-emergent use of the medical care system




Provide reassurance that there will be many, many survivors despite the disastrous nature of the incident.



Educate community of the importance of community resilience.



Educate community on normal responses to stress and mitigating actions that can be taken



Discuss guidelines for people returning to their homes and offices.



Plan for long-term registry and who should be followed for long-term cancer risk



Establish plans for long-term psychological support for responders and citizens.

IS #13

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  • This page last reviewed: February 14, 2012